%0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e65357 %T The EmpkinS-EKSpression Reappraisal Training Augmented With Kinesthesia in Depression: One-Armed Feasibility Study %A Keinert,Marie %A Schindler-Gmelch,Lena %A Rupp,Lydia Helene %A Sadeghi,Misha %A Richer,Robert %A Capito,Klara %A Eskofier,Bjoern M %A Berking,Matthias %+ Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Nägelsbachstraße 25a, Erlangen, 91052, Germany, 49 9131 8567563, marie.keinert@fau.de %K depression %K cognitive reappraisal %K facial expression %K kinesthesia %K smartphone-based intervention %K mobile phone %D 2025 %7 14.4.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Harboring dysfunctional depressogenic cognitions contributes to the development and maintenance of depression. A central goal of cognitive behavioral therapy (CBT) for depression is to invalidate such cognitions via cognitive reappraisal (CR). However, relatively low remission rates and high dropout rates in CBT demonstrate the need for further improvement. Potentially, the effects of CBT could be enhanced by addressing not only dysfunctional depressogenic cognitions but also body states associated with depression. This may be done, for example, by systematically pairing the invalidation of depressogenic cognitions with the performance of antidepressive kinesthesia. Objective: This study aimed to examine the feasibility and clinical potential of a smartphone-based cognitive restructuring task that required users to deliberately perform antidepressive kinesthesia in conjunction with the rejection of depressogenic statements and the affirmation of antidepressive statements. This feasibility study was conducted as a precursor to a large-scale randomized controlled trial. Methods: In total, 10 healthy participants engaged in a single 90-120-minute session of smartphone-based CR training. During the training, they completed 2 phases in which they were required to reject 20 depressogenic and affirm 20 antidepressive statements, respectively. Diagnostic assessments were conducted 1 week (T1) before and directly prior (T2) to the training, and again directly posttraining (T3) and at a 2-week follow-up posttraining (T4). Feasibility outcomes assessed at T3 included intervention safety recorded by study therapists, compliance, technical feasibility, usability assessed using the Short Version of the User Experience Questionnaire (UEQ-S), and acceptability assessed using the UEQ-S and self-developed items. Preliminary clinical potential was evaluated via single-item ratings of current depressed and positive mood assessed continuously during the training. Feasibility outcomes were analyzed descriptively, and clinical potential was examined using paired-sample t tests of pre and post ratings of mood at each training phase. Results: Overall, the results indicated that the training was safe, feasible, and usable (UEQ-S pragmatic quality scale: mean 1.45, SD 0.71). However, acceptance was limited (UEQ-S hedonic quality scale: mean 1.05, SD 0.79). While 80% (8/10) of the participants were generally satisfied with the training, 80% (8/10) would recommend it to a friend, 90% (9/10) found it interesting, and 80% (8/10) rated it as “leading edge,” 40% (4/10) to 70% (7/10) did not consider it particularly helpful and 50% (5/10) found it repetitive. Preliminary results regarding clinical potential were promising, with significant increases in positive mood (rejection: Hedges g=0.63; affirmation: Hedges g=0.25), whereas changes in depressed mood were not significant. Conclusions: This study evaluated the feasibility and acceptability of a smartphone-based CR training augmented with validating and invalidating kinesthesia. This provided valuable insights for further optimizing the intervention for the subsequent randomized controlled trial, but also potential similar interventions. If future studies confirm their clinical potential, such interventions offer a promising approach to enhancing CBT for depression. Trial Registration: OSF Registries pw6ma; https://osf.io/pw6ma/ %M 40228242 %R 10.2196/65357 %U https://formative.jmir.org/2025/1/e65357 %U https://doi.org/10.2196/65357 %U http://www.ncbi.nlm.nih.gov/pubmed/40228242 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e67772 %T Acoustic Features for Identifying Suicide Risk in Crisis Hotline Callers: Machine Learning Approach %A Su,Zhengyuan %A Jiang,Huadong %A Yang,Ying %A Hou,Xiangqing %A Su,Yanli %A Yang,Li %+ , Laboratory of Suicidal Behavior Research, Tianjin University, 135 Yaguan Road, Jinnan District, Tianjin, 300354, China, 86 13752183496, yangli@tju.edu.cn %K suicide %K crisis hotline %K acoustic feature %K machine learning %K acoustics %K suicide risk %K artificial intelligence %K feasibility %K prediction models %K hotline callers %K voice %D 2025 %7 14.4.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Crisis hotlines serve as a crucial avenue for the early identification of suicide risk, which is of paramount importance for suicide prevention and intervention. However, assessing the risk of callers in the crisis hotline context is constrained by factors such as lack of nonverbal communication cues, anonymity, time limits, and single-occasion intervention. Therefore, it is necessary to develop approaches, including acoustic features, for identifying the suicide risk among hotline callers early and quickly. Given the complicated features of sound, adopting artificial intelligence models to analyze callers’ acoustic features is promising. Objective: In this study, we investigated the feasibility of using acoustic features to predict suicide risk in crisis hotline callers. We also adopted a machine learning approach to analyze the complex acoustic features of hotline callers, with the aim of developing suicide risk prediction models. Methods: We collected 525 suicide-related calls from the records of a psychological assistance hotline in a province in northwest China. Callers were categorized as low or high risk based on suicidal ideation, suicidal plans, and history of suicide attempts, with risk assessments verified by a team of 18 clinical psychology raters. A total of 164 clearly categorized risk recordings were analyzed, including 102 low-risk and 62 high-risk calls. We extracted 273 audio segments, each exceeding 2 seconds in duration, which were labeled by raters as containing suicide-related expressions for subsequent model training and evaluation. Basic acoustic features (eg, Mel Frequency Cepstral Coefficients, formant frequencies, jitter, shimmer) and high-level statistical function (HSF) features (using OpenSMILE [Open-Source Speech and Music Interpretation by Large-Space Extraction] with the ComParE 2016 configuration) were extracted. Four supervised machine learning algorithms (logistic regression, support vector machine, random forest, and extreme gradient boosting) were trained and evaluated using grouped 5-fold cross-validation and a test set, with performance metrics, including accuracy, F1-score, recall, and false negative rate. Results: The development of machine learning models utilizing HSF acoustic features has been demonstrated to enhance recognition performance compared to models based solely on basic acoustic features. The random forest classifier, developed with HSFs, achieved the best performance in detecting the suicide risk among the models evaluated (accuracy=0.75, F1-score=0.70, recall=0.76, false negative rate=0.24). Conclusions: The results of our study demonstrate the potential of developing artificial intelligence–based early warning systems using acoustic features for identifying the suicide risk among crisis hotline callers. Our work also has implications for employing acoustic features to identify suicide risk in salient voice contexts. %M 40228243 %R 10.2196/67772 %U https://www.jmir.org/2025/1/e67772 %U https://doi.org/10.2196/67772 %U http://www.ncbi.nlm.nih.gov/pubmed/40228243 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e67381 %T Impact of Conversational and Animation Features of a Mental Health App Virtual Agent on Depressive Symptoms and User Experience Among College Students: Randomized Controlled Trial %A Six,Stephanie %A Schlesener,Elizabeth %A Hill,Victoria %A Babu,Sabarish V %A Byrne,Kaileigh %K depression %K mental health app %K virtual agents %K cognitive behavioral therapy %K conversational agents %K virtual agent %K animations %K college student %K CBT %K ANOVA %K randomized controlled trial %K depressive symptoms %K mental disorder %K mental illness %K user experience %K mHealth %K digital health %D 2025 %7 11.4.2025 %9 %J JMIR Ment Health %G English %X Background: Numerous mental health apps purport to alleviate depressive symptoms. Strong evidence suggests that brief cognitive behavioral therapy (bCBT)-based mental health apps can decrease depressive symptoms, yet there is limited research elucidating the specific features that may augment its therapeutic benefits. One potential design feature that may influence effectiveness and user experience is the inclusion of virtual agents that can mimic realistic, human face-to-face interactions. Objective: The goal of the current experiment was to determine the effect of conversational and animation features of a virtual agent within a bCBT-based mental health app on depressive symptoms and user experience in college students with and without depressive symptoms. Methods: College students (N=209) completed a 2-week intervention in which they engaged with a bCBT-based mental health app with a customizable therapeutic virtual agent that varied in conversational and animation features. A 2 (time: baseline vs 2-week follow-up) × 2 (conversational vs non-conversational agent) × 2 (animated vs non-animated agent) randomized controlled trial was used to assess mental health symptoms (Patient Health Questionnaire-8, Perceived Stress Scale-10, and Response Rumination Scale questionnaires) and user experience (mHealth App Usability Questionnaire, MAUQ) in college students with and without current depressive symptoms. The mental health app usability and qualitative questions regarding users’ perceptions of their therapeutic virtual agent interactions and customization process were assessed at follow-up. Results: Mixed ANOVA (analysis of variance) results demonstrated a significant decrease in symptoms of depression (P=.002; mean [SD]=5.5 [4.86] at follow-up vs mean [SD]=6.35 [4.71] at baseline), stress (P=.005; mean [SD]=15.91 [7.67] at follow-up vs mean [SD]=17.02 [6.81] at baseline), and rumination (P=.03; mean [SD]=40.42 [12.96] at follow-up vs mean [SD]=41.92 [13.61] at baseline); however, no significant effect of conversation or animation was observed. Findings also indicate a significant increase in user experience in animated conditions. This significant increase in animated conditions is also reflected in the user’s ease of use and satisfaction (F(1, 201)=102.60, P<.001), system information arrangement (F(1, 201)=123.12, P<.001), and usefulness of the application (F(1, 201)=3667.62, P<.001). Conclusions: The current experiment provides support for bCBT-based mental health apps featuring customizable, humanlike therapeutic virtual agents and their ability to significantly reduce negative symptomology over a brief timeframe. The app intervention reduced mental health symptoms, regardless of whether the agent included conversational or animation features, but animation features enhanced the user experience. These effects were observed in both users with and without depressive symptoms. Trial Registration: Open Science Framework B2HX5; https://doi.org/10.17605/OSF.IO/B2HX5 %R 10.2196/67381 %U https://mental.jmir.org/2025/1/e67381 %U https://doi.org/10.2196/67381 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e65452 %T Identifying Intersecting Factors Associated With Suicidal Thoughts and Behaviors Among Transgender and Gender Diverse Adults: Preliminary Conditional Inference Tree Analysis %A Stanton,Amelia M %A Trichtinger,Lauren A %A Kirakosian,Norik %A Li,Simon M %A Kabel,Katherine E %A Irani,Kiyan %A Bettis,Alexandra H %A O’Cleirigh,Conall %A Liu,Richard T %A Liu,Qimin %+ Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, Boston, MA, 02215, United States, 1 (617) 353 9610, stantona@bu.edu %K transgender and gender diverse adults %K suicidality %K intersectionality %K conditional inference tree %K electronic medical record %D 2025 %7 11.4.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Transgender and gender diverse (TGD) individuals are disproportionately impacted by suicidal thoughts and behaviors (STBs), and intersecting demographic and psychosocial factors may contribute to STB disparities. Objective: We aimed to identify intersecting factors associated with increased risk for suicidal ideation, intent, plan, and attempts in the US transgender population health survey (N=274), and determine age of onset for each outcome using conditional inference trees (CITs), which iteratively partitions subgroups of greater homogeneity with respect to a specific outcome. Methods: In separate analyses, we restricted variables to those typically available within electronic medical records (EMRs) and then included variables not typically within EMRs. We also compared the results of the CIT analyses with logistic regressions and Cox proportional hazards models. Results: In restricted analyses, younger adults endorsed more frequent ideation and planning. Adults aged ≤26 years who identified as Black or with another race not listed had the highest risk for ideation, followed by White, Latine, or multiracial adults aged ≤39 years who identified as sexual minority individuals. Adults aged ≤39 years who identified as sexual minority individuals had the highest risk for suicide planning. Increased risk for suicidal intent was observed among those who identified as multiracial, whereas no variables were associated with previous suicide attempts. In EMR-specific analyses, age of onset for ideation and attempts were associated with gender identity, such that transgender women were older compared to transgender men and nonbinary adults when they first experienced ideation; for attempts, transgender women and nonbinary adults were older than transgender men. In expanded analyses, including additional psychosocial variables, psychiatric distress was associated with increased risk for ideation, intent, and planning. High distress combined with high health care stereotype threat was linked to increased risk for intent and for suicide planning. Only high everyday discrimination was associated with increased risk for lifetime attempts. Ages of onset were associated with gender identity for ideation, the intersection of psychiatric distress and drug use for suicide planning, and gender identity alone for suicide attempts. No factors were associated with age of onset for suicide intent in the expanded variable set. The results of the CIT analysis and the traditional regressions were comparable for ordinal outcomes, but CITs substantially outperformed the regressions for the age of onset outcomes. Conclusions: In this preliminary test of the CIT approach to identify subgroups of TGD adults with increased STB risk, the risk was primarily influenced by age, racial identity, and sexual minority identity, as well as psychiatric distress, health care stereotype threat, and discrimination. Identifying intersecting factors linked to STBs is vital for early risk detection among TGD individuals. This approach should be tested on a larger scale using EMR data to facilitate service provision to TGD individuals at increased risk for STBs. %M 40215479 %R 10.2196/65452 %U https://www.jmir.org/2025/1/e65452 %U https://doi.org/10.2196/65452 %U http://www.ncbi.nlm.nih.gov/pubmed/40215479 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 8 %N %P e67137 %T Adapting Cognitive Behavioral Therapy for Adolescents in Iraq via Mobile Apps: Qualitative Study of Usability and Outcomes %A Ibrahim,Radhwan Hussein %A Yaas,Marghoob Hussein %A Hamarash,Mariwan Qadir %A Al-Mukhtar,Salwa Hazim %A Abdulghani,Mohammed Faris %A Al Mushhadany,Osama %K cognitive behavioral therapy %K CBT %K psychotherapy %K mHealth %K app %K adolescents %K teenager %K mental health %K usability %K engagement %K anxiety %K depression %K user experience %K UX %K focus group %K interview %K digital health %D 2025 %7 11.4.2025 %9 %J JMIR Pediatr Parent %G English %X Background: Mental health challenges, including anxiety and depression, are increasingly common among adolescents. Mobile health (mHealth) apps offer a promising way to deliver accessible cognitive behavioral therapy (CBT) interventions. However, research on the usability and effectiveness of apps explicitly tailored for adolescents is limited. Objective: This study aimed to explore the usability, engagement, and perceived effectiveness of a mobile CBT app designed for adolescents, focusing on user experiences and mental health outcomes. Methods: A qualitative study was conducted with 40 adolescents aged 13‐19 years (mean age 15.8, SD 1.9 years; 18/40, 45% male; 22/40, 55% female) who engaged with a CBT app for 4 weeks. Mental health diagnoses included anxiety (20/40, 50%), depression (15/40, 38%), and both (5/40, 13%). Of these, 10 (25%) of the 40 participants had previous CBT experience. Feedback was gathered through focus groups and individual interviews, and thematic analysis identified key themes related to usability, engagement, and perceived effectiveness. Quantitative data on mood and anxiety scores were analyzed with paired t tests. Results: The mean usability score was 3.8 (SD 0.6), and the mean effectiveness score was 3.9 (SD 0.7). Older participants (aged 16‐19 years) reported significantly higher usability (mean 4.1, SD 0.4) and effectiveness scores (mean 4.3, SD 0.5) compared to younger participants (aged 13‐15 years) (P=.03). Females had higher usability (mean 4, SD 0.6) and effectiveness scores (mean 4.2, SD 0.7) than males (mean 3.6, SD 0.7, and mean 3.5, SD 0.8, respectively; P=.03). Participants with prior CBT experience had 2.8 times higher odds of reporting high usability scores (95% CI 1.6‐5; P=.002) and 3.1 times higher odds of reporting high effectiveness scores (95% CI 1.7‐5.6; P=.001). Usability challenges included complex navigation (20/40, 50%), interface design issues (12/40, 30%), and content overload (8/40, 20%). Factors positively influencing engagement were motivation driven by personal relevance (20/40, 50%) and gamification features (10/40, 25%), while lack of personalization (14/40, 35%) and external distractions (18/40, 45%) were significant barriers. Mood improvement (15/40, 38%) and learning new coping skills (12/40, 30%) were the most reported outcomes. Conclusions: The mobile CBT app shows potential for improving adolescent mental health, with initial improvements in mood and anxiety. Future app iterations should prioritize simplifying navigation, adding personalization features, and enhancing technical stability to support long-term engagement. %R 10.2196/67137 %U https://pediatrics.jmir.org/2025/1/e67137 %U https://doi.org/10.2196/67137 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e59002 %T Text-Based Depression Prediction on Social Media Using Machine Learning: Systematic Review and Meta-Analysis %A Phiri,Doreen %A Makowa,Frank %A Amelia,Vivi Leona %A Phiri,Yohane Vincent Abero %A Dlamini,Lindelwa Portia %A Chung,Min-Huey %+ School of Nursing, College of Nursing, Taipei Medical University, 250 Wu-Xing Street, Taipei, 110, Taiwan, 886 227361661 ext 6317, minhuey300@tmu.edu.tw %K depression %K social media %K machine learning %K meta-analysis %K text-based %K depression prediction %D 2025 %7 11.4.2025 %9 Review %J J Med Internet Res %G English %X Background: Depression affects more than 350 million people globally. Traditional diagnostic methods have limitations. Analyzing textual data from social media provides new insights into predicting depression using machine learning. However, there is a lack of comprehensive reviews in this area, which necessitates further research. Objective: This review aims to assess the effectiveness of user-generated social media texts in predicting depression and evaluate the influence of demographic, language, social media activity, and temporal features on predicting depression on social media texts through machine learning. Methods: We searched studies from 11 databases (CINHAL [through EBSCOhost], PubMed, Scopus, Ovid MEDLINE, Embase, PubPsych, Cochrane Library, Web of Science, ProQuest, IEEE Explore, and ACM digital library) from January 2008 to August 2023. We included studies that used social media texts, machine learning, and reported area under the curve, Pearson r, and specificity and sensitivity (or data used for their calculation) to predict depression. Protocol papers and studies not written in English were excluded. We extracted study characteristics, population characteristics, outcome measures, and prediction factors from each study. A random effects model was used to extract the effect sizes with 95% CIs. Study heterogeneity was evaluated using forest plots and P values in the Cochran Q test. Moderator analysis was performed to identify the sources of heterogeneity. Results: A total of 36 studies were included. We observed a significant overall correlation between social media texts and depression, with a large effect size (r=0.630, 95% CI 0.565-0.686). We noted the same correlation and large effect size for demographic (largest effect size; r=0.642, 95% CI 0.489-0.757), social media activity (r=0.552, 95% CI 0.418-0.663), language (r=0.545, 95% CI 0.441-0.649), and temporal features (r=0.531, 95% CI 0.320-0.693). The social media platform type (public or private; P<.001), machine learning approach (shallow or deep; P=.048), and use of outcome measures (yes or no; P<.001) were significant moderators. Sensitivity analysis revealed no change in the results, indicating result stability. The Begg-Mazumdar rank correlation (Kendall τb=0.22063; P=.058) and the Egger test (2-tailed t34=1.28696; P=.207) confirmed the absence of publication bias. Conclusions: Social media textual content can be a useful tool for predicting depression. Demographics, language, social media activity, and temporal features should be considered to maximize the accuracy of depression prediction models. Additionally, the effects of social media platform type, machine learning approach, and use of outcome measures in depression prediction models need attention. Analyzing social media texts for depression prediction is challenging, and findings may not apply to a broader population. Nevertheless, our findings offer valuable insights for future research. Trial Registration: PROSPERO CRD42023427707; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023427707 %M 40215481 %R 10.2196/59002 %U https://www.jmir.org/2025/1/e59002 %U https://doi.org/10.2196/59002 %U http://www.ncbi.nlm.nih.gov/pubmed/40215481 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e58916 %T Association of Social Media Recruitment and Depression Among Racially and Ethnically Diverse Metabolic and Bariatric Surgery Candidates: Prospective Cohort Study %A Francis,Jackson M %A Neti,Sitapriya S %A Polavarapu,Dhatri %A Atem,Folefac %A Xie,Luyu %A Kapera,Olivia %A Mathew,Matthew S %A Marroquin,Elisa %A McAdams,Carrie %A Schellinger,Jeffrey %A Ngenge,Sophia %A Kukreja,Sachin %A Schneider,Benjamin E %A Almandoz,Jaime P %A Messiah,Sarah E %K social media %K social media recruitment %K depression %K depressed %K major depressive disorder %K MDD %K depressive disorder %K depressive %K race %K racial %K racial differences %K ethnic %K ethnic differences %K ethnicity %K metabolic surgery %K bariatric surgery %K obesity %K obese %K online health %K ethics %K mental health %K eHealth %K internet %K digital health %K digital mental health %K online interventions %K public engagement %K public health %D 2025 %7 10.4.2025 %9 %J JMIR Form Res %G English %X Background: Due to the widespread use of social media and the internet in today’s connected world, obesity and depression rates are increasing concurrently on a global scale. This study investigated the complex dynamics involving social media recruitment for scientific research, race, ethnicity, and depression among metabolic and bariatric surgery (MBS) candidates. Objective: This study aimed to determine (1) the association between social media recruitment and depression among MBS candidates and (2) racial and ethnic differences in social media recruitment engagement. Methods: The analysis included data from 380 adult MBS candidates enrolled in a prospective cohort study from July 2019 to December 2022. Race and ethnicity, recruitment method (social media: yes or no), and depression status were evaluated using χ2 tests and logistic regression models. Age, sex, and ethnicity were adjusted in multivariable logistic regression models. Results: The mean age of the candidates was 47.35 (SD 11.6) years, ranging from 18 to 78 years. Participants recruited through social media (n=41, 38.32%) were more likely to report past or current episodes of depression compared to nonsocial media–recruited participants (n=74, 27.11%; P=.03), with a 67% increased likelihood of depression (odds ratio [OR] 1.67, 95% CI 1.04‐2.68, P=.03). Further analysis showed that participants with a history of depression who were below the mean sample age were 2.26 times more likely to be recruited via social media (adjusted OR [aOR] 2.26, 95% CI 1.03‐4.95; P=.04) compared to those above the mean age. Hispanic (n=26, 38.81%) and non-Hispanic White (n=53, 35.10%) participants were significantly more likely to be recruited via social media than non-Hispanic Black (n=27, 18.37%) participants (P<.001). After adjusting for covariates, non-Hispanic Black participants were 60% less likely than non-Hispanic White participants to be recruited via social media (aOR 0.40, 95% CI 0.22‐0.71; P=.002). Conclusions: We found that individuals recruited through social media channels, especially younger participants, were more likely to report past or current episodes of depression compared to those recruited through nonsocial media. The study also showed that non-Hispanic Black individuals are less likely to engage in social media recruitment for scientific research versus other racial and ethnic groups. Future mental health–related studies should consider strategies to mitigate potential biases introduced by recruitment methods to ensure the validity and generalizability of research findings. %R 10.2196/58916 %U https://formative.jmir.org/2025/1/e58916 %U https://doi.org/10.2196/58916 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e67624 %T Provider Perspectives on Implementing an Enhanced Digital Screening for Adolescent Depression and Suicidality: Qualitative Study %A Coren,Morgan A %A Lindhiem,Oliver %A Angus,Abby R %A Toevs,Emma K %A Radovic,Ana %K depression %K suicidality %K adolescent mental health screening %K primary care %K digital tools %D 2025 %7 10.4.2025 %9 %J JMIR Form Res %G English %X Background: With a growing adolescent mental health crisis, pediatric societies are increasingly recommending that primary care providers (PCPs) engage in mental health screening. While symptom-level screens identify symptoms, novel technology interventions can assist PCPs with providing additional point-of-care guidance to increase uptake for behavioral health services. Objective: In this study, we sought community PCP feedback on a web-based, digitally enhanced mental health screening tool for adolescents in primary care previously only evaluated in research studies to inform implementation in community settings. Methods: A total of 10 adolescent providers were recruited to trial the new screening tool and participate in structured interviews based on the Consolidated Framework for Implementation Research domains. Interviews were audio recorded, transcribed, and coded according to a prespecified codebook using a template analysis approach. Results: Providers identified improving mental health screening and treatment in pediatric primary care as a priority and agreed that a web-based digitally enhanced screening tool could help facilitate identification of and management of adolescent depression. Salient barriers identified were lack of electronic health record integration, time to administer screening, implications on clinic workflow, accessibility, and lack of transparency within health care organizations about the process of approving new technologies for clinical use. Providers made multiple suggestions to enhance implementation in community settings, such as incorporating customization options. Conclusions: Technology interventions can help address the need for improved behavioral health support in primary care settings. However, numerous barriers exist, complicating implementation of new technologies in real-world settings. %R 10.2196/67624 %U https://formative.jmir.org/2025/1/e67624 %U https://doi.org/10.2196/67624 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e42406 %T Factors Impacting Mobile Health Adoption for Depression Care and Support by Adolescent Mothers in Nigeria: Preliminary Focus Group Study %A Kola,Lola %A Fatodu,Tobi %A Kola,Manasseh %A Olayemi,Bisola A %A Adefolarin,Adeyinka O %A Dania,Simpa %A Kumar,Manasi %A Ben-Zeev,Dror %+ WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, P.M.B 3017 G.P.O, Ibadan, 23401, Nigeria, 234 (2) 2411768, lola_kola2004@yahoo.com %K adolescent perinatal depression %K primary care %K mHealth app %K user centered design %K smartphone %K human-centered design %K HCD %K depression %K postpartum %K perinatal %K postnatal %K teenage %K adolescent %K youth %K low-middle-income countries %K LMIC %K middle income %K adoption %K acceptability %K mobile health %K mHealth %K mobile app %K women’s health %K mental health %K depressive %D 2025 %7 9.4.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Mobile health (mHealth), the use of mobile technology in health care, is increasingly being used for mental health service delivery even in low- and middle-income countries to scale up treatment, and a variety of evidence supports their potential in different populations. Objective: This study aims to use the Social Cognitive Theory (SCT) as a lens to explain knowledge of mHealth use for mental health care, personal behavioral capabilities, and the external social contexts that can impact the adoption of an mHealth app for depression care among perinatal adolescents in Nigeria. Methods: At the preliminary stage of a user-centered design (UCD), 4 focus group discussions were conducted among 39 participants: 19 perinatal adolescents with a history of depression and 20 primary care providers. Guided by the SCT, a popular model used for predicting and explaining health behaviors, we documented participants’ knowledge of mHealth use for health purposes, advantages, and challenges to the adoption of an mHealth app by young mothers, and approaches to mitigate challenges. Data collection and analysis was an iterative process until saturation of all topic areas was reached. Results: The mean age for young mothers was 17.3 (SD 0.9) years and 48 (SD 5.8) years for care providers. Mistrust from relatives on mobile phone use for therapeutic purposes, avoidance of clinic appointments, and sharing of application contents with friends were some challenges to adoption identified in the study population. Supportive personal factors and expressions of self-efficacy on mobile app use were found to be insufficient for adoption. This is because there are social complications and disapprovals that come along with getting pregnant at a young age. Adequate engagement of parents, guardians, and partners on mHealth solutions by care providers was identified as necessary to the uptake of digital tools for mental health care in this population. Conclusions: The SCT guided the interpretations of the study findings. Young mothers expressed excitement at the use of mHealth technology to manage perinatal depression. Real-life challenges, however, need to be attended to for successful implementation of such interventions. Communications between care providers and patients’ relatives on the therapeutic use of mHealth are vital to the success of a mHealth mental health management plan for depression in young mothers in Nigeria. %M 40203299 %R 10.2196/42406 %U https://formative.jmir.org/2025/1/e42406 %U https://doi.org/10.2196/42406 %U http://www.ncbi.nlm.nih.gov/pubmed/40203299 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e57368 %T Psychological eHealth Interventions for Patients With Cardiovascular Diseases: Systematic Review and Meta-Analysis %A Su,Jing Jing %A Lin,Rose %A Batalik,Ladislav %A Wong,Arkers Kwan Ching %A Grace,Sherry L %+ Elaine C. Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, 255 Crittenden Blvd, Rochester, NY, 14642, United States, 1 (585) 276 6833, sinyirose_lin@urmc.rochester.edu %K cardiovascular diseases %K eHealth %K digital health %K iCBT %K mental health %K psychological intervention %K cognitive behavioral therapy %K CBT %K depression %K heart %K cardiology %K psychological %K anxiety %K high-risk %K systematic review %K meta-analysis %K CVD %K evidence-based %K psychosocial %K GRADE approach %K Cochrane Risk of Bias Tool %K internet-based %K psychological therapy %K psychotherapy %D 2025 %7 7.4.2025 %9 Review %J J Med Internet Res %G English %X Background: Psychological distress is recognized as an independent risk factor for cardiovascular diseases (CVDs), contributing to increased morbidity and mortality. While eHealth is increasingly used to deliver psychological interventions, their effectiveness for patients with CVDs remains unclear. Objective: This meta-analysis aimed to evaluate the effects of eHealth psychological interventions for patients with CVDs. Methods: Eligible studies were retrieved from 5 databases (Embase, Medline, PubMed, CINAHL, and Cochrane Library), covering the period from database inception to December 2024. Randomized controlled trials (RCTs) investigating the effect of evidence-based psychological eHealth interventions to improve psychosocial well-being and cardiovascular outcomes for people with CVDs were included. The Cochrane Risk of Bias tool (version 2) was used to judge the methodological quality of reviewed studies. RevMan (version 5.3) was used for meta-analysis. Results: A total of 12 RCTs, comprising 2319 participants from 10 countries, were included in the review. The results demonstrated significant alleviation of depressive symptoms for patients receiving psychological eHealth intervention compared to controls (number of paper included in that particular analysis, n=7; standardized mean difference=–0.30, 95% CI –0.47 to –0.14; I2=57%; P<.001). More specifically, in 6 trials where internet-based cognitive behavioral therapy was delivered, a significant alleviation of depressive symptoms was achieved (standardized mean difference=–0.39, 95% CI –0.56 to –0.21; I2=53%; P<.001). There was no significant change in anxiety or quality of life. Synthesis without meta-analysis regarding stress, adverse events, and cardiovascular events showed inconclusive findings. Conclusions: Psychological eHealth interventions, particularly internet-based cognitive behavioral therapy, can significantly reduce depressive symptoms among patients with CVDs. A multidisciplinary approach is crucial for comprehensively improving psychological and cardiovascular outcomes. Future studies should explore integrating persuasive design features into eHealth and involving mental health professionals for intervention delivery. Trial Registration: PROSPERO CRD42023452276; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023452276 %M 40194269 %R 10.2196/57368 %U https://www.jmir.org/2025/1/e57368 %U https://doi.org/10.2196/57368 %U http://www.ncbi.nlm.nih.gov/pubmed/40194269 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e70594 %T Are Dating App Algorithms Making Men Lonely and Does This Present a Public Health Concern? %A Balki,Eric %+ Faculty of Health and Medicine, Department of Health, Lancaster University, Innovation One, Sir John Fisher Dr, Bailrigg, Lancaster, LA1 4AT, United Kingdom, 44 1524 593763, e.balkhi@lancaster.ac.uk %K dating apps %K mental health %K men %K algorithm %K anxiety %K depression %K loneliness %D 2025 %7 7.4.2025 %9 Viewpoint %J JMIR Form Res %G English %X During the pandemic, dating apps emerged as essential platforms connecting users amid social isolation, experiencing rapid growth in engagement and profile creation. This paper examines the evolution of these apps, highlighting their shift from facilitating offline encounters to promoting match accumulation for revenue. In particular, the study investigates gender disparities, addictive behaviors, and algorithmic match throttling that disproportionately impact men’s psychological well-being. Drawing on evidence linking dating app use to increased depression and anxiety, the analysis calls for regulatory intervention to eliminate pay-for-advantage models and ensure fair, healthy user experiences, thereby mitigating adverse public health outcomes. %M 40193188 %R 10.2196/70594 %U https://formative.jmir.org/2025/1/e70594 %U https://doi.org/10.2196/70594 %U http://www.ncbi.nlm.nih.gov/pubmed/40193188 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e65268 %T Effect of a WeChat-Based Hybrid Intervention on the Adaptation Outcomes of People Living With HIV/AIDS: Pilot Randomized Controlled Trial %A Wang,Honghong %A Qin,Ziqi %A Li,Yixuan %A Duan,Yuqiong %A Lu,Qiaoyue %A Xiao,Xueling %+ Xiangya School of Nursing, Central South University, No. 172 Tongzipo Road, Changsha, 410083, China, 86 15286826132, xuelingxiao93@hotmail.com %K HIV/AIDS %K quality of life %K acceptance of illness %K mental health %K randomized controlled trial %K mobile phone %D 2025 %7 3.4.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: People living with HIV/AIDS face multiple challenges that collectively impede their adaptation outcomes. These outcomes include quality of life (QoL), acceptance of illness, mental health (including symptoms of anxiety and depression), and antiretroviral therapy (ART) adherence. While existing evidence addresses specific challenges, it often overlooks the interactions among the various problems people living with HIV/AIDS encounter. The comprehensive-task disease management framework and positive self-management framework provide a theoretical basis for understanding the adaptation process. A culturally tailored, theory-based intervention may be necessary and effective in facilitating better adaptation outcomes for people living with HIV/AIDS. Objective: This study aimed to evaluate the effect of a hybrid intervention called AiCare (Adaptation intervention with Comprehensive-task disease management framework to achieve renormal life) on improving QoL, acceptance of illness, mental health (anxiety and depression), and ART adherence among people living with HIV/AIDS in China. Methods: We conducted a 2-arm randomized controlled trial, recruiting 92 people living with HIV/AIDS from an HIV clinic in Hunan, China. Participants were randomly assigned in a 1:1 ratio to either the control group (receiving standard care) or the intervention group (receiving AiCare in addition to standard care). All analyses were performed from an intention-to-treat perspective. Sociodemographic and HIV-specific clinical characteristics, along with key adaptation outcomes—including QoL, acceptance of illness, mental health (anxiety and depression), and ART adherence—were assessed at baseline (T0), post intervention (T1), and 3 months post intervention (T2). We used generalized estimating equation models and difference-in-difference analysis to evaluate the interventions’ effects. Results: The difference-in-difference model showed that at T1, the intervention group experienced significant improvements compared to the control group. QoL increased by 6.35 (95% CI 2.62-10.93, P=.001), acceptance of illness improved by 4.49 (95% CI 2.29-6.68, P<.001), and anxiety decreased by 2.15 (95% CI 1.19-3.11; P=.01). At T2, the intervention group’s improvement in QoL was not statistically significant (β 3.62, 95% CI –1.53 to 8.77; P=.17). However, acceptance of illness remained significantly improved by 3.65 (95% CI 1.22-6.08; P=.003), and anxiety decreased by 1.58 (95% CI 0.42-2.74; P=.007). No significant changes were observed in depression or ART adherence between the intervention and control groups. Feedback regarding the AiCare program indicated its acceptability and feasibility. Conclusions: The AiCare program demonstrated promising effects in improving disease adaptation outcomes among people living with HIV/AIDS, notably in enhancing QoL, fostering acceptance of illness, and mitigating anxiety symptoms. These findings underscore the hybrid program’s potential clinical utility to facilitate the adaptation of people living with HIV/AIDS. Trial Registration: Chinese Clinical Trial Registry ChiCTR2400087255; https://www.chictr.org.cn/showproj.html?proj=220729 %M 39988931 %R 10.2196/65268 %U https://www.jmir.org/2025/1/e65268 %U https://doi.org/10.2196/65268 %U http://www.ncbi.nlm.nih.gov/pubmed/39988931 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e72414 %T Exploring the Relationship Between Cyberchondria and Suicidal Ideation: Cross-Sectional Mediation Analysis %A Xu,Richard Huan %A Liang,Xiao %A Starcevic,Vladan %+ Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, Hong Kong Polytechnic University, ST-538, Hung Hom, Kowloon, Hong Kong, China (Hong Kong), 852 27664199, richard.xu@polyu.edu.hk %K cyberchondria %K suicidal ideation %K distress %K structural equation modeling %K mediation analysis %D 2025 %7 2.4.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: The proliferation of internet-based health information has intensified cyberchondria, or anxiety resulting from excessive health-related searches. The relationship between cyberchondria and suicidal ideation remains underexplored, although there are indications that people with high levels of cyberchondria may also be suicidal. Understanding this relationship is critical, given rising digital health-seeking behaviors and the need to mitigate suicide risk. Emerging evidence suggests that psychological distress can mediate the relationship between cyberchondria and suicidal ideation. However, to the best of our knowledge, no research has directly examined these associations. Objective: This study had two aims. The first was to examine the relationship between cyberchondria and suicidal ideation in a sample of the general Chinese population. The second aim was to investigate the possible role of psychological distress, reflecting the symptoms of depression and anxiety, as a mediator in the relationship between cyberchondria and suicidal ideation. Methods: Data were obtained from a cross-sectional and web-based survey conducted in 2024. Structural equation modeling analysis was used to assess the hypothesized association between cyberchondria and suicidal ideation, as well as the mediating effect of psychological distress on this association. The Cyberchondria Severity Scale-12 items, Suicidal Ideation Attributes Scale, and Kessler Psychological Distress Scale-10 items were used to measure cyberchondria, suicidal ideation, and psychological distress, respectively. Standardized (β) estimates, along with their 95% CIs, were calculated for all structural paths, adjusting for participants’ background characteristics. Results: A total of 2415 individuals completed the questionnaire (response rate=98.5%). Scores on the Cyberchondria Severity Scale-12 items ranged from 12 to 60, with the mean score being 40 (SD 7.9). The mean score on the Suicidal Ideation Attributes Scale was 12.7 (SD 9.9). Scores on the Kessler Psychological Distress Scale-10 items ranged from 10 to 50, and the mean score was 22 (SD 6.9). Cyberchondria, suicidal ideation, and psychological distress were significantly correlated. Structural equation modeling revealed a significant association between cyberchondria and psychological distress (β=.281; P<.001), between psychological distress and suicidal ideation (β=.504; P<.001), and between cyberchondria and suicidal ideation (β=.107; P<.001). The indirect effect of cyberchondria on suicidal ideation through psychological distress was also significant (β=.142; P<.001). Conclusions: The main contribution of this study is that it highlights an important relationship between cyberchondria and suicidal ideation, with a direct and statistically significant association between these variables. Their relationship is also mediated by psychological distress, which reflects the role of depressive and anxiety symptoms. %M 40173445 %R 10.2196/72414 %U https://www.jmir.org/2025/1/e72414 %U https://doi.org/10.2196/72414 %U http://www.ncbi.nlm.nih.gov/pubmed/40173445 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e68249 %T Examining the Client Experience of Digital Tools in Blended Care Therapy: Qualitative Interview Study %A Lattie,Emily G %A Beltzer,Miranda %A Varra,Alethea %A Chen,Connie E %A Lungu,Anita %+ , Lyra Health, 270 East Lane, Burlingame, CA, 94010, United States, 1 (877) 505 7147, elattie@lyrahealth.com %K anxiety %K depression %K blended care therapy %K mental health care %K digital mental health %K digital tools %K qualitative interviews %K Lyra Care Therapy %K video lesson %K symptom assessment %K written exercise %K thematic analysis %K LCT model %K therapeutic value %K client experience %D 2025 %7 2.4.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Lyra Health’s short-term blended care therapy model, Lyra Care Therapy (LCT), has demonstrated effectiveness at scale. In LCT, clients participate in synchronous telehealth sessions and asynchronous guided practice sessions, in which they are provided with digital tools to reinforce key concepts and skills. These digital tools include animated video lessons that use storytelling to show characters learning and implementing new skills from therapy, written psychoeducational materials, interactive exercises that prompt reflection and skills practice, symptom assessments, and messaging with therapists. Past research on LCT found that time spent in therapy sessions and viewing digital video lessons predicts improvements in depression and anxiety symptoms. Objective: This study aims to explore the client experience of LCT digital tools and to understand clients’ perceived benefits and challenges of using digital tools while in LCT. Methods: In total, 12 ethnically and racially diverse adults (5 male, 6 female, and 1 pangender) who had graduated from LCT in the previous 4 months participated in semistructured interviews. Interviews focused on experiences with the digital components of LCT (ie, video lessons, symptom assessments, and written exercises). Transcripts were analyzed using thematic analytic methods to determine the benefits and challenges associated with components of the LCT model. Results: In total, 3 primary themes were generated through thematic analysis. These themes centered around supporting knowledge and skill development, the benefits and challenges associated with the range of digital tools, and the combination of flexibility and accountability promoting positive change. First, we summarize the ways in which guided practice sessions allow clients to develop additional knowledge and learn skills related to their mental health and well-being. Then, we describe how the range of digital tools included in LCT presents different benefits and challenges for clients. Finally, we discuss how flexibility inherent in having both synchronous and asynchronous sessions, along with the accountability from a provider, encourages clients to continue to practice skills related to their mental health and well-being. Conclusions: Results provide insights into the unique contributions of different components of the LCT model on therapeutic gains. While perceived time constraints and content preferences can impact engagement with digital tools, overall the digital tools were perceived as carrying significant value for participants in the LCT program. %M 40173439 %R 10.2196/68249 %U https://formative.jmir.org/2025/1/e68249 %U https://doi.org/10.2196/68249 %U http://www.ncbi.nlm.nih.gov/pubmed/40173439 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e54062 %T Evaluation of an Online-Based Self-Help Program for Patients With Panic Disorder: Randomized Controlled Trial %A Lalk,Christopher %A Väth,Teresa %A Hanraths,Sofie %A Pruessner,Luise %A Timm,Christina %A Hartmann,Steffen %A Barnow,Sven %A Rubel,Julian %+ Clinical Psychology and Psychotherapy of Adulthood, Institute of Psychology, University Osnabrück, Lise-Meitner-Straße 3, Osnabrück, 49076, Germany, 49 541 969 76, christopher.lalk@uni-osnabrueck.de %K internet-based CBT %K agoraphobia %K well-being %K iCBT %K internet-based intervention %K panic disorder with and without agoraphobia %K panic disorder %K self-help %K quality of life %K effectiveness %K online %K self-help intervention %K panic symptoms %K well-being %K daily functioning %D 2025 %7 2.4.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Panic disorder is an anxiety disorder marked by severe fear of panic attacks in the absence of causes. Agoraphobia is a related anxiety disorder, which involves fear and avoidance of specific situations in which escape or help may be difficult. Both can be debilitating and impair well-being. One treatment option may be internet-based cognitive behavioral therapy (iCBT), which allows large-scale application and may overcome treatment barriers for some individuals. Objective: This study aimed to evaluated the effectiveness of a novel online self-help intervention for panic disorder with or without agoraphobia. As our primary hypotheses, we expected the intervention to improve panic and agoraphobia symptoms and well-being. Our secondary hypotheses entailed improvements in daily functioning, mental health literacy, working ability, and health care use in the intervention group. Methods: German-speaking patients (N=156) aged 18-65 years with internet access and a diagnosis of panic disorder with or without agoraphobia were recruited for this randomized controlled trial. The intervention group (n=82) received access to a 12-week online self-help program entailing psychoeducation, cognitive restructuring, exposure, and mindfulness elements. The control group (n=72) received care as usual during the study period and was offered the prospect of using the program after 12 weeks. The primary outcomes were assessed via the Panic and Agoraphobia Scale (PAS) and the WHO (World Health Organization)-5 Well-Being Index (WHO-5). Mixed effect models were computed using multivariate imputation by chained equation for the analysis of intervention effects. Results: In the intervention group, participants completed on average 7.3 out of 12 (60.8%) modules, and 27 out of 82 (32.1%) participants finished the whole course. Changes in PAS revealed a significant effect in favor of the intervention group (t110.1=–2.22, Padj=.03) with a small to moderate effect size (d=–0.37, 95% CI –0.70 to –0.04). No significant effect was found for the second primary outcome WHO-5 (t149.8=1.35, Padj=.09) or the secondary outcomes. Improvements were observed in anxiety (t206.8=–4.12; P<.001; Cohen d=–0.60, 95% CI –0.089 to –0.32) and depression (t257.4=–3.20; P<.001; Cohen d=–0.41 95% CI –0.66 to –0.16). No negative effects were associated with the intervention (t125=–1.14, P=.26). Conclusions: The presented online intervention can help reduce the core symptomatology of panic disorder and agoraphobia, as well as anxiety symptoms and associated depression. No effects were found for well-being and secondary outcomes. This may be due to higher illness burden in the intervention group and possibly the COVID pandemic, which caused unique challenges to patients suffering from panic disorder. Therefore, further research and intervention adaptations may be warranted to improve these outcomes. Trial Registration: German Clinical Trials Register DRKS00023800; https://drks.de/search/en/trial/DRKS00023800 %M 40173444 %R 10.2196/54062 %U https://www.jmir.org/2025/1/e54062 %U https://doi.org/10.2196/54062 %U http://www.ncbi.nlm.nih.gov/pubmed/40173444 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e67545 %T Videoconference-Delivered Acceptance and Commitment Therapy for Family Caregivers of People With Dementia: Pilot Randomized Controlled Trial %A Han,Areum %A Oster,Robert %A Yuen,Hon %A Jenkins,Jeremy %A Hawkins,Jessica %A Edwards,Lauren %+ , Department of Occupational Therapy, University of Alabama at Birmingham, SHPB 339, 1720 2nd Avenue South, Birmingham, AL, 35294, United States, 1 2059752882, ahan@uab.edu %K acceptance and commitment therapy %K Alzheimer disease %K caregivers %K dementia %K depression %K web-based intervention %K quality of life %K randomized controlled trial %K stress %K videoconferencing %D 2025 %7 31.3.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Family caregivers of individuals with dementia face significant mental health challenges. Acceptance and commitment therapy (ACT) has emerged as a promising intervention for improving these caregivers’ mental health. While various delivery modes of ACT have been explored, there is a need for evidence on the efficacy of videoconference-delivered ACT programs for this population. Objective: This pilot randomized controlled trial, conducted in the United States, aims to assess the effects of a videoconference-delivered, therapist-guided ACT program on reducing depressive symptoms and improving other mental health outcomes among family caregivers with depression who give care to individuals with dementia, compared to a control group that received psychoeducation materials only. Methods: This 2-arm, parallel-group pilot randomized controlled trial randomly assigned 33 family caregivers to either a 10-week videoconference-delivered ACT program (n=16, 48%) or a control group that received psychoeducation materials alone (n=17, 52%). Depressive symptoms (primary outcome) were measured using the Patient Health Questionnaire-9. Secondary outcomes included anxiety, stress, psychological quality of life (QoL), caregiver burden, predeath grief, guilt, and ACT process measures. Outcomes were assessed in the pretest, posttest (10-12 weeks after pretest), and a 3-month follow-up (3 months after posttest, approximately 5-6 months after pretest). An intent-to-treat approach was used for all outcome analyses. Linear mixed-effects models for repeated measures were used to analyze outcomes. Results: The ACT group reported significantly greater improvements in stress (P=.043) and psychological QoL (P=.014) in the posttest compared to the control group. Within the ACT group, participants experienced a significant decrease in depressive symptoms, with a mean (SE) change of –6.09 (1.16) points (95% CI –8.42 to –3.76; P<.001) in the posttest and –6.71 (1.45) points (95% CI –9.63 to –3.81; P<.001) in the 3-month follow-up. These changes exceed the estimated minimal clinically important difference on the Patient Health Questionnaire-9. In addition, the ACT group reported significant improvements in anxiety, stress, psychological QoL, caregiver burden, predeath grief, guilt, values-driven action, and experiential avoidance at both posttest and 3-month follow-up. A sensitivity analysis, excluding 1 participant with near-outlier data, revealed statistically significant between-group differences in depressive symptoms at posttest (P=.037); stress at posttest (P<.001) and in 3-month follow-up (P=.001); psychological QoL at posttest (P<.001); caregiver burden at posttest (P=.003) and in 3-month follow-up (P=.003); predeath grief in 3-month follow-up (P=.031); and values-driven action at posttest (P=.032). Conclusions: The videoconference-delivered ACT program showed promise in improving mental health outcomes and ACT processes among family caregivers with depression who give care to individuals with dementia. Future studies should aim to replicate these findings with larger, more diverse caregiver populations and explore the long-term efficacy of videoconference-delivered ACT programs. Trial Registration: ClinicalTrials.gov NCT05043441; https://clinicaltrials.gov/study/NCT05043441 %M 40163859 %R 10.2196/67545 %U https://formative.jmir.org/2025/1/e67545 %U https://doi.org/10.2196/67545 %U http://www.ncbi.nlm.nih.gov/pubmed/40163859 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e59527 %T Patients’ and Health Care Professionals’ Expectations of Virtual Therapeutic Agents in Outpatient Aftercare: Qualitative Survey Study %A Immel,Diana %A Hilpert,Bernhard %A Schwarz,Patricia %A Hein,Andreas %A Gebhard,Patrick %A Barton,Simon %A Hurlemann,René %+ Department of Psychiatry, School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Hermann-Ehlers-Str. 7, Oldenburg, 26160, Germany, 49 441961517, diana.immel@uni-oldenburg.de %K socially interactive agent %K e-mental health %K mental illness %K mental disorder %K depression %K major depressive disorder %K suicide prevention %K suicidal ideation %K outpatient aftercare %K artificial intelligence %K virtual therapeutic assistant %K public health %K digital technology %K digital intervention %K digital health care %D 2025 %7 26.3.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression is a serious mental health condition that can have a profound impact on the individual experiencing the disorder and those providing care. While psychotherapy and medication can be effective, there are gaps in current approaches, particularly in outpatient care. This phase is often associated with a high risk of relapse and readmission, and patients often report a lack of support. Socially interactive agents represent an innovative approach to the provision of assistance. Often powered by artificial intelligence, these virtual agents can interact socially and elicit humanlike emotions. In health care, they are used as virtual therapeutic assistants to fill gaps in outpatient aftercare. Objective: We aimed to explore the expectations of patients with depression and health care professionals by conducting a qualitative survey. Our analysis focused on research questions related to the appearance and role of the assistant, the assistant-patient interaction (time of interaction, skills and abilities of the assistant, and modes of interaction) and the therapist-assistant interaction. Methods: A 2-part qualitative study was conducted to explore the perspectives of the 2 groups (patients and care providers). In the first step, care providers (n=30) were recruited during a regional offline meeting. After a short presentation, they were given a link and were asked to complete a semistructured web-based questionnaire. Next, patients (n=20) were recruited from a clinic and were interviewed in a semistructured face-to-face interview. Results: The survey findings suggested that the assistant should be a multimodal communicator (voice, facial expressions, and gestures) and counteract negative self-evaluation. Most participants preferred a female assistant or wanted the option to choose the gender. In total, 24 (80%) health care professionals wanted a selectable option, while patients exhibited a marked preference for a female or diverse assistant. Regrading patient-assistant interaction, the assistant was seen as a proactive recipient of information, and the patient as a passive one. Gaps in aftercare could be filled by the unlimited availability of the assistant. However, patients should retain their autonomy to avoid dependency. The monitoring of health status was viewed positively by both groups. A biofeedback function was desired to detect early warning signs of disease. When appropriate to the situation, a sense of humor in the assistant was desirable. The desired skills of the assistant can be summarized as providing structure and emotional support, especially warmth and competence to build trust. Consistency was important for the caregiver to appear authentic. Regarding the assistant–care provider interaction, 3 key areas were identified: objective patient status measurement, emergency suicide prevention, and an information tool and decision support system for health care professionals. Conclusions: Overall, the survey conducted provides innovative guidelines for the development of virtual therapeutic assistants to fill the gaps in patient aftercare. %M 40138692 %R 10.2196/59527 %U https://formative.jmir.org/2025/1/e59527 %U https://doi.org/10.2196/59527 %U http://www.ncbi.nlm.nih.gov/pubmed/40138692 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e64746 %T Use of e-Mental Health Tools for Suicide Prevention in Clinical Practice by Mental Health Professionals in NSW, Australia: Cross-Sectional Survey %A Hood,Carol %A Hunt,Sally %A Metse,Alexandra P %A Hodder,Rebecca K %A Colyvas,Kim %A Sheather-Reid,Rachel %A Duerden,David %A Bowman,Jenny %+ , School of Psychological Sciences, The University of Newcastle, College of Engineering, Science and Environment, Callaghan, 2308, Australia, 61 2 4921 5958, Carol.Hood@uon.edu.au %K suicide prevention %K digital mental health %K mental health professionals %K peer support %K internet %K mobile apps %K clinical practice %K cross-sectional survey %K Australia %K e-mental health tools %D 2025 %7 26.3.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is a significant global health concern. In the context of increased demand for mental health services and workforce shortages, exacerbated by the COVID-19 pandemic, electronic mental health (eMH) tools represent a promising means of augmenting mental health care generally and for suicide prevention specifically. A significant research gap exists however with respect to the use and uptake of eMH tools, especially electronic mental health tools for suicide prevention (eMH-SP). Objective: This study aimed to investigate the use of eMH tools by Australian mental health professionals, both in general and with respect to suicide prevention specifically, examining changes in use since COVID-19. Further, it explored factors associated with frequent use of eMH-SP, including sociodemographic and professional characteristics. Methods: A web-based cross-sectional survey was conducted across 15 local health districts (LHDs) in New South Wales, Australia, from May 2022 to July 2023. The sample was drawn from over 10,000 mental health professionals working in government services statewide. The survey explored the use of electronic mental health tools for general mental health issues (eMH-gen) and eMH-SP, explored the changes in the use of both since COVID-19, and used multivariable logistic regression to identify factors associated with the current use of eMH-SP. Results: Among 469 participants, increased use since COVID-19 was reported by over half (247/469, 52.7%) for eMH-gen, and by approximately one-third (141/386, 36.6%) for eMH-SP. The proportion reporting frequent use increased significantly from before to after COVID-19 for both eMH-gen (243/469, 51.8% to 283/469, 60.3%; P<.001) and eMH-SP (152/386, 39.4% to 170/385, 44.2%; P=.01). Since COVID-19, the most frequently used types of eMH tools for eMH-gen and eMH-SP, respectively, were information sites (231/469, 49.3% and 130/385, 33.8%), phone/online counseling (173/469, 36.9% and 130/385, 33.8%), and apps (145/469, 30.9% and 107/385, 27.8%). Professionals more likely to use eMH-SP frequently were females (odds ratio [OR] 3.32, 95% CI 1.88-5.87; P<.001) compared with males; peer workers (OR 2.17, 95% CI 1.0-4.71; P<.001) compared with nurses; those located in regional/rural LHDs (OR 1.65, 95% CI 1.04-2.61; P=.03) compared with metropolitan LHDs; and those practicing in emergency health care settings (OR 8.31, 95% CI 2.17-31.75; P=.03) compared with inpatient settings. Conclusions: The study’s findings highlight the increasing adoption of eMH tools and delivery of remote care by mental health professionals and provide valuable new insights into sociodemographic factors associated with the use of eMH for suicide prevention specifically. Continued research on the role eMH is playing is essential for guiding policy, optimizing resources, and enhancing mental health care and suicide prevention efforts. %M 40138690 %R 10.2196/64746 %U https://www.jmir.org/2025/1/e64746 %U https://doi.org/10.2196/64746 %U http://www.ncbi.nlm.nih.gov/pubmed/40138690 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e68165 %T Effectiveness of General Practitioner Referral Versus Self-Referral Pathways to Guided Internet-Delivered Cognitive Behavioral Therapy for Depression, Panic Disorder, and Social Anxiety Disorder: Naturalistic Study %A Bjarke,Jill %A Gjestad,Rolf %A Nordgreen,Tine %K referral pathway %K GP-referral %K self-referral %K guided internet-delivered cognitive behavioral therapy %K ICBT %K routine care clinic %K depression %K panic disorder %K social anxiety disorder %K psychological therapy %K referrals %K cognitive %K behavioral therapy %K anxiety %K SAD %K treatment effectiveness %K mental health %K pathways %D 2025 %7 25.3.2025 %9 %J JMIR Ment Health %G English %X Background: Therapist-guided, internet-delivered cognitive behavioral therapy (guided ICBT) appears to be efficacious for depression, panic disorder (PD), and social anxiety disorder (SAD) in routine care clinical settings. However, implementation of guided ICBT in specialist mental health services is limited partly due to low referral rates from general practitioners (GP), which may stem from lack of awareness, limited knowledge of its effectiveness, or negative attitudes toward the treatment format. In response, self-referral systems were introduced in mental health care about a decade ago to improve access to care, yet little is known about how referral pathways may affect treatment outcomes in guided ICBT. Objective: This study aims to compare the overall treatment effectiveness of GP referral and self-referral to guided ICBT for patients with depression, PD, or SAD in a specialized routine care clinic. This study also explores if the treatment effectiveness varies between referral pathways and the respective diagnoses. Methods: This naturalistic open effectiveness study compares treatment outcomes from pretreatment to posttreatment and from pretreatment to 6-month follow-up across 2 referral pathways. All patients underwent module-based guided ICBT lasting up to 14 weeks. The modules covered psychoeducation, working with negative or automatic thoughts, exposure training, and relapse prevention. Patients received weekly therapist guidance through asynchronous messaging, with therapists spending an average of 10‐30 minutes per patient per week. Patients self-reported symptoms before, during, immediately after, and 6 months posttreatment. Level and change in symptom severity were measured across all diagnoses. Results: In total, 460 patients met the inclusion criteria, of which 305 were GP-referred (“GP” group) and 155 were self-referred (“self” group). Across the total sample, about 60% were female, and patients had a mean age of 32 years and average duration of disorder of 10 years. We found no significant differences in pretreatment symptom levels between referral pathways and across the diagnoses. Estimated effect sizes based on linear mixed modeling showed large improvements from pretreatment to posttreatment and from pretreatment to follow-up across all diagnoses, with statistically significant differences between referral pathways (GP: 0.97‐1.22 vs self: 1.34‐1.58, P<.001-.002) and for the diagnoses separately: depression (GP: 0.86‐1.26, self: 1.97‐2.07, P<.001-.02), PD (GP: 1.32‐1.60 vs self: 1.64‐2.08, P=.06-.02) and SAD (GP: 0.80‐0.99 vs self: 0.99‐1.19, P=.18-.22). Conclusions: Self-referral to guided ICBT for depression and PD appears to yield greater treatment outcomes compared to GP referrals. We found no difference in outcome between referral pathway for SAD. This study underscores the potential of self-referral pathways to enhance access to evidence-based psychological treatment, improve treatment outcomes, and promote sustained engagement in specialist mental health services. Future studies should examine the effect of the self-referral pathway when it is implemented on a larger scale. %R 10.2196/68165 %U https://mental.jmir.org/2025/1/e68165 %U https://doi.org/10.2196/68165 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e65790 %T Predicting Therapy Outcomes in Patients With Stress-Related Disorders: Protocol for a Predictive Modeling Study %A Franke Föyen,Ludwig %A Sennerstam,Victoria %A Kontio,Evelina %A Flygare,Oskar %A Boman,Magnus %A Lindsäter,Elin %+ Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Nobels väg 9, Stockholm, 171 65, Sweden, 46 8 123 395 50, ludwig.franke.foyen@ki.se %K adjustment disorder %K cognitive behavioral therapy %K exhaustion disorder %K machine learning %K predictive modeling %K psychological stress %K therapy outcome %D 2025 %7 25.3.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: While cognitive behavioral therapy has shown efficacy in treating stress-related disorders, such as adjustment disorder and exhaustion disorder, knowledge about factors contributing to treatment response is limited. Improved identification of such factors could enhance assessment procedures and treatment strategies. In addition, evaluating how traditional prediction methods and machine learning can complement each other may help bridge gaps in understanding and predicting treatment response. Objective: This study aims to (1) evaluate putative predictors of treatment response in patients with stress-related disorders using traditional prediction methods and (2) model treatment outcomes using a machine learning approach. This design combines the interpretability of traditional methods with the ability of machine learning to identify complex patterns. Methods: We will analyze data from a randomized controlled trial comparing 2 internet-delivered treatments, cognitive behavioral therapy versus an active control treatment, for patients diagnosed with adjustment disorder or exhaustion disorder (N=300). Prediction models will be based on pooled data from both treatment arms due to the limited sample size and lack of knowledge on predictors of treatment effects. Putative predictors include sociodemographic and clinical information, clinician-assessed data, self-rated symptoms, and cognitive test scores. The primary outcome of interest is responder status on the Perceived Stress Scale-10, evaluated based on the reliable change index posttreatment. For the traditional approach, univariate logistic regressions will be conducted for each predictor, followed by an ablation study for significant predictors. For the machine learning approach, 4 classifiers (logistic regression with elastic net, random forest, support vector machine, and AdaBoost) will be trained and evaluated. The dataset will be split into training (70%) and testing (30%) sets. Hyperparameter tuning will be conducted using 5-fold cross-validation with randomized search. Model performance will be assessed using balanced accuracy, precision, recall, and area under the curve. Results: All data were collected between April 2021 and September 2022. We hypothesize that key predictors will include younger age, education level, baseline symptom severity, treatment credibility, and history of sickness absence. We anticipate that the machine learning models will outperform a dummy model predicting the majority class and achieve a balanced accuracy of ≥67%, thus indicating clinical usefulness. Conclusions: This study will contribute to the limited research on predictors of treatment outcome in stress-related disorders. The findings could support the development of more personalized and effective treatments for individuals diagnosed with adjustment disorder or exhaustion disorder, potentially improving clinical practice and patient outcomes. If successful, this dual approach may encourage future studies with larger datasets and the implementation of machine learning models in clinical settings, ultimately enhancing precision in mental health care. International Registered Report Identifier (IRRID): DERR1-10.2196/65790 %M 40132191 %R 10.2196/65790 %U https://www.researchprotocols.org/2025/1/e65790 %U https://doi.org/10.2196/65790 %U http://www.ncbi.nlm.nih.gov/pubmed/40132191 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 14 %N %P e66630 %T Prevalence and Correlates of Clinically Elevated Depressive Symptoms in a Nationwide Sample of Transgender, Nonbinary, and Gender Diverse Young Adults in the United States: Cross-Sectional Survey Study %A Reisner,Sari %A Liu,Yuxin %A Tham,Regina %A Kane,Kaiden %A Cole,S Wilson %A Boskey,Elizabeth R %A Katz-Wise,Sabra L %A Keuroghlian,Alex S %A Xu,Rena %K transgender %K depression %K preventive screening %K young adult %K LGBTQ+ %K nonbinary %K gender minority %K gender diverse %K mental health %K prevalence %K cross-sectional %K survey %K questionnaire %K nationwide %K USA %K United States %K North America %D 2025 %7 24.3.2025 %9 %J Interact J Med Res %G English %X Background: In the United States, transgender, nonbinary, and gender diverse (TGD) young adults experience a higher risk of depression compared to their cisgender peers. Understanding factors associated with increased risk of depression within the TGD young adult population is important to guide clinical care as well as inform the development of interventions to reduce mental health disparities. Objective: This exploratory study investigated the prevalence and correlates of positive screening for depressive symptoms among TGD young adults to inform the design, development, and implementation of national interventions aimed at improving mental health in this at-risk population. Methods: In August 2022, a cross-sectional, nationwide online survey was conducted among TGD young adults aged 18‐25 (N=104) in the United States. Measures included sociodemographic variables, family characteristics, mental health care utilization, and the two-item Patient Health Questionnaire-2 (PHQ-2) screener for depression. Poisson regression models with robust variance estimation were fitted to estimate adjusted prevalence ratios (aPR) and 95% CI for correlates of PHQ-2 depression (score ≥3). Results: The study sample had a mean age of 22 (SD 2) years; 48/104 (46%) individuals identified as Black, Indigenous, or other People of Color, and 69/104 (66%) were nonbinary. Overall, 44 (42%) individuals screened positive for depression using PHQ-2. In a multivariable model adjusted for age, race and ethnicity, US census region, and health insurance status, factors associated with increased depression prevalence using PHQ-2 included low versus high family support (aPR 1.54, 95% CI 1.05‐2.27) and identifying with a nonChristian religion versus being unaffiliated (aPR 1.66, 95% CI 1.04‐2.63). Factors associated with reduced depression prevalence included living in a rural versus suburban area (aPR 0.48, 95% CI 0.26‐0.92) and receiving mental health therapy versus not (aPR 0.71, 95% CI 0.53‐0.97). Conclusions: The high prevalence of depressive symptoms among TGD young adults in this study sample highlights the need for comprehensive mental health evaluation and support in this population. Depression risk is increased among certain subgroups, such as those with low family support. These findings are valuable in informing the development of interventions that aim to improve mental health outcomes among TGD young people. %R 10.2196/66630 %U https://www.i-jmr.org/2025/1/e66630 %U https://doi.org/10.2196/66630 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e62870 %T Facilitators and Barriers to Digital Mental Health Interventions for Depression, Anxiety, and Stress in Adolescents and Young Adults: Scoping Review %A Zhu,Shimin %A Wang,Yongyi %A Hu,Yuxi %+ Department of Applied Social Sciences, Hong Kong Polytechnic University, 11 Yuk Choi Road, Hung Hom, Kowloon, Hong Kong SAR, 999077, China (Hong Kong), 852 27665787, jasmine.zhu@polyu.edu.hk %K digital mental health interventions %K adolescents %K young adults %K common mental disorders %K thematic analysis %K relative frequency of occurrence %D 2025 %7 24.3.2025 %9 Review %J J Med Internet Res %G English %X Background: Digital mental health interventions (DMHIs) offer unique strengths as emerging services with practical applications for adolescents and young adults (AYAs) experiencing depression, anxiety, and stress. Although promising, acceptance and participation in DMHIs vary across interventions, participants, and contexts. It is essential to delineate and synthesize the factors that promote or hinder DMHI use. Objective: This review aims to assess and synthesize the facilitators and barriers to accessing DMHIs for depression, anxiety, and stress in AYAs through a scoping review. Methods: A comprehensive search was conducted across multiple databases, including PubMed, Web of Science, PsycINFO, CNKI, OpenGrey, and APA PsycExtra, up to October 31, 2023. Articles examining facilitators and barriers to DMHIs among AYAs with disorders or symptoms of depression, anxiety, and stress were included. Data synthesis and analysis involved quality assessment, thematic analysis, and relative frequency meta-analysis. Results: A total of 27 records met the eligibility criteria, and 14 facilitators and 13 barriers were identified across the external, intervention, and individual levels. The relative frequency meta-analysis indicated that factors influencing AYAs’ use of DMHIs varied based on delivery modes. Among these factors, “quality and effect” emerged as the predominant theme—high quality and effect served as the primary facilitator, while low quality and effect acted as a barrier across both portable and nonportable devices, as well as single and multiple platforms. Conclusions: The uptake of DMHIs among AYAs is influenced by a complex interplay of facilitators and barriers, particularly those related to quality and effect. Our syntheses provide crucial guidance for intervention designers, emphasizing the importance of user-centered approaches that balance scientific rigor with engaging and adaptive features. Enhancing the alignment of DMHIs with adolescent needs can improve both adoption and real-world mental health impact. Trial Registration: PROSPERO CRD42023479880; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023479880 %R 10.2196/62870 %U https://www.jmir.org/2025/1/e62870 %U https://doi.org/10.2196/62870 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e67175 %T Co-Design of a Depression Self-Management Tool for Adolescent and Young Adult Cancer Survivors: User-Centered Design Approach %A Murphy,Karly M %A Glock,Rachel %A Victorson,David %A Reddy,Madhu %A Birken,Sarah A %A Salsman,John M %+ Department of Psychology, East Carolina University, 1000 E 5th St, Greenville, NC, 27858, United States, 1 2527374638, murphykar22@ecu.edu %K adolescent and young adult %K cancer survivorship %K depressive symptoms %K self-management %K co-design workshops %K user-centered design %K thematic analysis %K intervention tailoring %K digital mental health %K evidence-based intervention %K digital tools %K psychosocial support %D 2025 %7 24.3.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Adolescent and young adult (AYA) cancer survivors are more likely to experience elevated depressive symptoms than older survivors and healthy age-matched peers. Despite the elevated risk of depressive symptoms in AYA cancer survivors and the existence of evidence-based interventions to address depression, it is unclear whether AYA cancer survivors can access support services. Digital tools are a potential solution to overcoming barriers to AYA cancer survivors’ unmet needs for psychosocial support, but they have not been tailored to the needs and preferences of this unique population. Objective: This study engaged AYA cancer survivors and their providers in the concept generation and ideation step of the user-centered design process through online co-design workshops. The goal was to generate concepts and ideas for a digital depression self-management tool tailored to AYA cancer survivors. Methods: We conducted 5 co-design workshops—4 with AYA cancer survivors and 1 with providers who serve them. Participants were asked to provide feedback on an existing digital mindfulness course using an “I like, I wish, I wonder” framework. Then, participants were asked “How might we...” questions focused on brainstorming ideas for how the digital tool might work. Participants brainstormed responses independently and then worked as a group to categorize and expand on their ideas. Co-design workshops were autotranscribed using Webex (Cisco) software. Transcripts underwent thematic analysis with additional context provided by the products created during the workshop. Results: Eight AYA cancer survivors (aged 15-37 years) and 4 providers (2 oncologists and 2 social workers) participated in co-design workshops. We identified 6 themes: barriers to engagement, desired content, preferences for content delivery, preferences for interface, features, and aspects to avoid. Each theme had 2-7 subthemes that we relied upon when making design decisions for the prototype. Conclusions: Co-design workshops provided critical insights that informed the prototype development of a digital depression self-management tool tailored to AYA cancer survivors. Key takeaways that were integrated into prototype design include (1) using stories from other AYA cancer survivors to demonstrate concepts; (2) delivering content in brief lessons; and (3) using encouraging notifications, organizational tools, and reward systems to keep AYA cancer survivors engaged with the tool. Some of the themes identified in this study (eg, desired content and features) are consistent with known strategies for promoting user engagement and co-design work in other cancer survivors. However, this study extended previous research by identifying uniquely relevant strategies for tailoring to AYA cancer survivors, such as delivering content in brief sessions to overcome the time constraints AYA cancer survivors experience, providing opportunities for private expression, and maintaining an encouraging tone throughout the tool. These data were used to inform the prototype development of a digital depression self-management tool tailored to AYA cancer survivors. %M 40126551 %R 10.2196/67175 %U https://formative.jmir.org/2025/1/e67175 %U https://doi.org/10.2196/67175 %U http://www.ncbi.nlm.nih.gov/pubmed/40126551 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e63338 %T Measuring Adult Health and Well-Being Outcomes Associated With Nature Contact in Parks and Other Forms of Protected Areas: Protocol for a Scoping Review %A Bueddefeld,Jill %A Reining,Catherine E %A Lavallee,Loraine %A Brady,Ryan %A Groulx,Mark W %A Lemieux,Christopher James %+ Geography and Environmental Studies, Wilfrid Laurier University, 75 University Ave. West, Waterloo, ON, N2L 3C5, Canada, 1 5194968554, clemieux@wlu.ca %K nature contact %K human health %K mental health %K well-being %K parks %K protected areas %K outcomes %D 2025 %7 24.3.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Growing evidence shows various health and well-being benefits from nature contact in parks and other forms of protected areas. However, the methods to measure these outcomes lack systematic identification, critical appraisal, and synthesis. Researchers working in this area would benefit from a clear framework highlighting key considerations when selecting measurement tools, along with a summary of the measures used, and insights into the limitations of generalizing existing research findings. Objective: The objectives of this scoping review are 2-fold. First, we aim to identify the instruments used to measure mental health and well-being outcomes of adults associated with direct nature contact in parks and other forms of protected areas. Second, we aim to evaluate the psychometric properties associated with the validity of these instruments to better understand the strengths and weaknesses of current measurement approaches. Methods: Following PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines, 8 scholarly databases were searched (PubMed, Web of Science, PsycINFO [via ProQuest], ERIC [via EBSCOhost], CINAHL [via EBSCOhost], GreenFILE [via EBSCOhost], OVID, and GEOBASE) on January 4, 2023, for literature measuring the mental health and well-being outcomes associated with nature contact in protected areas. Sources were screened by reviewers based on clear inclusion or exclusion criteria relevant to the research questions: peer-reviewed English language studies measuring mental health and well-being focused on adults (aged 18+ years) with direct, in-person nature contact in parks and protected areas. Data will be extracted, analyzed, and represented according to 3 domains. This includes study details, characteristics of the measurement instruments, and their validity. Results: The results of the study and submission of a manuscript for peer review are expected in April 2025. The results of the scoping review are expected to contribute to an understanding of the diverse methods used to measure mental health and well-being related to nature contact in protected areas. Expected findings will include an organized summary of existing quantitative and qualitative instruments for measuring mental health and well-being outcomes, including appraisal of the instrument’s psychometric properties. Conclusions: To the authors’ knowledge, this will be the first scoping review undertaken on measures used to assess mental health and well-being outcomes related to nature contact in parks and protected areas context, offering a starting point from which to critically examine the validity and consistency of such methods. Findings will aid in identifying the strengths and weaknesses of current measurement approaches to mental health and well-being outcomes of nature contact and may be used to guide future research on this topic, helping researchers choose the best tool to assess outcomes. International Registered Report Identifier (IRRID): DERR1-10.2196/63338 %M 40126537 %R 10.2196/63338 %U https://www.researchprotocols.org/2025/1/e63338 %U https://doi.org/10.2196/63338 %U http://www.ncbi.nlm.nih.gov/pubmed/40126537 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e56975 %T Effectiveness of Digital Lifestyle Interventions on Depression, Anxiety, Stress, and Well-Being: Systematic Review and Meta-Analysis %A Brinsley,Jacinta %A O'Connor,Edward J %A Singh,Ben %A McKeon,Grace %A Curtis,Rachel %A Ferguson,Ty %A Gosse,Georgia %A Willems,Iris %A Marent,Pieter-Jan %A Szeto,Kimberley %A Firth,Joseph %A Maher,Carol %+ Alliance for Research in Exercise, Nutrition and Activity, University of South Australia, 108 North Terrace, Adelaide, 5000, Australia, 61 8 8302 6558, jacinta.brinsley@unisa.edu.au %K depression %K anxiety %K stress %K well-being %K mental health %K lifestyle intervention %K physical activity %K sleep %K diet %K digital health %K mobile phone %D 2025 %7 20.3.2025 %9 Review %J J Med Internet Res %G English %X Background: There is a growing body of robust evidence to show that lifestyle behaviors influence mental health outcomes. Technology offers an accessible and cost-effective implementation method for interventions, yet the study of the effectiveness of interventions to date has been specific to the mode of delivery, population, or behavior. Objective: The primary aim of this review was to comprehensively evaluate the effectiveness of digital lifestyle interventions for improving symptoms of depression, anxiety, stress, and well-being as coprimary outcomes in adults. The secondary aim was to explore the technological, methodological, intervention-specific, and population-specific characteristics that were associated with major changes in mental health outcomes. Methods: A systematic search was conducted across the MEDLINE, CINAHL, Embase, Emcare, PsycINFO, and Scopus databases to identify studies published between January 2013 and January 2023. Randomized controlled trials of lifestyle interventions (physical activity, sleep, and diet) that were delivered digitally; reported changes in symptoms of depression, anxiety, stress, or well-being in adults (aged ≥18 years); and were published in English were included. Multiple authors independently extracted data, which was evaluated using the 2011 Levels of Evidence from the Oxford Centre for Evidence-Based Medicine. Inverse-variance random-effects meta-analyses were used for data analysis. The primary outcome was the change in symptoms of depression, anxiety, stress, and well-being as measured by validated self-report of clinician-administered outcomes from pre- to postintervention. Subgroup analyses were conducted to determine whether results differed based on the target lifestyle behavior, delivery method, digital features, design features, or population characteristics. Results: Of the 14,356 studies identified, 61 (0.42%) were included. Digital lifestyle interventions had a significant small-to-medium effect on depression (standardized mean difference [SMD] −0.37; P<.001), a small effect on anxiety (SMD −0.29; P<.001) and stress (SMD −0.17; P=.04), and no effect on well-being (SMD 0.14; P=.15). Subgroup analyses generally suggested that effects were similar regardless of the delivery method or features used, the duration and frequency of the intervention, the population, or the lifestyle behavior targeted. Conclusions: Overall, these results indicate that delivering lifestyle interventions via a range of digital methods can have significant positive effects on depression (P<.001), anxiety (P<.001), and stress (P=.04) for a broad range of populations, while effects on well-being are inconclusive. Future research should explore how these interventions can be effectively implemented and embedded within health care with a concerted focus on addressing digital health equity. Trial Registration: PROSPERO CRD42023428908; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023428908 %M 40112295 %R 10.2196/56975 %U https://www.jmir.org/2025/1/e56975 %U https://doi.org/10.2196/56975 %U http://www.ncbi.nlm.nih.gov/pubmed/40112295 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e64459 %T A Brief Cognitive Behavioral Therapy–Based Digital Intervention for Reducing Hazardous Alcohol Use in South Korea: Development and Prospective Pilot Study %A Kwon,Manjae %A Moon,Daa Un %A Kang,Minjae %A Jung,Young-Chul %K alcohol %K hazardous alcohol use %K digital intervention %K cognitive behavioral therapy %K mobile apps %K prevention %K therapy-based %K cognitive behavioral %K alcohol use %K South Korea %K prospective pilot study %K pilot study %K alcohol consumption %K death %K disability %K chronic medical condition %K digital health interventions %K traditional treatment methods %K Korean %K hazardous drinking %K acceptability %K feasibility %K smartphone app %K alcohol use disorder %K psychiatric symptoms %K mobile phone %D 2025 %7 19.3.2025 %9 %J JMIR Form Res %G English %X Background: Alcohol consumption is a leading cause of death and disability worldwide, associated with numerous acute and chronic medical conditions. Digital health interventions offer a promising solution to overcome barriers associated with traditional treatment methods, providing accessible, scalable, and cost-effective means to support individuals in reducing hazardous drinking. Objective: This pilot study aims to evaluate the feasibility, acceptability, and preliminary efficacy of the Sober smartphone app in individuals with hazardous alcohol use. Methods: This single-group, pre- and postpilot study included 20 participants with risky alcohol use, identified using the Alcohol Use Disorder Identification Test. Participants used the Sober app for 4 weeks, incorporating cognitive behavioral therapy–based interventions. Feasibility was assessed by study and session completion rates, acceptability by participant satisfaction and perceived usefulness, and preliminary efficacy by changes in alcohol consumption and psychiatric symptoms. Semistructured interviews with participants and clinicians provided qualitative perspectives on the app’s usability, efficacy, and areas for improvement. Results: Of the 20 enrolled participants, 17 completed the study. The app demonstrated high feasibility with an 85% (17/20) study completion rate, and 59% (10/17) completed all cognitive behavioral therapy sessions. Participants reported positive acceptability, with average satisfaction and usefulness ratings of 3.8 and 3.7 of 5, respectively. Preliminary efficacy outcomes showed significant improvements: abstinence days increased from 67% to 85% (z=−3.17; P=.002), heavy drinking episodes decreased from 3.3 to 1.9 (t16=−2.97; P=.003), and total alcohol consumption reduced from 456.8 to 195.9 mL (t16=3.16; P=.002). Alcohol Use Disorder Identification Test scores dropped from 17.5 to 10.7 (t16=4.51; P<.001). Additionally, depression (Patient Health Questionnaire-9) scores decreased from 5.8 to 4.4 (t16=2.91; P=.01), and anxiety (Generalized Anxiety Disorder-7) scores from 3.4 to 2.1 (z=−2.80; P=.005). No adverse events were reported. Qualitative analysis found participants valued daily logging but noted usability issues, while clinicians called for tailored goals, enhanced communication features, and age-specific content. Conclusions: The mobile app Sober shows promise as an effective tool for reducing hazardous alcohol consumption and improving related psychiatric symptoms. The study demonstrated high feasibility and positive acceptability, with significant preliminary efficacy in reducing alcohol use. Qualitative findings provided actionable evidence for refining the app’s usability and clinical integration. Further research through a randomized controlled trial is warranted to confirm these findings and optimize the app’s features and content. Trial Registration: ClinicalTrials.gov NCT06502756; https://clinicaltrials.gov/study/NCT06502756 %R 10.2196/64459 %U https://formative.jmir.org/2024/1/e64459 %U https://doi.org/10.2196/64459 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e66321 %T Online Safety When Considering Self-Harm and Suicide-Related Content: Qualitative Focus Group Study With Young People, Policy Makers, and Social Media Industry Professionals %A La Sala,Louise %A Sabo,Amanda %A Michail,Maria %A Thorn,Pinar %A Lamblin,Michelle %A Browne,Vivienne %A Robinson,Jo %+ Orygen, 35 Poplar Road, Parkville, 3052, Australia, 61 3 9966 9512, louise.lasala@orygen.org.au %K young people %K suicide prevention %K self-harm %K social media %K online safety %K policy %D 2025 %7 10.3.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Young people are disproportionately impacted by self-harm and suicide, and concerns exist regarding the role of social media and exposure to unsafe content. Governments and social media companies have taken various approaches to address online safety for young people when it comes to self-harm and suicide; however, little is known about whether key stakeholders believe current approaches are fit-for-purpose. Objective: From the perspective of young people, policy makers and professionals who work within the social media industry, this study aimed to explore (1) the perceived challenges and views regarding young people communicating on social media about self-harm and suicide, and (2) what more social media companies and governments could be doing to address these issues and keep young people safe online. Methods: This qualitative study involved 6 focus groups with Australian young people aged 12-25 years (n=7), Australian policy makers (n=14), and professionals from the global social media industry (n=7). Framework analysis was used to summarize and chart the data for each stakeholder group. Results: In total, 3 primary themes and six subthemes are presented: (1) challenges and concerns, including the reasons for, and challenges related to, online communication about self-harm and suicide as well as reasoning with a deterministic narrative of harm; (2) roles and responsibilities regarding online safety and suicide prevention, including who is responsible and where responsibility starts and stops, as well as the need for better collaborations; and (3) future approaches and potential solutions, acknowledging the limitations of current safety tools and policies, and calling for innovation and new ideas. Conclusions: Our findings highlight tensions surrounding roles and responsibilities in ensuring youth online safety and offer perspectives on how social media companies can support young people discussing self-harm and suicide online. They also support the importance of cross-industry collaborations and consideration of social media in future suicide prevention solutions intended to support young people. %M 40063940 %R 10.2196/66321 %U https://www.jmir.org/2025/1/e66321 %U https://doi.org/10.2196/66321 %U http://www.ncbi.nlm.nih.gov/pubmed/40063940 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e60435 %T Generative AI–Enabled Therapy Support Tool for Improved Clinical Outcomes and Patient Engagement in Group Therapy: Real-World Observational Study %A Habicht,Johanna %A Dina,Larisa-Maria %A McFadyen,Jessica %A Stylianou,Mona %A Harper,Ross %A Hauser,Tobias U %A Rollwage,Max %+ Limbic Ltd, Kemp House, 128 City Road, London, EC1V 2NX, United Kingdom, 44 020 3818 3240, max@limbic.ai %K artificial intelligence %K National Health Service %K NHS Talking Therapies %K mental health %K therapy support tool %K cognitive behavioral therapy %K CBT %K chatbot %K conversational agent %K clinical %K patient engagement %K therapist %K treatment %K medication %K depression %K anxiety disorder %K exercise %K observational study %K control group %K patient adherence %D 2025 %7 10.3.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive behavioral therapy (CBT) is a highly effective treatment for depression and anxiety disorders. Nonetheless, a substantial proportion of patients do not respond to treatment. The lack of engagement with therapeutic materials and exercises between sessions, a necessary component of CBT, is a key determinant of unsuccessful treatment. Objective: The objective of this study was to test whether the deployment of a generative artificial intelligence (AI)–enabled therapy support tool, which helps patients to engage with therapeutic materials and exercises in between sessions, leads to improved treatment success and patient treatment adherence compared with the standard delivery of CBT exercises through static workbooks. Methods: We conducted a real-world observational study of 244 patients receiving group-based CBT in 5 of the United Kingdom’s National Health Service Talking Therapies services, comparing 150 (61.5%) patients who used the AI-enabled therapy support tool to 94 (38.5%) patients who used the standard delivery of CBT exercises. The groups were equivalent with respect to the content of the CBT materials and the human-led therapy sessions; however, the intervention group received support from the AI-enabled therapy support tool in conducting CBT exercises. Results: Patients using the AI-enabled therapy support tool exhibited greater attendance at therapy sessions and fewer dropouts from treatment. Furthermore, these patients demonstrated higher reliable improvement, recovery, and reliable recovery rates when compared to the control group, which was related to the degree of use of the AI-enabled therapy support tool. Moreover, we found that engagement with AI-supported CBT interventions, relative to psychoeducational materials, predicted better treatment adherence and treatment success, highlighting the role of personalization in the intervention’s effectiveness. To investigate the mechanisms of these effects further, we conducted a separate qualitative experiment in a nonclinical sample of users (n=113). Results indicated that users perceived the AI-enabled therapy support tool as most useful for discussing their problems to gain awareness and clarity of their situation as well as learning how to apply coping skills and CBT techniques in their daily lives. Conclusions: Our results show that an AI-enabled, personalized therapy support tool in combination with human-led group therapy is a promising avenue to improve the efficacy of and adherence to mental health care. %M 40063074 %R 10.2196/60435 %U https://www.jmir.org/2025/1/e60435 %U https://doi.org/10.2196/60435 %U http://www.ncbi.nlm.nih.gov/pubmed/40063074 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e50326 %T Effects and Acceptability of a 1-Week Home-Based Virtual Reality Training for Supporting the Management of Stress and Anxiety: Randomized Pilot Trial %A Pallavicini,Federica %A Orena,Eleonora %A Arnoldi,Lisa %A Achille,Federica %A Stefanini,Stefano %A Cassa,Maddalena %A Pepe,Alessandro %A Veronese,Guido %A Bernardelli,Luca %A Sforza,Francesca %A Fascendini,Sara %A Defanti,Carlo Alberto %A Gemma,Marco %A Clerici,Massimo %A Riva,Giuseppe %A Mantovani,Fabrizia %+ Department of Human Sciences for Education “Riccardo Massa”, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, 20126, Milan, 20100, Italy, 39 02 64484944, federica.pallavicini@unimib.it %K virtual reality %K relaxation %K anxiety %K depression %K emotions %K health care professionals %K health care workers %K hospital %K randomized clinicial trial %K hospitals %D 2025 %7 6.3.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) is helpful for the management of stress and anxiety. However, current interventions have limitations related to location (ie, therapist’s office or hospitals) and content (ie, virtual experiences only for relaxation). Objective: This randomized pilot trial aims to investigate the efficacy and acceptability of a brief remote VR-based training for supporting stress and anxiety management in a sample of Italian health care workers. Methods: A total of 29 doctors and nurses (n=21; 72% female; mean age 35.6, SD 10.3 years) were recruited and randomized to a VR intervention group or a control group in a passive control condition. Participants assigned to the VR intervention group received remote VR-based training consisting of 3 sessions at home delivered in 1 week using the VR psychoeducational experience “MIND-VR” and the 360° relaxing video “The Secret Garden.” The primary outcome measures were stress, anxiety, depression, and the knowledge of stress and anxiety assessed at baseline and posttreatment. We also evaluated the immediate effect of the remote VR-based training sessions on the perceived state of anxiety and negative and positive emotions. The secondary outcome measure was the usability at home of the VR system and content. Results: The VR intervention significantly reduced stress levels as assessed by the Perceived Stress Scale (6.46, 95% CI 2.77 to 10.5; P=.046) and increased the knowledge of stress and anxiety, as evaluated by the ad hoc questionnaire adopted (–2.09, 95% CI –3.86 to –0.529; P=.046). However, the home-based VR training did not yield similar reductions in stress, anxiety, and depression levels as assessed by the Depression, Anxiety, and Stress Scale-21 items or in trait anxiety as evaluated through the State-Trait Anxiety Inventory Form Y-1. After the home training sessions with VR, there was a significant decrease in anxiety, anger, and sadness and an increase in happiness levels. Analyses of the questionnaires on usability indicated that the health care workers found using the VR system at home easy and without adverse effects related to cybersickness. Of 33 participants, 29 (88%) adhered to the protocol. Conclusions: The results of this randomized pilot study suggest that a week-long home VR intervention, created with content created specifically for this purpose and available free of charge, can help individuals manage stress and anxiety, encouraging further research investigating the potential of remote VR interventions to support mental health. Trial Registration: ClinicalTrials.gov NCT04611399; https://tinyurl.com/scxunprd %M 40053782 %R 10.2196/50326 %U https://games.jmir.org/2025/1/e50326 %U https://doi.org/10.2196/50326 %U http://www.ncbi.nlm.nih.gov/pubmed/40053782 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 14 %N %P e63959 %T Therapeutic Guidelines for the Self-Management of Major Depressive Disorder: Scoping Review %A de Campos Tibúrcio,Priscila %A Maria Marcheti,Priscila %A Miori Pascon,Daniela %A Montebello Junior,Marco Antônio %A Alzete de Lima,Maria %A Fernandes,Carla Sílvia %A Samarina Vilaça de Brito Santos,Célia %A Socorro de Sousa Nóbrega,Maria do Perpétuo %+ School of Nursing, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 419, São Paulo, 05403-000, Brazil, 55 19997889041, priscila.campostib13@gmail.com %K major depressive disorder %K nursing %K revision %K self-management %K symptoms %K PRISMA %D 2025 %7 6.3.2025 %9 Review %J Interact J Med Res %G English %X Background: Major depressive disorder contributes to the global burden of mental illness. Therapeutic guidelines promote treatment self-management and support caregivers and family members in this process. Objective: We aimed to identify therapeutic guidelines for the symptoms of major depressive disorder. Methods: This scoping review followed the assumptions established by the Joanna Briggs Institute and the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) protocol, carried out in 12 databases (LILACS, PubMed, SciELO, Scopus, Web of Science, b-on, BDENF, AgeLine, Cochrane, BVS, IBECS, and CINAHL) and 5 secondary gray literature sources (Google Scholar, Global ETD Search, EBSCO Open Dissertations, CAPES Catalog of Theses and Dissertations, and the Digital Library of Theses and Dissertations of the University of Sao Paulo). The eligibility criteria were based on the population, concept, and context framework: people diagnosed with major depressive disorder aged >18 years (population), therapeutic guidelines for self-management of major depressive disorder symptoms (concept), and symptoms of major depressive disorder (context). Data collection was carried out from March to July 2022 and updated in June 2024. The included studies were experimental, quasi-experimental, analytical observational, descriptive observational, qualitative, or quantitative studies; systematic reviews and meta-analyses; and scoping and literature reviews published in full without time restrictions in English, Spanish, or Portuguese. All the information, as well as the studies captured, was stored in a Microsoft Excel spreadsheet using Rayyan and the JBI Manual for Evidence Synthesis. The titles, abstracts, and full texts were carefully read and classified, extracting the results. After review by 2 independent researchers, 62 studies were selected. The results are presented descriptively, including characterization of the studies and mapping and categorization of groups and subgroups of therapeutic guidelines for self-management of major depressive disorder. Results: In total, 62 studies published between 2011 and 2023 were included, where 44 (71%) came from indexed data sources and 18 (29%) were gray literature indexed on Google Scholar (13/62, 21%), doctoral theses (3/62, 5%), and master’s dissertations (2/62, 3%). Among the therapeutic guidelines identified, mapped, and categorized, 7 major groups were identified for self-management: psychotherapy (32/62, 52%), adoption of healthy habits (25/62, 40%), integrative and complementary practices (17/62, 27%), relaxation techniques (9/62, 14%), consultation with a health professional (14/62, 22%), pharmacological therapy (9/62, 14%), and leisure or pleasurable activities (4/62, 6%). Conclusions: It was possible to identify therapeutic guidelines to promote self-management of major depressive disorder in the adult population. Therapeutic guidance is an important resource for patients, their families, and the community, making patients the protagonists of their own health. For health professionals, therapeutic guidelines become tools that help develop skills and competencies for care among patients, thus ensuring their ability to self-manage major depressive disorder. %M 40053745 %R 10.2196/63959 %U https://www.i-jmr.org/2025/1/e63959 %U https://doi.org/10.2196/63959 %U http://www.ncbi.nlm.nih.gov/pubmed/40053745 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 13 %N %P e59660 %T Applying AI in the Context of the Association Between Device-Based Assessment of Physical Activity and Mental Health: Systematic Review %A Woll,Simon %A Birkenmaier,Dennis %A Biri,Gergely %A Nissen,Rebecca %A Lutz,Luisa %A Schroth,Marc %A Ebner-Priemer,Ulrich W %A Giurgiu,Marco %+ Mental mHealth Lab, Institute of Sports and Sports Science, Karlsruhe Institute of Technology, Hertzstrasse 16, Karlsruhe, 76187, Germany, 49 721 608 ext 41974, simon.woll@kit.edu %K machine learning %K mental health %K wearables %K physical behavior %K artificial intelligence %K mobile phone %K smartphone %D 2025 %7 6.3.2025 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Wearable technology is used by consumers worldwide for continuous activity monitoring in daily life but more recently also for classifying or predicting mental health parameters like stress or depression levels. Previous studies identified, based on traditional approaches, that physical activity is a relevant factor in the prevention or management of mental health. However, upcoming artificial intelligence methods have not yet been fully established in the research field of physical activity and mental health. Objective: This systematic review aims to provide a comprehensive overview of studies that integrated passive monitoring of physical activity data measured via wearable technology in machine learning algorithms for the detection, prediction, or classification of mental health states and traits. Methods: We conducted a review of studies processing wearable data to gain insights into mental health parameters. Eligibility criteria were (1) the study uses wearables or smartphones to acquire physical behavior and optionally other sensor measurement data, (2) the study must use machine learning to process the acquired data, and (3) the study had to be published in a peer-reviewed English language journal. Studies were identified via a systematic search in 5 electronic databases. Results: Of 11,057 unique search results, 49 published papers between 2016 and 2023 were included. Most studies examined the connection between wearable sensor data and stress (n=15, 31%) or depression (n=14, 29%). In total, 71% (n=35) of the studies had less than 100 participants, and 47% (n=23) had less than 14 days of data recording. More than half of the studies (n=27, 55%) used step count as movement measurement, and 44% (n=21) used raw accelerometer values. The quality of the studies was assessed, scoring between 0 and 18 points in 9 categories (maximum 2 points per category). On average, studies were rated 6.47 (SD 3.1) points. Conclusions: The use of wearable technology for the detection, prediction, or classification of mental health states and traits is promising and offers a variety of applications across different settings and target groups. However, based on the current state of literature, the application of artificial intelligence cannot realize its full potential mostly due to a lack of methodological shortcomings and data availability. Future research endeavors may focus on the following suggestions to improve the quality of new applications in this context: first, by using raw data instead of already preprocessed data. Second, by using only relevant data based on empirical evidence. In particular, crafting optimal feature sets rather than using many individual detached features and consultation with in-field professionals. Third, by validating and replicating the existing approaches (ie, applying the model to unseen data). Fourth, depending on the research aim (ie, generalization vs personalization) maximizing the sample size or the duration over which data are collected. %M 40053765 %R 10.2196/59660 %U https://mhealth.jmir.org/2025/1/e59660 %U https://doi.org/10.2196/59660 %U http://www.ncbi.nlm.nih.gov/pubmed/40053765 %0 Journal Article %@ 2564-1891 %I JMIR Publications %V 5 %N %P e65632 %T Using Natural Language Processing Methods to Build the Hypersexuality in Bipolar Reddit Corpus: Infodemiology Study of Reddit %A Harvey,Daisy %A Rayson,Paul %A Lobban,Fiona %A Palmier-Claus,Jasper %A Dolman,Clare %A Chataigné,Anne %A Jones,Steven %+ Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Bailrigg, Lancaster, LA1 4YW, United Kingdom, 44 1524 65201, d.harvey4@lancaster.ac.uk %K bipolar %K hypersexuality %K natural language processing %K Linguistic Inquiry and Word Count %K LIWC %K BERTopic %K topic modeling %K computational linguistics %D 2025 %7 6.3.2025 %9 Original Paper %J JMIR Infodemiology %G English %X Background: Bipolar is a severe mental health condition affecting at least 2% of the global population, with clinical observations suggesting that individuals experiencing elevated mood states, such as mania or hypomania, may have an increased propensity for engaging in risk-taking behaviors, including hypersexuality. Hypersexuality has historically been stigmatized in society and in health care provision, which makes it more difficult for service users to talk about their behaviors. There is a need for greater understanding of hypersexuality to develop better evidence-based treatment, support, and training for health professionals. Objective: This study aimed to develop and assess effective methodologies for identifying posts on Reddit related to hypersexuality posted by people with a self-reported bipolar diagnosis. Using natural language processing techniques, this research presents a specialized dataset, the Talking About Bipolar on Reddit Corpus (TABoRC). We used various computational tools to filter and categorize posts that mentioned hypersexuality, forming the Hypersexuality in Bipolar Reddit Corpus (HiB-RC). This paper introduces a novel methodology for detecting hypersexuality-related conversations on Reddit and offers both methodological insights and preliminary findings, laying the groundwork for further research in this emerging field. Methods: A toolbox of computational linguistic methods was used to create the corpora and infer demographic variables for the Redditors in the dataset. The key psychological domains in the corpus were measured using Linguistic Inquiry and Word Count, and a topic model was built using BERTopic to identify salient language clusters. This paper also discusses ethical considerations associated with this type of analysis. Results: The TABoRC is a corpus of 6,679,485 posts from 5177 Redditors, and the HiB-RC is a corpus totaling 2146 posts from 816 Redditors. The results demonstrate that, between 2012 and 2021, there was a 91.65% average yearly increase in posts in the HiB-RC (SD 119.6%) compared to 48.14% in the TABoRC (SD 51.2%) and an 86.97% average yearly increase in users (SD 93.8%) compared to 27.17% in the TABoRC (SD 38.7%). These statistics suggest that there was an increase in posting activity related to hypersexuality that exceeded the increase in general Reddit use over the same period. Several key psychological domains were identified as significant in the HiB-RC (P<.001), including more negative tone, more discussion of sex, and less discussion of wellness compared to the TABoRC. Finally, BERTopic was used to identify 9 key topics from the dataset. Conclusions: Hypersexuality is an important symptom that is discussed by people with bipolar on Reddit and needs to be systematically recognized as a symptom of this illness. This research demonstrates the utility of a computational linguistic framework and offers a high-level overview of hypersexuality in bipolar, providing empirical evidence that paves the way for a deeper understanding of hypersexuality from a lived experience perspective. %M 40053804 %R 10.2196/65632 %U https://infodemiology.jmir.org/2025/1/e65632 %U https://doi.org/10.2196/65632 %U http://www.ncbi.nlm.nih.gov/pubmed/40053804 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 8 %N %P e64352 %T Building Consensus on the Relevant Criteria to Screen for Depressive Symptoms Among Near-Centenarians and Centenarians: Modified e-Delphi Study %A Gomes da Rocha,Carla %A von Gunten,Armin %A Vandel,Pierre %A Jopp,Daniela S %A Ribeiro,Olga %A Verloo,Henk %+ School of Health Sciences, University of Applied Sciences and Arts Western Switzerland (HES-SO), Chemin de l'Agasse 5, Sion, 1950, Switzerland, 41 58 606 84 73, carla.gomesdarocha@hevs.ch %K centenarians %K near-centenarians %K depressive symptoms %K depression diagnosis %K screening %K assessment %K e-Delphi technique %K web-based survey %D 2025 %7 5.3.2025 %9 Original Paper %J JMIR Aging %G English %X Background: The number of centenarians worldwide is expected to increase dramatically, reaching 3.4 million by 2050 and >25 million by 2100. Despite these projections, depression remains a prevalent yet underdiagnosed and undertreated condition among this population that carries significant health risks. Objective: This study aimed to identify and achieve consensus on the most representative signs and symptoms of depression in near-centenarians and centenarians (aged ≥95 years) through an e-Delphi study with an international and interdisciplinary panel of experts. Ultimately, the outcomes of this study might help create a screening instrument that is specifically designed for this unique population. Methods: A modified e-Delphi study was carried out to achieve expert consensus on depressive symptoms in near-centenarians and centenarians. A panel of 28 international experts was recruited. Consensus was defined as 70% agreement on the relevance of each item. Data were collected through a web-based questionnaire over 3 rounds. Experts rated 104 items that were divided into 24 dimensions and 80 criteria to identify the most representative signs and symptoms of depression in this age group. Results: The panel consisted of experts from various countries, including physicians with experience in old age psychiatry or geriatrics as well as nurses and psychologists. The response rate remained consistent over the rounds (20/28, 71% to 21/28, 75%). In total, 4 new dimensions and 8 new criteria were proposed by the experts, and consensus was reached on 86% (24/28) of the dimensions and 80% (70/88) of the criteria. The most consensual potentially relevant dimensions were lack of hope (21/21, 100%), loss of interest (27/28, 96%), lack of reactivity to pleasant events (27/28, 96%), depressed mood (26/28, 93%), and previous episodes of depression or diagnosed depression (19/21, 90%). In addition, the most consensual potentially relevant criteria were despondency, gloom, and despair (25/25, 100%); depressed (27/27, 100%); lack of reactivity to pleasant events or circumstances (28/28, 100%); suicidal ideation (28/28, 100%); suicide attempt(s) (28/28, 100%); ruminations (27/28, 96%); recurrent thoughts of death or suicide (27/28, 96%); feelings of worthlessness (25/26, 96%); critical life events (20/21, 95%); anhedonia (20/21, 95%); loss of interest in activities (26/28, 93%); loss of pleasure in activities (26/28, 93%); and sadness (24/26, 92%). Moreover, when assessing depression in very old age, the duration, number, frequency, and severity of signs and symptoms should also be considered, as evidenced by the high expert agreement. Conclusions: The classification of most elements as relevant highlights the importance of a multidimensional approach for optimal depression screening among individuals of very old age. This study offers a first step toward improving depression assessment in near-centenarians and centenarians. The development of a more adapted screening tool could improve early detection and intervention, enhancing the quality of mental health care for this population. %M 40053803 %R 10.2196/64352 %U https://aging.jmir.org/2025/1/e64352 %U https://doi.org/10.2196/64352 %U http://www.ncbi.nlm.nih.gov/pubmed/40053803 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e63279 %T Testing a Dashboard Intervention for Tracking Digital Social Media Activity in Clinical Care of Individuals With Mood and Anxiety Disorders: Protocol and Design Considerations for a Pragmatic Randomized Trial %A Nesbitt,Brittany %A Virgadamo,Danielle %A Aguirre,Carlos %A DeCamp,Matthew %A Dredze,Mark %A Harrigian,Keith %A Lhaksampa,Tenzin %A Meuchel,Jennifer M %A Meyer,Aja M %A Walker,Alex %A Zirikly,Ayah %A Chisolm,Margaret S %A Zandi,Peter P %A Miller,Leslie %+ Johns Hopkins University School of Medicine, 5500 East Lombard St, Baltimore, MD, 21224, United States, 1 410 550 0091, lmille84@jhmi.edu %K digital mental health %K mental health %K dashboards %K psychiatry %K measurement-based care %K electronic communication %K social media %K depression %K anxiety %K personal health information %D 2025 %7 5.3.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mood and anxiety disorders are prevalent mental health diagnoses. Numerous studies have shown that measurement-based care, which is used to monitor patient symptoms, functioning, and treatment progress and help guide clinical decisions and collaboration on treatment goals, can improve outcomes in patients with these disorders. Including digital information regarding patients’ electronic communications and social media activity is an innovative approach to augmenting measurement-based care. Recent data indicate interest and willingness from both mental health clinicians and patients to share this type of digital information in treatment sessions. However, the clinical benefit of systematically doing this has been minimally evaluated. Objective: This study aims to develop an electronic dashboard for tracking patients’ digital social activity and a protocol for a pragmatic randomized trial to test the feasibility and efficacy of using the dashboard in real-world clinical care of patients with depression or anxiety disorders. Methods: We developed a personalized electronic dashboard that tracks patients’ electronic communications and social media activity, visualizes data on these interactions through key graphics and figures, and provides a tool that can be readily integrated into routine clinical care for use by clinicians and patients during treatment sessions. We then designed a randomized trial to evaluate the feasibility and effectiveness of using the electronic dashboard in real-world care compared to treatment as usual. The trial included patients aged ≥12 years with a mood or anxiety disorder who were receiving treatment in outpatient psychiatry clinics in the Johns Hopkins Health System and the Kennedy Krieger Institute. The primary outcome includes changes in patient-rated depression symptoms. Secondary outcomes include changes in patient-rated anxiety symptoms and overall functioning. Exploratory analyses examine the impact of the intervention on measures of therapeutic alliance and the detection of clinically actionable targets. Results: We successfully developed an electronic dashboard for tracking patients’ electronic communications and social media activity, and we implemented a protocol for evaluating the feasibility and efficacy of using the dashboard in routine care for mood or anxiety disorders. The protocol was approved by the Johns Hopkins University School of Medicine Institutional Review Board. In this study, we report the technological, ethical, and pragmatic considerations in developing the dashboard and testing it in a real-world setting. Conclusions: The integration of an electronic dashboard to monitor digital social activity in mental health care treatment is novel. This study examines the feasibility and effectiveness of the dashboard and the challenges in implementing this protocol. The lessons learned from developing and implementing the study will inform ongoing discussions about the value of gathering collateral information on patients’ digital social activity and how to do so in a way that is acceptable and clinically effective. Trial Registration: ClinicalTrials.gov NCT03925038; https://clinicaltrials.gov/study/NCT03925038 International Registered Report Identifier (IRRID): DERR1-10.2196/63279 %M 40053788 %R 10.2196/63279 %U https://www.researchprotocols.org/2025/1/e63279 %U https://doi.org/10.2196/63279 %U http://www.ncbi.nlm.nih.gov/pubmed/40053788 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e67891 %T Competency of Large Language Models in Evaluating Appropriate Responses to Suicidal Ideation: Comparative Study %A McBain,Ryan K %A Cantor,Jonathan H %A Zhang,Li Ang %A Baker,Olesya %A Zhang,Fang %A Halbisen,Alyssa %A Kofner,Aaron %A Breslau,Joshua %A Stein,Bradley %A Mehrotra,Ateev %A Yu,Hao %+ RAND, 1200 S Hayes St, Arlington, VA, United States, 1 5088433901, rmcbain@rand.org %K depression %K suicide %K mental health %K large language model %K chatbot %K digital health %K Suicidal Ideation Response Inventory %K ChatGPT %K suicidologist %K artificial intelligence %D 2025 %7 5.3.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: With suicide rates in the United States at an all-time high, individuals experiencing suicidal ideation are increasingly turning to large language models (LLMs) for guidance and support. Objective: The objective of this study was to assess the competency of 3 widely used LLMs to distinguish appropriate versus inappropriate responses when engaging individuals who exhibit suicidal ideation. Methods: This observational, cross-sectional study evaluated responses to the revised Suicidal Ideation Response Inventory (SIRI-2) generated by ChatGPT-4o, Claude 3.5 Sonnet, and Gemini 1.5 Pro. Data collection and analyses were conducted in July 2024. A common training module for mental health professionals, SIRI-2 provides 24 hypothetical scenarios in which a patient exhibits depressive symptoms and suicidal ideation, followed by two clinician responses. Clinician responses were scored from –3 (highly inappropriate) to +3 (highly appropriate). All 3 LLMs were provided with a standardized set of instructions to rate clinician responses. We compared LLM responses to those of expert suicidologists, conducting linear regression analyses and converting LLM responses to z scores to identify outliers (z score>1.96 or <–1.96; P<0.05). Furthermore, we compared final SIRI-2 scores to those produced by health professionals in prior studies. Results: All 3 LLMs rated responses as more appropriate than ratings provided by expert suicidologists. The item-level mean difference was 0.86 for ChatGPT (95% CI 0.61-1.12; P<.001), 0.61 for Claude (95% CI 0.41-0.81; P<.001), and 0.73 for Gemini (95% CI 0.35-1.11; P<.001). In terms of z scores, 19% (9 of 48) of ChatGPT responses were outliers when compared to expert suicidologists. Similarly, 11% (5 of 48) of Claude responses were outliers compared to expert suicidologists. Additionally, 36% (17 of 48) of Gemini responses were outliers compared to expert suicidologists. ChatGPT produced a final SIRI-2 score of 45.7, roughly equivalent to master’s level counselors in prior studies. Claude produced an SIRI-2 score of 36.7, exceeding prior performance of mental health professionals after suicide intervention skills training. Gemini produced a final SIRI-2 score of 54.5, equivalent to untrained K-12 school staff. Conclusions: Current versions of 3 major LLMs demonstrated an upward bias in their evaluations of appropriate responses to suicidal ideation; however, 2 of the 3 models performed equivalent to or exceeded the performance of mental health professionals. %M 40053817 %R 10.2196/67891 %U https://www.jmir.org/2025/1/e67891 %U https://doi.org/10.2196/67891 %U http://www.ncbi.nlm.nih.gov/pubmed/40053817 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e67386 %T Internet-Based Cognitive Behavioral Therapy for Preventing Postpartum Depressive Symptoms Among Pregnant Individuals With Depression: Multicenter Randomized Controlled Trial in China %A Duan,Chen-Chi %A Zhang,Chen %A Xu,Hua-Lin %A Tao,Jing %A Yu,Jia-Le %A Zhang,Dan %A Wu,Shan %A Zeng,Xiu %A Zeng,Wan-Ting %A Zhang,Zhi-Yin %A Dennis,Cindy-Lee %A Liu,Han %A Wu,Jia-Ying %A Mol,Ben Willem J %A Huang,He-Feng %A Wu,Yan-Ting %+ Obstetrics and Gynecology Hospital, Institute of Reproduction and Development, Fudan University, No.419, Fangxie Rd, Shanghai, 200000, China, 86 17321218018, yanting_wu@163.com %K antenatal depression %K postpartum depression %K internet-based cognitive behavioral therapy %K randomized controlled trial %D 2025 %7 4.3.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Women are particularly vulnerable to depression during pregnancy, which is one of the strongest risk factors for developing postpartum depression (PPD). Addressing antenatal depressive symptoms in these women is crucial for preventing PPD. However, little is known about the effectiveness of internet-based cognitive behavioral therapy (ICBT) in preventing PPD in this high-risk group. Objective: This study aims to evaluate the short- and long-term effects of ICBT in preventing PPD among women with antenatal depressive symptoms. Methods: Participants were screened for antenatal depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS) and randomly allocated (1:1) to either the ICBT group (receiving weekly online modules starting antenatally and continuing into early postpartum) or the control group (observed without treatment). Follow-up assessments were conducted up to 12 months postpartum, and data were analyzed using generalized estimating equations. The primary outcome was the prevalence of depressive symptoms at 6 weeks postpartum. A subgroup analysis based on the severity of antenatal depressive symptoms was also performed. The secondary outcomes included the long-term effects of ICBT on maternal depression, as well as its impact on anxiety, sleep quality, social support, parenting stress, co-parenting relationships, and infant development. Results: Between August 2020 and September 2021, 300 pregnant individuals were recruited from 5 centers across China. No significant differences were observed in depressive symptoms at 6 weeks postpartum (P=.18) or at any longer-term follow-up time points (P=.18). However, a post hoc subgroup analysis showed that participants with antenatal EPDS scores of 10-12 in the ICBT group had a lower risk of developing depression during the first year postpartum (odds ratio 0.534, 95% CI 0.313-0.912; P=.02), but this was not observed for participants with more severe depression. Additionally, this subgroup demonstrated higher levels of co-parenting relationships (P=.02). Conclusions: Among individuals with antenatal depression, ICBT did not prevent the development of PPD. However, ICBT may be a preferable option for those with mild to moderate antenatal depressive symptoms. Future research is needed to explore modifications to ICBT to address more severe depressive symptoms. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000033433; https://www.chictr.org.cn/showproj.html?proj=54482 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-022-06728-5 %M 40053801 %R 10.2196/67386 %U https://www.jmir.org/2025/1/e67386 %U https://doi.org/10.2196/67386 %U http://www.ncbi.nlm.nih.gov/pubmed/40053801 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 8 %N %P e67715 %T Development and Feasibility Study of HOPE Model for Prediction of Depression Among Older Adults Using Wi-Fi-based Motion Sensor Data: Machine Learning Study %A Nejadshamsi,Shayan %A Karami,Vania %A Ghourchian,Negar %A Armanfard,Narges %A Bergman,Howard %A Grad,Roland %A Wilchesky,Machelle %A Khanassov,Vladimir %A Vedel,Isabelle %A Abbasgholizadeh Rahimi,Samira %+ Family Medicine Department, Faculty of Medicine and Health Sciences, McGill University, 5858 Côte des Negies, Montreal, QC, H3S 1Z1, Canada, 1 5143987375, samira.rahimi@mcgill.ca %K depression %K classification %K machine learning %K artificial intelligence %K older adults %D 2025 %7 3.3.2025 %9 Original Paper %J JMIR Aging %G English %X Background: Depression, characterized by persistent sadness and loss of interest in daily activities, greatly reduces quality of life. Early detection is vital for effective treatment and intervention. While many studies use wearable devices to classify depression based on physical activity, these often rely on intrusive methods. Additionally, most depression classification studies involve large participant groups and use single-stage classifiers without explainability. Objective: This study aims to assess the feasibility of classifying depression using nonintrusive Wi-Fi–based motion sensor data using a novel machine learning model on a limited number of participants. We also conduct an explainability analysis to interpret the model’s predictions and identify key features associated with depression classification. Methods: In this study, we recruited adults aged 65 years and older through web-based and in-person methods, supported by a McGill University health care facility directory. Participants provided consent, and we collected 6 months of activity and sleep data via nonintrusive Wi-Fi–based sensors, along with Edmonton Frailty Scale and Geriatric Depression Scale data. For depression classification, we proposed a HOPE (Home-Based Older Adults’ Depression Prediction) machine learning model with feature selection, dimensionality reduction, and classification stages, evaluating various model combinations using accuracy, sensitivity, precision, and F1-score. Shapely addictive explanations and local interpretable model-agnostic explanations were used to explain the model’s predictions. Results: A total of 6 participants were enrolled in this study; however, 2 participants withdrew later due to internet connectivity issues. Among the 4 remaining participants, 3 participants were classified as not having depression, while 1 participant was identified as having depression. The most accurate classification model, which combined sequential forward selection for feature selection, principal component analysis for dimensionality reduction, and a decision tree for classification, achieved an accuracy of 87.5%, sensitivity of 90%, and precision of 88.3%, effectively distinguishing individuals with and those without depression. The explainability analysis revealed that the most influential features in depression classification, in order of importance, were “average sleep duration,” “total number of sleep interruptions,” “percentage of nights with sleep interruptions,” “average duration of sleep interruptions,” and “Edmonton Frailty Scale.” Conclusions: The findings from this preliminary study demonstrate the feasibility of using Wi-Fi–based motion sensors for depression classification and highlight the effectiveness of our proposed HOPE machine learning model, even with a small sample size. These results suggest the potential for further research with a larger cohort for more comprehensive validation. Additionally, the nonintrusive data collection method and model architecture proposed in this study offer promising applications in remote health monitoring, particularly for older adults who may face challenges in using wearable devices. Furthermore, the importance of sleep patterns identified in our explainability analysis aligns with findings from previous research, emphasizing the need for more in-depth studies on the role of sleep in mental health, as suggested in the explainable machine learning study. %M 40053734 %R 10.2196/67715 %U https://aging.jmir.org/2025/1/e67715 %U https://doi.org/10.2196/67715 %U http://www.ncbi.nlm.nih.gov/pubmed/40053734 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e64251 %T The Effect of Predicted Compliance With a Web-Based Intervention for Anxiety and Depression Among Latin American University Students: Randomized Controlled Trial %A Benjet,Corina %A Zainal,Nur Hani %A Albor,Yesica %A Alvis-Barranco,Libia %A Carrasco Tapia,Nayib %A Contreras-Ibáñez,Carlos C %A Cortés-Morelos,Jacqueline %A Cudris-Torres,Lorena %A de la Peña,Francisco R %A González,Noé %A Gutierrez-Garcia,Raúl A %A Vargas-Contreras,Eunice %A Medina-Mora,Maria Elena %A Patiño,Pamela %A Gildea,Sarah M %A Kennedy,Chris J %A Luedtke,Alex %A Sampson,Nancy A %A Petukhova,Maria V %A Zubizarreta,Jose R %A Cuijpers,Pim %A Kazdin,Alan E %A Kessler,Ronald C %+ Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA, 02115, United States, 1 617 432 3587, kessler@hcp.med.harvard.edu %K anxiety %K depression %K web-based cognitive behavioral therapy %K compliance %K randomized controlled trial %D 2025 %7 28.2.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Web-based cognitive behavioral therapy (wb-CBT) is a scalable way to reach distressed university students. Guided wb-CBT is typically superior to self-guided wb-CBT over short follow-up periods, but evidence is less clear over longer periods. Objective: This study aimed to compare short-term (3 months) and longer-term (12 months) aggregate effects of guided and self-guided wb-CBT versus treatment as usual (TAU) in a randomized controlled trial of Colombian and Mexican university students and carry out an initially unplanned secondary analysis of the role of differential predicted compliance in explaining these differences. Methods: The 1319 participants, recruited either through email and social media outreach invitations or from waiting lists of campus mental health clinics, were undergraduates (1038/1319, 78.7% female) with clinically significant baseline anxiety (Generalized Anxiety Disorder–7 score≥10) or depression (Patient Health Questionnaire–9 score≥10). The intervention arms comprised guided wb-CBT with weekly asynchronous written human feedback, self-guided wb-CBT with the same content as the guided modality, and TAU as provided at each university. The prespecified primary outcome was joint remission (Generalized Anxiety Disorder–7 score=0-4 and Patient Health Questionnaire–9 score=0-4). The secondary outcome was joint symptom reduction (mean scores on the Patient Health Questionnaire Anxiety and Depression Scale) at 3 and 12 months after randomization. Results: As reported previously, 3-month outcomes were significantly better with guided wb-CBT than self-guided wb-CBT (P=.02) or TAU (P=.02). However, subsequent follow-up showed that 12-month joint remission (adjusted risk differences=6.0-6.5, SE 0.4-0.5, and P<.001 to P=.007; adjusted mean differences=2.70-2.69, SE 0.7-0.8, and P<.001 to P=.001) was significantly better with self-guided wb-CBT than with the other interventions. Participants randomly assigned to the guided wb-CBT arm spent twice as many minutes logged on as those in the self-guided wb-CBT arm in the first 12 weeks (mean 12.5, SD 36.9 vs 5.9, SD 27.7; χ21=107.1, P<.001), whereas participants in the self-guided wb-CBT arm spent twice as many minutes logged on as those in the guided wb-CBT arm in weeks 13 to 52 (mean 0.4, SD 7.5 vs 0.2, SD 4.4; χ21=10.5, P=.001). Subgroup analysis showed that this longer-term superiority of self-guided wb-CBT was confined to the 40% (528/1319) of participants with high predicted self-guided wb-CBT compliance beyond 3 months based on a counterfactual nested cross-validated machine learning model. The 12-month outcome differences were nonsignificant across arms among other participants (all P>.05). Conclusions: The results have important practical implications for precision intervention targeting to maximize longer-term wb-CBT benefits. Future research needs to investigate strategies to increase sustained guided wb-CBT use once guidance ends. Trial Registration: ClinicalTrials.gov NCT04780542; https://www.clinicaltrials.gov/study/NCT04780542 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-022-06255-3 %M 40053727 %R 10.2196/64251 %U https://mental.jmir.org/2025/1/e64251 %U https://doi.org/10.2196/64251 %U http://www.ncbi.nlm.nih.gov/pubmed/40053727 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e62680 %T Probing Public Perceptions of Antidepressants on Social Media: Mixed Methods Study %A Zhu,Jianfeng %A Zhang,Xinyu %A Jin,Ruoming %A Jiang,Hailong %A Kenne,Deric R %K antidepressant %K AskaPatient %K natural language processing %K BERTopic %K large language models %K Reddit %D 2025 %7 26.2.2025 %9 %J JMIR Form Res %G English %X Background: Antidepressants are crucial for managing major depressive disorders; however, nonadherence remains a widespread challenge, driven by concerns over side effects, fear of dependency, and doubts about efficacy. Understanding patients’ experiences is essential for improving patient-centered care and enhancing adherence, which prioritizes individual needs in treatment. Objective: This study aims to gain a deeper understanding of patient experiences with antidepressants, providing insights that health care providers, families, and communities can develop into personalized treatment strategies. By integrating patient-centered care, these processes may improve satisfaction and adherence with antidepressants. Methods: Data were collected from AskaPatient and Reddit, analyzed using natural language processing and large language models. Analytical techniques included sentiment analysis, emotion detection, personality profiling, and topic modeling. Furthermore, demographic variations in patient experiences were also examined to offer a comprehensive understanding of discussions around antidepressants. Results: Sentiment and emotion analysis revealed that the majority of discussions (21,499/36,253, 59.3%) expressed neutral sentiments, with negative sentiments following closely (13,922/36,253, 38.4%). The most common emotions were fear (16,196/36,253, 44.66%) and sadness (12,507/36,253, 34.49%). The largest topic, “Mental Health and Relationships,” accounted for 11.69% (3755/36,253) of the discussions, which indicated a significant focus on managing mental health conditions. Discussions around nonadherence were marked by fear, followed by sadness, while self-care discussions showed a notable trend of sadness. Conclusions: These psychological insights into public perceptions of antidepressants provide a foundation for developing tailored, patient-centered treatment approaches that align with individual needs, enhancing both effectiveness and empathy of care. %R 10.2196/62680 %U https://formative.jmir.org/2025/1/e62680 %U https://doi.org/10.2196/62680 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e69602 %T Automated Digital Safety Planning Interventions for Young Adults: Qualitative Study Using Online Co-design Methods %A Meyerhoff,Jonah %A Popowski,Sarah A %A Lakhtakia,Tanvi %A Tack,Emily %A Kornfield,Rachel %A Kruzan,Kaylee P %A Krause,Charles J %A Nguyen,Theresa %A Rushton,Kevin %A Pisani,Anthony R %A Reddy,Madhu %A Van Orden,Kimberly A %A Mohr,David C %+ Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 750 North Lake Shore Drive, Chicago, IL, 60611, United States, 1 3125031232, jonah.meyerhoff@northwestern.edu %K mental health services %K technology %K therapy %K computer assisted %K SMS text messaging %D 2025 %7 26.2.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Young adults in the United States are experiencing accelerating rates of suicidal thoughts and behaviors but have the lowest rates of formal mental health care. Digital suicide prevention interventions have the potential to increase access to suicide prevention care by circumventing attitudinal and structural barriers that prevent access to formal mental health care. These tools should be designed in collaboration with young adults who have lived experience of suicide-related thoughts and behaviors to optimize acceptability and use. Objective: This study aims to identify the needs, preferences, and features for an automated SMS text messaging–based safety planning service to support the self-management of suicide-related thoughts and behaviors among young adults. Methods: We enrolled 30 young adults (age 18-24 years) with recent suicide-related thoughts and behaviors to participate in asynchronous remote focus groups via an online private forum. Participants responded to researcher-posted prompts and were encouraged to reply to fellow participants—creating a threaded digital conversation. Researcher-posted prompts centered on participants’ experiences with suicide-related thought and behavior-related coping, safety planning, and technologies for suicide-related thought and behavior self-management. Focus group transcripts were analyzed using thematic analysis to extract key needs, preferences, and feature considerations for an automated SMS text messaging–based safety planning tool. Results: Young adult participants indicated that an automated digital SMS text message–based safety planning intervention must meet their needs in 2 ways. First, by empowering them to manage their symptoms on their own and support acquiring and using effective coping skills. Second, by leveraging young adults’ existing social connections. Young adult participants also shared 3 key technological needs of an automated intervention: (1) transparency about how the intervention functions, the kinds of actions it does and does not take, the limits of confidentiality, and the role of human oversight within the program; (2) strong privacy practices—data security around how content within the intervention and how private data created by the intervention would be maintained and used was extremely important to young adult participants given the sensitive nature of suicide-related data; and (3) usability, convenience, and accessibility were particularly important to participants—this includes having an approachable and engaging message tone, customizable message delivery options (eg, length, number, content focus), and straightforward menu navigation. Young adult participants also highlighted specific features that could support core coping skill acquisition (eg, self-tracking, coping skill idea generation, reminders). Conclusions: Engaging young adults in the design process of a digital suicide prevention tool revealed critical considerations that must be addressed if the tool is to effectively expand access to evidence-based care to reach young people at risk for suicide-related thoughts and behaviors. Specifically, automated digital safety planning interventions must support building skillfulness to cope effectively with suicidal crises, deepening interpersonal connections, system transparency, and data privacy. %M 40009840 %R 10.2196/69602 %U https://formative.jmir.org/2025/1/e69602 %U https://doi.org/10.2196/69602 %U http://www.ncbi.nlm.nih.gov/pubmed/40009840 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e59829 %T Formative Evaluation of Suicide Prevention Websites for Men: Qualitative Study with Men at Risk of Suicide and with Potential Gatekeepers %A Reifegerste,Doreen %A Wagner,Anna J M %A Huber,Lisa %A Fastuca,Manuel %+ School of Public Health, Bielefeld University, Universitaetsstrasse 25, Bielefeld, 33615, Germany, 49 521 10667 ext 807, doreen.reifegerste@uni-bielefeld.de %K mental health %K suicide prevention %K men’s health %K evaluation %K website %K gatekeeper %K suicide %K male %K suicide risk %K digital communication %K intervention %K suicidal behavior %K digital intervention %K digital media %D 2025 %7 26.2.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: The suicide rate among men exceeds that of women worldwide. One important measure in suicide prevention for men is digital communication interventions, as they enable easy and anonymous access to information resources. This is especially important for men who might not be reached by traditional, in-person prevention methods. Thus, as part of an interdisciplinary project on suicide prevention for men, two specific digital communication prevention measures were developed: (1) a website to inform men at risk about suicide prevention, and (2) a website to educate potential gatekeepers who are in contact with men at risk of suicide about appropriate life-saving measures. Both websites needed evaluation to explore how they are perceived by (1) men and by (2) potential gatekeepers of men at risk of suicide. This is crucial, as existing research lacks formative evaluation that informs the development of intervention communication materials. Objective: This study aimed to analyze whether these websites were perceived as (1) comprehensible and engaging, (2) authentic and trustworthy, as well as (3) useful by (potential) users. Furthermore, we examined (4) additional ideas for effective communication about suicide prevention. Methods: We conducted (1) individual videoconference interviews with 24 men to evaluate the website and (2) four focus groups with 8 gatekeepers in each group (32 participants) to evaluate the online education program. The focus group sample was equally distributed regarding gender and age. Recruitment was conducted together with a field research partner who posted adverts on Facebook and Instagram (Meta) to reach as many potential participants as possible in an efficient way. All participants were asked to evaluate the intervention materials using a fictitious scenario of a man experiencing a mental health crisis before the interviews or focus groups took place. Results: The videos were perceived as (1) catchy, comprehensible, and empathetic, but too long for a short introduction. A balanced mix of emotional and informative content was considered appropriate and helpful. The health information provided was perceived as (2) serious and trustworthy due to citing scientific institutions and video material of men who had experienced suicidal ideation. (3) The intervention’s applicability for men experiencing acute crisis was critiqued, but it was regarded as very useful for comprehensive information. (4) Further communication channels and addressing other male subgroups or gender identities were presented as possible extensions of the program. Conclusions: Effective suicide prevention research should address both the groups at risk and their support network. Digital communication interventions can provide low-threshold access. Videos with personalized examples are important to give men someone to identify with, which validates their emotional responses and supports their self-esteem, while videos with experts provide relevant and credible information. %M 40009838 %R 10.2196/59829 %U https://formative.jmir.org/2025/1/e59829 %U https://doi.org/10.2196/59829 %U http://www.ncbi.nlm.nih.gov/pubmed/40009838 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 12 %N %P e64867 %T Provider Perspectives on the Use of Mental Health Apps, and the BritePath App in Particular, With Adolescents at Risk for Suicidal Behavior: Qualitative Study %A Lynch,Frances %A Cavese,Julie %A Fulton,Lucy %A Vuckovic,Nancy %A Brent,David %+ , Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR, 97227, United States, 1 503 335 2400, frances.lynch@kpchr.org %K depression %K adolescent %K suicidality %K safety plan %K mental health %K apps %K suicide %D 2025 %7 26.2.2025 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Many youth with significant mental health concerns face limited access to mental health services. Digital programs, such as mobile apps designed to address mental health issues, have the potential to expand access to strategies for managing these conditions. However, few mental health apps are specifically designed for youth experiencing severe concerns, such as suicidal ideation. BritePath is a new app developed to enhance communication and interaction between providers and youth at risk for suicidal behavior. Objective: This study aims to explore health care providers’ opinions and concerns regarding the use of mental health apps for youth at significant risk of suicidal behavior. Methods: We conducted individual semistructured interviews with 17 providers across 7 states. Interviews were conducted via video, recorded, and transcribed. Codes were developed using a team-based approach, with discrepancies resolved through team discussions. Results: Most providers were aware of mental health apps in general and expressed interest in trying the BritePath app with patients experiencing depression, suicidality, or both. Analyses identified 4 key themes related to mental health apps: (1) almost all providers viewed mental health apps as an adjunct to, rather than a replacement for, psychotherapy visits; (2) most providers were concerned about the cost of apps and youth access to them; (3) providers noted the challenge of maintaining patient engagement with apps over time; and (4) providers were concerned about patient privacy, in terms of both data shared with app developers and data privacy within families. Analyses of providers’ opinions specifically about the BritePath app identified 4 additional themes: (1) providers believed that access to safety plans within BritePath could be beneficial for youth at risk for suicidal behavior; (2) providers reported that BritePath’s interactive features could enhance communication between providers and youth; (3) providers appreciated BritePath’s flexibility and the ability for both youth and providers to tailor its content to individual needs; and (4) providers expressed concerns about integrating BritePath into clinical workflows within health systems. Conclusions: The use of mental health apps is expanding, yet there is limited understanding of how to effectively integrate these tools into mental health treatment. Providers are increasingly referring patients to mental health apps, and most expressed interest in trying the BritePath app for patients with depression, suicidality, or both. However, providers also identified several concerns, particularly regarding privacy and safety. %M 40009843 %R 10.2196/64867 %U https://humanfactors.jmir.org/2025/1/e64867 %U https://doi.org/10.2196/64867 %U http://www.ncbi.nlm.nih.gov/pubmed/40009843 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e57907 %T The Moderated Mediating Effects of Social Media Identity and Loneliness on the Relationship Between Problematic Internet Use and Mental Health in China: Nationwide Cross-Sectional Questionnaire Study %A Liu,Chenxi %A Liu,Yushu %A Liu,Chaojie %A Lin,Rujiao %A Wang,Xi %A Zhang,Xinyi %A Wu,Yibo %A Wang,Dan %+ School of Management, Hubei University of Chinese Medicine, 16 Huangjiahu West Rd, Hongshan District, Wuhan, 430065, China, 86 13476237004, 815310016@qq.com %K problematic internet use %K loneliness %K anxiety %K depression %K mediation and moderation model %D 2025 %7 26.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health disorders are a major public health challenge, and problematic internet use (PIU) may play an important role in this issue. However, the underlying mechanisms of PIU and its effects on mental health have not yet been elucidated. Objective: This study examines the mediating effect of loneliness on the relationship between PIU and mental health, as well as the moderating effect of social media identity on the relationships among PIU, loneliness, and mental health. Methods: A cross-sectional questionnaire survey was conducted on 21,292 participants recruited using a multistage stratified sampling strategy from 31 provinces/regions in mainland China from June 20 to August 31, 2022. This study assesses PIU (PIU questionnaire-short form-6), depression (9-item Patient Health Questionnaire [PHQ-9]), anxiety (7-item Generalized Anxiety Disorder scale [GAD-7]), loneliness (3-item loneliness scale), and social media identity (identity bubble reinforcement scale). Additionally, we collected the sociodemographic characteristics of the participants. Participants whose total score of PHQ-9≥15 or total score of GAD-7≥10 were considered to have moderate or severe symptoms of depression or anxiety, respectively. A moderated mediation model was established to examine the mediating effect of loneliness on the association between PIU and mental health outcomes (depression and anxiety), moderated by social media identity. Results: Approximately 22.80% (4854/21,292) and 14.20% (3023/21,292) of the respondents reported moderate or severe symptoms of depression and anxiety, respectively. Loneliness significantly mediated the association between PIU and mental health outcomes, explaining 42.53% and 45.48% of the total effect of PIU on depression and anxiety, respectively. Social media identity significantly moderated the associations between PIU and depression (β=0.002, 95% CI 0.001-0.002), PIU and anxiety (β=0.001, 95% CI 0.000-0.002), loneliness and depression (β=0.010, 95% CI 0.007-0.013), and loneliness and anxiety (β=0.007, 95% CI 0.004-0.010), but not between PIU and loneliness (β=0.000, 95% CI –0.003 to 0.003). Higher levels of social media identity were significantly associated with lower levels of loneliness (β=–0.018, 95% CI –0.020 to –0.016). Conclusions: Addressing loneliness may serve as a valuable approach to mitigate the impact of PIU on mental health outcomes. However, social media identity poses a significant challenge in addressing health issues linked to PIU. %M 40009436 %R 10.2196/57907 %U https://www.jmir.org/2025/1/e57907 %U https://doi.org/10.2196/57907 %U http://www.ncbi.nlm.nih.gov/pubmed/40009436 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e64451 %T More Cyberbullying, Less Happiness, and More Injustice—Psychological Changes During the Pericyberbullying Period: Quantitative Study Based on Social Media Data %A Liu,Xingyun %A Liu,Miao %A Kang,Xin %A Han,Nuo %A Liao,Yuehan %A Ren,Zhihong %+ , Key Laboratory of Adolescent Cyberpsychology and Behavior, Ministry of Education, No 382 Xiongchu Avenue, Hongshan District, Wuhan, 430079, China, 86 13627131550, ren@ccnu.edu.cn %K cyberbullying %K pericyberbullying period %K social media %K well-being %K morality %K suicide risk %K personality traits %D 2025 %7 25.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: The phenomenon of cyberbullying is becoming increasingly severe, and many studies focus on the negative psychological impacts of cyberbullying survivors. However, current survey methods cannot provide direct and reliable evidence of the short-term psychological effects of cyberbullying survivors, as it is impractical to measure psychological changes before and after such an unpredictable event in a short period. Objective: This study aims to explore the psychological impacts of cyberbullying on survivors during the pericyberbullying period, defined as the critical time frame surrounding the first cyberbullying incident, encompassing the psychological changes before, during, and after the event. Methods: We collected samples from 60 cyberbullying survivors (experimental group, 94/120, 78% female) and 60 individuals who have not experienced cyberbullying (control group, matched by sex, location, and number of followers) on Sina Weibo, a social media platform developed by Sina Corporation. During the pericyberbullying period, we retrospectively measured psychological traits 3 months before and after the first cyberbullying incident for both groups. Social media data and predictive models were used to identify survivors’ internal psychological traits, including happiness, suicide risk, personality traits, and moral perceptions of the external environment. Network analysis was then performed to explore the interplay between cyberbullying experiences and psychological characteristics. Results: During the pericyberbullying period, survivors exhibited significantly reduced happiness (t59=2.14; P=.04), marginally increased suicide risk, and significant changes in the Big 5 personality traits, including decreased conscientiousness (t59=2.27; P=.03), agreeableness (t59=2.79; P=.007), and extraversion (t59=2.26; P=.03), alongside increased neuroticism (t59=–3.42; P=.001). Regarding moral perceptions of the external environment, survivors showed significant increases in communicative moral motivation (t59=–2.62; P=.011) and FairnessVice (t59=–2.20; P=.03), with a marginal rise in PurityVice (t59=–1.88; P=.07). In contrast, the control group exhibited no significant changes during the same time frame. Additionally, network analysis revealed that beyond cyberbullying experiences, core psychological characteristics in the network were neuroticism, conscientiousness, and Oxford Happiness. Conclusions: By leveraging noninvasive retrospective social media data, this study provides novel insights into the short-term psychological impacts of cyberbullying during the pericyberbullying period. The findings highlight the need for timely interventions focusing on enhancing survivors’ happiness, reducing suicide risk, adjusting personality traits, and rebuilding moral cognition to mitigate the negative effects of cyberbullying. %M 39998871 %R 10.2196/64451 %U https://www.jmir.org/2025/1/e64451 %U https://doi.org/10.2196/64451 %U http://www.ncbi.nlm.nih.gov/pubmed/39998871 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e64303 %T Culturally Adapted Guided Internet-Based Cognitive Behavioral Therapy for Hong Kong People With Depressive Symptoms: Randomized Controlled Trial %A Pan,Jia-Yan %A Rafi,Jonas %+ Department of Social Work, Hong Kong Baptist University, AAB1026, 10/F, Academic and Administration Building, 15 Baptist University Road, Baptist University Road Campus, Hong Kong Baptist University, Kowloon Tong, KLN, Hong Kong, China (Hong Kong), 852 34116415, jiayan@hkbu.edu.hk %K Internet-based cognitive behavioral therapy %K depression %K Chinese %K Hong Kong, culturally adapted internet intervention %D 2025 %7 25.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: A significant number of individuals with depression in Hong Kong remain undiagnosed and untreated through traditional face-to-face psychotherapy. Internet-based cognitive behavioral therapy (iCBT) has emerged as a tool to improve access to mental health services. However, iCBT remains underdeveloped in Chinese communities, particularly in Hong Kong. Objective: This study aims to (1) develop and evaluate the effectiveness of a culturally and linguistically appropriate guided iCBT program for Hong Kong Chinese with depressive symptoms, and (2) explore their treatment adherence. Methods: An 11-week guided iCBT program, “Confront and Navigate Depression Online” (CANDO), consisting of 8 online modules, was developed and implemented for Hong Kong residents. The program was accessible via either an online platform (web-based iCBT) or a smartphone app (app-based iCBT). A 3-arm randomized controlled trial was conducted, with participants recruited through open recruitment and referrals from 2 local non-governmental organizations. A total of 402 eligible participants with mild to moderate depressive symptoms were randomly allocated into 3 groups: (1) web-based iCBT (n=139); (2) app-based iCBT (n=131); and (3) waitlist control (WLC) group (n=132), who transitioned to the web-based iCBT group after waiting for 11 weeks. Therapist support was provided by a clinical psychologist through 3 counseling sessions and weekly assignment feedback. The primary outcomes were the Beck Depression Inventory-II (BDI-II) and the 9-item Patient Health Questionnaire (PHQ-9), while the secondary outcome measures included the 12-item General Health Questionnaire (GHQ-12), the Chinese Automatic Thoughts Questionnaire (CATQ), and the Chinese Affect Scale (CAS). These scales were administered at preintervention, postintervention, and at 3-month and 6-month follow-up assessments. Data analysis was conducted using linear mixed effects modeling, adhering to the intent-to-treat principle. Results: Participants in both the web- and app-based iCBT groups reported significant improvements compared with the WLC group on all primary (P<.001) and secondary measures (P<.001 and P=.009) at posttreatment. Large between-group effect sizes were observed in the reduction of depressive symptoms, with Cohen's d value of 1.07 (95% CI 0.81-1.34) for the web-based group and 1.15 (95% CI 0.88-1.43) for the app-based group on the BDI-II. Additionally, the web- and app-based groups showed effect sizes of 0.78 (95% CI 0.52-1.04) and 0.95 (95% CI 0.63-1.27) on PHQ-9, respectively. Medium to large effect sizes were observed for secondary outcomes at posttreatment. These positive effects were maintained at both the 3- and 6-month follow-ups, with medium to large within-group effect sizes. The adherence rate in the 2 iCBT groups was 154 out of 270 (57.0%) for completing all 8 online modules and 152 out of 270 (56.3%) for attending all 4 counseling sessions (including an intake interview). The recovery rate, as measured by the BDI-II at posttreatment, was 35 out of 90 (39%) for the web-based group and 36 out of 91 (40%) for the app-based group, compared with 3 out of 112 (3%) in the WLC group. Conclusions: Culturally and linguistically adapted iCBT is an effective and feasible treatment for Hong Kong Chinese with mild to moderate depressive symptoms, demonstrating a satisfactory recovery rate and treatment adherence. ICBT offers an accessible and viable alternative to face-to-face interventions in Hong Kong. The Hong Kong government should allocate more resources and support the use of iCBT as a tool to treat people with depressive symptoms. Trial Registration: ClinicalTrials.gov (NCT04388800); https://clinicaltrials.gov/study/NCT04388800 %M 39998865 %R 10.2196/64303 %U https://www.jmir.org/2025/1/e64303 %U https://doi.org/10.2196/64303 %U http://www.ncbi.nlm.nih.gov/pubmed/39998865 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e63497 %T Patterns of Skills Review in Smartphone Cognitive Behavioral Therapy for Depression: Observational Study of Intervention Content Use %A Bernstein,Emily E %A Daniel,Katharine E %A Miyares,Peyton E %A Hoeppner,Susanne S %A Bentley,Kate H %A Snorrason,Ivar %A Fisher,Lauren B %A Greenberg,Jennifer L %A Weingarden,Hilary %A Harrison,Oliver %A Wilhelm,Sabine %+ University of Virginia, 560 Ray C Hunt Drive, Charlottesville, 22903, United States, 1 434 924 2495, ked4fd@virginia.edu %K smartphone %K cognitive behavioral therapy %K engagement %K depression %K mental health %K Mindset %K mHealth %K mobile health %K app %K digital health %K mobile phone %D 2025 %7 24.2.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Smartphones could enhance access to effective cognitive behavioral therapy (CBT). Users may frequently and flexibly access bite-size CBT content on personal devices, review and practice skills, and thereby achieve better outcomes. Objective: We explored the distribution of actual interactions participants had with therapeutic content in a trial of smartphone CBT for depression and whether interactions were within assigned treatment modules or revisits to prior module content (ie, between-module interactions). Methods: We examined the association between the number of within- and between-module interactions and baseline and end-of-treatment symptom severity during an 8-week, single-arm open trial of a therapist-guided CBT for depression mobile health app. Results: Interactions were more frequent early in treatment and modestly declined in later stages. Within modules, most participants consistently made more interactions than required to progress to the next module and tended to return to all types of content rather than focus on 1 skill. By contrast, only 15 of 26 participants ever revisited prior module content (median number of revisits=1, mode=0, IQR 0-4). More revisits were associated with more severe end-of-treatment symptom severity after controlling for pretreatment symptom severity (P<.05). Conclusions: The results suggest that the frequency of use is an insufficient metric of engagement, lacking the nuance of what users are engaging with and when during treatment. This lens is essential for developing personalized recommendations and yielding better treatment outcomes. Trial Registration: ClinicalTrials.gov NCT05386329; https://clinicaltrials.gov/study/NCT05386329?term=NCT05386329 %M 39993308 %R 10.2196/63497 %U https://mental.jmir.org/2025/1/e63497 %U https://doi.org/10.2196/63497 %U http://www.ncbi.nlm.nih.gov/pubmed/39993308 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e56230 %T Improving Maternal Mental Health and Weight Control With a Mindfulness Blended Care Approach: Insights From a Randomized Controlled Trial %A Hassdenteufel,Kathrin %A Müller,Mitho %A Abele,Harald %A Brucker,Sara Yvonne %A Graf,Johanna %A Zipfel,Stephan %A Bauer,Armin %A Jakubowski,Peter %A Pauluschke-Fröhlich,Jan %A Wallwiener,Markus %A Wallwiener,Stephanie %+ Department of Obstetrics and Gynecology, University Hospital Heidelberg, Im Neuenheimer Feld 440, 69120 Heidelberg, Heidelberg, 69120, Germany, 49 15238492062, Kathrin.hassdenteufel@med.uni-heidelberg.de %K peripartum mental health %K digital intervention %K depression %K anxiety %K personal coaching %K ehealth %K pregnancy %K maternal mental health %K weight gain %K mindfulness-based intervention %K coaching %K randomized controlled clinical trial %K postpartum %K treatment %K electronic %K effectiveness %K women %K digital intervention %D 2025 %7 24.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Perinatal maternal mental health problems, such as depression and anxiety, are highly prevalent during pregnancy and post partum. Electronic mindfulness-based interventions (eMBIs) are a promising treatment option, which can be provided in a low-threshold, cost-effective manner. However, research underscores the fact that face-to-face coaching sessions are more effective than solely digital methods. A blended care approach (eMBI with direct face-to-face coaching) could amplify the therapeutic impact on maternal mental health and weight gain during the perinatal period. Objective: We investigated whether combining an eMBI intervention with face-to-face personal support significantly improves maternal mental health, and whether the intervention can influence weight gain in affected women during pregnancy. Methods: A community-based sample of 460 pregnant women with a singleton pregnancy who screened positive for depression was enrolled in a multicenter randomized controlled trial (RCT) including the University Hospitals of Heidelberg and Tübingen as well as more than 200 gynecological practices within the state of Baden-Württemberg in Germany between February 2019 and October 2020. Participating women were randomized 1:1 to the control group (CG) or intervention group (IG) that received access to an 8-week pregnancy-adapted eMBI between the 29th and 36th gestational week. In a subanalysis, we grouped participants in those receiving only the initial face-to-face coaching session at recruitment (no personal coaching) and those with ≥2 personal coaching sessions. Primary outcome measures were severity of depressive symptoms using the Edinburgh Postnatal Depression Scale, anxiety using the State-Trait Anxiety Inventory, the Pregnancy-Related Anxiety Questionnaire, the Freiburg Mindfulness Inventory, and the Patient Health Questionnaire; secondary outcome measure, BMI. Results: In the final sample, 137 CG women and 102 IG women received only one coaching session, whereas 37 CG women and 40 IG women received at least 2 (mean 2.3, SD 0.7) coaching sessions. The analyses were adjusted for significant confounders. The IG’s mindfulness scores increased significantly (F1.873,344.619=4.560, P=.01, η²=0.024, ω²=0.012) regardless of coaching frequency. Both general anxiety (F12,129=2.361, P=.01, η²=0.0180, ω²=0.100) and depression symptoms (F4.758, 699.423=3.033, P=.01, η²=0.020, ω²=0.009) were significantly lower in the group that received ≥2 coaching sessions than in the no-personal-coaching group. In the group receiving ≥2 coaching sessions, BMI generally was lower in the IG than in the CG (F3.555,444.416=4.732, P=.002, η²=0.036, ω²=0.013). Conclusions: Adding a minimal amount of PC to the digital eMBI increased mindfulness and decreased birth-related anxiety, symptoms of depression, and anxiety in at-risk pregnant women. Favorable effects on gestational weight gain were found in the respective IGs, the strongest effect being within the PC group. This blended digital health approach amplifies the effectiveness of the digital intervention. Trial Registration: German Clinical Trials Register DRKS00017210; https://www.drks.de/search/de/trial/DRKS00017210 %M 39992700 %R 10.2196/56230 %U https://www.jmir.org/2025/1/e56230 %U https://doi.org/10.2196/56230 %U http://www.ncbi.nlm.nih.gov/pubmed/39992700 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e63622 %T Multimodal Digital Phenotyping Study in Patients With Major Depressive Episodes and Healthy Controls (Mobile Monitoring of Mood): Observational Longitudinal Study %A Aledavood,Talayeh %A Luong,Nguyen %A Baryshnikov,Ilya %A Darst,Richard %A Heikkilä,Roope %A Holmén,Joel %A Ikäheimonen,Arsi %A Martikkala,Annasofia %A Riihimäki,Kirsi %A Saleva,Outi %A Triana,Ana Maria %A Isometsä,Erkki %+ , Department of Computer Science, Aalto University, Konemiehentie 2, Espoo, 02150, Finland, 358 505632634, talayeh.aledavood@aalto.fi %K digital health %K mental disorders %K depression %K digital phenotyping %K smartphones %K mobile devices %K multisensor %K mobile phone %D 2025 %7 21.2.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mood disorders are among the most common mental health conditions worldwide. Wearables and consumer-grade personal digital devices create digital traces that can be collected, processed, and analyzed, offering a unique opportunity to quantify and monitor individuals with mental disorders in their natural living environments. Objective: This study comprised (1) 3 subcohorts of patients with a major depressive episode, either with major depressive disorder, bipolar disorder, or concurrent borderline personality disorder, and (2) a healthy control group. We investigated whether differences in behavioral patterns could be observed at the group level, that is, patients versus healthy controls. We studied the volume and temporal patterns of smartphone screen and app use, communication, sleep, mobility, and physical activity. We investigated whether patients or controls exhibited more homogenous temporal patterns of activity when compared with other individuals in the same group. We examined which variables were associated with the severity of depression. Methods: In total, 188 participants were recruited to complete a 2-phase study. In the first 2 weeks, data from bed sensors, actigraphy, smartphones, and 5 sets of daily questions were collected. In the second phase, which lasted up to 1 year, only passive smartphone data and biweekly 9-item Patient Health Questionnaire data were collected. Survival analysis, statistical tests, and linear mixed models were performed. Results: Survival analysis showed no statistically significant difference in adherence. Most participants did not stay in the study for 1 year. Weekday location variance showed lower values for patients (control: mean –10.04, SD 2.73; patient: mean –11.91, SD 2.50; Mann-Whitney U [MWU] test P=.004). Normalized entropy of location was lower among patients (control: mean 2.10, SD 1.38; patient: mean 1.57, SD 1.10; MWU test P=.05). The temporal communication patterns of controls were more diverse compared to those of patients (MWU test P<.001). In contrast, patients exhibited more varied temporal patterns of smartphone use compared to the controls. We found that the duration of incoming calls (β=–0.08, 95% CI –0.12 to –0.04; P<.001) and the SD of activity magnitude (β=–2.05, 95% CI –4.18 to –0.20; P=.02) over the 14 days before the 9-item Patient Health Questionnaire records were negatively associated with depression severity. Conversely, the duration of outgoing calls showed a positive association with depression severity (β=0.05, 95% CI 0.00-0.09; P=.02). Conclusions: Our work shows the important features for future analyses of behavioral markers of mood disorders. However, among outpatients with mild to moderate depressive disorders, the group-level differences from healthy controls in any single modality remain relatively modest. Therefore, future studies need to combine data from multiple modalities to detect more subtle differences and identify individualized signatures. The high dropout rates for longer study periods remain a challenge and limit the generalizability. %M 39984168 %R 10.2196/63622 %U https://mental.jmir.org/2025/1/e63622 %U https://doi.org/10.2196/63622 %U http://www.ncbi.nlm.nih.gov/pubmed/39984168 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e56418 %T Depression Self-Care Apps’ Characteristics and Applicability to Older Adults: Systematic Assessment %A Yin,Ruoyu %A Rajappan,Dakshayani %A Martinengo,Laura %A Chan,Frederick H F %A Smith,Helen %A Griva,Konstadina %A Subramaniam,Mythily %A Tudor Car,Lorainne %+ Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Clinical Sciences Building, Singapore, 308232, Singapore, 65 65138572, l.tudor.car@imperial.ac.uk %K older adults %K elder %K elderly %K mental health %K mental illness %K mental disorders %K mHealth %K mobile health %K mobile application %K app %K application %K smartphone %K depression %K self-care %K mobile apps %K systematic assessment %K assessment %K effectiveness %K self-care %K Android app %K mental health apps %K mobile interventions %K behaviour %K therapy %K mood monitoring %K adaptations %K online communities %K impairments %D 2025 %7 21.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression affects 32% of older adults. Loneliness and social isolation are common risk factors for depression in older adults. Mobile apps can connect users and are also effective in depression management in the general population. However, older adults have specific needs in terms of the content of depression self-care interventions and their accessibility. It remains unknown whether existing apps for depression self-care are applicable to older adults. Objective: The initial aim of this assessment was to systematically identify interactive depression self-care apps specifically designed for older adults. As we did not find any, we assessed the applicability of existing depression self-care apps to the needs of older adult users. Methods: Using an established app assessment methodology, we searched for Android and iOS interactive mental health apps providing self-care for depression in English and Chinese in the 42Matters database, Chinese Android app stores, and the first 10 pages of Google and Baidu. We developed an assessment rubric based on extensive revision of the literature. The rubric consisted of the following sections: general characteristics of the apps (eg, developer, platform, and category), app content (eg, epidemiology and risk factors of depression in older adults, techniques to improve mood and well-being), and technical aspects (eg, accessibility, privacy and confidentiality, and engagement). Results: We identified 23 apps (n=19, 82.6%, English and n=4, 17.4%, Chinese apps), with 5 (21.7%) iOS-only apps, 3 (13%) Android-only apps, and 15 (65.2%) apps on both platforms. None specifically targeted older adults with depression. All apps were designed by commercial companies and were free to download. Most of the apps incorporated cognitive behavior therapy, mood monitoring, or journaling. All but 3 (13%) apps had a privacy and confidentiality policy. In addition, 14 (60.9%) apps covered depression risk factors in older adults, and 3 (13%) apps delivered information about depression epidemiology in older adults via a chatbot. Furthermore, 17 (73.9%) apps mentioned other topics relevant to older adults, such as pain management, grief, loneliness, and social isolation. Around 30% (n=7) of the apps were supported by an online forum. Common accessibility issues included a lack of adaptations for users with visual or hearing impairments and incompatibility with larger font sizes in the phone settings. Conclusions: There are no depression apps developed specifically for older adults. Available mobile apps have limited applicability to older adults in terms of their clinical and technical features. Depression self-care apps should aim to incorporate content relevant to older adults, such as grief and loss; include online communities; and improve accessibility to adapt to potential health impairments in older adults. %M 39983112 %R 10.2196/56418 %U https://www.jmir.org/2025/1/e56418 %U https://doi.org/10.2196/56418 %U http://www.ncbi.nlm.nih.gov/pubmed/39983112 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e67567 %T Cost Utility Analysis of Internet-Based Cognitive Behavioral Therapy for Major Depressive Disorder: Randomized Controlled Trial %A Zhou,Wenjing %A Chen,Yan %A Wu,Herui %A Zhao,Hao %A Li,Yanzhi %A Shi,Guangduoji %A Wang,Wanxin %A Liu,Yifeng %A Liao,Yuhua %A Zhang,Huimin %A Gao,Caihong %A Hao,Jiejing %A Le,Gia Han %A McIntyre,Roger S %A Han,Xue %A Lu,Ciyong %+ Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, No.74 Zhongshan Road 2, Guangzhou, 510080, China, 86 13610355985, luciyong@mail.sysu.edu.cn %K cost utility analysis %K CUA %K cost-effectiveness %K economic evaluation %K costs %K quality of life %K internet-based cognitive behavioral therapy %K ICBT %K digital psychiatry %K major depressive disorder %K depression %K China %D 2025 %7 19.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Unguided internet-based cognitive behavioral therapy (ICBT) has been proven effective for major depressive disorder (MDD). However, few studies have examined its cost-effectiveness in low-resource countries and under nonspecialist routine care. Objective: This study aimed to evaluate the short- and long-term cost utility of unguided ICBT compared to a waitlist control for persons with MDD from the perspectives of society and the health care system. Methods: This analysis was implemented alongside an 8-week 2-arm randomized controlled trial with a 12-month follow-up period conducted in Shenzhen, China. Outcomes including cost and health utility were collected at the pretreatment and posttreatment time points and 3, 6, and 12 months after the intervention. Direct medical costs and indirect costs were prospectively collected using the hospital information system and the Sheehan Disability Scale. Health outcomes were measured using the Chinese version of the Short-Form Six-Dimension health index. The primary outcome was incremental cost utility ratio (ICUR) expressed as the difference in costs between 2 therapies by the difference in quality-adjusted life years (QALYs). The seemingly unrelated regression model and the bootstrap method were performed to estimate adjusted ICURs. Cost-effectiveness planes and cost-effectiveness acceptability curves were used to demonstrate uncertainty. A series of scenario analyses were conducted to verify the robustness of base-case results. Results: In total, 244 participants with MDD were randomly allocated to the ICBT (n=122, 50%) or waitlist control (n=122, 50%) groups. At the pretreatment time point, no statistically significant difference was observed in direct medical cost (P=.41), indirect cost (P=.10), or health utility (P=.11) between the 2 groups. In the base-case analysis, the ICBT group reported higher direct medical costs and better quality of life but lower total costs at the posttreatment time point. The adjusted ICURs at the posttreatment time point were CN ¥–194,720.38 (US $–26,551.50; 95% CI CN ¥–198,766.78 to CN ¥–190,673.98 [US $–27,103.20 to US $–25,999.70]) and CN ¥49,700.33 (US $6776.99; 95% CI CN ¥46,626.34-CN ¥52,774.31 [US $6357.83-$7196.15]) per QALY from the societal and health care system perspectives, respectively, with a probability of unguided ICBT being cost-effective of 75.93% and 54.4%, respectively, if the willingness to pay was set at 1 time the per-capita gross domestic product. In the scenario analyses, the probabilities increased to 76.85% and 77.61%, respectively, indicating the potential of ICBT to be cost-effective over the long term. Conclusions: Unguided ICBT is a cost-effective treatment for MDD. This intervention not only helps patients with MDD improve clinically but also generates societal savings. These findings provide health economic evidence for a potential scalable MDD treatment method in low- and middle-income countries. Trial Registration: Chinese Clinical Trial Registry (ChiCTR) ChiCTR2100046425; https://tinyurl.com/bdcrj4zv %M 39970426 %R 10.2196/67567 %U https://www.jmir.org/2025/1/e67567 %U https://doi.org/10.2196/67567 %U http://www.ncbi.nlm.nih.gov/pubmed/39970426 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e68419 %T Designing Values Elicitation Technologies for Mental Health and Chronic Care Integration: User-Centered Design Approach %A Rooper,Isabel R %A Liem,William W %A Burla,Martha %A Gordon,Jacob %A Baez,Lara M %A Kornfield,Rachel %A Berry,Andrew B L %+ , Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 N Michigan Ave, Ste 2100, Chicago, IL, 60611, United States, 1 312 503 4910, andrew.berry@northwestern.edu %K chronic care management %K anxiety %K depression %K values elicitation %K eHealth %K patient-centered care %K technology-enabled services %K human-centered design %K multimorbidity %K user-centered design %K multiple chronic conditions %D 2025 %7 19.2.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Individuals with multiple chronic conditions (MCCs) and mental health challenges such as depression or anxiety have complex health needs and experience significant challenges with care coordination. Approaches to enhance care for patients with MCCs typically focus on eliciting patients’ values to identify and align treatment priorities across patients and providers. However, these efforts are often hindered by both systems- and patient-level barriers, which are exacerbated for patients with co-occurring mental health symptoms. Technology-enabled services (TES) offer a promising avenue to facilitate values elicitation and promote patient-centered care for these patients, though TES have not yet been tailored to their unique needs. Objective: This study aimed to identify design and implementation considerations for TES that facilitate values elicitation among patients with MCCs and depression or anxiety. We sought to understand the preferences of both clinicians and patients for TES that could bridge the gap between mental and physical health care. Methods: Using human-centered design methods, we conducted 7 co-design workshops with 18 participants, including primary care clinicians, mental health clinicians, and patients with MCCs and depression or anxiety. Participants were introduced to TES prototypes that used various formats (eg, worksheets and artificial intelligence chatbots) to elicit and communicate patients’ values. Prototypes were iteratively refined based on participant feedback. Data from these sessions were analyzed using reflexive thematic analysis to uncover themes related to service, technology, and implementation considerations. Results: Three primary themes were identified. (1) Service considerations: TES should help patients translate elicited values into actionable treatment plans and include low-burden, flexible activities to accommodate fluctuations in their mental health symptoms. Both patients and clinicians indicated that TES could be valuable for improving appointment preparation and patient-provider communication through interpersonal skill-building. (2) Technology considerations: Patients expressed openness to TES prototypes that used artificial intelligence, particularly those that provided concise summaries of appointment priorities. Visual aids and simplified language were highlighted as essential features to support accessibility for neurodiverse patients. (3) Implementation considerations: Clinicians and patients favored situating values elicitation in mental health care settings over primary care and preferred self-guided TES that patients could complete independently before appointments. Conclusions: Findings indicate that TES can address the unique needs of patients with MCCs and mental health challenges by facilitating values-based care. Key design considerations include ensuring TES flexibility to account for fluctuating mental health symptoms, facilitating skill-building for effective communication, and creating user-friendly technology interfaces. Future research should explore how TES can be integrated into health care settings to enhance care coordination and support patient-centered treatment planning. By aligning TES design with patient and clinician preferences, there is potential to bridge gaps in care for this complex patient population. %M 39970432 %R 10.2196/68419 %U https://formative.jmir.org/2025/1/e68419 %U https://doi.org/10.2196/68419 %U http://www.ncbi.nlm.nih.gov/pubmed/39970432 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e57512 %T Nomophobia, Psychopathology, and Smartphone-Inferred Behaviors in Youth With Depression: Longitudinal Study %A Zhang,Tianyi %A Camargo,Andres %A Schmaal,Lianne %A Kostakos,Vassilis %A D'Alfonso,Simon %+ School of Computing and Information Systems, University of Melbourne, Level 4, Melbourne Connect (Building 290), Melbourne, 3010, Australia, 61 449930128, tianyiz4@student.unimelb.edu.au %K mobile sensing %K nomophobia %K digital phenotyping %K depression %K mental health %K smartphone use %K personal sensing %K behavior analysis %K machine learning %K mobile health %K mobile phone %D 2025 %7 19.2.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Smartphones have become an indispensable part of people’s lives, and the fear of being without them, what has been termed “no mobile phone phobia” (nomophobia), is a growing phenomenon. The rise of problematic smartphone use highlights the urgent need to explore the intricate relationship between smartphones and human behavior. However, the connections between nomophobia, mental health indicators, smartphone use patterns, and daily activities remain largely underexplored. Objective: This study aimed to explore the relationship between young adults with depression and smartphones and investigate nomophobia by analyzing data obtained from a pilot study of depression in a youth cohort. Exploring nomophobia can enhance our understanding of the dynamics between young adults and smartphone use, potentially empowering them to manage and regulate their smartphone use more effectively. Methods: During an 8-week period, data collected via smartphone sensors, such as locations and screen status, were gathered from a cohort of 41 individuals diagnosed with major depressive disorder. In addition to passive-sensing smartphone data, the study collected ecological momentary assessments and psychometric measures, including the Nomophobia Questionnaire, which formed the basis of our investigation. We explored statistical associations among smartphone-derived behavioral features, psychometric indicators, and nomophobia. In addition, we used behavioral and psychometric data to develop regression models demonstrating the prediction of nomophobia levels. Results: Our findings revealed that the level of nomophobia was positively associated with depression and negative affect, lower geolocation movements, and higher comfort with smartphone sensing. The exploratory predictive linear regression models demonstrated the feasibility of predicting an individual’s Nomophobia Questionnaire score based on their smartphone sensing data. These models effectively used input features derived from both a combination of smartphone sensing data and psychometric measures and from smartphone sensing data alone. Conclusions: Our work is the first to explore the relationship between nomophobia and smartphone sensor data. It provides valuable insights into the predictors of nomophobia level, contributing to the understanding of the relationship between smartphones and human behavior and paving the way for future studies. %M 39969982 %R 10.2196/57512 %U https://formative.jmir.org/2025/1/e57512 %U https://doi.org/10.2196/57512 %U http://www.ncbi.nlm.nih.gov/pubmed/39969982 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e56289 %T User Personas for eHealth Regarding the Self-Management of Depressive Symptoms in People Living With HIV: Mixed Methods Study %A Zhao,Ting %A Tang,Chulei %A Ma,Jun %A Yan,Huang %A Su,Xinyi %A Zhong,Xueyuan %A Wang,Honghong %+ Xiangya School of Nursing, Central South University, Yuelu District, Changsha, 410013, China, 86 731 89665663, honghong_wang@hotmail.com %K HIV %K depressive symptoms %K depression %K self-management %K eHealth %K personas %D 2025 %7 17.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: eHealth has enormous potential to support the self-management of depressive symptoms in people living with HIV. However, a lack of personalization is an important barrier to user engagement with eHealth. According to goal-directed design, personalized eHealth requires the identification of user personas before concrete design to understand the goals and needs of different users. Objective: This study aimed to identify user personas for eHealth regarding the self-management of depressive symptoms in people living with HIV and explore the goals and needs of different user personas for future eHealth. Methods: We used an explanatory sequential mixed methods design at the First Hospital of Changsha City, Hunan Province, China, from April to October 2022. In the quantitative phase, 572 people living with HIV completed validated questionnaires with questions related to demographics, self-efficacy, self-management abilities of depressive symptoms, and eHealth literacy. Latent profile analysis was performed to identify different user personas. In the qualitative phase, 43 one-to-one semistructured interviews across different user personas were conducted, transcribed verbatim, and analyzed using conventional content analysis. The findings from both phases were integrated during the interpretation phase. Results: Three types of user personas could be identified, including “high-level self-managers” (254/572, 44.4%), “medium-level self-managers” (283/572, 49.5%), and “low-level self-managers” (35/572, 6.1%). High-level self-managers had relatively high levels of self-efficacy, self-management abilities of depressive symptoms, and eHealth literacy. High-level self-managers had a positive attitude toward using eHealth for the self-management of depressive symptoms and desired access to self-management support for depressive symptoms from eHealth with high usability. Medium-level self-managers had relatively medium levels of self-efficacy, self-management abilities of depressive symptoms, and eHealth literacy. Medium-level self-managers felt burdened by using eHealth for the self-management of depressive symptoms and preferred to access self-management support for HIV from eHealth with privacy. Low-level self-managers had relatively low levels of self-efficacy, self-management abilities of depressive symptoms, and eHealth literacy. Low-level self-managers had an acceptable attitude toward using eHealth for the self-management of depressive symptoms and desired access to professional guidance from eHealth with privacy and no cost (“free of charge”). Conclusions: The 3 user personas shed light on the possibility of personalized eHealth to support the self-management of depressive symptoms in different people living with HIV. Further research is needed to examine the generalizability of the user personas across study sites. %M 39960763 %R 10.2196/56289 %U https://www.jmir.org/2025/1/e56289 %U https://doi.org/10.2196/56289 %U http://www.ncbi.nlm.nih.gov/pubmed/39960763 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e64615 %T Posttraumatic Growth Among Suicide-Loss Survivors: Protocol for an Updated Systematic Review and Meta-Analysis %A Whittaker,Spence %A Rasmussen,Susan %A Cogan,Nicola %A Tse,Dwight %A Martin,Bethany %A Andriessen,Karl %A Shiramizu,Victor %A Krysinska,Karolina %A Levi-Belz,Yossi %+ Department of Psychological Sciences and Health, University of Strathclyde, Graham Hills Building, 40 George St, Glasgow, G1 1QE, United Kingdom, 44 141 548 2700, spence.whittaker@strath.ac.uk %K posttraumatic growth %K suicide-loss survivors %K trauma %K systematic review %K meta-analysis %K posttraumatic %K suicidal %K systematic review %K meta-analysis protocol %K traumatic impacts %K bereaved survivor %K social support %K bereavement %K data collection %K sociodemographic %K psychological %K databases %D 2025 %7 14.2.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Losing a loved one to suicide is an event that can have strong and potentially traumatic impacts on the lives of the bereaved survivors, especially regarding their grief, which can be complicated. These bereaved individuals are also less likely to receive social support following their bereavement. However, besides these adverse impacts, growing evidence supports the concept of posttraumatic growth following suicide bereavement. Posttraumatic growth is the personal improvement that occurs as a consequence of experiencing a traumatic or extremely challenging event or crisis. Only 1 systematic review and meta-analysis on posttraumatic growth following suicide bereavement has been conducted; this protocol is for the planned systematic review and meta-analysis update of the original systematic review and meta-analysis, as the original review collected its data in 2018. Objective: This review aims to investigate demographic characteristics, correlational relationships, and facilitative factors of posttraumatic growth in individuals bereaved by suicide. In addition, as this is an update of a previous systematic review and meta-analysis, we aim to compare our findings with the original review and to identify any similarities or differences. Methods: This protocol outlines the planned procedures of the updated systematic review and meta-analysis. MEDLINE, PsycINFO, Embase, CINAHL, Scopus, and Web of Science (Core Collection) were examined, and the search results were imported to Covidence, where title and abstract screenings and full-text screenings occurred. The inclusion and exclusion criteria for this updated review match those in the original review: (1) the study population must contain participants bereaved by suicide, (2) the study data must be quantitative, and (3) the study must report data on posttraumatic or stress-related growth. The original review conducted its search before 2019; thus, this updated review searched databases for the timeframe of January 2019 to January 2024. The updated meta-analysis will synthesize data from both the original and updated reviews to examine trends over time. The Newcastle-Ottawa Scale (NOS) will be used to assess publication quality. Random-effects meta-analyses will be conducted using RStudio (R Foundation for Statistical Computing). Results: The review was funded in October 2023 and is currently in progress. Results are expected to be finalized in October 2024. There are 21 articles that have been included in the review and are being analyzed at this time. We aim to submit the full article for publication in December 2024. Conclusions: The results of this updated systematic review and meta-analysis will be used to examine key relationships and findings regarding posttraumatic growth in individuals bereaved by suicide. The discussion will also investigate the findings of this updated review in comparison to the findings of the original review. Any differences would be highlighted. Limitations of the current review will be discussed, such as the quality of the articles included. Trial Registration: PROSPERO CRD42024485421; https://tinyurl.com/3hzpnzr3 International Registered Report Identifier (IRRID): DERR1-10.2196/64615 %R 10.2196/64615 %U https://www.researchprotocols.org/2025/1/e64615 %U https://doi.org/10.2196/64615 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e64017 %T Mental Health Changes in US Transgender Adults Beginning Hormone Therapy Via Telehealth: Longitudinal Cohort Study %A Corman,Jae Downing %A Hughto,Jaclyn M W %A Shireman,Theresa I %A Baker,Kellan %A Steinle,Kate %A Forcier,Michelle %+ FOLX Health, 1 Boston Pl, Ste 2600, Boston, MA, 02108, United States, 1 617 792 6855, jae@folxhealth.com %K transgender %K LGBT persons %K telehealth %K depression %K anxiety %K suicide %K mental health %K adult %K virtual care %K longitudinal cohort study %K gender-affirming hormone therapy %K United States %K observational study %K adolescent %K mobile health %D 2025 %7 14.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Gender-affirming hormone therapy (GAHT) has shown potential for improving mental health outcomes among transgender and gender-diverse adults. How clinical outcomes change among adults receiving GAHT via telehealth across the United States is not well known. Objective: This study evaluated the relationship between initiating GAHT via a telehealth clinic and changes in depression, anxiety, and suicide ideation over a 3-month period. Methods: This cohort study evaluated the relationship between initiating GAHT via a telehealth clinic and changes in mental health over a 3-month period. Data were collected at baseline and 3 months later among adults who had their first GAHT visit between August and November 2023. The study included adults aged 18 years and older initiating GAHT for the first time, with a final sample of 342 adults across 43 states (192 initiated estrogen and 150 initiated testosterone therapy). The primary outcomes were depression symptoms using the Patient Health Questionnaire-9 (PHQ-9), anxiety symptoms using the General Anxiety Disorder-7 (GAD-7), and suicide ideation in the past 2 weeks. Results: Before GAHT initiation, 40% (136/342) of participants reported depression (PHQ-9 ≥10), 36% (120/342) reported anxiety (GAD-7 ≥8), and 25% (91/342) reported suicidal ideation. By follow-up, significant reductions were observed in PHQ-9 (−2.4, 95% CI −3.0 to −1.8) and GAD-7 scores (−1.5, 95% CI −2.0 to −1.0). Among those with elevated symptoms, 40% (48/120) to 42% (56/133) achieved a clinically meaningful response (≥50% reduction in baseline scores), and 27% (36/133) to 28% (33/120) achieved remission (PHQ-9 or GAD-7 score <5). Of those with suicide ideation at baseline, 60% (50/83) had none at follow-up. Conclusions: This study highlights the important relationship between telehealth-delivered GAHT and mental health, emphasizing the importance of accessible and timely care. %M 39951700 %R 10.2196/64017 %U https://www.jmir.org/2025/1/e64017 %U https://doi.org/10.2196/64017 %U http://www.ncbi.nlm.nih.gov/pubmed/39951700 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e55583 %T Effectiveness of an Internet-Based, Self-Guided, Short-Term Mindfulness Training (ISSMT) Program for Relieving Depressive Symptoms in the Adult Population in China: Single-Blind, Randomized Controlled Trial %A Zhu,Tingfei %A Zhang,Liuyi %A Weng,Wenqi %A Gan,Ruochen %A Sun,Limin %A Wei,Yanping %A Zhu,Yueping %A Yu,Hongyan %A Xue,Jiang %A Chen,Shulin %+ Department of Psychology and Behavioral Sciences, Zhejiang University, No.148 Tianmushan Road, Hangzhou, China, 86 18958001648, chenshulin@zju.edu.cn %K internet-based %K self-guided %K short-term %K mindfulness %K depression %K randomized controlled trial %D 2025 %7 13.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is a significant global public health issue, and in China, access to mental health services remains limited despite high demand. Research has shown that mindfulness can effectively alleviate depressive symptoms and that telehealth solutions offer a promising avenue for addressing this service gap. Despite this potential, there are currently few studies in China focusing on short-term online mindfulness training. Most existing online mindfulness studies relied on traditional 8-week programs, which can be challenging for participant adherence due to limited accessibility and high dropout rates. Additionally, limited research exists on short-term online mindfulness interventions, and findings remain inconsistent. Objective: This study aimed to develop and evaluate an internet-based, self-guided, short-term mindfulness training (ISSMT) program based on the Monitor and Acceptance Theory (MAT) to reduce depression symptoms. Methods: The ISSMT program was delivered via an online platform, “Hi Emotion,” and was accessible to the general public. Interested individuals aged 18 years and older were randomized into either the ISSMT group or a wait-list control group. Participants in the ISSMT group received daily reminders to participate in a 15- to 20-minute session over a 14-day training period. Measurements, including mindfulness and depressive symptoms, were collected at baseline and weekly for the subsequent 3 weeks. Results: A total of 205 adults participated in the 14-day online intervention. Linear mixed models were used to analyze both per-protocol (PP) and intention-to-treat (ITT) samples. Compared with the wait-list control group, participants in the ISSMT group showed significant improvements in mindfulness (Cohen d=0.44 for ITT; Cohen d=0.55 for PP) and reductions in depressive symptoms (Cohen d=0.50 for ITT; Cohen d=0.53 for PP). Furthermore, participants expressed high acceptance of this training format with a relatively low dropout rate (<40%). Conclusions: The ISSMT program based on the MAT effectively enhanced mindfulness and alleviated depressive symptoms. This intervention could be considered for integration into psychosocial service systems to improve mental health outcomes and help bridge the gap between limited resources and the high demand for services in China. Future research should focus on personalizing these programs and incorporating advanced technologies to enhance their effectiveness and user engagement. Trial Registration: Open Science Framework; https://doi.org/10.17605/OSF.IO/8P4V6 %M 39946708 %R 10.2196/55583 %U https://www.jmir.org/2025/1/e55583 %U https://doi.org/10.2196/55583 %U http://www.ncbi.nlm.nih.gov/pubmed/39946708 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e66696 %T Analyzing Themes, Sentiments, and Coping Strategies Regarding Online News Coverage of Depression in Hong Kong: Mixed Methods Study %A Chen,Sihui %A Ngai,Cindy Sing Bik %A Cheng,Cecilia %A Hu,Yangna %+ Department of Chinese and Bilingual Studies, Hong Kong Polytechnic University, AG502, Hung Hom, Kowloon, China (Hong Kong), 852 27667465, cindy.sb.ngai@polyu.edu.hk %K online news coverage %K depression %K natural language processing %K NLP %K latent Dirichlet allocation %K LDA %K sentiment %K coping strategies %K content analysis %D 2025 %7 13.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression, a highly prevalent global mental disorder, has prompted significant research concerning its association with social media use and its impact during Hong Kong’s social unrest and COVID-19 pandemic. However, other mainstream media, specifically online news, has been largely overlooked. Despite extensive research conducted in countries, such as the United States, Australia, and Canada, to investigate the latent subthemes, sentiments, and coping strategies portrayed in depression-related news, the landscape in Hong Kong remains unexplored. Objective: This study aims to uncover the latent subthemes presented in the online news coverage of depression in Hong Kong, examine the sentiment conveyed in the news, and assess whether coping strategies have been provided in the news for individuals experiencing depression. Methods: This study used natural language processing (NLP) techniques, namely the latent Dirichlet allocation topic modeling and the Valence Aware Dictionary and Sentiment Reasoner (VADER) sentiment analysis, to fulfill the first and second objectives. Coping strategies were rigorously assessed and manually labeled with designated categories by content analysis. The online news was collected from February 2019 to May 2024 from Hong Kong mainstream news websites to examine the latest portrayal of depression, particularly during and after the social unrest and the COVID-19 pandemic. Results: In total, 2435 news articles were retained for data analysis after the news screening process. A total of 7 subthemes were identified based on the topic modeling results. Societal system, law enforcement, global recession, lifestyle, leisure, health issues, and US politics were the latent subthemes. Moreover, the overall news exhibited a slightly positive sentiment. The correlations between the sentiment scores and the latent subthemes indicated that the societal system, law enforcement, health issues, and US politics revealed negative tendencies, while the remainder leaned toward a positive sentiment. The coping strategies for depression were substantially lacking; however, the categories emphasizing information on skills and resources and individual adjustment to cope with depression emerged as the priority focus. Conclusions: This pioneering study used a mixed methods approach where NLP was used to investigate latent subthemes and underlying sentiment in online news. Content analysis was also performed to examine available coping strategies. The findings of this research enhance our understanding of how depression is portrayed through online news in Hong Kong and the preferable coping strategies being used to mitigate depression. The potential impact on readers was discussed. Future research is encouraged to address the mentioned implications and limitations, with recommendations to apply advanced NLP techniques to a new mental health issue case or language. %M 39946170 %R 10.2196/66696 %U https://www.jmir.org/2025/1/e66696 %U https://doi.org/10.2196/66696 %U http://www.ncbi.nlm.nih.gov/pubmed/39946170 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 13 %N %P e64318 %T Performance Assessment of Large Language Models in Medical Consultation: Comparative Study %A Seo,Sujeong %A Kim,Kyuli %A Yang,Heyoung %+ Future Technology Analysis Center, Korea Institute of Science and Technology Information, Hoegi-ro 66, Dongdaemun-gu, Seoul, 92456, Republic of Korea, 82 10 9265 5661, hyyang@kisti.re.kr %K artificial intelligence %K biomedical %K large language model %K depression %K similarity measurement %K text validity %D 2025 %7 12.2.2025 %9 Original Paper %J JMIR Med Inform %G English %X Background: The recent introduction of generative artificial intelligence (AI) as an interactive consultant has sparked interest in evaluating its applicability in medical discussions and consultations, particularly within the domain of depression. Objective: This study evaluates the capability of large language models (LLMs) in AI to generate responses to depression-related queries. Methods: Using the PubMedQA and QuoraQA data sets, we compared various LLMs, including BioGPT, PMC-LLaMA, GPT-3.5, and Llama2, and measured the similarity between the generated and original answers. Results: The latest general LLMs, GPT-3.5 and Llama2, exhibited superior performance, particularly in generating responses to medical inquiries from the PubMedQA data set. Conclusions: Considering the rapid advancements in LLM development in recent years, it is hypothesized that version upgrades of general LLMs offer greater potential for enhancing their ability to generate “knowledge text” in the biomedical domain compared with fine-tuning for the biomedical field. These findings are expected to contribute significantly to the evolution of AI-based medical counseling systems. %M 39763114 %R 10.2196/64318 %U https://medinform.jmir.org/2025/1/e64318 %U https://doi.org/10.2196/64318 %U http://www.ncbi.nlm.nih.gov/pubmed/39763114 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e66665 %T Identifying Adolescent Depression and Anxiety Through Real-World Data and Social Determinants of Health: Machine Learning Model Development and Validation %A Mardini,Mamoun T %A Khalil,Georges E %A Bai,Chen %A DivaKaran,Aparna Menon %A Ray,Jessica M %K social determinants of health %K adolescents %K anxiety %K depression %K machine learning %K real-world data %K teenagers %K youth %K XGBoost %K cross-validation technique %K SHapley Additive exPlanation %K mental health %K mental disorder %K mental illness %K health outcomes %K clinical data %D 2025 %7 12.2.2025 %9 %J JMIR Ment Health %G English %X Background: The prevalence of adolescent mental health conditions such as depression and anxiety has significantly increased. Despite the potential of machine learning (ML), there is a shortage of models that use real-world data (RWD) to enhance early detection and intervention for these conditions. Objective: This study aimed to identify depression and anxiety in adolescents using ML techniques on RWD and social determinants of health (SDoH). Methods: We analyzed RWD of adolescents aged 10‐17 years, considering various factors such as demographics, prior diagnoses, prescribed medications, medical procedures, and laboratory measurements recorded before the onset of anxiety or depression. Clinical data were linked with SDoH at the block-level. Three separate models were developed to predict anxiety, depression, and both conditions. Our ML model of choice was Extreme Gradient Boosting (XGBoost) and we evaluated its performance using the nested cross-validation technique. To interpret the model predictions, we used the Shapley additive explanation method. Results: Our cohort included 52,054 adolescents, identifying 12,572 with anxiety, 7812 with depression, and 14,019 with either condition. The models achieved area under the curve values of 0.80 for anxiety, 0.81 for depression, and 0.78 for both combined. Excluding SDoH data had a minimal impact on model performance. Shapley additive explanation analysis identified gender, race, educational attainment, and various medical factors as key predictors of anxiety and depression. Conclusions: This study highlights the potential of ML in early identification of depression and anxiety in adolescents using RWD. By leveraging RWD, health care providers may more precisely identify at-risk adolescents and intervene earlier, potentially leading to improved mental health outcomes. %R 10.2196/66665 %U https://mental.jmir.org/2025/1/e66665 %U https://doi.org/10.2196/66665 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 8 %N %P e66448 %T Changes in Internet Activities and Influencing Factors for Problematic Internet Use During the COVID-19 Pandemic in Korean Adolescents: Repeated Cross-Sectional Study %A Kim,Sol I %A Jin,Jae-Chan %A Yoo,Seo-Koo %A Han,Doug Hyun %+ Department of Psychiatry, Chung Ang University Hospital, 102 Heusok ro, Seoul, 06973, Republic of Korea, 82 62993132, hduk70@gmail.com %K coronavirus pandemic %K internet use pattern %K internet games %K short-form videos %K social network system %K depressed mood %K internet use %K pandemic %K internet %K COVID-19 %K video %K internet behavior %K social media %K internet addiction %K depression %K anxiety %K digital platforms %K mobile phone %D 2025 %7 11.2.2025 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: As adolescents increasingly engage with digital experiences, the internet serves as a platform for social interaction, entertainment, and learning. The COVID-19 pandemic accelerated this trend, with remote learning and restricted physical interactions driving changes in internet behavior. Adolescents spent more time on gaming and social media, reflecting a notable shift in use patterns. Objective: We hypothesized that the COVID-19 pandemic changed internet use patterns among Korean adolescents, including content types, time spent on web-based activities, and pathological use prevalence. Additionally, we anticipated that these changes would correlate with shifts in adolescents’ psychological status during the pandemic. Methods: Data from 827 adolescents aged 12 to 15 years (n=144 in 2018, n=142 in 2019, n=126 in 2020, n=130 in 2021, n=143 in 2022, and n=142 in 2023) were gathered over 6 years from 43 middle schools across 16 regions and 1 hospital in South Korea. The demographic data collected included age, sex, and school year. Participants also provided information on their internet use patterns and levels of internet addiction. Additionally, psychological status, including mood, anxiety, attention, and self-esteem, was assessed. Results: There were significant differences in the depression scale (Patient Health Questionnaire 9). The Patient Health Questionnaire 9 scores for 2018, 2019, and 2023 decreased compared to those in 2020, 2021, and 2022 (F5=3.07; P=.007). Regarding changes in internet use behavior, game playing among adolescents decreased after the pandemic compared to before, while watching videos increased. Additionally, the rate of problematic internet use was highest for games before COVID-19, but after COVID-19, it was highest for videos, and this trend continued until 2023 (χ23=8.16, P=.04). Furthermore, this study showed that the Young’s Internet Addiction Scale (YIAS) score was highest in the game group in 2018 compared to other groups before COVID-19 (F5=14.63; P<.001). In 2019, both the game and video groups had higher YIAS scores than other groups (F5=9.37; P<.001), and by 2022, the YIAS scores among the game, video, and Social Network Service groups did not differ significantly. The degree of influence on the severity of internet addiction was also greatest for games before COVID-19, but after COVID-19, the effect was greater for videos than for games. Conclusions: During the COVID-19 pandemic, internet use for academic and commercial purposes, including remote classes and videoconferences, increased rapidly worldwide, leading to a significant rise in overall internet use time. The demand for and dependence on digital platforms is expected to grow even further in the coming era. Until now, concerns have primarily focused on the use of games, but it is now necessary to consider what types of internet behaviors cause problems and how to address them. %M 39933170 %R 10.2196/66448 %U https://pediatrics.jmir.org/2025/1/e66448 %U https://doi.org/10.2196/66448 %U http://www.ncbi.nlm.nih.gov/pubmed/39933170 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 11 %N %P e57500 %T Incidence of Deliberate Self-Harm in Hong Kong Before and During the COVID-19 Pandemic: Population-Wide Retrospective Cohort Study %A Luk,Luke Y F %A Ching,Christie J Y %A Yip,Tsz Fung %A Chan,Sunny C L %A Lam,Catherine Y T %A Lam,Elizabeth T C %A Yue,Serena R B %A Pang,Hoi Ching %A Wong,Janet Y H %A Wong,Carlos K H %A Tong,Chak Kwan %A Yamamoto,Tafu %A Rainer,Timothy H %A Wai,Abraham K C %A Ho,Joshua W K %K emergency department %K COVID-19 %K deliberate self-harm %K mental health %K self-harm %K self-injury %K self-violence %K Hong Kong %K SARS-Cov-2 %D 2025 %7 10.2.2025 %9 %J JMIR Public Health Surveill %G English %X Background: COVID-19 ended on May 5, 2023, and since then Hong Kong reported increased mental distress, which was speculated to be from the policies implemented during the pandemic. Despite this, longitudinal surveillance of deliberate self-harm (DSH) incidences throughout the pandemic in Hong Kong remained insufficient. Objective: The objective of this study was to outline the changes in DSH incidences before and during the COVID-19 pandemic in Hong Kong, with respect to sex, age, and co-occurring mental health issues. Methods: A quasi-experiment was conducted using an interrupted time series design to estimate the impact of the pandemic on DSH-related emergency department (ED) visits. This design enabled the estimation of DSH-related ED visits based on prepandemic data from 2016 to 2019, assuming the pandemic had not occurred, and allowed for a comparison with observed DSH-related ED visits during the pandemic. The descriptive results were reported as the observed monthly DSH-related ED visits and observed incidence ratios during the pandemic. Afterwards, a negative binomial model was fitted to the prepandemic data (2016‐2019) and adjusted for temporal trends, seasonality, and population variation to estimate the expected monthly DSH-related ED visits and adjusted incidence ratios (aIRs). Results: Between January 2016 and December 2022, a total of 31,893 DSH episodes were identified. Initial descriptive analysis showed a significant difference in demographic characteristics (sex) and clinical characteristics (death within 28 d, diagnoses of co-occurring mental health issues, public assistance pay code, and triage level). Subsequent interrupted time-series analysis demonstrated significantly increasing trends in comparison with the prepandemic period. As reported in the aIRs among young adult males (aIR in 2020=1.34, P=.002; 2021: aIR=1.94, P<.001; and 2022: aIR=2.53, P<.001), adult males (aIR in 2020=1.58, P<.001; 2021: aIR=2.64, P<.001; and 2022: aIR=3.13, P<.001), adult females (aIR in 2020=1.13, P=.01; 2021: aIR=1.52, P<.001; and 2022: aIR=1.64, P<.001), and older male adults (aIR in 2020=1.53, P<.001; 2021: aIR=2.37, P<.001; and 2022: aIR=3.01, P<.001). Conclusions: The average annual DSH-related ED visits increased during the pandemic period. Therefore, there is a need to raise awareness for such vulnerable groups in Hong Kong to prepare for postpandemic spillover. %R 10.2196/57500 %U https://publichealth.jmir.org/2025/1/e57500 %U https://doi.org/10.2196/57500 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e56203 %T Efficacy of a Blended Low-Intensity Internet-Delivered Psychological Program in Patients With Multimorbidity in Primary Care: Randomized Controlled Trial %A Monreal-Bartolomé,Alicia %A Castro,Adoración %A Pérez-Ara,M Ángeles %A Gili,Margalida %A Mayoral,Fermín %A Hurtado,María Magdalena %A Varela Moreno,Esperanza %A Botella,Cristina %A García-Palacios,Azucena %A Baños,Rosa M %A López-Del-Hoyo,Yolanda %A García-Campayo,Javier %A Montero-Marin,Jesus %+ Aragon Institute for Health Research, IIS Aragon, C. de Pedro Cerbuna, 12, Zaragoza, 50009, Spain, 34 686 673 302, jgarcamp@gmail.com %K multimorbidity %K depression %K type 2 diabetes %K low back pain %K primary care %K blended %K internet %K randomized controlled trial %K RCT %D 2025 %7 10.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Multimorbidity is a highly prevalent phenomenon whose presence causes a profound physical, psychological, and economic impact. It hinders help seeking, diagnosis, quality of care, and adherence to treatment, and it poses a significant dilemma for present-day health care systems. Objective: This study aimed to assess the effectiveness of improved treatment as usual (iTAU) combined with a blended low-intensity psychological intervention delivered using information and communication technologies for the treatment of multimorbidity (depression and type 2 diabetes or low back pain) in primary care settings. Methods: A 2-armed, parallel-group, superiority randomized controlled trial was designed for this study. Participants diagnosed with depression and either type 2 diabetes or low back pain (n=183) were randomized to “intervention + iTAU” (combining a face-to-face intervention with a supporting web-based program) or “iTAU” alone. The main outcome consisted of a standardized composite score to consider (1) severity of depressive symptoms and (2a) diabetes control or (2b) pain intensity and physical disability 3 months after the end of treatment as the primary end point. Differences between the groups were estimated using mixed effects linear regression models, and mediation evaluations were conducted using path analyses to evaluate the potential mechanistic role of positive and negative affectivity and openness to the future. Results: At 3-month follow-up, the intervention + iTAU group (vs iTAU) exhibited greater reductions in composite multimorbidity score (B=–0.34, 95% CI –0.64 to –0.04; Hedges g=0.39) as well as in depression and negative affect and improvements in perceived health, positive affect, and openness to the future. Similar positive effects were observed after the intervention, including improvements in physical disability. No significant differences were found in glycosylated hemoglobin, pain intensity, or disability at 3-month follow-up (P=.60; P=.79; and P=.43, respectively). Path analyses revealed that the intervention had a significant impact on the primary outcome, mediated by both positive and negative affect (positive affect: indirect effect=–0.15, bootstrapped 95% CI –0.28 to –0.03; negative affect: indirect effect=–0.14, bootstrapped 95% CI –0.28 to –0.02). Conclusions: This study supports the efficacy of a low-intensity psychological intervention applied in a blended format on multimorbidity in primary care. It justifies the exploration of the conceptualization of depression in type 2 diabetes as well as the analysis of the implementation of such interventions in routine clinical practice. Trial Registration: ClinicalTrials.gov NCT03426709; https://clinicaltrials.gov/study/NCT03426709 International Registered Report Identifier (IRRID): RR2-10.1186/S12888-019-2037-3 %M 39928931 %R 10.2196/56203 %U https://www.jmir.org/2025/1/e56203 %U https://doi.org/10.2196/56203 %U http://www.ncbi.nlm.nih.gov/pubmed/39928931 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e63799 %T Urban-Rural Differences in the Association Between Internet Use Trajectories and Depressive Symptoms in Chinese Adolescents: Longitudinal Observational Study %A Liu,Yujie %A Ge,Xin %A Wang,Ying %A Yang,Xue %A Liu,Shangbin %A Xu,Chen %A Xiang,Mi %A Hu,Fan %A Cai,Yong %+ Public Health Research Center, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, 1111 Xianxia Road, Shanghai, 200335, China, 86 021 63846590 ext 776198, caiyong202028@hotmail.com %K internet use %K trajectory %K depressive symptoms %K adolescent %K urban %K rural %D 2025 %7 7.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet use exhibits diverse trajectories during adolescence, which may contribute to depressive symptoms. Currently, it remains unclear whether the association between internet use trajectories and depressive symptoms varies between urban and rural areas. Objective: This study aimed to investigate the association between internet use trajectories and adolescent depressive symptoms and to explore variation in this association between urban and rural areas. Methods: This longitudinal study used 3-wave data from the 2014-2018 China Family Panel Study. Weekly hours of internet use and depressive symptoms were measured using self-reported questionnaires. Latent class growth modeling was performed to identify the trajectories of internet use. Multivariable logistic regressions were used to examine the association between internet use trajectories and depressive symptoms, stratified by rural and urban residence. Results: Participants were 2237 adolescents aged 10 to 15 years at baseline (mean age 12.46, SD 1.73 years). Two latent trajectory classes of internet use were identified: the low-growth group (n=2008, 89.8%) and the high-growth group (n=229, 10.2%). The high-growth group was associated with higher odds of depressive symptoms (OR 1.486, 95% CI 1.065-2.076) compared to the low-growth group. In the stratified analysis, the association between internet use trajectories and depressive symptoms was significant solely among rural adolescents (OR 1.856, 95% CI 1.164-2.959). Conclusions: This study elucidates urban-rural differences in the associations between trajectories of internet use and adolescent depressive symptoms. Our findings underscore the importance of prioritizing interventions for rural adolescents’ internet use behaviors to mitigate negative effects on their mental health. %M 39919294 %R 10.2196/63799 %U https://www.jmir.org/2025/1/e63799 %U https://doi.org/10.2196/63799 %U http://www.ncbi.nlm.nih.gov/pubmed/39919294 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e62915 %T Women Empowered to Connect With Addiction Resources and Engage in Evidence-Based Treatment (WE-CARE)—an mHealth Application for the Universal Screening of Alcohol, Substance Use, Depression, and Anxiety: Usability and Feasibility Study %A Isaacs,Krystyna %A Shifflett,Autumn %A Patel,Kajal %A Karpisek,Lacey %A Cui,Yi %A Lawental,Maayan %A Tzilos Wernette,Golfo %A Borsari,Brian %A Chang,Katie %A Ma,Tony %+ Benten Technologies, 9408 Grant Ave, Unit 206, Manassas, VA, 20110, United States, 1 7036625858, krysisaacs@gmail.com %K service linkage %K digital health %K education %K mental health %K substance use disorder %K SUD %K alcohol use disorder %K chatbot %K childbearing women %K women %K alcohol %K substance use %K empowerment %K evidence-based treatment %K usability %K feasibility %K mobile health %K mhealth %K app %K depression %K anxiety %K screening %K e-screening %D 2025 %7 7.2.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Women of childbearing age (aged 18-44 years) face multiple barriers to receiving screening and treatment for unhealthy alcohol and substance use, depression, and anxiety, including lack of screening in the primary care setting and lack of support in accessing care. The Women Empowered to Connect with Addiction Resources and Engage in Evidence-based Treatment (WE-CARE) mobile app was developed to test universal screening with women of childbearing age and linkage to care after an anonymous assessment. Objective: In this study, we aimed to investigate the feasibility and acceptability of providing anonymous screening instruments through mobile phones for alcohol and substance use, as well as depression and anxiety, for women of childbearing age. Methods: We used agile development principles based on previous formative research to test WE-CARE mobile health app with women of childbearing age (N=30) who resided in 1 of 6 counties in central Florida. WE-CARE included screening instruments (for alcohol, substance use, depression, and anxiety), a moderated discussion forum, educational microlearning videos, a frequently asked questions section, and resources for linkage to treatment. Individuals were recruited using flyers, academic listserves, and a commercial human subject recruiting company (Prolific). Upon completion of the screening instruments, women explored the educational and linkage to care features of the app and filled out a System Usability Scale to evaluate the mobile health app’s usability and acceptability. Postpilot semistructured interviews (n=4) were conducted to further explore the women’s reactions to the app. Results: A total of 77 women downloaded the application and 30 completed testing. Women of childbearing age gave the WE-CARE app an excellent System Usability Scale score of 86.7 (SD 12.43). Our results indicate elevated risk for substance use in 18 of the 30 (60%) participants, 9/18 (50%) also had an elevated risk for anxiety or depression, and 11/18 (61%) had an elevated risk for substance use, anxiety, or depression. Participants reported that WE-CARE was easy to navigate and use but they would have liked to see more screening questions and more educational content. Linkage to care was an issue; however, as none of the women identified as “at-risk” for substance use disorders contacted the free treatment clinic for further evaluation. Conclusions: The mobile health app was highly rated for acceptability and usability, but participants were not receptive to seeking help at a treatment center after only a few brief encounters with the app. The linkage to care design features was likely insufficient to encourage them to seek treatment. The next version of WE-CARE will include normative scores for participants to self-evaluate their screening status compared with their age- and gender-matched peers and enhanced linkages to care features. Future development will focus on enhancing engagement to improve change behaviors and assess readiness for change. %M 39918861 %R 10.2196/62915 %U https://formative.jmir.org/2025/1/e62915 %U https://doi.org/10.2196/62915 %U http://www.ncbi.nlm.nih.gov/pubmed/39918861 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e63515 %T Evaluation of a Guided Chatbot Intervention for Young People in Jordan: Feasibility Randomized Controlled Trial %A de Graaff,Anne Marijn %A Habashneh,Rand %A Fanatseh,Sarah %A Keyan,Dharani %A Akhtar,Aemal %A Abualhaija,Adnan %A Faroun,Muhannad %A Aqel,Ibrahim Said %A Dardas,Latefa %A Servili,Chiara %A van Ommeren,Mark %A Bryant,Richard %A Carswell,Kenneth %+ Department of Mental Health, Brain Health and Substance Use, World Health Organization, Av. Appia 20, Geneva, 1211, Switzerland, 41 792493513, degraaffa@who.int %K chatbot %K youth %K depression %K anxiety %K feasibility study %K randomized controlled trial %K mental health %K evaluation %K Jordan %K CBT %K psychological treatment %K digital intervention %K health intervention %K mood disorder %K digital health %D 2025 %7 5.2.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression and anxiety are a leading cause of disability worldwide and often start during adolescence and young adulthood. The majority of young people live in low- and middle-income countries where there is a lack of mental health services. The World Health Organization (WHO) developed a guided, nonartificial intelligence chatbot intervention called Scalable Technology for Adolescents and youth to Reduce Stress (STARS) to reduce symptoms of depression and anxiety among young people affected by adversity. Objective: The objective of this study was to evaluate the feasibility of the STARS intervention and study procedures among young people in Jordan. Methods: A 2-arm, single-blind, feasibility randomized controlled trial was conducted among 60 young people aged 18 years to 21 years living in Jordan with self-reported elevated levels of psychological distress. Immediately after baseline, participants were randomized 1:1 into the STARS intervention or enhanced care as usual (ECAU). STARS consisted of 10 lessons in which participants interacted with a chatbot and learned several cognitive behavioral therapy strategies, with optional guidance by a trained e-helper through 5 weekly phone calls. ECAU consisted of a static web page providing basic psychoeducation. Online questionnaires were administered at baseline (week 0) and postassessment (week 8) to assess depression (Hopkins Symptom Checklist-25 [HSCL-25]), anxiety (HSCL-25), functional impairment (WHO Disability Assessment Schedule [WHODAS] 2.0), psychological well-being (WHO-Five Well-Being Index [WHO-5]), and agency (State Hope Scale). Process evaluation interviews with stakeholders were conducted after the postassessment. Results: Participants were recruited in December 2022 and January 2023. Of 700 screening website visits, 160 participants were eligible, and 60 participants (mean age 19.7, SD 1.16 years; 49/60, 82% female) continued to baseline and were randomized into STARS (n=30) or ECAU (n=30). Of those who received STARS, 37% (11/30) completed at least 8 chatbot lessons, and 13% (4/30) completed all 5 support calls. The research protocol functioned well in terms of balanced randomization, high retention at postassessment (48/60, 80%), and good psychometric properties of the online questionnaires. Process evaluation interviews with STARS participants, ECAU participants, e-helpers, and the clinical supervisor indicated the acceptability of the study procedures and the STARS and ECAU conditions and highlighted several aspects that could be improved, including the e-helper support and features of the STARS chatbot. Conclusions: This study demonstrated the feasibility and acceptability of the STARS intervention and research procedures. A fully powered, definitive randomized controlled trial will be conducted to evaluate the effectiveness of STARS. Trial Registration: ISRCTN ISRCTN19217696; https://doi.org/10.1186/ISRCTN19217696 %M 39908538 %R 10.2196/63515 %U https://mental.jmir.org/2025/1/e63515 %U https://doi.org/10.2196/63515 %U http://www.ncbi.nlm.nih.gov/pubmed/39908538 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 12 %N %P e43618 %T The Effects of Digital eHealth Versus Onsite 2-Day Group-Based Education in 255 Patients With Irritable Bowel Syndrome: Cohort Study %A Berentsen,Birgitte %A Thuen,Camilla %A Hillestad,Eline Margrete Randulff %A Steinsvik,Elisabeth Kjelsvik %A Hausken,Trygve %A Hatlebakk,Jan Gunnar %K irritable bowel syndrome %K IBS %K eHealth %K internet-guided %K patient education %K self-management %K self-reported %K patient behavior %K quality of life %K QOL %K anxiety %K depression %K gastrointestinal %K physiotherapist %K kinesiology %K cognitive behavioural therapy %K CBT %K Hospital Anxiety and Depression Scale %K HADS %K client satisfaction questionnaire %K CSQ %K Mann-Whitney U test %K nonparametric %K Wilcoxon test %K neurogastroenterology %D 2025 %7 3.2.2025 %9 %J JMIR Hum Factors %G English %X Background: Irritable bowel syndrome (IBS) has a high worldwide prevalence and there are few effective treatment options. Patient education can influence patient behavior that subsequently may lead to changes in attitudes and skills necessary for maintenance or improvement in management of symptom severity and quality of life. However, as postdiagnostic patient education can be resource demanding, assessment of digital approaches and verification of their effectiveness is warranted. Objective: This cohort study aimed to investigate the effects of a digital web-based multidisciplinary eHealth program on the domains of symptom severity (Irritable Bowel Syndrome Symptom Severity Scale [IBS-SSS]), quality of life (irritable bowel syndrome quality of life [IBS-QOL]), anxiety and depression (Hospital Anxiety and Depression Scale), and a measure of general client satisfaction (client satisfaction questionnaire), compared with an onsite multidisciplinary 2-day group-based education program (“IBS-school”), in 2 cohorts of 255 patients with IBS. Methods: Patients diagnosed with IBS, aged 15-70 years, were enrolled after referral to the Section of Gastroenterology at Haukeland University Hospital, Norway. In total, 132 patients were recruited to the eHealth program and 123 to the IBS-school group for comparison. Data were self-reported and collected digitally at enrollment and after 3 months, between 2017 and 2019. Furthermore, 71 attending the eHealth program and 49 attending the IBS-school completed the questionnaires at 3 months. Intervention response was defined as a reduction of ≥50 points on the IBS-SSS. Results: Patients attending the eHealth program reported a significant reduction in IBS symptom severity 3 months after treatment (n=71), compared with patients attending the IBS-school (n=50). Overall, patients categorized as intervention responders in both programs showed a significant reduction in symptom severity at 3 months. Here, 41% (29/71) of patients attending the eHealth program reported a mean IBS-SSS reduction of 103 (SD 72.0) points (P<.001). In addition, these patients reported reduced anxiety (P>.001) and depression (P=.002) and enhanced quality of life (P=.03), especially the degrees of dysphoria, body image, food avoidance, health worry, interference with activity, relations, and social relations. Patients responding to the IBS-school intervention (18/50, 36%) reported a mean IBS-SSS reduction of 119 (SD 86.2) points (P<.001), and reduced depression scores (P=.046), but no difference in overall quality of life. Both groups reported the respective interventions as “good” quality health care programs, scoring them 23.5 (SD 4)—the eHealth program 23.5 (SD 4), and the IBS-school 24.2 (SD 4)—on the client satisfaction questionnaire. Conclusions: We conclude that the digital multidisciplinary eHealth program has a significant effect on IBS symptom severity in a portion of patients; it is useful as a tool in disease self-management and does not result in worse symptom scores than an onsite multidisciplinary 2-day group-based education program after 3 months. We believe these results indicate that a digital eHealth approach is preferable to an onsite multidisciplinary 2-day group-based education program covering the same topics. %R 10.2196/43618 %U https://humanfactors.jmir.org/2025/1/e43618 %U https://doi.org/10.2196/43618 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e63139 %T Effectiveness of Cognitive Behavioral Therapy Provided Through a Web Application for Subthreshold Depression, Subthreshold Insomnia, and Subthreshold Panic: Open-Labeled 6-Arm Randomized Clinical Trial Pilot Study %A Taguchi,Kayoko %A Miyoshi,Mirai %A Seki,Yoichi %A Baba,Shiori %A Shimizu,Eiji %+ Research Center for Child Mental Development, Chiba University, chuo-ku, Inohana 1-8-1, Chiba, 260-8670, Japan, 81 43 226 2027, k.taguchi@chiba-u.jp %K minimally important change %K nonguided cognitive behavioral therapy %K subthreshold depression %K subthreshold insomnia %K subthreshold panic %K cognitive behavioral therapy %K CBT %K psychiatric disease %K primary care %K interventions %K depression %K anxiety %K insomnia %K psychological therapy %D 2025 %7 3.2.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: A common definition of “subthreshold” is that the diagnostic threshold is not met but the individuals are not asymptomatic. Some symptoms are present, causing significant difficulty in functioning and negatively impacting quality of life. Despite the attention given to subthreshold symptoms and the interventions for subthreshold symptoms being efficient in preventing the transition to psychiatric disease in primary care, reports on specific interventions are insufficient. Objective: This study aimed to verify the effectiveness of internet-delivered cognitive behavioral therapy (ICBT) for subthreshold depression (SD), subthreshold insomnia (SI), and subthreshold panic (SP). Additionally, this study aimed to explore the minimally important change (MIC) of each subthreshold group’s effectiveness outcome. Methods: Participants aged 18-70 years from internet research monitors were categorized into SD, SI, and SP groups based on screening assessment. They were randomly assigned to intervention or control groups within each subthreshold symptom. The intervention groups worked on 4 weeks of nonguided ICBT (“Mentre”), while the control groups worked on a sham app. The primary outcome was the score change from screening (T1) to 4-week follow-up (T4) using the Center for Epidemiologic Studies Depression Scale (CESD) in the SD group, the Pittsburgh Sleep Quality Index (PSQI) in the SI group, and the Panic and Agoraphobia Scale (PAS) in the SP group. Secondary outcomes were score changes in the Generalized Anxiety Disorder-7 (GAD-7) scale, the Patient Health Questionnaire 9 (PHQ-9), the CESD, the PSQI, and the PAS, except the primary outcome in each group. Secondary outcomes were analyzed using complete-case analysis and repeated-measures ANOVA. Additionally, the MIC in the primary endpoint for each group was also calculated as an exploratory outcome. Results: The SD, SP, and SI groups contained 846, 597, and 1106 participants, respectively. In the SD group, the difference in the CESD score change from baseline to follow-up between the intervention and control groups was significant (difference=0.52, 95% CI 1.29-4.66, P<.001). In the SI group, the difference in the PSQI score change was also significant (difference=0.53, 95% CI 0.11-0.94, P=.01). However, in the SP group, the difference in the PAS score change was not significant (difference=0.07, 95% CI –2.00 to 2.15, P=.94). Conclusions: Our ICBT program Mentre contributes to the improvement of SI and SD. This suggests that nonguided ICBT may be effective in preventing SI and SD from progressing to the full threshold. However, appropriate definitions of subthreshold symptoms are necessary. In particular, it is difficult to define SP, and further research that considers the specific factors of each subthreshold symptom is necessary to accumulate evidence. Trial Registration: University Hospital Medical Information Network (UMIN) UMIN000051280; https://tinyurl.com/2wyahhe3 %M 39899369 %R 10.2196/63139 %U https://formative.jmir.org/2025/1/e63139 %U https://doi.org/10.2196/63139 %U http://www.ncbi.nlm.nih.gov/pubmed/39899369 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e65399 %T Impact of Internet Usage on Depression Among Older Adults: Comprehensive Study %A Guo,Lin %A Li,Yunwei %A Cheng,Kai %A Zhao,Ying %A Yin,Wenqiang %A Liu,Ying %+ School of Humanities and Management, Zhejiang Chinese Medical University, No. 260 Baichuan Street, Fuyang District, Hangzhou, 311402, China, 86 18667013568, skyliu2171@163.com %K internet usage %K depression %K older people %K mechanism %K heterogeneity %K mobile phone %D 2025 %7 31.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is a widespread mental health issue affecting older adults globally, with substantial implications for their well-being. Although digital interventions have proven effective in high-income countries, research on the potential of internet usage to alleviate depression among older adults in high-income countries remains limited. Objective: This study aimed to examine the impact of internet usage on depression among older adults in high-income countries by developing a comprehensive theoretical framework and testing key hypotheses. Methods: Using data from the China Health and Retirement Longitudinal Study (CHARLS), a 2-stage instrumental variable approach was applied to address endogeneity and estimate causal relationships between internet usage and depression. Results: The findings indicate that internet usage results in a 1.41% reduction in depression levels among older adults. This effect is mediated by four primary mechanisms: (1) enhanced social interaction, (2) increased physical activity, (3) improved intergenerational contact, and (4) expanded access to educational opportunities. A heterogeneity analysis revealed that these effects are more pronounced in urban areas, eastern regions, and regions with superior internet infrastructure. Conclusions: Internet usage plays a crucial role in alleviating depression among older adults in high-income countries, with regional variations. The findings highlight the need for targeted policy interventions to improve internet access and digital literacy, which can mitigate depression and enhance the mental health of older adults. %M 39890098 %R 10.2196/65399 %U https://www.jmir.org/2025/1/e65399 %U https://doi.org/10.2196/65399 %U http://www.ncbi.nlm.nih.gov/pubmed/39890098 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e52351 %T Access to Health Care and Use of Health Care Services Among Males in Africa: Protocol for a Scoping Review %A Mashilo,Nkoleleng Johannah %A Oladimeji,Kelechi Elizabeth %A Gumede,Siphamandla %A Lalla-Edward,Samanta Tresha %+ Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Sunnyside Office Park, Parktown, Johannesburg, 2193, South Africa, 27 0824447126, nkolemashilo@gmail.com %K health-seeking behavior %K health care %K access %K uptake %K services %K men %K boys %K scoping review %K Africa %K male %K health care services %K accessibility %K use %K noncommunicable disease %K depression %K substance abuse %K overdose %K physical disability %K stress %K older men %K men’s health %K well-being %K health literacy %K perception %K systematic reviews %K meta-analysis %K electronic database %K EHR %K electronic health record %K narrative synthesis %D 2025 %7 31.1.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is a scarcity of data on males’ health-seeking behavior, as well as their access to and use of health care services, in Africa. According to some studies, men are less likely than women to seek medical help for issues such as communicable and noncommunicable diseases, depression, substance abuse, physical disabilities, and stressful life events. The study of males’ health-seeking behaviors is important, because it allows us to learn about male health, how masculinity encourages underuse of health care services, how this affects males’ overall health and well-being, and how cultural values and backgrounds may impact older men’s health-seeking behaviors. Objective: The objective of this review is to assess evidence on how males access and use health care services and their health knowledge, attitudes, and perceptions to identify gaps for targeted, context-specific strategies to improve males’ health and outcomes, particularly in Africa. Methods: The scoping review process will be guided by the methodology frameworks of the Joanna Briggs Institute and Arksey and O’Malley and will follow the Preferred Reporting Items for Systematic reviews and Meta-analysis Protocols Extension for Scoping Reviews guidelines. The following electronic databases will be systematically searched for evidence published between January 2010 and 2023: PubMed, Scopus, Web of Science, African Journals Online, and Google Scholar. Two reviewers will independently screen full texts and chart the data; a third reviewer will be engaged in the event of disagreement between the 2 independent reviewers. The results of this scoping review will be summarized quantitatively through numerical counts and qualitatively through a narrative synthesis. Results: The electronic database search was conducted between March and April 2023 and redone in April 2024 to include the most recent articles. A total of 114,737 articles were retrieved and 4258 removed as duplicates. After title screening, 337 results remained, and after abstract selection, 140 results remained. As of December 2024, the scoping review was in the full-text screening phase. We plan to complete data extraction, synthesis, and writing of the entire manuscript of the review in January 2025, and then submit it to a journal for peer review and publication in February 2025. Conclusions: The scoping review results will advance the current knowledge about health-seeking behavior and access to and uptake of health care services among African males. To our knowledge, this scoping review is the first on this topic, and it will identify vital information on the barriers to and facilitators of African males’ health care access and uptake. It will also provide information on successful health care programs for males that may be tailored and adopted across different African contexts. Trial Registration: OSF Registries https://osf.io/xz6sr International Registered Report Identifier (IRRID): DERR1-10.2196/52351 %M 39889277 %R 10.2196/52351 %U https://www.researchprotocols.org/2025/1/e52351 %U https://doi.org/10.2196/52351 %U http://www.ncbi.nlm.nih.gov/pubmed/39889277 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e54216 %T Self-Guided Smartphone App (Vimbo) for the Reduction of Symptoms of Depression and Anxiety in South African Adults: Pilot Quantitative Single-Arm Study %A Steyn,Sherrie %A Slabbert,Meggan %+ Vimbo Health SA (Pty) Ltd, 20 Riverclub Mews, 7 Sycamore Avenue, Riverclub, Sandton, 2191, South Africa, 27 63 861 6780, sherrie@vimbohealth.com %K treatment gap %K mental health %K health %K depression %K anxiety %K South Africa %K CBT %K cognitive behavioral therapy %K app-based intervention %K mobile health %K mental health app %K smartphone %K mobile phone %D 2025 %7 30.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Barriers to mental health assessment and intervention have been well documented within South Africa, in both urban and rural settings. Internationally, evidence has emerged for the effectiveness of technology and, specifically, app-based mental health tools and interventions to help overcome some of these barriers. However, research on digital interventions specific to the South African context and mental health is limited. Objective: This pilot study investigated the feasibility of using an app (Vimbo) to treat symptoms of anxiety and depression in South African adults recruited from a community sample. The Vimbo app is a self-guided, cognitive behavioral therapy–based digital intervention for common mental health difficulties developed for the South African context. Methods: This pilot study used a naturalistic, single-arm design testing the Vimbo app over 12 weeks, from October 2020 to February 2021. Participants were recruited through the South African Depression and Anxiety Group and social media advertisements online. A 2-week retention period was used to allow for a minimum of 2 datasets. App usage and engagement metrics were extracted directly from the back end of the app. Based on the model, researchers expected many users to discontinue usage when their symptom levels entered a healthy range. Pre-post review of symptom levels was used to reflect on clinical recovery status at discontinuation after the retention period. Results: A total of 218 applicants met study eligibility criteria and were invited to download the Vimbo app. Of these, 52% (114/218) of the participants registered with the app, who indicated multiple variances of depression and anxiety symptoms ranging in severity from mild to severe. Two participants users withdrew from the study. Moreover, 69% (77/112) of users were retained, including 8 who had technical issues with their treatment. When comparing broad uptake across all interested participants, chi-square analysis indicated significantly reduced uptake in participants identifying as “unemployed but seeking employment” (χ24=10.47; N=251; P=.03). When considering app usage for the entire cohort (n=69, excluding participants with technical issues), there was a mean of 72.87 (SD 71.425) total module pages read, a mean of 30% (SD 29.473%) of prescribed content completed, and a mean of 19.93 (SD 27.517) times engaging with tools and skills. Conclusions: Our findings support the case for continued exploration of app-based interventions for treating depression and anxiety in South Africa. Developing strategies to increase access and improve intervention uptake may prove essential to helping mobile health interventions make as significant an impact as possible. Future research should include a randomized controlled trial with a larger sample to further assess the efficacy of app-based interventions in treating mental health difficulties in South Africa. %M 39883938 %R 10.2196/54216 %U https://formative.jmir.org/2025/1/e54216 %U https://doi.org/10.2196/54216 %U http://www.ncbi.nlm.nih.gov/pubmed/39883938 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e55308 %T Investigating Smartphone-Based Sensing Features for Depression Severity Prediction: Observation Study %A Terhorst,Yannik %A Messner,Eva-Maria %A Opoku Asare,Kennedy %A Montag,Christian %A Kannen,Christopher %A Baumeister,Harald %+ Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Lise-Meitner-Str. 16, Ulm, 89081, Germany, 49 8921805057, yannik.terhorst@psy.lmu.de %K smart sensing %K digital phenotyping %K depression %K observation study %K smartphone %K mHealth %K mobile health %K app %K mental health %K symptoms %K assessments %D 2025 %7 30.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Unobtrusively collected objective sensor data from everyday devices like smartphones provide a novel paradigm to infer mental health symptoms. This process, called smart sensing, allows a fine-grained assessment of various features (eg, time spent at home based on the GPS sensor). Based on its prevalence and impact, depression is a promising target for smart sensing. However, currently, it is unclear which sensor-based features should be used in depression severity prediction and if they hold an incremental benefit over established fine-grained assessments like the ecological momentary assessment (EMA). Objective: The aim of this study was to investigate various features based on the smartphone screen, app usage, and call sensor alongside EMA to infer depression severity. Bivariate, cluster-wise, and cluster-combined analyses were conducted to determine the incremental benefit of smart sensing features compared to each other and EMA in parsimonious regression models for depression severity. Methods: In this exploratory observational study, participants were recruited from the general population. Participants needed to be 18 years of age, provide written informed consent, and own an Android-based smartphone. Sensor data and EMA were collected via the INSIGHTS app. Depression severity was assessed using the 8-item Patient Health Questionnaire. Missing data were handled by multiple imputations. Correlation analyses were conducted for bivariate associations; stepwise linear regression analyses were used to find the best prediction models for depression severity. Models were compared by adjusted R2. All analyses were pooled across the imputed datasets according to Rubin’s rule. Results: A total of 107 participants were included in the study. Ages ranged from 18 to 56 (mean 22.81, SD 7.32) years, and 78% of the participants identified as female. Depression severity was subclinical on average (mean 5.82, SD 4.44; Patient Health Questionnaire score ≥10: 18.7%). Small to medium correlations were found for depression severity and EMA (eg, valence: r=–0.55, 95% CI –0.67 to –0.41), and there were small correlations with sensing features (eg, screen duration: r=0.37, 95% CI 0.20 to 0.53). EMA features could explain 35.28% (95% CI 20.73% to 49.64%) of variance and sensing features (adjusted R2=20.45%, 95% CI 7.81% to 35.59%). The best regression model contained EMA and sensing features (R2=45.15%, 95% CI 30.39% to 58.53%). Conclusions: Our findings underline the potential of smart sensing and EMA to infer depression severity as isolated paradigms and when combined. Although these could become important parts of clinical decision support systems for depression diagnostics and treatment in the future, confirmatory studies are needed before they can be applied to routine care. Furthermore, privacy, ethical, and acceptance issues need to be addressed. %M 39883512 %R 10.2196/55308 %U https://www.jmir.org/2025/1/e55308 %U https://doi.org/10.2196/55308 %U http://www.ncbi.nlm.nih.gov/pubmed/39883512 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e67814 %T Experiences of Peer Mentoring Sexual and Gender Minority Emerging Adults Who Are at Risk for Suicide: Mixed Methods Study %A Tran,Jennifer T %A Webster,Jessica %A Wolfe,James R %A Ben Nathan,Jennifer %A Mayinja,Lindiwe %A Kautz,Marin %A Oquendo,Maria A %A Brown,Gregory K %A Mandell,David %A Mowery,Danielle %A Bauermeister,José A %A Brown,Lily A %+ Department of Family and Community Health, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA, 19104, United States, 1 2158983616, jtgtran@nursing.upenn.edu %K suicide prevention %K peer mentorship %K LGBTQIA health %K mental health %D 2025 %7 29.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Sexual and Gender Diverse Youth (SGDY) are at increased risk for suicide due to unique experiences including discrimination, family or friend rejection, and low positive affect. Peer mentors (PMs) may offer a unique opportunity for intervention but are underutilized for suicide prevention among SGDY. Objective: Little is known about the training needed for PMs when working with SGDY at risk for suicide. We developed an intervention, Supporting Transitions to Adulthood and Reducing Suicide (STARS), to improve suicide prevention among SGDY and increase social support, coping, and positive effects. PMs were trained by a licensed clinical therapist and provided a manual. PMs meet virtually for 6 weeks, providing social support, strategies to diminish the impact of discrimination, connection to safe spaces, and reinforcement of intentions to use Safety Plans with mentees. Methods: To understand PMs’ experiences in their role, including distress, fidelity to the manual, and perceptions of feasibility and acceptability of STARS and mentees’ Safety Plan, we collected survey data from mentees and PMs as well as in-depth interviews with PMs after the completion of the intervention. Results: As of September 2024, all peer mentees (N=64) have completed the study and all PMs have finished providing sessions for peer mentees. PMs (n=5) reported overall high comfort (8.52) and low distress (1.93) during sessions. All 5 PMs had high fidelity (>90%) to the PM intervention training. All 5 PMs reported high feasibility (17.50), acceptability (20), and appropriateness (20) of the STARS intervention. Mentees (n=27) reported high confidence ratings (3.54) in speaking with their PMs. Conclusions: Peer mentorship for SGDY who are at risk for suicide was feasible and acceptable by PMs and mentees alike. PMs reported that they felt comfortable and confident during the sessions. Mentees also reported confidence in working with their PMs. Future research should explore the optimal strategies to support PMs and mentees as they engage in suicide prevention work as well as incorporate feedback from the PMs in this study to ensure optimal outcomes. Trial Registration: ClinicalTrials.gov NCT05018143; https://clinicaltrials.gov/study/NCT05018143 International Registered Report Identifier (IRRID): RR2-10.2196/48177 %M 39879591 %R 10.2196/67814 %U https://formative.jmir.org/2025/1/e67814 %U https://doi.org/10.2196/67814 %U http://www.ncbi.nlm.nih.gov/pubmed/39879591 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 11 %N %P e63809 %T An Explainable Artificial Intelligence Text Classifier for Suicidality Prediction in Youth Crisis Text Line Users: Development and Validation Study %A Thomas,Julia %A Lucht,Antonia %A Segler,Jacob %A Wundrack,Richard %A Miché,Marcel %A Lieb,Roselind %A Kuchinke,Lars %A Meinlschmidt,Gunther %+ Division of Clinical Psychology and Epidemiology, Faculty of Psychology, University of Basel, Missionsstrasse 60/62, Basel, 4055, Switzerland, 49 30 57714627, julia.thomas@krisenchat.de %K deep learning %K explainable artificial intelligence (XAI) %K large language model (LLM) %K machine learning %K neural network %K prevention %K risk monitoring %K suicide %K transformer model %K suicidality %K suicidal ideation %K self-murder %K self-harm %K youth %K adolescent %K adolescents %K public health %K language model %K language models %K chat protocols %K crisis helpline %K help-seeking behaviors %K German %K Shapley %K decision-making %K mental health %K health informatics %K mobile phone %D 2025 %7 29.1.2025 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Suicide represents a critical public health concern, and machine learning (ML) models offer the potential for identifying at-risk individuals. Recent studies using benchmark datasets and real-world social media data have demonstrated the capability of pretrained large language models in predicting suicidal ideation and behaviors (SIB) in speech and text. Objective: This study aimed to (1) develop and implement ML methods for predicting SIBs in a real-world crisis helpline dataset, using transformer-based pretrained models as a foundation; (2) evaluate, cross-validate, and benchmark the model against traditional text classification approaches; and (3) train an explainable model to highlight relevant risk-associated features. Methods: We analyzed chat protocols from adolescents and young adults (aged 14-25 years) seeking assistance from a German crisis helpline. An ML model was developed using a transformer-based language model architecture with pretrained weights and long short-term memory layers. The model predicted suicidal ideation (SI) and advanced suicidal engagement (ASE), as indicated by composite Columbia-Suicide Severity Rating Scale scores. We compared model performance against a classical word-vector-based ML model. We subsequently computed discrimination, calibration, clinical utility, and explainability information using a Shapley Additive Explanations value-based post hoc estimation model. Results: The dataset comprised 1348 help-seeking encounters (1011 for training and 337 for testing). The transformer-based classifier achieved a macroaveraged area under the curve (AUC) receiver operating characteristic (ROC) of 0.89 (95% CI 0.81-0.91) and an overall accuracy of 0.79 (95% CI 0.73-0.99). This performance surpassed the word-vector-based baseline model (AUC-ROC=0.77, 95% CI 0.64-0.90; accuracy=0.61, 95% CI 0.61-0.80). The transformer model demonstrated excellent prediction for nonsuicidal sessions (AUC-ROC=0.96, 95% CI 0.96-0.99) and good prediction for SI and ASE, with AUC-ROCs of 0.85 (95% CI 0.97-0.86) and 0.87 (95% CI 0.81-0.88), respectively. The Brier Skill Score indicated a 44% improvement in classification performance over the baseline model. The Shapley Additive Explanations model identified language features predictive of SIBs, including self-reference, negation, expressions of low self-esteem, and absolutist language. Conclusions: Neural networks using large language model–based transfer learning can accurately identify SI and ASE. The post hoc explainer model revealed language features associated with SI and ASE. Such models may potentially support clinical decision-making in suicide prevention services. Future research should explore multimodal input features and temporal aspects of suicide risk. %M 39879608 %R 10.2196/63809 %U https://publichealth.jmir.org/2025/1/e63809 %U https://doi.org/10.2196/63809 %U http://www.ncbi.nlm.nih.gov/pubmed/39879608 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e47927 %T Implementing Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety in Adults: Systematic Review %A Duffy,Daniel %A Richards,Derek %A Hisler,Garrett %A Timulak,Ladislav %+ Amwell Science, Amwell, 75th State St., 26th Floor, Boston, MA, 02109, United States, 1 617 204 3500, Daniel.Duffy@amwell.com %K mixed methods systematic review %K internet-delivered cognitive behavioral therapy %K iCBT %K implementation science %K implementation research %K depression %K anxiety %D 2025 %7 28.1.2025 %9 Review %J J Med Internet Res %G English %X Background: Scientific implementation findings relevant to the implementation of internet-delivered cognitive behavioral therapy (iCBT) for depression and anxiety in adults remain sparse and scattered across different sources of published information. Identifying evidence-based factors that influence the implementation of iCBT is key to successfully using iCBT in real-world clinical settings. Objective: This systematic review evaluated the following: (1) aspects that research articles postulate as important for the implementation of iCBT and (2) aspects relevant to the day-to-day running of iCBT services. A mixed methods systematic review using a convergent synthesis design was conducted to bring together evidence across this sparse literature consisting of divergent scientific article types to investigate the implementation of iCBT for depression and anxiety in adults. Methods: We searched the PsycINFO, PsycArticles, MEDLINE, CINAHL Complete, and Embase databases for any published peer-reviewed scientific articles that report on the implementation of iCBT for depression or anxiety disorders in adults. A total of 40 articles spanning the case study, commentary, meta-analysis, mixed methods study, pilot randomized controlled trial, randomized controlled trial, qualitative study, quantitative study, review, and systematic review article types were identified as eligible for this mixed methods review. Data were analyzed qualitatively using the descriptive-interpretive approach. Results: The first domain highlighted the impact of therapist and patient attitudes when implementing iCBT, the superiority of guided iCBT over unguided iCBT, its noninferiority to equivalent face-to-face treatments, and its utility outside of the original target of mild-to-moderate depression and anxiety. In total, 3 subdomains were identified under the second domain: (1) the management of iCBT in the workplace, detailing the importance of managing the iCBT service, related staff, and their motivations for using it; (2) the practice of iCBT in the workplace, describing the therapeutic aspects of iCBT provision, such as the provision of support, the background of supporters, and screening procedures; and (3) contextual considerations, detailing the impact of governmental legislation on therapy conducted over the internet, the lack of an iCBT workforce as a limiting factor, and the cost estimates associated with iCBT provision. Conclusions: Broadly, the findings describe several aspects that should be taken into account when researchers or practitioners implement iCBT as part of their work. However, the findings should be interpreted with caution, as the articles reviewed spanned many article types, and few of the included studies were directly focused on evaluating the implementation of iCBT. While findings provide insight into important factors to consider during iCBT implementation, these findings and their limitations highlight the need for more implementation-specific research in this area. %M 39874577 %R 10.2196/47927 %U https://www.jmir.org/2025/1/e47927 %U https://doi.org/10.2196/47927 %U http://www.ncbi.nlm.nih.gov/pubmed/39874577 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e59461 %T Feasibility of a Mobile App–Based Cognitive-Behavioral Perinatal Skills Program: Protocol for Nonrandomized Pilot Trial %A Temkin-Yu,Andrea B %A Ayaz,Aliza %A Blicker,Ella %A Liu,Michael X %A Oh,Ace %A Siegel,Isabelle E %A Seewald,Meredith J %A Hermann,Alison D %A Givrad,Soudebah %A Baez,Lara M %A Osborne,Lauren M %A Green,Cori M %A Schier,Maddy M %A Davis,Alexandra M %A Zhu,Shasha %A Falk,Avital %A Bennett,Shannon M %+ Psychiatry Department, Weill Cornell Medicine, 525 E 68th Street, New York, NY, 10065, United States, 1 6402038301, andreabtemkin@gmail.com %K perinatal mood and anxiety disorders %K apps %K smartphones %K digital intervention %K cognitive behavioral therapy %K feasibility %K pilot trial %K mobile phones %D 2025 %7 28.1.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mental illness is one of the top causes of preventable pregnancy-related deaths in the United States. There are many barriers that interfere with the ability of perinatal individuals to access traditional mental health care. Digital health interventions, including app-based programs, have the potential to increase access to useful tools for these individuals. Although numerous mental health apps exist, there is little research on developing programs to address the unique needs of perinatal individuals. In an effort to fill this gap, a multidisciplinary team of experts in psychology, psychiatry, obstetrics, and pediatric primary care collaborated to develop the novel Perinatal Skills Program within Maya, a flexible and customizable cognitive-behavioral skills app. Maya-Perinatal Skills Program (M-PSP) uses evidence-based strategies to help individuals manage their mood and anxiety symptoms during pregnancy and post partum. Objective: This pilot study aims to assess the feasibility, acceptability, and usability of M-PSP and explore links between program use and symptoms of anxiety and low mood. Methods: This single-arm trial will recruit 50 pregnant or postpartum individuals with mild-to-moderate anxiety or mood symptoms. Participants will be recruited from a variety of public and private insurance-based psychiatry, obstetrics, and primary care clinics at a large academic medical center located in New York City. Participants will complete all sessions of M-PSP and provide feedback. Outcome measures will include qualitative and quantitative assessments of feasibility, acceptability, and usability, passively collected program usage data, and symptom measures assessing mood, anxiety, and trauma. Planned data analysis includes the use of the grounded theory approach to identify common themes in qualitative feedback, as well as an exploration of possible associations between quantitative data regarding program use and symptoms. Results: The recruitment began on August 2023. As of October 2024, a total of 32 participants have been enrolled. The recruitment will continue until 50 participants have been enrolled. Conclusions: Digital health interventions, like M-PSP, have the potential to create new pathways to reach individuals struggling with their mental health. The results of this study will be the groundwork for future iterations of M-PSP in the hopes of providing an accessible and helpful tool for pregnant and postpartum individuals. Trial Registration: ClinicalTrials.gov NCT05897619; https://classic.clinicaltrials.gov/ct2/show/NCT05897619 International Registered Report Identifier (IRRID): PRR1-10.2196/59461 %M 39874578 %R 10.2196/59461 %U https://www.researchprotocols.org/2025/1/e59461 %U https://doi.org/10.2196/59461 %U http://www.ncbi.nlm.nih.gov/pubmed/39874578 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e63564 %T LoVE4MUM Mobile App to Prevent Postpartum Depression: Protocol for a Pilot Randomized Controlled Trial %A Kamarudin,Siti Sabrina %A Idris,Idayu Badilla %A Sharip,Shalisah %A Ahmad,Norfazilah %+ Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000, Malaysia, 60 91455887 ext 5888, idayubadilla.idris@ukm.edu.my %K postpartum depression %K mHealth intervention %K mobile phone %K prevention %K self-guided %K virtual engagement %K engagement %K maternal %K protocol %K randomized controlled trial %K postpartum %K depression %K maternal %K well-being %K mobile health %K preventive care %K mobile app %K mental health literacy %K postpartum care %D 2025 %7 27.1.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Postpartum depression remains a significant concern, posing substantial challenges to maternal well-being, infant health, and the mother-infant bond, particularly in the face of barriers to traditional support and interventions. Previous studies have shown that mobile health (mHealth) interventions offer an accessible means to facilitate early detection and management of mental health issues while at the same time promoting preventive care. Objective: This study aims to evaluate the effectiveness of the Leveraging on Virtual Engagement for Maternal Understanding & Mood-enhancement (LoVE4MUM) mobile app, which was developed based on the principles of cognitive behavioral therapy and psychoeducation and serves as an intervention to prevent postpartum depression. Methods: This single-blinded, pilot randomized controlled trial includes 64 mothers recruited from the postnatal ward and randomized using a 1:1 ratio to receive either postpartum care (treatment as usual) or postpartum care (treatment as usual) plus the self-guided LoVE4MUM mobile app. The primary outcome is the effectiveness of the mobile app at improving postpartum depression. Secondary outcomes are changes in the mental health literacy score and negative automatic thoughts, which are collected using a self-reported questionnaire. Results: Patient recruitment began on September 1, 2024. As of January 1, 2025, recruitment was successfully completed, with a total of 72 participants enrolled: 36 in the intervention group and 36 in the control group . The final results are anticipated to be available by March 2025, and publication is expected by the end of 2025. Conclusions: By examining the LoVE4MUM app alongside standard postpartum care, this pilot randomized controlled trial seeks to offer preliminary evidence on the potential of mHealth tools to improve maternal mental health as well as to reduce postpartum depression symptoms. The findings are expected to contribute to the future development of effective, accessible, and scalable interventions for mothers. Trial Registration: ClinicalTrials.gov NCT06366035; https://clinicaltrials.gov/study/NCT06366035 International Registered Report Identifier (IRRID): PRR1-10.2196/63564 %M 39869891 %R 10.2196/63564 %U https://www.researchprotocols.org/2025/1/e63564 %U https://doi.org/10.2196/63564 %U http://www.ncbi.nlm.nih.gov/pubmed/39869891 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e55932 %T Exploring Web-Based Support for Suicidal Ideation in the Scottish Population: Usability Study %A McClelland,Heather %A O'Connor,Rory C %A Gibson,Laura %A MacIntyre,Donald J %+ School of Health and Wellbeing, University of Glasgow, 90 Byres Road, Clarice Pears Building, Glasgow, G12 8TB, United Kingdom, 44 141 330 3299, heather.mcclelland@glasgow.ac.uk %K suicide prevention %K Scotland %K suicidal thoughts %K digital intervention %K internet %K self-help %K crisis intervention %D 2025 %7 24.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Suicide is a global health concern. In the United Kingdom, Scotland has the highest suicide rate. Lived experience and suicide prevention stakeholders in Scotland have identified a key gap in suicide prevention activities: the lack of 24-hour peer-driven web-based support for people who are suicidal. Objective: This usability study aimed to evaluate the feasibility, acceptability, utility, and reach of a suicide prevention website (Surviving Suicidal Thoughts) specifically designed to support residents in Scotland who are experiencing suicidal thoughts themselves or suspect or know someone who is experiencing suicidal thoughts. Intended support was delivered through the provision of personal testimony videos of individuals with lived experience. Methods: A peer-driven website was developed specifically to support residents of Scotland experiencing suicidal thoughts. The website included resources (eg, videos from lived experience and written guidance about how to respond to someone who may be experiencing suicidal thoughts) to help reduce distress, normalize experiences, and challenge distressing thoughts. The website was promoted via leading web-based social media channels and Google Ads. Evaluation of the website was based on website engagement, marketing strategy, and direct web user feedback via a cross-sectional survey. Results: Data were collected for 41 weeks (June 2022 to February 2023) spanning the launch of the website and the conclusion of the second marketing campaign. On average, the website received 99.9 visitors per day. A total of 56% (n=14,439) of visitors were female, ages ranged from younger than 18 years to older than 70 years (commonly between 25 and 34 years) and originated from all regions of Scotland. According to Google Search terms of Scottish residents, of the individuals indicated to be experiencing suicidal thoughts but not looking for help, 5.3% (n=920) engaged with the website compared to 10.5% (n=2898) who were indicated to be looking for help for themselves. Based on participant responses to the evaluation survey (n=101), the website was associated with a significant reduction in suicidal thoughts (P=.03). Reasons for visiting the website varied. Marketing data implied that people were more likely to engage with advertisements, which they felt were more personal, and visitors to the website were more likely to engage with videos, which corresponded to their age. Conclusions: A peer-led website may help residents of Scotland who are experiencing suicidal thoughts. Web-based interventions may have considerable reach in Scotland both in terms of age and geographic area. Engagement with the website was similar to other self-help websites for suicidal ideation; however, more nuanced methods of analyzing website engagement for help-seeking behavior are recommended. Future work would benefit from exploring the effectiveness of this website based on a larger participant sample with website modifications guided by the principles of social learning theory. %M 39854713 %R 10.2196/55932 %U https://formative.jmir.org/2025/1/e55932 %U https://doi.org/10.2196/55932 %U http://www.ncbi.nlm.nih.gov/pubmed/39854713 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e68031 %T Improving Mental Health and Well-Being Through the Paradym App: Quantitative Study of Real-World Data %A Metaxa,Athina Marina %A Liverpool,Shaun %A Eisenstadt,Mia %A Pollard,John %A Carlsson,Courtney %+ Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX2 6GG, United Kingdom, 30 6930228210, athina.metaxa@hmc.ox.ac.uk %K well-being %K awareness %K mental health %K formative %K mobile phone %K well-being %K apps %K quantitative evaluation %K real-world data %K emotional well-being %K pre-post %K single arm %K quantitative data %D 2025 %7 23.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: With growing evidence suggesting that levels of emotional well-being have been decreasing globally over the past few years, demand for easily accessible, convenient, and affordable well-being and mental health support has increased. Although mental health apps designed to tackle this demand by targeting diagnosed conditions have been shown to be beneficial, less research has focused on apps aiming to improve emotional well-being. There is also a dearth of research on well-being apps structured around users’ lived experiences and emotional patterns and a lack of integration of real-world evidence of app usage. Thus, the potential benefits of these apps need to be evaluated using robust real-world data. Objective: This study aimed to explore usage patterns and preliminary outcomes related to mental health and well-being among users of an app (Paradym; Paradym Ltd) designed to promote emotional well-being and positive mental health. Methods: This is a pre-post, single-arm evaluation of real-world data provided by users of the Paradym app. Data were provided as part of optional built-in self-assessments that users completed to test their levels of depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder Questionnaire-7), life satisfaction (Satisfaction With Life Scale), and overall well-being (World Health Organization-5 Well-Being Index) when they first started using the app and at regular intervals following initial usage. Usage patterns, including the number of assessments completed and the length of time between assessments, were recorded. Data were analyzed using within-subjects t tests, and Cohen d estimates were used to measure effect sizes. Results: A total of 3237 app users completed at least 1 self-assessment, and 787 users completed a follow-up assessment. The sample was diverse, with 2000 users (61.8%) being located outside of the United States. At baseline, many users reported experiencing strong feelings of burnout (677/1627, 41.6%), strong insecurities (73/211, 34.6%), and low levels of thriving (140/260, 53.8%). Users also experienced symptoms of depression (mean 9.85, SD 5.55) and anxiety (mean 14.27, SD 6.77) and reported low levels of life satisfaction (mean 12.14, SD 7.42) and general well-being (mean 9.88, SD 5.51). On average, users had been using the app for 74 days when they completed a follow-up assessment. Following app usage, small but significant improvements were reported across all outcomes of interest, with anxiety and depression scores improving by 1.20 and 1.26 points on average, respectively, and life satisfaction and well-being scores improving by 0.71 and 0.97 points, respectively. Conclusions: This real-world data analysis and evaluation provided positive preliminary evidence for the Paradym app’s effectiveness in improving mental health and well-being, supporting its use as a scalable intervention for emotional well-being, with potential applications across diverse populations and settings, and encourages the use of built-in assessments in mental health app research. %M 39848610 %R 10.2196/68031 %U https://formative.jmir.org/2025/1/e68031 %U https://doi.org/10.2196/68031 %U http://www.ncbi.nlm.nih.gov/pubmed/39848610 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e63126 %T Applications of Large Language Models in the Field of Suicide Prevention: Scoping Review %A Holmes,Glenn %A Tang,Biya %A Gupta,Sunil %A Venkatesh,Svetha %A Christensen,Helen %A Whitton,Alexis %+ Black Dog Institute, University of New South Wales, Sydney, Hospital Road, Randwick, 2031, Australia, 61 290659046, a.whitton@unsw.edu.au %K suicide %K suicide prevention %K large language model %K self-harm %K artificial intelligence %K AI %K PRISMA %D 2025 %7 23.1.2025 %9 Review %J J Med Internet Res %G English %X Background: Prevention of suicide is a global health priority. Approximately 800,000 individuals die by suicide yearly, and for every suicide death, there are another 20 estimated suicide attempts. Large language models (LLMs) hold the potential to enhance scalable, accessible, and affordable digital services for suicide prevention and self-harm interventions. However, their use also raises clinical and ethical questions that require careful consideration. Objective: This scoping review aims to identify emergent trends in LLM applications in the field of suicide prevention and self-harm research. In addition, it summarizes key clinical and ethical considerations relevant to this nascent area of research. Methods: Searches were conducted in 4 databases (PsycINFO, Embase, PubMed, and IEEE Xplore) in February 2024. Eligible studies described the application of LLMs for suicide or self-harm prevention, detection, or management. English-language peer-reviewed articles and conference proceedings were included, without date restrictions. Narrative synthesis was used to synthesize study characteristics, objectives, models, data sources, proposed clinical applications, and ethical considerations. This review adhered to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) standards. Results: Of the 533 studies identified, 36 (6.8%) met the inclusion criteria. An additional 7 studies were identified through citation chaining, resulting in 43 studies for review. The studies showed a bifurcation of publication fields, with varying publication norms between computer science and mental health. While most of the studies (33/43, 77%) focused on identifying suicide risk, newer applications leveraging generative functions (eg, support, education, and training) are emerging. Social media was the most common source of LLM training data. Bidirectional Encoder Representations from Transformers (BERT) was the predominant model used, although generative pretrained transformers (GPTs) featured prominently in generative applications. Clinical LLM applications were reported in 60% (26/43) of the studies, often for suicide risk detection or as clinical assistance tools. Ethical considerations were reported in 33% (14/43) of the studies, with privacy, confidentiality, and consent strongly represented. Conclusions: This evolving research area, bridging computer science and mental health, demands a multidisciplinary approach. While open access models and datasets will likely shape the field of suicide prevention, documenting their limitations and potential biases is crucial. High-quality training data are essential for refining these models and mitigating unwanted biases. Policies that address ethical concerns—particularly those related to privacy and security when using social media data—are imperative. Limitations include high variability across disciplines in how LLMs and study methodology are reported. The emergence of generative artificial intelligence signals a shift in approach, particularly in applications related to care, support, and education, such as improved crisis care and gatekeeper training methods, clinician copilot models, and improved educational practices. Ongoing human oversight—through human-in-the-loop testing or expert external validation—is essential for responsible development and use. Trial Registration: OSF Registries osf.io/nckq7; https://osf.io/nckq7 %M 39847414 %R 10.2196/63126 %U https://www.jmir.org/2025/1/e63126 %U https://doi.org/10.2196/63126 %U http://www.ncbi.nlm.nih.gov/pubmed/39847414 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e67878 %T Crisis Text Line and Loris.ai Controversy Highlights the Complexity of Informed Consent on the Internet and Data-Sharing Ethics for Machine Learning and Research %A Eysenbach,Gunther %+ , JMIR Publications, 130 Queens Quay East, Suite 1100-1102, Toronto, ON, M5A 0P6, Canada, 1 416 786 6970, geysenba@gmail.com %K data ethics %K data sharing %K informed consent %K disclosure %K conflict of interest %K transparency %K trust %D 2025 %7 22.1.2025 %9 Editorial %J J Med Internet Res %G English %X %R 10.2196/67878 %U https://www.jmir.org/2025/1/e67878 %U https://doi.org/10.2196/67878 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e64015 %T Response From Crisis Text Line to “Commentary on ‘Protecting User Privacy and Rights in Academic Data-Sharing Partnerships: Principles From a Pilot Program at Crisis Text Line’” %A Trujillo,Dena %+ Crisis Text Line, 225 West 34th Street, Floor 9 — PMB#9135, New York, NY, 10122, United States, 1 3322304008, dena@crisistextline.org %K crisis %K research %K data privacy %K research ethics %K digital rights %D 2025 %7 22.1.2025 %9 Letter to the Editor %J J Med Internet Res %G English %X %R 10.2196/64015 %U https://www.jmir.org/2025/1/e64015 %U https://doi.org/10.2196/64015 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e59734 %T Authors' Reply: Commentary on “Protecting User Privacy and Rights in Academic Data-Sharing Partnerships: Principles From a Pilot Program at Crisis Text Line” %A Pisani,Anthony R %A Gallo,Carlos %A Gould,Madelyn S %A Kanuri,Nitya %A Marcotte,John E %A Pascal,Brian %A Rousseau,David %A Ranney,Megan L %A Filbin,Bob %A Turner,Shairi %+ Department of Psychiatry, Center for the Study and Prevention of Suicide, University of Rochester Medical Center, University of Rochester, 300 Crittenden Blvd, Rochester, NY, 14642, United States, 1 5855077177, anthony_pisani@urmc.rochester.edu %K ethics %K data sharing %K digital data %K text messaging %K technology %K cooperative behavior %D 2025 %7 22.1.2025 %9 Letter to the Editor %J J Med Internet Res %G English %X We appreciate Reierson’s thoughtful commentary on our 2019 paper, which described our experiences, ethical process, judgment calls, and lessons from a 2016-2017 data-sharing pilot between Crisis Text Line and academic researchers. The commentary raises important questions about the ethical conduct of health research in the digital age, particularly regarding informed consent, potential conflicts of interest, and the protection of vulnerable populations. Our article focused specifically on the noncommercial use of Crisis Text Line data for research purposes, so we restrict our reply to points relevant to such usage. While we acknowledge the limitations of Crisis Text Line’s Terms of Service as a means of informing users about data sharing for research, we maintain that our guidelines were ethically sound and aligned with well-established practices for institutional review board (IRB) review and researcher training. We emphasize the critical role of IRBs in ensuring that research involving vulnerable populations, including minors, is conducted ethically and with appropriate safeguards. Regarding potential conflicts of interest, we argue that unpaid, nonfiduciary advisory board service for a nonprofit organization does not constitute a conflict requiring disclosure. The transparent nature of our collaboration with Crisis Text Line, as evidenced by the authorship and acknowledgments in our paper, further underscores our commitment to ethical research practices. We recognize the complexity and evolving nature of the challenges surrounding data-sharing partnerships in digital health research. As the field progresses, we remain committed to ongoing, transparent engagement and to refining best practices in collaboration with colleagues, stakeholders, and the public. Our response aims to provide clarity and context for the concerns raised in the commentary while reaffirming the integrity and value of our original work. Ultimately, we maintain that our paper contributed meaningfully to the ongoing discourse on ethical data sharing and laid the groundwork for future improvements in this critical area of digital health research. %R 10.2196/59734 %U https://www.jmir.org/2025/1/e59734 %U https://doi.org/10.2196/59734 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e56945 %T Codeveloping an Online Resource for People Bereaved by Suicide: Mixed Methods User-Centered Study %A Leaune,Edouard %A Bislimi,Kushtrim %A Lau-Taï,Pauline %A Rouzé,Héloïse %A Chalancon,Benoit %A Lestienne,Laurène %A Grandgenevre,Pierre %A Morgiève,Margot %A Laplace,Nathalie %A Vaiva,Guillaume %A Haesebaert,Julie %A Poulet,Emmanuel %+ Le Vinatier - Lyon Metropole Academic Hospital Center, 95, Boulevard Pinel, Bron, 69500, France, 33 0674111823, edouard.leaune@ch-le-vinatier.fr %K suicide bereavement %K social media %K mixed methods %K participatory %K user-centered %K mobile phone %K online resource %K suicide %K risk %K suicidal behaviors %K mental health %K impairments %K adaptive online resource %K Information System Research %K France %D 2025 %7 20.1.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Although suicide bereavement is highly distressing and is associated with an increased risk of suicidal behaviors and mental and physical health impairments, those bereaved by suicide encounter difficulties accessing support. Digital resources offer new forms of support for bereaved people. However, digital resources dedicated to those bereaved by suicide are still limited. Objective: This paper aimed to develop and implement an evidence-based, innovative, and adaptive online resource for people bereaved by suicide, based on their needs and expectations. Methods: We performed a mixed methods, participatory, user-centered study seeking to build resources from the perspectives of people bereaved by suicide and professionals or volunteers working in the field of postvention. We used the Information System Research framework, which uses a three-stage research cycle, including (1) the relevance cycle, (2) the design cycle, and (3) the rigor cycle, and the Design Science Research framework. Results: A total of 478 people participated in the study, including 451 people bereaved by suicide, 8 members of charities, and 19 mental health professionals working in the field of postvention. The development stage of the resource lasted 18 months, from October 2021 to March 2023. A total of 9 focus groups, 1 online survey, 30 usability tests, and 30 semistructured interviews were performed. A website for people bereaved by suicide named “espoir-suicide” was developed that includes (1) evidence-based information on suicide prevention and bereavement, (2) testimonies of people bereaved by suicide, (3) a delayed chat to ask questions on suicide and bereavement to a specialized team of mental health professionals, and (4) an interactive nationwide resource directory. The mean system usability score was 90.3 out of 100 for 30 participants, with 93% (n=28) of them having a rating above 80. Since the implementation of espoir-suicide in March 2023, a total of 19,400 connections have been recorded, 117 local resources have been registered nationwide, and 73 questions have been posted in the chat. Conclusions: The use of a mixed methods, participatory, user-centered design allowed us to implement an evidence-based, innovative, and functional website for people bereaved by suicide that was highly relevant for fulfilling the needs and expectations of French people bereaved by suicide. International Registered Report Identifier (IRRID): RR2-10.3389/fpsyt.2021.770154 %M 39832356 %R 10.2196/56945 %U https://mental.jmir.org/2025/1/e56945 %U https://doi.org/10.2196/56945 %U http://www.ncbi.nlm.nih.gov/pubmed/39832356 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e65434 %T Explainable Predictive Model for Suicidal Ideation During COVID-19: Social Media Discourse Study %A Bouktif,Salah %A Khanday,Akib Mohi Ud Din %A Ouni,Ali %+ Department of Computer Science and Software Engineering, College of Information Technology, United Arab Emirates University, Sheikh Khalifa Bin Zayed, Asharij, Al Ain, Abu Dhabi, 1551, United Arab Emirates, 971 507605406, salahb@uaeu.ac.ae %K COVID-19 %K suicide %K social networking sites %K deep learning %K explainable artificial intelligence %K suicidal ideation %K artificial intelligence %K AI %K social media %K predictive model %K mental health %K pandemic %K natural language processing %K NLP %K suicidal thought %K deep neural network approach %D 2025 %7 17.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Studying the impact of COVID-19 on mental health is both compelling and imperative for the health care system’s preparedness development. Discovering how pandemic conditions and governmental strategies and measures have impacted mental health is a challenging task. Mental health issues, such as depression and suicidal tendency, are traditionally explored through psychological battery tests and clinical procedures. To address the stigma associated with mental illness, social media is used to examine language patterns in posts related to suicide. This strategy enhances the comprehension and interpretation of suicidal ideation. Despite easy expression via social media, suicidal thoughts remain sensitive and complex to comprehend and detect. Suicidal ideation captures the new suicidal statements used during the COVID-19 pandemic that represents a different context of expressions. Objective: In this study, our aim was to detect suicidal ideation by mining textual content extracted from social media by leveraging state-of-the-art natural language processing (NLP) techniques. Methods: The work was divided into 2 major phases, one to classify suicidal ideation posts and the other to extract factors that cause suicidal ideation. We proposed a hybrid deep learning–based neural network approach (Bidirectional Encoder Representations from Transformers [BERT]+convolutional neural network [CNN]+long short-term memory [LSTM]) to classify suicidal and nonsuicidal posts. Two state-of-the-art deep learning approaches (CNN and LSTM) were combined based on features (terms) selected from term frequency–inverse document frequency (TF-IDF), Word2vec, and BERT. Explainable artificial intelligence (XAI) was used to extract key factors that contribute to suicidal ideation in order to provide a reliable and sustainable solution. Results: Of 348,110 records, 3154 (0.9%) were selected, resulting in 1338 (42.4%) suicidal and 1816 (57.6%) nonsuicidal instances. The CNN+LSTM+BERT model achieved superior performance, with a precision of 94%, a recall of 95%, an F1-score of 94%, and an accuracy of 93.65%. Conclusions: Considering the dynamic nature of suicidal behavior posts, we proposed a fused architecture that captures both localized and generalized contextual information that is important for understanding the language patterns and predict the evolution of suicidal ideation over time. According to Local Interpretable Model-Agnostic Explanations (LIME) and Shapley Additive Explanations (SHAP) XAI algorithms, there was a drift in the features during and before COVID-19. Due to the COVID-19 pandemic, new features have been added, which leads to suicidal tendencies. In the future, strategies need to be developed to combat this deadly disease. %M 39823631 %R 10.2196/65434 %U https://www.jmir.org/2025/1/e65434 %U https://doi.org/10.2196/65434 %U http://www.ncbi.nlm.nih.gov/pubmed/39823631 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e59154 %T Considering Comorbidities and Individual Differences in Testing a Gaming Behavioral Activation App for Perinatal Depression and Anxiety: Open Trial Pilot Intervention Study %A Hamlett,Gabriella E %A Schrader,Chloe %A Ferguson,Craig %A Kobylski,Lauren A %A Picard,Rosalind %A Locascio,Joseph J %A McNally,Richard J %A Cohen,Lee S %A Vanderkruik,Rachel %K perinatal anxiety %K perinatal depression %K behavioral activation %K digital mental health %K mobile phone %D 2025 %7 14.1.2025 %9 %J JMIR Form Res %G English %X Background: There is increasing interest in the development of scalable digital mental health interventions for perinatal populations to increase accessibility. Mobile behavioral activation (BA) is efficacious for the treatment of perinatal depression; however, the effect of comorbid anxiety and depression (CAD) on symptom trajectories remains underexplored. This is important given that at least 10% of women in the perinatal period experience CAD. Objective: We assessed whether there were differences in symptom trajectories in pregnant participants with CAD as compared to those with depression only (ie, major depressive disorder [MDD]) during intervention with a BA mobile gaming app. Methods: Pregnant adults with either CAD (n=10) or MDD (n=7) used a BA app for 10 weeks and completed biweekly symptom severity questionnaires for depression and anxiety. We assessed whether baseline diagnoses were associated with differential symptom trajectories across the study with mixed effects longitudinal models. Results: When controlling for baseline symptoms, results revealed a significant interaction between baseline diagnosis and the quadratic component of study week on anxiety (β=.18, SE 0.07; t62=2.61; P=.01), revealing a tendency for anxiety in the CAD group to increase initially and then decrease at an accelerated rate, whereas MDD symptoms were relatively stable across time. There was a significant effect of linear time on depression (β=−.39, SE 0.11; t68=−3.51; P=.001), showing that depression declined steadily across time for both groups. There was a significant effect of baseline diagnosis on depression (β=−8.53, SE 3.93; t13=−2.17; P=.05), suggesting that those with MDD had higher follow-up depression compared to those with CAD when holding other predictors constant. Conclusions: The app was beneficial in reducing depression symptoms in perinatal individuals with different comorbidity profiles. With respect to anxiety symptom trajectories, however, there was more variability. The app may be especially effective for the treatment of anxiety symptoms among individuals with CAD, as it encourages in-the-moment ecologically relevant exposure to anxiety-provoking stimuli. Despite no significant group difference in baseline anxiety symptoms, the MDD group did not have a significant reduction in their anxiety symptoms across the study period, and some individuals had an increase in anxiety. Findings may point to opportunities for the augmentation of BA gaming apps for those with MDD to more effectively target anxiety symptoms. Overall, findings suggest there may be value in considering comorbidities and individual variations in participants when developing scalable mobile interventions for perinatal populations. %R 10.2196/59154 %U https://formative.jmir.org/2025/1/e59154 %U https://doi.org/10.2196/59154 %0 Journal Article %@ 1947-2579 %I JMIR Publications %V 17 %N %P e51602 %T E-Screening for Prenatal Depression in Kampala, Uganda Using the Edinburgh Postnatal Depression Scale: Survey Results %A Namatovu,Hasifah Kasujja %A Magumba,Mark Abraham %A Akena,Dickens %K perinatal %K prenatal %K antenatal %K antepartum %K depression %K Edinburgh Postnatal Depression Scale %D 2025 %7 14.1.2025 %9 %J Online J Public Health Inform %G English %X Background: Perinatal depression remains a substantial public health challenge, often overlooked or incorrectly diagnosed in numerous low-income nations. Objective: The goal of this study was to establish statistical baselines for the prevalence of perinatal depression in Kampala and understand its relationship with key demographic variables. Methods: We employed an Android-based implementation of the Edinburgh Postnatal Depression Scale (EPDS) to survey 12,913 women recruited from 7 government health facilities located in Kampala, Uganda. We used the standard EPDS cutoff, which classifies women with total scores above 13 as possibly depressed and those below 13 as not depressed. The χ2 test of independence was used to determine the most influential categorical variables. We further analyzed the most influential categorical variable using odds ratios. For continuous variables such as age and the weeks of gestation, we performed a simple correlation analysis. Results: We found that 21.5% (2783/12,913, 95% CI 20.8%‐22.3%) were possibly depressed. Respondents’ relationship category was found to be the most influential variable (χ21=806.9, P<.001; Cramer’s V=0.25), indicating a small effect size. Among quantitative variables, we found a weak negative correlation between respondents’ age and the total EPDS score (r=−0.11, P<.001). Similarly, a weak negative correlation was also observed between the total EPDS score and the number of previous children of the respondent (r=−0.07, P<.001). Moreover, a weak positive correlation was noted between weeks of gestation and the total EPDS score (r=0.02, P=.05) Conclusions: This study shows that demographic factors such as spousal employment category, age, and relationship status have an influence on the respondents’ EPDS scores. These variables may serve as proxies for latent factors such as financial stability and emotional support. %R 10.2196/51602 %U https://ojphi.jmir.org/2025/1/e51602 %U https://doi.org/10.2196/51602 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e66181 %T Acceptance, Safety, and Effect Sizes in Online Dialectical Behavior Therapy for Borderline Personality Disorder: Interventional Pilot Study %A Vonderlin,Ruben %A Boritz,Tali %A Claus,Carola %A Senyüz,Büsra %A Mahalingam,Saskia %A Tennenhouse,Rachel %A Lis,Stefanie %A Schmahl,Christian %A Margraf,Jürgen %A Teismann,Tobias %A Kleindienst,Nikolaus %A McMain,Shelley %A Bohus,Martin %+ Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, J5, Mannheim, 68159, Germany, 49 621 1703 4445, ruben.vonderlin@zi-mannheim.de %K dialectical behavior therapy %K borderline personality disorder %K online psychotherapy %K virtual psychotherapy %K telehealth %K personality disorders %K mental %K psychotherapy %K online %K internet %K telemedicine %K psychiatry %K psychiatric %K acceptance %D 2025 %7 14.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: The potential of telehealth psychotherapy (ie, the online delivery of treatment via a video web-based platform) is gaining increased attention. However, there is skepticism about its acceptance, safety, and efficacy for patients with high emotional and behavioral dysregulation. Objective: This study aims to provide initial effect size estimates of symptom change from pre- to post treatment, and the acceptance and safety of telehealth dialectical behavior therapy (DBT) for individuals diagnosed with borderline personality disorder (BPD). Methods: A total of 39 individuals meeting the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) criteria for BPD received 1 year of outpatient telehealth DBT at 3 sites in Germany and Canada. Effect size estimates were assessed using pre-post measures of BPD symptoms, dissociation, and quality of life. Safety was evaluated by analyzing suicide attempts and self-harm. Additionally, acceptance and feasibility, satisfaction with treatment, useability of the telehealth format, and the quality of the therapeutic alliance were assessed from both therapists’ and patients’ perspectives. All analyses were conducted on both the intention-to-treat (ITT) and according-to-protocol (ATP) samples. Results: Analyses showed significant and large pre-post effect sizes for BPD symptoms (d=1.13 in the ITT sample and d=1.44 in the ATP sample; P<.001) and for quality of life (d=0.65 in the ITT sample and d=1.24 in the ATP sample). Dissociative symptoms showed small to nonsignificant reductions. Self-harm behaviors decreased significantly from 80% to 28% of all patients showing at least 1 self-harm behavior in the last 10 weeks (risk ratio 0.35). A high dropout rate of 38% was observed. One low-lethality suicide attempt was reported. Acceptance, feasibility, and satisfaction measures were high, although therapists reported only moderate useability of the telehealth format. Conclusions: Telehealth DBT for BPD showed large pre-post effect sizes for BPD symptoms and quality of life. While the telehealth format appeared feasible and well-accepted, the dropout rate was relatively high. Future research should compare the efficacy of telehealth DBT with in-person formats in randomized controlled trials. Overall, telehealth DBT might offer a potentially effective alternative treatment option, enhancing treatment accessibility. However, strategies for decreasing drop-out should be considered. Trial Registration: German Clinical Trials Register DRKS00027824; https://drks.de/search/en/trial/DRKS00027824 %M 39808784 %R 10.2196/66181 %U https://formative.jmir.org/2025/1/e66181 %U https://doi.org/10.2196/66181 %U http://www.ncbi.nlm.nih.gov/pubmed/39808784 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e60292 %T The Impact of Linguistic Signals on Cognitive Change in Support Seekers in Online Mental Health Communities: Text Analysis and Empirical Study %A Li,Min %A Gu,Dongxiao %A Li,Rui %A Gu,Yadi %A Liu,Hu %A Su,Kaixiang %A Wang,Xiaoyu %A Zhang,Gongrang %+ School of Management, Hefei University of Technology, 193 Tunxi Road, Hefei, 230009, China, 86 13866167367, gudongxiao@hfut.edu.cn %K mental health %K online communities %K cognitive change %K signaling theory %K text analysis %D 2025 %7 14.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: In online mental health communities, the interactions among members can significantly reduce their psychological distress and enhance their mental well-being. The overall quality of support from others varies due to differences in people’s capacities to help others. This results in some support seekers’ needs being met, while others remain unresolved. Objective: This study aimed to examine which characteristics of the comments posted to provide support can make support seekers feel better (ie, result in cognitive change). Methods: We used signaling theory to model the factors affecting cognitive change and used consulting strategies from the offline, face-to-face psychological counseling process to construct 6 characteristics: intimacy, emotional polarity, the use of first-person words, the use of future-tense words, specificity, and language style. Through text mining and natural language processing (NLP) technology, we identified linguistic features in online text and conducted an empirical analysis using 12,868 online mental health support reply data items from Zhihu to verify the effectiveness of those features. Results: The findings showed that support comments are more likely to alter support seekers’ cognitive processes if those comments have lower intimacy (βintimacy=–1.706, P<.001), higher positive emotional polarity (βemotional_polarity=.890, P<.001), lower specificity (βspecificity=–.018, P<.001), more first-person words (βfirst-person=.120, P<.001), more future- and present-tense words (βfuture-words=.301, P<.001), and fewer function words (βlinguistic_style=–.838, P<.001). The result is consistent with psychotherapists’ psychotherapeutic strategy in offline counseling scenarios. Conclusions: Our research contributes to both theory and practice by proposing a model to reveal the factors that make support seekers feel better. The findings have significance for support providers. Additionally, our study offers pointers for managing and designing online communities for mental health. %M 39808783 %R 10.2196/60292 %U https://www.jmir.org/2025/1/e60292 %U https://doi.org/10.2196/60292 %U http://www.ncbi.nlm.nih.gov/pubmed/39808783 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 11 %N %P e64564 %T Identifying Community-Built Environment’s Effect on Physical Activity and Depressive Symptoms Trajectories Among Middle-aged and Older Adults: Chinese National Longitudinal Study %A Zhang,Kaili %A Huang,Bowen %A Divigalpitiya,Prasanna %+ , Zigong Academy of Urban Planning and Design, Number 19, Donghuan Road, Bancang Street, High-Tech Zone, Zigong, Sichuan Province, 643031, China, 86 15882073304, jpby5223248@gmail.com %K community-built environment %K physical activity %K depressive symptom trajectories %K middle-aged and older adults %K latent growth curve modeling %K longitudinal study %D 2025 %7 13.1.2025 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The effects of physical activity (PA) across different domains and intensities on depressive symptoms remain inconclusive. Incorporating the community-built environment (CBE) into longitudinal analyses of PA’s impact on depressive symptoms is crucial. Objective: This study aims to examine the effects of PA at different intensities—low-intensity PA (eg, walking activities) and moderate-to-vigorous-intensity PA (eg, activities requiring substantial effort and causing faster breathing or shortness of breath)—across leisure-time and occupational domains on depressive symptom trajectories among middle-aged and older adults. Additionally, it investigated how CBEs influence depressive symptoms and PA trajectories. Methods: This longitudinal study included 6865 middle-aged and older adults from the China Health and Retirement Longitudinal Survey. A CBE variable system was developed using a community questionnaire to assess attributes of the physical built environment. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale. Latent growth curve modeling was applied to analyze 3 waves of the cohort data (2015, 2018, and 2020) to explore the differential effects of PA on depressive symptoms and the role of the CBE. Results: In the 2015 and 2018 waves, higher low-intensity leisure-time physical activity (LTPA) was associated with lower depressive symptoms (β=–.025, P=.01 and β=–.027, P=.005, respectively). Across all waves, moderate-to-vigorous-intensity LTPA showed no significant predictive effects (P=.21 in 2015, P=.57 in 2018, and P=.85 in 2020, respectively). However, higher occupational physical activity (OPA), particularly at moderate-to-vigorous intensities, was consistently associated with higher depressive symptoms. Parallel process latent growth curve modeling revealed that the initial level of total LTPA negatively predicted the initial level of depressive symptoms (β=–.076, P=.01). OPA exhibited dual effects, positively predicting the initial level of depressive symptoms (β=.108, P<.001) but negatively predicting their upward trajectory (β=–.136, P=.009). Among CBE variables, better infrastructure conditions (β=–.082, P<.001) and greater accessibility to public facilities (β=–.036, P=.045) negatively predicted the initial level of depressive symptoms. However, greater accessibility to public facilities positively predicted the upward trajectory of depressive symptoms (β=.083, P=.04). Better infrastructure conditions (β=.100, P=.002) and greater accessibility to public transport (β=.060, P=.01) positively predicted the initial level of total LTPA. Meanwhile, better infrastructure conditions (β=–.281, P<.001) and greater accessibility to public facilities (β=–.073, P<.001) negatively predicted the initial level of total OPA. Better infrastructure conditions positively predicted the declining trajectory of total OPA (β=.100, P=.004). Conclusions: This study underscores the importance of considering the differential effects of PA across domains and intensities on depressive symptoms in public policies and guidelines. Given the influence of the environment on PA and depressive symptoms, targeted community measures should be implemented. %M 39804686 %R 10.2196/64564 %U https://publichealth.jmir.org/2025/1/e64564 %U https://doi.org/10.2196/64564 %U http://www.ncbi.nlm.nih.gov/pubmed/39804686 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 11 %N %P e62730 %T The Association Between Posting WeChat Moments and the Risk of Depressive Symptoms Among Middle-Aged and Older Chinese Adults: Prospective National Cohort Study %A Wang,Wei %A Wang,Hui %A Hu,Xinru %A Yu,Qian %A Chen,Fangyi %A Qiu,Xirui %A Wang,Xiaoxiao %K cohort study %K depression %K depressive symptoms %K mental health %K middle-aged adults %K modified Poisson regression %K older adults %K WeChat %D 2025 %7 13.1.2025 %9 %J JMIR Public Health Surveill %G English %X Background: The association between social media usage and the risk of depressive symptoms has attracted increasing attention. WeChat is a popular social media software in China. The impact of using WeChat and posting WeChat moments on the risk of developing depressive symptoms among community-based middle-aged and older adults in China is unknown. Objective: The objective was to assess the association between using WeChat and posting WeChat moments and the risk of depressive symptoms among middle-aged and older adults in China. Methods: A prospective national cohort study was designed based on the data obtained from the fourth and fifth waves of the China Health and Retirement Longitudinal Study (CHARLS). The strength of association between using WeChat and posting WeChat moments and the risk of depressive symptoms was estimated by modified Poisson regressions. Depressive symptoms were determined using the 10-item Center for Epidemiologic Studies Depression Scale. Meanwhile, the heterogeneity of the associations was explored through multiple subgroup analyses. Moreover, multiple sensitivity analyses were performed to verify the robustness of the associations between the exposures and depressive symptoms. Results: A total of 9670 eligible participants were included in the cohort study, and the incidence rate of depressive symptoms was 19.08% (1845/9670, 95% CI 19.07%‐19.09%) from the fourth to fifth waves of the CHARLS. Using WeChat (adjusted relative risk [aRR] 0.691, 95% CI 0.582‐0.520) and posting WeChat moments (aRR 0.673, 95% CI 0.552‐0.821) reduced the risk of depressive symptoms among middle-aged and older Chinese adults. The association between the exposures and depressive symptoms was robust, proved through multiple sensitivity analyses (all P<.05). However, the associations were heterogeneous in certain subgroup catagories, such as solitude, duration of sleep at night, nap after lunch, physical activity, and having multiple chronic conditions. Conclusions: Using WeChat and especially posting WeChat moments can mitigate the risk of depressive symptoms among community-based middle-aged and older Chinese adults. However, there is likely a need for a longer follow-up period to explore the impact of the exposures on the risk of long-term depressive outcomes. %R 10.2196/62730 %U https://publichealth.jmir.org/2025/1/e62730 %U https://doi.org/10.2196/62730 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 13 %N %P e52764 %T mHealth-Augmented Care for Reducing Depression Symptom Severity Among Patients With Chronic Pain: Exploratory, Retrospective Cohort Study %A Holley,Dan %A Brooks,Amanda %A Hartz,Matthew %A Rao,Sudhir %A Zaubler,Thomas %K mHealth %K mobile health %K app %K behavioral health care %K depression %K mental health %K screening %K pain %K chronic pain %K psychiatric screenings %K digital health care %K psychiatry %K psychiatric %K longitudinal %K assessment %K behavioral %K self-help %K integrated %K comorbidity %K augmented care %D 2025 %7 10.1.2025 %9 %J JMIR Mhealth Uhealth %G English %X Background: Depression and chronic pain are commonly comorbid, mutually reinforcing, and debilitating. Emerging approaches to mobile behavioral health care (mHealth) promise to improve outcomes for patients with comorbid depression and chronic pain by integrating with existing care models to bolster support and continuity between clinical visits; however, the evidence base supporting the use of mHealth to augment care for this patient population is limited. Objective: To develop an evidence base that sets the stage for future research, we aimed to explore the associations between changes in depression severity and various integrated care models, with and without mHealth augmentation, among patients with comorbid depression and nonmalignant chronic pain. Methods: Our team leveraged retrospective, real-world data from 3837 patients with comorbid depression and nonmalignant chronic pain who received integrated behavioral health care (IBH) at a subspecialty pain clinic. We analyzed one IBH-only, non-mHealth cohort (n=2765), an mHealth-augmented cohort (n=844), and a collaborative care (CoCM)+mHealth cohort (n=136), which were supported by the NeuroFlow mHealth platform, and a pre-CoCM mHealth cohort (n=92), which was supported by the mHealth platform for 3 months prior to beginning the chronic pain treatment. We evaluated changes in depression severity between treatment cohorts via longitudinal analyses of both clinician- and mHealth-administered Patient Health Questionnaire-9 (PHQ-9) assessments. Results: mHealth-augmented integrated care led to significantly greater proportions of patients reaching clinical benchmarks for reduction (725/844, 86% vs 2112/2765, 76%), response (689/844, 82% vs 2027/2765, 73%), and remission (629/844, 75% vs 1919/2765, 69%) compared with integrated care alone. Furthermore, hierarchical regression modeling revealed that patients who received mHealth-augmented psychiatric CoCM experienced the greatest sustained reductions in on-average depression severity compared with other cohorts, irrespective of clinical benchmarks. In addition, patients who engaged with an mHealth platform before entering CoCM experienced a 7.2% reduction in average depression severity before starting CoCM treatment. Conclusions: Our findings suggest that mHealth platforms have the potential to improve treatment outcomes for patients with comorbid chronic pain and depression by providing remote measurement–based care, tailored interventions, and improved continuity between appointments. Moreover, our study set the stage for further research, including randomized controlled trials to evaluate causal relationships between mHealth engagement and treatment outcomes in integrated care settings. %R 10.2196/52764 %U https://mhealth.jmir.org/2025/1/e52764 %U https://doi.org/10.2196/52764 %0 Journal Article %@ 2817-092X %I JMIR Publications %V 4 %N %P e56679 %T Exploring Remote Monitoring of Poststroke Mood With Digital Sensors by Assessment of Depression Phenotypes and Accelerometer Data in UK Biobank: Cross-Sectional Analysis %A Zawada,Stephanie J %A Ganjizadeh,Ali %A Conte,Gian Marco %A Demaerschalk,Bart M %A Erickson,Bradley J %K depression %K cerebrovascular disease %K remote monitoring %K stroke %K accelerometers %K mobile phone %D 2025 %7 10.1.2025 %9 %J JMIR Neurotech %G English %X Background: Interest in using digital sensors to monitor patients with prior stroke for depression, a risk factor for poor outcomes, has grown rapidly; however, little is known about behavioral phenotypes related to future mood symptoms and if patients with and without previously diagnosed depression experience similar phenotypes. Objective: This study aimed to assess the feasibility of using digital sensors to monitor mood in patients with prior stroke with a prestroke depression diagnosis (DD) and controls. We examined relationships between physical activity behaviors and self-reported depression frequency. Methods: In the UK Biobank wearable accelerometer cohort, we retrospectively identified patients who had previously suffered a stroke (N=1603) and conducted cross-sectional analyses with those who completed a subsequent depression survey follow-up. Sensitivity analyses assessed a general population cohort excluding previous stroke participants and 2 incident cohorts: incident stroke (IS) and incident cerebrovascular disease (IC). Results: In controls, the odds of being in a higher depressed mood frequency category decreased by 23% for each minute spent in moderate‐to‐vigorous physical activity (odds ratio 0.77, 95% CI 0.69‐0.87; P<.001). This association persisted in both general cohorts and in the IC control cohort. Conclusions: Although moderate‐to‐vigorous physical activity was linked with less frequent depressed mood in patients with prior stroke without DD, this finding did not persist in DDs. Thus, accelerometer-mood monitoring may provide clinically useful insights about future mood in patients with prior stroke without DDs. Considering the finding in the IC cohort and the lack of findings in the IS cohorts, accelerometer-mood monitoring may also be appropriately applied to observing broader cerebrovascular disease pathogenesis. %R 10.2196/56679 %U https://neuro.jmir.org/2025/1/e56679 %U https://doi.org/10.2196/56679 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e55633 %T Virtual Reality–Based Psychological Intervention for Young Adults Living With HIV: Protocol for a Randomized Controlled Trial %A Zhang,Hanxi %A Han,Jing %A Su,Ye %A Zhao,Hongxin %A Zhang,Fujie %+ Beijing Ditan Hospital Capital Medical University, NO.8, Jingshun East Street, Chaoyang Dostrict, Beijing, 100015, China, 86 13001953958, treatment@chinaaids.cn %K HIV %K young adults %K mental health %K virtual reality %K VR %K psychological intervention %K depression %K anxiety %K living with HIV %K privacy %K mental health %K intervention %D 2025 %7 10.1.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Young adults (15-24 years old) living with HIV may experience pressure both from HIV infection and social role change problems, resulting in a series of psychological problems such as depression and anxiety. Effective psychological intervention can improve their mental health and quality of life. Objective: The study aims to explore the effectiveness of VR-based mental intervention on young adults living with HIV. The application and advantages of virtual reality (VR) in children’s psychotherapy provide new ideas for psychological intervention for young adults living with HIV. Methods: We use the qualitative interviews and questionnaire results as well as guided by classical psychotherapy to create a personalized psychological intervention system for young adults living with HIV through VR technology, which is based on the long-term AIDS treatment cohort and infectious diseases cohort of children. We use the mental scales and biochemical indexes as the outcomes, conducting a prospective randomized controlled trial to verify the feasibility and effectiveness of the VR psychological intervention system. Results: The study began enrollment in September 2023. To date, 160 participants have finished the baseline questionnaires. Conclusions: The study results might provide a scientific basis for accurate psychological treatment among young adults living with HIV in the future. International Registered Report Identifier (IRRID): DERR1-10.2196/55633 %M 39793015 %R 10.2196/55633 %U https://www.researchprotocols.org/2025/1/e55633 %U https://doi.org/10.2196/55633 %U http://www.ncbi.nlm.nih.gov/pubmed/39793015 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e64218 %T Community-Based 4-Level Intervention Targeting Depression and Suicidal Behavior in Europe: Protocol for an Implementation Project %A Schnitzspahn,Katharina %A Abdulla,Kahar %A Arensman,Ella %A Van Audenhove,Chantal %A Mere,Rainer %A Pérez Sola,Victor %A Sisask,Merike %A Székely,András %A Toczyski,Piotr %A Hegerl,Ulrich %+ European Alliance Against Depression e.V., Heinrich-Hoffmann-Str. 10, Leipzig, 60528, Germany, 49 069630180928, katharina.schnitzspahn@eaad.net %K depression %K suicide %K mental health %K European Alliance Against Depression %K EAAD %K 4-level community-based intervention %K iFightDepression %K cognitive behavioral therapy %K mHealth %D 2025 %7 10.1.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: The community-based, 4-level intervention of the European Alliance Against Depression (EAAD) is simultaneously addressing depression and suicidal behavior. Intervention activities target primary care health professionals (level 1), the general public (level 2), community facilitators (level 3), and patients and their relatives (level 4). Activities comprise the digital iFightDepression tool, a guided self-management tool based on cognitive behavioral therapy. Objective: This study aimed to present the European Union–cofunded EAAD-Best study protocol, aiming at the implementation, dissemination, and evaluation of the 4-level intervention and the iFightDepression tool in several countries across Europe. Methods: The 4-level intervention has been implemented for the first time in Bulgaria, Estonia, Greece, and Poland. In 3 countries that have already implemented the 4-level intervention (Hungary, Ireland, and Spain), activities have been extended to new regions. In addition, the nationwide uptake of the iFightDepression tool by patients with depression has been promoted in all mentioned countries and Italy. Results: To evaluate the implementation of the 4-level intervention and the iFightDepression tool, data related to the process, output, and outcome were collected between 2022 and 2024. Data processing and analyses started in 2023. Analyses are expected to be completed in 2024. Results are expected to be published in 2025. Conclusions: This paper informs researchers, practitioners, and stakeholders on how to implement best practices in mental health promotion and evaluate their effectiveness. International Registered Report Identifier (IRRID): DERR1-10.2196/64218 %M 39793023 %R 10.2196/64218 %U https://www.researchprotocols.org/2025/1/e64218 %U https://doi.org/10.2196/64218 %U http://www.ncbi.nlm.nih.gov/pubmed/39793023 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e67627 %T Trends in Mental Health Outcomes of College Students Amid the Pandemic (Roadmap mHealth App): Longitudinal Observational Study %A Jayaraj,Gautham %A Cao,Xiao %A Horwitz,Adam %A Rozwadowski,Michelle %A Shea,Skyla %A Hanauer,Shira N %A Hanauer,David A %A Tewari,Muneesh %A Shedden,Kerby %A Choi,Sung Won %+ Department of Pediatrics, Medical School, University of Michigan, 1200 E Hospital Dr, Medical Professional Building D4115, Ann Arbor, MI, 48109, United States, 1 734 615 5707, sungchoi@med.umich.edu %K mHealth %K college %K student %K mental health %K positive psychology %K flourishing %K COVID-19 %K wellbeing %K mobile phone %K SARS-CoV-2 %K coronavirus %K pandemic %K COVID %K app %K digital health %K smartphone %K eHealth %K telehealth %K telemedicine %K longitudinal %K higher education %K depression %K anxiety %K loneliness %D 2025 %7 9.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: The mental health crisis among college students intensified amid the COVID-19 pandemic, suggesting an urgent need for innovative solutions to support them. Previous efforts to address mental health concerns have been constrained, often due to the underuse or shortage of services. Mobile health (mHealth) technology holds significant potential for providing resilience-building support and enhancing access to mental health care. Objective: This study aimed to examine the trends in mental health and well-being outcomes over 3 years among college students, with an exploratory aim to assess the potential impact of the Roadmap mHealth app on these outcomes. Methods: A fully automated longitudinal observational study was conducted remotely from a large public academic institution in the Midwestern United States, evaluating mental health and well-being outcomes among college students using the Roadmap mHealth app over 3 fall semesters from 2020 to 2022. The study enrolled 2164 college students in Year I, with 1128 and 1033 students returning in Years II and III, respectively. Participants completed various self-reported measures, including the Patient Health Questionnaire-9 for depression, Generalized Anxiety Disorder-7 for anxiety, and additional metrics for coping, flourishing, and loneliness. Results: The findings indicated an evolving trajectory in students’ mental health. In Year I, depression and anxiety levels were higher compared with levels reported between 2014 and 2019, remaining stable into Year II. However, significant decreases were noted by Year III for both depression (Year I mean 7.78, SD 5.65 vs Year III mean 6.21, SD 4.68; t108=–2.90; P=.01) and anxiety (Year I mean 6.61, SD 4.91 vs Year III mean 5.62, SD 4.58; t116=–2.02; P=.046). Problem-focused coping decreased initially from Year I (mean 2.46, SD 0.58) to Year II (mean 2.36, SD 0.60; t1073=–5.87; P<.001), then increased by Year III (mean 2.40, SD 0.63; t706=2.26; P=.02). Emotion-focused (Year I mean 2.33, SD 0.41 vs Year III mean 2.22, SD 0.47; t994=–7.47; P<.001) and avoidant coping (Year I mean 1.76, SD 0.37 vs Year III mean 1.65, SD 0.38; t997=–8.53; P=.02) consistently decreased. Loneliness significantly decreased from Year I (mean 5.79, SD 1.74) to Year III (mean 5.17, SD 1.78; t1013=–10.74; P<.001), accompanied by an increase in flourishing from Year I (mean 63.78, SD 14.76) to Year III (mean 66.98, SD 15.06; t994=7.22; P<.001). Analysis of app usage indicated that the positive piggy bank and gratitude journal were the favored activities. Greater engagement with the app was positively correlated with enhanced flourishing, even after adjusting for demographic and sociobehavioral factors (β=.04, SE .016; t3974=2.17; P=.03). Conclusions: In this study, students’ mental health and well-being improved, with notable reductions in depression, anxiety, and loneliness, associated with an increase in flourishing. The app did not appear to worsen students’ mental health. Based on the usage pattern, it is possible the app enhanced positive psychology-based practices. Future research should explore the efficacy of mHealth interventions through randomized controlled trials to further understand their impact on college students’ mental health outcomes. Trial Registration: ClinicalTrials.gov NCT04766788; https://clinicaltrials.gov/ct2/show/NCT04766788 International Registered Report Identifier (IRRID): RR2-10.2196/29561 %M 39787592 %R 10.2196/67627 %U https://www.jmir.org/2025/1/e67627 %U https://doi.org/10.2196/67627 %U http://www.ncbi.nlm.nih.gov/pubmed/39787592 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e57624 %T The Trifecta of Industry, Academic, and Health System Partnership to Improve Mental Health Care Through Smartphone-Based Remote Patient Monitoring: Development and Usability Study %A Epperson,C Neill %A Davis,Rachel %A Dempsey,Allison %A Haller,Heinrich C %A Kupfer,David J %A Love,Tiffany %A Villarreal,Pamela M %A Matthews,Mark %A Moore,Susan L %A Muller,Kimberly %A Schneck,Christopher D %A Scott,Jessica L %A Zane,Richard D %A Frank,Ellen %+ Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, 1890 N Revere Ct, Suite 4003, Mail Stop F546, Aurora, CO, 80045, United States, 1 303 724 4940, neill.epperson@cuanschutz.edu %K digital health %K mobile intervention %K telepsychiatry %K artificial intelligence %K psychiatry %K mental health %K depression %K mood %K bipolar %K monitor %K diagnostic tool %K diagnosis %K electronic health record %K EHR %K alert %K notification %K prediction %K mHealth %K mobile health %K smartphone %K passive %K self-reported %K patient generated %D 2025 %7 7.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Mental health treatment is hindered by the limited number of mental health care providers and the infrequency of care. Digital mental health technology can help supplement treatment by remotely monitoring patient symptoms and predicting mental health crises in between clinical visits. However, the feasibility of digital mental health technologies has not yet been sufficiently explored. Rhythms, from the company Health Rhythms, is a smartphone platform that uses passively acquired smartphone data with artificial intelligence and predictive analytics to alert patients and providers to an emerging mental health crisis. Objective: The objective of this study was to test the feasibility and acceptability of Rhythms among patients attending an academic psychiatric outpatient clinic. Methods: Our group embedded Rhythms into the electronic health record of a large health system. Patients with a diagnosis of major depressive disorder, bipolar disorder, or other mood disorder were contacted online and enrolled for a 6-week trial of Rhythms. Participants provided data by completing electronic surveys as well as by active and passive use of Rhythms. Emergent and urgent alerts were monitored and managed according to passively collected data and patient self-ratings. A purposively sampled group of participants also participated in qualitative interviews about their experience with Rhythms at the end of the study. Results: Of the 104 participants, 89 (85.6%) completed 6 weeks of monitoring. The majority of the participants were women (72/104, 69.2%), White (84/104, 80.8%), and non-Hispanic (100/104, 96.2%) and had a diagnosis of major depressive disorder (71/104, 68.3%). Two emergent alerts and 19 urgent alerts were received and managed according to protocol over 16 weeks. More than two-thirds (63/87, 72%) of those participating continued to use Rhythms after study completion. Comments from participants indicated appreciation for greater self-awareness and provider connection, while providers reported that Rhythms provided a more nuanced understanding of patient experience between clinical visits. Conclusions: Rhythms is a user-friendly, electronic health record–adaptable, smartphone-based tool that provides patients and providers with a greater understanding of patient mental health status. Integration of Rhythms into health systems has the potential to facilitate mental health care and improve the experience of both patients and providers. %M 39773396 %R 10.2196/57624 %U https://formative.jmir.org/2025/1/e57624 %U https://doi.org/10.2196/57624 %U http://www.ncbi.nlm.nih.gov/pubmed/39773396 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e52083 %T The Association Between Internet Addiction and the Risk of Suicide Attempts in Chinese Adolescents Aged 11-17 Years: Prospective Cohort Study %A Li,Sihong %A Jin,Xingyue %A Song,Lintong %A Fan,Tianqing %A Shen,Yanmei %A Zhou,Jiansong %+ Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, No.139, Renmin Road Central Changsha-Hunan-China, Changsha, 410011, China, 86 15116269263, ymshen@csu.edu.cn %K adolescents %K pathological internet use %K internet addiction %K suicide attempts %K risk factors %K cohort study %D 2025 %7 3.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is a critical public health issue in adolescents worldwide. Internet addiction may play a role in the increased rate of suicide attempts in this population. However, few studies have explored the relationship between pathological internet use and suicide attempts among adolescents. Objective: This study aimed to conduct a prospective cohort study to examine whether higher severity of pathological internet use was associated with an increased risk of suicide attempts among Chinese adolescents. Methods: A total of 782 adolescents were recruited from a middle school from November 2020 to December 2020 and followed up for 6 months. An online self-reported questionnaire was used to collect the participants’ demographic data and assess their mental health. The Depression, Anxiety, and Stress Scale–21 items (DASS-21) was used to evaluate depression, anxiety, and stress. The Chen Internet Addiction Scale–Revised (CIAS-R) was used to assess the symptoms and severity of pathological internet use. χ2 test and ANOVA were used for intergroup comparison, and logistic regression analysis was used to examine the relationship between the severity of pathological internet use and suicide attempts. We also used a restricted cubic splines model to investigate the pattern of the association. Results: The participants had an average age of 12.59 (SD 0.64) years, with the majority being of Han ethnicity (743/782, 95.01%) and more than half being male (426/782, 54.48%). Most participants had no previous history of depression (541/782, 69.18%), anxiety (415/782, 53.07%), or stress (618/782, 79.03%). The rate of newly reported suicide attempts was 4.6% (36/782). A significant positive association was observed between internet addiction and suicide attempts (odds ratio 3.88, 95% CI 1.70-8.82), which remained significant after adjusting for age, sex, ethnicity, anxiety, depression, and stress (odds ratio 2.65, 95% CI 1.07-6.55). In addition, this association exhibited a linear pattern in the restricted cubic spline regression model. Conclusions: This study suggested that internet addiction, rather than internet overuse, was associated with a higher likelihood of suicide attempts, which highlighted the importance of addressing internet addiction symptoms among Chinese adolescents for suicide prevention. %M 39752720 %R 10.2196/52083 %U https://www.jmir.org/2025/1/e52083 %U https://doi.org/10.2196/52083 %U http://www.ncbi.nlm.nih.gov/pubmed/39752720 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 13 %N %P e63538 %T Development and Evaluation of a Mental Health Chatbot Using ChatGPT 4.0: Mixed Methods User Experience Study With Korean Users %A Kang,Boyoung %A Hong,Munpyo %+ Sungkyunkwan University, 25-2, Sungkyunkwan-Ro, Jongno-gu, Seoul, 03063, Republic of Korea, 82 027401770, bykang2015@gmail.com %K mental health chatbot %K Dr. CareSam %K HoMemeTown %K ChatGPT 4.0 %K large language model %K LLM %K cross-lingual %K pilot testing %K cultural sensitivity %K localization %K Korean students %D 2025 %7 3.1.2025 %9 Original Paper %J JMIR Med Inform %G English %X Background: Mental health chatbots have emerged as a promising tool for providing accessible and convenient support to individuals in need. Building on our previous research on digital interventions for loneliness and depression among Korean college students, this study addresses the limitations identified and explores more advanced artificial intelligence–driven solutions. Objective: This study aimed to develop and evaluate the performance of HoMemeTown Dr. CareSam, an advanced cross-lingual chatbot using ChatGPT 4.0 (OpenAI) to provide seamless support in both English and Korean contexts. The chatbot was designed to address the need for more personalized and culturally sensitive mental health support identified in our previous work while providing an accessible and user-friendly interface for Korean young adults. Methods: We conducted a mixed methods pilot study with 20 Korean young adults aged 18 to 27 (mean 23.3, SD 1.96) years. The HoMemeTown Dr CareSam chatbot was developed using the GPT application programming interface, incorporating features such as a gratitude journal and risk detection. User satisfaction and chatbot performance were evaluated using quantitative surveys and qualitative feedback, with triangulation used to ensure the validity and robustness of findings through cross-verification of data sources. Comparative analyses were conducted with other large language models chatbots and existing digital therapy tools (Woebot [Woebot Health Inc] and Happify [Twill Inc]). Results: Users generally expressed positive views towards the chatbot, with positivity and support receiving the highest score on a 10-point scale (mean 9.0, SD 1.2), followed by empathy (mean 8.7, SD 1.6) and active listening (mean 8.0, SD 1.8). However, areas for improvement were noted in professionalism (mean 7.0, SD 2.0), complexity of content (mean 7.4, SD 2.0), and personalization (mean 7.4, SD 2.4). The chatbot demonstrated statistically significant performance differences compared with other large language models chatbots (F=3.27; P=.047), with more pronounced differences compared with Woebot and Happify (F=12.94; P<.001). Qualitative feedback highlighted the chatbot’s strengths in providing empathetic responses and a user-friendly interface, while areas for improvement included response speed and the naturalness of Korean language responses. Conclusions: The HoMemeTown Dr CareSam chatbot shows potential as a cross-lingual mental health support tool, achieving high user satisfaction and demonstrating comparative advantages over existing digital interventions. However, the study’s limited sample size and short-term nature necessitate further research. Future studies should include larger-scale clinical trials, enhanced risk detection features, and integration with existing health care systems to fully realize its potential in supporting mental well-being across different linguistic and cultural contexts. %M 39752663 %R 10.2196/63538 %U https://medinform.jmir.org/2025/1/e63538 %U https://doi.org/10.2196/63538 %U http://www.ncbi.nlm.nih.gov/pubmed/39752663 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e42144 %T Commentary on “Protecting User Privacy and Rights in Academic Data-Sharing Partnerships: Principles From a Pilot Program at Crisis Text Line” %A Reierson,Timothy D %+ 6604 Appleview Rd, Yakima, WA, 98908, United States, 1 509 965 7175, holdspacefree@proton.me %K bias %K data ethics %K data sharing %K consent %K crisis intervention %K text messaging %K commercial use %K conflict of interest %D 2024 %7 30.12.2024 %9 Commentary %J J Med Internet Res %G English %X %R 10.2196/42144 %U https://www.jmir.org/2024/1/e42144 %U https://doi.org/10.2196/42144 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e64578 %T Momentary Depression Severity Prediction in Patients With Acute Depression Who Undergo Sleep Deprivation Therapy: Speech-Based Machine Learning Approach %A Hartnagel,Lisa-Marie %A Emden,Daniel %A Foo,Jerome C %A Streit,Fabian %A Witt,Stephanie H %A Frank,Josef %A Limberger,Matthias F %A Schmitz,Sara E %A Gilles,Maria %A Rietschel,Marcella %A Hahn,Tim %A Ebner-Priemer,Ulrich W %A Sirignano,Lea %K ambulatory assessment %K depression %K speech features %K openSMILE %K machine learning %K sleep deprivation therapy %K remote monitoring %K depressive disorder %K mobile phone %K digital health %K mobile health %K mHealth %K mental health %D 2024 %7 23.12.2024 %9 %J JMIR Ment Health %G English %X Background: Mobile devices for remote monitoring are inevitable tools to support treatment and patient care, especially in recurrent diseases such as major depressive disorder. The aim of this study was to learn if machine learning (ML) models based on longitudinal speech data are helpful in predicting momentary depression severity. Data analyses were based on a dataset including 30 inpatients during an acute depressive episode receiving sleep deprivation therapy in stationary care, an intervention inducing a rapid change in depressive symptoms in a relatively short period of time. Using an ambulatory assessment approach, we captured speech samples and assessed concomitant depression severity via self-report questionnaire over the course of 3 weeks (before, during, and after therapy). We extracted 89 speech features from the speech samples using the Extended Geneva Minimalistic Acoustic Parameter Set from the Open-Source Speech and Music Interpretation by Large-Space Extraction (audEERING) toolkit and the additional parameter speech rate. Objective: We aimed to understand if a multiparameter ML approach would significantly improve the prediction compared to previous statistical analyses, and, in addition, which mechanism for splitting training and test data was most successful, especially focusing on the idea of personalized prediction. Methods: To do so, we trained and evaluated a set of >500 ML pipelines including random forest, linear regression, support vector regression, and Extreme Gradient Boosting regression models and tested them on 5 different train-test split scenarios: a group 5-fold nested cross-validation at the subject level, a leave-one-subject-out approach, a chronological split, an odd-even split, and a random split. Results: In the 5-fold cross-validation, the leave-one-subject-out, and the chronological split approaches, none of the models were statistically different from random chance. The other two approaches produced significant results for at least one of the models tested, with similar performance. In total, the superior model was an Extreme Gradient Boosting in the odd-even split approach (R²=0.339, mean absolute error=0.38; both P<.001), indicating that 33.9% of the variance in depression severity could be predicted by the speech features. Conclusions: Overall, our analyses highlight that ML fails to predict depression scores of unseen patients, but prediction performance increased strongly compared to our previous analyses with multilevel models. We conclude that future personalized ML models might improve prediction performance even more, leading to better patient management and care. %R 10.2196/64578 %U https://mental.jmir.org/2024/1/e64578 %U https://doi.org/10.2196/64578 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e55450 %T Service Attributes and Acceptability of Digital and Nondigital Depression Management Methods Among Individuals With Depressive Symptoms: Survey Study %A Auyeung,Larry %A Mak,Winnie W S %A Tsang,Ella Zoe %+ Department of Psychology, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China (Hong Kong), 852 31906792, larryauyeung@link.cuhk.edu.hk %K eHealth %K acceptability %K user preference %K diffusion of innovation %K mental health services %D 2024 %7 19.12.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Academic research on digital mental health tends to focus on its efficacy and effectiveness, with much less attention paid to user preferences and experiences in real-world settings. Objective: This study aims to analyze service characteristics that service users value and compare the extent to which various digital and nondigital mental health treatments and management methods fulfill users’ expectations. Methods: A total of 114 people with at least moderate levels of depressive symptoms (as measured by Patient Health Questionnaire–9 score ≥10) completed a web-based questionnaire measuring their awareness and adoption of digital mental health services and their valuation of 15 psychological service attributes, including effectiveness, credibility, waiting time, and more. They were also assessed on their expectations toward seven common mental health treatments and management methods, including (1) face-to-face psychological intervention, (2) medication, (3) guided internet-based psychological intervention, (4) face-to-face counseling service, (5) self-guided mental health apps for depression, (6) self-help bibliotherapy, and (7) psychological intervention via videoconferencing. Results: A Friedman test with a Dunn posttest showed the average importance rank of “effectiveness” was significantly higher than all other measured attributes. “Privacy,” “credibility,” and “cost” were ranked as equally important. Participants rated face-to-face psychological intervention the most effective management method, while other digital management methods were perceived as less effective. Medication was perceived as the least appealing method, while other methods were deemed equally appealing. Face-to-face psychological intervention, medication, and counseling were considered less satisfactory due to their higher costs and longer waiting times when compared to digital services. Repeated measures ANOVA showed some forms of management method were more likely to be adopted, including guided internet-based psychological intervention, psychological intervention via videoconferencing, face-to-face psychological intervention, and face-to-face counseling services provided by a counselor as compared to self-guided mobile apps, self-help bibliotherapy, and medication. Conclusions: The study highlights the importance of considering multiple service attributes beyond effectiveness in depression management methods, despite effectiveness being regarded as the most crucial factor using the rank method. Compared to nondigital services, digital services were identified as having specific strengths as perceived by users. Future dissemination and promotion efforts may focus on debunking myths of guided internet-based psychological intervention as a less effective option and promoting the particular service strengths of digital services. %M 39699956 %R 10.2196/55450 %U https://formative.jmir.org/2024/1/e55450 %U https://doi.org/10.2196/55450 %U http://www.ncbi.nlm.nih.gov/pubmed/39699956 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e60879 %T A Digital Approach for Addressing Suicidal Ideation and Behaviors in Youth Mental Health Services: Observational Study %A Chong,Min K %A Hickie,Ian B %A Ottavio,Antonia %A Rogers,David %A Dimitropoulos,Gina %A LaMonica,Haley M %A Borgnolo,Luke J %A McKenna,Sarah %A Scott,Elizabeth M %A Iorfino,Frank %+ Brain and Mind Centre, The University of Sydney, 94 Mallett Street, Camperdown, 2050, Australia, 61 (02) 9114 2199, min.chong@sydney.edu.au %K mental health service %K youth mental health %K suicide management %K clinical decision support %K primary care %K personalization %K suicide %K suicidal %K youth %K mental health %K mental health care %K suicide prevention %K digital technology %K online assessment %K clinician %K digital health %K health informatics %K clinical information %D 2024 %7 18.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Long wait times for mental health treatments may cause delays in early detection and management of suicidal ideation and behaviors, which are crucial for effective mental health care and suicide prevention. The use of digital technology is a potential solution for prompt identification of youth with high suicidality. Objective: The primary aim of this study was to evaluate the use of a digital suicidality notification system designed to detect and respond to suicidal needs in youth mental health services. Second, the study aimed to characterize young people at different levels of suicidal ideation and behaviors. Methods: Young people aged between 16 and 25 years completed multidimensional assessments using a digital platform, collecting demographic, clinical, social, functional, and suicidality information. When the suicidality score exceeded a predetermined threshold, established based on clinical expertise and service policies, a rule-based algorithm configured within the platform immediately generated an alert for treating clinicians. Subsequent clinical actions and response times were analyzed. Results: A total of 2021 individuals participated, of whom 266 (11%) triggered one or more high suicidal ideation and behaviors notification. Of the 292 notifications generated, 76% (222/292) were resolved, with a median response time of 1.9 (range 0-50.8) days. Clinical actions initiated to address suicidality included creating safety plans (60%, 134/222), conducting safety checks (18%, 39/222), psychological therapy (8%, 17/222), transfer to another service (3%, 8/222), and scheduling of new appointments (2%, 4/222). Young people with high levels of suicidality were more likely to present with more severe and comorbid symptoms, including low engagement in work or education, heterogenous psychopathology, substance misuse, and recurrent illness. Conclusions: The digital suicidality notification system facilitated prompt clinical actions by alerting clinicians to high levels of suicidal ideation and behaviors detected among youth. Further, the multidimensional assessment revealed complex and comorbid symptoms exhibited in youth with high suicidality. By expediting and personalizing care for those displaying elevated suicidality, the digital notification system can play a pivotal role in preventing rapid symptom progression and its detrimental impacts on young people’s mental health. %M 39693140 %R 10.2196/60879 %U https://www.jmir.org/2024/1/e60879 %U https://doi.org/10.2196/60879 %U http://www.ncbi.nlm.nih.gov/pubmed/39693140 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e57154 %T Exploring the Relationship Between Public Social Media Accounts, Adolescent Mental Health, and Parental Guidance in England: Large Cross-Sectional School Survey Study %A Mabaso,Wakithi Siza %A Hein,Sascha %A Pavarini,Gabriela %A , %A Fazel,Mina %+ Department of Psychiatry, University of Oxford, University Department of Psychiatry, Warneford Hospital, Oxford, OX3 7JX, United Kingdom, 44 01865 618200, wakithi.mabaso@trinity.ox.ac.uk %K social media %K adolescent health %K privacy %K parental guidance %K mood disorders %K adolescent %K anxiety %K depression %K cross-sectional %K mental health %K public %K account %K school-going %K school %K England %K survey %K logistic regression %K observational %D 2024 %7 17.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Although associations between social media use and adolescent mental health have been described, more information is needed on the potential components characterizing this complex exposure, in particular, those related to maintaining a public social media account. Objective: This study aims to investigate the association between having a public social media account and anxiety and depression in school-going adolescents. Methods: Overall, 80 secondary schools and further education colleges in England were sampled using a cross-sectional web-based survey as part of the 2023 OxWell Student Survey. Social media exposure was categorized among the adolescents as having a public social media account versus not having a public social media account. The risk of clinical anxiety and depression was determined using the Revised Child Anxiety and Depression Scale-11. Adolescents self-reported the content and platforms accessed in the previous 24 hours. Associations between having a public social media account and symptoms of anxiety and depression were assessed using logistic regression controlling for age, sex, the experience of being bullied, parental guidance of online behavior (describing perceived parental approaches to adolescents’ online activity), the proportion of close friendships engaged with online, poverty status, and placement in statutory care. Age, sex, and parental guidance of online behavior were assessed for primary association effect modification. Results: Data collected from 16,655 adolescents (aged 11-18 y) were analyzed. Of these 16,655 adolescents, 6734 (40.43%) had a public social media account, while 9921 (59.57%) either had a private social media account or no social media account. Moreover, 32.6% (5429/16,655) of the adolescents screened positive for symptoms of anxiety and depression. Those with a public social media account had higher odds of anxiety and depression (odds ratio [OR] 1.41, 95% CI 1.32-1.50) than those without a public social media account in an unadjusted and fully adjusted model (OR 1.39, 95% CI 1.29-1.49). Adolescents reporting active parental guidance had lower odds of anxiety and depression (OR 0.85, 95% CI 0.75-0.93) than those reporting no parental guidance, and these parental approaches to online behaviors significantly modified the association between having a public social media account and symptoms of anxiety and depression (P=.004; χ22=11.1). Conclusions: Our OxWell study findings suggest a potential mental health risk for adolescents with a public social media account. We show evidence indicating some protection from anxiety and depression among adolescents who do not have a public social media account and those reporting some form of parental guidance of their online behavior. This was pronounced in adolescents reporting active parental guidance compared to stricter regulatory approaches or no guidance at all. The specific roles that social media account choices and parental guidance of online behavior may play in supporting the mental health of adolescents are highlighted for further investigation. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2021-052717 %M 39688898 %R 10.2196/57154 %U https://www.jmir.org/2024/1/e57154 %U https://doi.org/10.2196/57154 %U http://www.ncbi.nlm.nih.gov/pubmed/39688898 %0 Journal Article %@ 2563-3570 %I JMIR Publications %V 5 %N %P e65506 %T Effect of a Web-Based Heartfulness Program on the Mental Well-Being, Biomarkers, and Gene Expression Profile of Health Care Students: Randomized Controlled Trial %A Thimmapuram,Jayaram %A Patel,Kamlesh D %A Bhatt,Deepti %A Chauhan,Ajay %A Madhusudhan,Divya %A Bhatt,Kashyap K %A Deshpande,Snehal %A Budhbhatti,Urvi %A Joshi,Chaitanya %+ WellSpan Health, 1001 S George St, York, PA, 17403, United States, 1 7174956027, jthimmapuram@wellspan.org %K heartfulness %K meditation %K stress %K anxiety %K depression %K interleukins %K gene expression %K dehydroepiandrosterone %K DHEA %K gene %K mental health %K meditation %K randomized study %K web-based program %K mental well-being %K well-being %K mental %K health care students %K student %K mRNA %K messenger ribonucleic acid %K youth %K young adults %K web-based %K biomarker %K RNA %K bioinformatics %K randomized %K statistical analysis %K nursing %K physiotherapy %K pharmacy %D 2024 %7 16.12.2024 %9 Original Paper %J JMIR Bioinform Biotech %G English %X Background: Health care students often experience high levels of stress, anxiety, and mental health issues, making it crucial to address these challenges. Variations in stress levels may be associated with changes in dehydroepiandrosterone sulfate (DHEA-S) and interleukin-6 (IL-6) levels and gene expression. Meditative practices have demonstrated effectiveness in reducing stress and improving mental well-being. Objective: This study aims to assess the effects of Heartfulness meditation on mental well-being, DHEA-S, IL-6, and gene expression profile. Methods: The 78 enrolled participants were randomly assigned to the Heartfulness meditation (n=42, 54%) and control (n=36, 46%) groups. The participants completed the Perceived Stress Scale (PSS) and Depression Anxiety Stress Scale (DASS-21) at baseline and after week 12. Gene expression with messenger RNA sequencing and DHEA-S and IL-6 levels were also measured at baseline and the completion of the 12 weeks. Statistical analysis included descriptive statistics, paired t test, and 1-way ANOVA with Bonferroni correction. Results: The Heartfulness group exhibited a significant 17.35% reduction in PSS score (from mean 19.71, SD 5.09 to mean 16.29, SD 4.83; P<.001) compared to a nonsignificant 6% reduction in the control group (P=.31). DASS-21 scores decreased significantly by 27.14% in the Heartfulness group (from mean 21.15, SD 9.56 to mean 15.41, SD 7.87; P<.001) while it increased nonsignificantly by 17% in the control group (P=.04). For the DASS-21 subcomponents—the Heartfulness group showed a statistically significant 28.53% reduction in anxiety (P=.006) and 27.38% reduction in stress (P=.002) versus an insignificant 22% increase in anxiety (P=.02) and 6% increase in stress (P=.47) in the control group. Further, DHEA-S levels showed a significant 20.27% increase in the Heartfulness group (from mean 251.71, SD 80.98 to mean 302.74, SD 123.56; P=.002) compared to an insignificant 9% increase in the control group (from mean 285.33, SD 112.14 to mean 309.90, SD 136.90; P=.10). IL-6 levels showed a statistically significant difference in both the groups (from mean 4.93, SD 1.35 to mean 3.67, SD 1.0; 28.6%; P<.001 [Heartfulness group] and from mean 4.52, SD 1.40 to mean 2.72, SD 1.74; 40%; P<.001 [control group]). Notably, group comparison at 12 weeks revealed a significant difference in perceived stress, DASS-21 and its subcomponents, and IL-6 (all P<.05/4). The gene expression profile with messenger RNA sequencing identified 875 upregulated genes and 1539 downregulated genes in the Heartfulness group compared to baseline, and there were 292 upregulated genes and 1180 downregulated genes in the Heartfulness group compared to the control group after the intervention. Conclusions: Heartfulness practice was associated with decreased depression, anxiety, and stress scores and improved health measures in DHEA-S and IL-6 levels. The gene expression data point toward possible mechanisms of alleviation of symptoms of stress, anxiety and depression. Trial Registration: ISRCTN Registry ISRCTN82860715; https://doi.org/10.1186/ISRCTN82860715 %M 39680432 %R 10.2196/65506 %U https://bioinform.jmir.org/2024/1/e65506 %U https://doi.org/10.2196/65506 %U http://www.ncbi.nlm.nih.gov/pubmed/39680432 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e53720 %T Perceived Experiences and Needs of Digital Resources Among Postpartum Women in the United Arab Emirates: Qualitative Focus Group Study %A Hanach,Nivine %A Saqan,Roba %A Radwan,Hadia %A Baniissa,Wegdan %A de Vries,Nanne %+ Faculty of Health, Medicine, and Life Sciences, Care and Public Health Research Institute, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, Netherlands, 31 43 388 5655, n.hanach@maastrichtuniversity.nl %K digital health %K social support %K telemedicine %K postpartum women %K focus group %K maternal health %K postpartum mental health %K postpartum depression %K emotional support %K health information %D 2024 %7 16.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: The postpartum period is a critical phase in a woman's life, marked by various physical, psychological, and social challenges. In light of the rapid proliferation and uptake of digital technologies, particularly in the United Arab Emirates (UAE), mothers increasingly seek informational and emotional support from digital resources. No previous study has thoroughly explored the usage of various digital resources beyond telehealth services in the UAE. This literature gap is particularly relevant for the postpartum period, which remains largely understudied in the UAE. Objective: This study aims to delve into the digital experiences of postpartum women in the UAE by exploring the types of resources they navigate and the purposes those resources serve. In addition, it seeks to identify their perspectives and needs regarding digital resources that support their postpartum journey. Methods: Four focus groups were conducted synchronously on the web, involving a total of 27 multicultural mothers (mean age 32.47, SD 4.56 years), between 2 and 12 months post partum and living in the UAE. Descriptive interpretive thematic analysis was used to analyze the data. Results: Sixteen out of 27 women exhibited severe depressive symptoms at the time of the discussions (Edinburgh Postnatal Depression Scale score of >12). Two main themes were generated from the analysis: (1) Mothers’ Experiences with Digital Resources: Participants valued digital resources for providing immediate information, convenience, and support. They primarily used these resources to seek information on infant health, parenting advice, and emotional support through web-based communities. However, the abundance of conflicting information and the pressure to conform to health recommendations often created stress and anxiety. (2) The Perceived Need for Digital Resources: Despite their extensive use of digital resources, mothers articulated the need for a reliable UAE government digital platform tailored specifically to postpartum care, offering trusted information on infant health and postpartum mental well-being. They also emphasized the need for tailored postpartum telemedicine services and moderated web-based discussion forums to foster peer support among mothers. Conclusions: This study reveals the multifaceted role of digital resources in supporting mothers during the postpartum period, highlighting unmet needs that present opportunities for advancing postpartum care in the UAE. It demonstrates the importance of developing reliable digital solutions for postpartum women, especially regarding mental health and to enhance access to care through tailored telemedicine services. Collaborative efforts are required to ensure the implementation of user-centered digital platforms. Future research should focus on the diverse needs of postpartum women, including cultural sensitivity, the feasibility of telemedicine services, and the integration of partner support in digital interventions to improve maternal health outcomes. %M 39680428 %R 10.2196/53720 %U https://www.jmir.org/2024/1/e53720 %U https://doi.org/10.2196/53720 %U http://www.ncbi.nlm.nih.gov/pubmed/39680428 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e58206 %T Frontal Pole Neuromodulation for Impulsivity and Suicidality in Veterans With Mild Traumatic Brain Injury and Common Co-Occurring Mental Health Conditions: Protocol for a Pilot Randomized Controlled Trial %A Bernanke,Alyssa %A Hasley,Rebecca %A Sabetfakhri,Niki %A de Wit,Harriet %A Smith,Bridget M %A Wang,Lei %A Brenner,Lisa A %A Hanlon,Colleen %A Philip,Noah S %A Ajilore,Olusola %A Herrold,Amy %A Aaronson,Alexandra %+ Edward Hines Department of Veteran Affairs, Mental Health Service Line, 5001 S 5th Ave, Hines, IL, 60141, United States, 1 708 202 8387, alexandra.aaronson@va.gov %K mild traumatic brain injury %K transcranial magnetic stimulation %K intermittent theta burst stimulation %K suicidality %K suicidal ideation %K impulsivity %K neuromodulation %K social and occupational functioning %D 2024 %7 13.12.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide remains a leading cause of death among veterans in the United States, and mild traumatic brain injury (mTBI) increases the risk of suicidal ideation (SI) and suicide attempts (SAs). mTBI worsens impulsivity and contributes to poor social and occupational functioning, which further increases the risk of SI and SAs. Repetitive transcranial magnetic stimulation is a neuromodulatory treatment approach that induces neuroplasticity, potentially repairing neurodamage. Intermittent theta burst stimulation (iTBS) is a second-generation form of transcranial magnetic stimulation that is safe, shorter in duration, displays a minimal side effect profile and is a promising treatment approach for impulsivity in mTBI. Our novel proposed treatment protocol uses frontal pole iTBS to target the ventromedial prefrontal cortex, which may reduce impulsivity by strengthening functional connectivity between the limbic system and frontal cortex, allowing for improved top-down control of impulsive reactions, including SI and SAs. Objective: The objectives of this study are to (1) develop an iTBS intervention for veterans with mTBI, impulsivity, and SI; (2) assess the feasibility and tolerability of the intervention; and (3) gather preliminary clinical outcome data on SI, impulsivity, and functions that will guide future studies. Methods: This is a pilot, double-blinded, randomized controlled trial. In developing this protocol, we referenced the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) guidelines. We will enroll 56 participants (28 active iTBS and 28 sham iTBS). The iTBS intervention will be performed daily, 5 days a week, for 2 weeks. We will collect 10 validated, psychometric, quantitative outcome measures before, during, and after the intervention. Measures included will assess functioning, impulsivity, suicidality, posttraumatic stress disorder, and depressive symptoms. We will collect qualitative data through semistructured interviews to elicit feedback on the participants’ experiences and symptoms. We will perform quantitative and qualitative analyses to (1) assess the feasibility, tolerability, and acceptability of the treatment; (2) gather advanced neuroimaging data to assess neural changes elicited by treatment; and (3) assess improvements in outcome measures of impulsivity and suicidality in veterans with mTBI. Results: This study protocol was approved by the Edward Hines, Jr. VA Hospital Institutional Review Board (Hines IRB number 14-003). This novel treatment is a 5-year research project (April 1, 2023, to March 31, 2028) funded by the Veterans Administration Rehabilitation Research and Development service (CDA2 award IK2 RX002938). Study results will be disseminated at or before the project’s end date in March 2028. Conclusions: We will provide preliminary evidence of the safety, feasibility, and acceptability of a novel frontal pole iTBS treatment for mTBI, impulsivity, SI and SAs, and functional deficits. Trial Registration: ClinicalTrials.gov NCT05647044; https://clinicaltrials.gov/study/NCT05647044 International Registered Report Identifier (IRRID): PRR1-10.2196/58206 %M 39671573 %R 10.2196/58206 %U https://www.researchprotocols.org/2024/1/e58206 %U https://doi.org/10.2196/58206 %U http://www.ncbi.nlm.nih.gov/pubmed/39671573 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e55856 %T Screening for Depression and Anxiety Using a Nonverbal Working Memory Task in a Sample of Older Brazilians: Observational Study of Preliminary Artificial Intelligence Model Transferability %A Georgescu,Alexandra Livia %A Cummins,Nicholas %A Molimpakis,Emilia %A Giacomazzi,Eduardo %A Rodrigues Marczyk,Joana %A Goria,Stefano %K depression %K anxiety %K Brazil %K machine learning %K n-back %K working memory %K artificial intelligence %K gerontology %K older adults %K mental health %K AI %K transferability %K detection %K screening %K questionnaire %K longitudinal study %D 2024 %7 12.12.2024 %9 %J JMIR Form Res %G English %X Background: Anxiety and depression represent prevalent yet frequently undetected mental health concerns within the older population. The challenge of identifying these conditions presents an opportunity for artificial intelligence (AI)–driven, remotely available, tools capable of screening and monitoring mental health. A critical criterion for such tools is their cultural adaptability to ensure effectiveness across diverse populations. Objective: This study aims to illustrate the preliminary transferability of two established AI models designed to detect high depression and anxiety symptom scores. The models were initially trained on data from a nonverbal working memory game (1- and 2-back tasks) in a dataset by thymia, a company that develops AI solutions for mental health and well-being assessments, encompassing over 6000 participants from the United Kingdom, United States, Mexico, Spain, and Indonesia. We seek to validate the models’ performance by applying it to a new dataset comprising older Brazilian adults, thereby exploring its transferability and generalizability across different demographics and cultures. Methods: A total of 69 Brazilian participants aged 51-92 years old were recruited with the help of Laços Saúde, a company specializing in nurse-led, holistic home care. Participants received a link to the thymia dashboard every Monday and Thursday for 6 months. The dashboard had a set of activities assigned to them that would take 10-15 minutes to complete, which included a 5-minute game with two levels of the n-back tasks. Two Random Forest models trained on thymia data to classify depression and anxiety based on thresholds defined by scores of the Patient Health Questionnaire (8 items) (PHQ-8) ≥10 and those of the Generalized Anxiety Disorder Assessment (7 items) (GAD-7) ≥10, respectively, were subsequently tested on the Laços Saúde patient cohort. Results: The depression classification model exhibited robust performance, achieving an area under the receiver operating characteristic curve (AUC) of 0.78, a specificity of 0.69, and a sensitivity of 0.72. The anxiety classification model showed an initial AUC of 0.63, with a specificity of 0.58 and a sensitivity of 0.64. This performance surpassed a benchmark model using only age and gender, which had AUCs of 0.47 for PHQ-8 and 0.53 for GAD-7. After recomputing the AUC scores on a cross-sectional subset of the data (the first n-back game session), we found AUCs of 0.79 for PHQ-8 and 0.76 for GAD-7. Conclusions: This study successfully demonstrates the preliminary transferability of two AI models trained on a nonverbal working memory task, one for depression and the other for anxiety classification, to a novel sample of older Brazilian adults. Future research could seek to replicate these findings in larger samples and other cultural contexts. Trial Registration: ISRCTN Registry ISRCTN90727704; https://www.isrctn.com/ISRCTN90727704 %R 10.2196/55856 %U https://formative.jmir.org/2024/1/e55856 %U https://doi.org/10.2196/55856 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e63311 %T Discussions of Cannabis Over Patient Portal Secure Messaging: Content Analysis %A Shetty,Vishal A %A Gregor,Christina M %A Tusing,Lorraine D %A Pradhan,Apoorva M %A Romagnoli,Katrina M %A Piper,Brian J %A Wright,Eric A %+ Department of Health Promotion and Policy, University of Massachusetts, 715 North Pleasant St., Amherst, MA, 01003, United States, 1 413 230 4015, vashetty@geisinger.edu %K patient portal %K secure message %K marijuana %K patient-provider communication %K message content %K content analysis %K United States %K pain %K anxiety %K depression %K insomnia %K electronic messaging %K electronic health record %K EHR %K cannabis %D 2024 %7 12.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Patient portal secure messaging allows patients to describe health-related behaviors in ways that may not be sufficiently captured in standard electronic health record (EHR) documentation, but little is known about how cannabis is discussed on this platform. Objective: This study aimed to identify patient and provider secure messages that discussed cannabis and contextualize these discussions over periods before and after its legalization for medical purposes in Pennsylvania. Methods: We examined 382,982 secure messages sent by 15,340 patients and 6101 providers from an integrated health delivery system in Pennsylvania, United States, from January 2012 to June 2022. We used an unsupervised natural language processing approach to construct a lexicon that identified messages explicitly discussing cannabis. We then conducted a qualitative content analysis on a random sample of identified messages to understand the medical reasons behind patients’ use, the primary purposes of the cannabis-related discussions, and changes in these purposes over time. Results: We identified 1782 messages sent by 1098 patients (7.2% of total patients in the study) and 800 messages sent by 430 providers (7% of total providers in the study) as explicitly discussing cannabis. The most common medical reasons for use stated by patients in 190 sampled messages included pain or a pain-related condition (50.5% of messages), anxiety (13.7% of messages), and sleep (11.1% of messages). We coded 56 different purposes behind the mentions of cannabis in patient messages and 33 purposes in 100 sampled provider messages. In years before the legalization (2012-2016), patient and provider messages (n=20 for both) were primarily driven by discussions about cannabis screening results (38.9% and 76.5% of messages, respectively). In the years following legalization (2017-2022), patient messages (n=170) primarily involved seeking assistance to facilitate medical use (35.2% of messages) and reporting current use (25.3% of messages). Provider messages (n=80) were driven by giving assistance with medical marijuana access (27.5% of messages) and stating that they were unable to refer, prescribe or recommend medical marijuana (26.3% of messages). Conclusions: Patients showed a willingness to discuss cannabis use over patient portal secure messages and expressed interest in use after the legalization of medical marijuana. Some providers responded to patient inquiries with assistance in obtaining access to medical marijuana, while others cautioned patients on the risks of use. Insight into cannabis-related discussions through secure messages can help health systems determine opportunities to improve care processes around patients’ cannabis use, and providers should be supported to communicate accurate and consistent information. %M 39666375 %R 10.2196/63311 %U https://www.jmir.org/2024/1/e63311 %U https://doi.org/10.2196/63311 %U http://www.ncbi.nlm.nih.gov/pubmed/39666375 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e60760 %T Prevalence and Independent Predictors of Anxiety and Depression Among Elementary and High School Educators: Cross-Sectional Study %A Agyapong,Belinda %A Brett-MacLean,Pamela %A Orimalade,Adedamola %A Dias,Raquel da Luz %A Wei,Yifeng %A Agyapong,Vincent Israel Opoku %+ Department of Psychiatry, Faculty of Medicine & Dentistry, University of Alberta, 4-142A Katz Group Centre for Research, 11315- 87 Ave NW, Edmonton, AB, T6G 2H5, Canada, 1 7804928560, bagyapon@ualberta.ca %K generalized anxiety disorder %K major depressive disorder %K resilience %K stress %K Wellness4Teachers %K teachers %K prevalence %K predictors %D 2024 %7 11.12.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Globally, anxiety and depression are primary contributors to work disability and impact the mental and physical well-being of educators. Objective: This study aims to determine the prevalence and independent predictors of likely generalized anxiety disorder (GAD) and likely major depressive disorder (MDD) among teachers in the Canadian provinces of Newfoundland and Labrador, Alberta, and Nova Scotia. Methods: The study used a cross-sectional design. Educators from the 3 Canadian provinces participated by completing a web-based survey after enrolling in the Wellness4Teachers program, a free, self-subscription, daily, supportive SMS text messaging initiative. The program was launched at the beginning of the 2022-2023 academic year, and all teachers in the 3 provinces were eligible to enroll. Likely GAD and likely MDD among subscribers were assessed using the Generalized Anxiety Disorder-7 scale and the Patient Health Questionnaire-9, respectively. Data analysis was conducted using SPSS (version 28.0). Results: Of the 1912 Wellness4Teachers subscribers, 763 (39.9%) completed the survey. The prevalence of likely MDD was 55.7% (425/763) and that of likely GAD was 46% (349/759). After controlling for all other variables in the regression model, participants who reported high stress were 7.24 times more likely to experience MDD (odds ratio [OR] 7.24, 95% CI 4.22-12.42) and 7.40 times more likely to experience GAD (OR 7.40, 95% CI 4.63-11.80) than those with mild to moderate stress. Participants with emotional exhaustion were 4.92 times more likely to experience MDD (OR 4.92, 95% CI 3.01-8.05) and 4.34 times more likely to experience GAD (OR 4.34, 95% CI 2.47-7.62) than those without. Moreover, respondents with a lack of professional accomplishment were 2.13 times as likely to have MDD symptoms (OR 2.13, 95% CI 1.41-3.23) and 1.52 times more likely to experience GAD symptoms (OR 1.524, 95% CI 1.013-2.293) than those without. Similarly, respondents with low resilience were 1.82 times more likely to have likely MDD than those with normal to high resilience (OR 1.82, 95% CI 1.24-2.66). In addition, respondents with low resilience were 3.01 times more likely to experience likely GAD than those with normal to high resilience (OR 3.01, 95% CI 2.03-7.62). Participants with >20 years of teaching experience were 0.28 times less likely to experience GAD symptoms than those with ≤5 years of teaching experience (OR 0.28, 95% CI 0.12-0.64). Sociodemographic and work-related variables did not independently predict likely GAD and likely MDD. Conclusions: This study underscores the need for governments and policy makers in the education sector to implement comprehensive mental health support programs. Addressing the unique stressors faced by educators, reducing emotional exhaustion, and enhancing resilience are crucial steps toward mitigating anxiety and depression, promoting educators’ well-being, and improving the quality of educational delivery. International Registered Report Identifier (IRRID): RR2-10.2196/37934. %M 39528340 %R 10.2196/60760 %U https://formative.jmir.org/2024/1/e60760 %U https://doi.org/10.2196/60760 %U http://www.ncbi.nlm.nih.gov/pubmed/39528340 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 13 %N %P e50754 %T Weight and Lifestyle Behavior Changes in Chinese Health Care Workers During the COVID-19 Pandemic: 3-Year Retrospective Survey %A Guo,Xinyue %A Gong,Shaoqing %A Chen,Ying %A Hou,Xiaohui %A Sun,Tong %A Wen,Jianqiang %A Wang,Zhiyao %A He,Jingyang %A Sun,Xuezhu %A Wang,Sufang %A Chen,Zhixin %A Feng,Xue %A Tian,Xiangyang %+ Chinese Center for Health Education, Building 12, District 1, Anhua Xili, outside Andingmen, Beijing, Beijing, China, 1 01064263018, healthtian@163.com %K COVID-19 %K healthcare workers %K lifestyle behavior %K overweight %K obesity %K physical activity %K mental health %K stress %K anxiety,depression %K pandemic %D 2024 %7 10.12.2024 %9 Original Paper %J Interact J Med Res %G English %X Background: Health care workers (HCWs) played a key role in preventing and controlling COVID-19. Higher infection risks and intensive work led to occupational burnout for many HCWs, which may affect their lifestyle behaviors and weight. Objective: This study aimed to assess HCWs’ self-rated health status, overweight and obesity rates, lifestyle behaviors, and psychoemotional changes from 2019 to 2022 across China and to analyze the factors associated with changes from underweight or normal weight in 2019 to overweight or obese in 2022. Methods: In this retrospective study, 100 health care institutions were randomly selected from 5 provinces or regions in China. All HCWs who worked in the institutions for at ≥3 years were invited to complete the electronic questionnaire and participate in the online survey from August 1, 2022, to August 31, 2022. Collected data included changes in lifestyle behaviors (dietary habits, physical activity, sleep quality, smoking, alcohol consumption), psychoemotional conditions (persistent stress or recurrent anxiety or depressed mood), health status, and chronic disease control from December 2019 to August 2022. Height and weight in 2019 and 2022 were retrieved from annual physical examination records. Overweight and obesity were defined as 24.0 kg/m2≤BMI<28.0 kg/m2 (overweight) and BMI≥28.0 kg/m2 (obesity). Chi square tests and ANOVAs were used to assess the associations between groups. Logistic regression models were used to analyze the factors associated with HCWs becoming overweight or obese from 2019 to 2022. Results: The questionnaire was submitted by 23,234 HCWs. Of the underweight or normal weight HCWs in 2019, 12.67% (1486/23,234) became overweight or obese in 2022; this change was associated with the following factors: 34-43 years old (OR 0.843, 95% CI 0.740-0.960), 44-53 years old (OR 0.738, 95% CI 0.635-0.960), and 54-63 years old (OR 0.503, 95% CI 0.368-0.685; reference: 24-33 years old), reduction in or never or rarely engaging in physical activity (OR 1.201, 95% CI 1.055-1.368; reference: increase in physical activity; P=.006), increased appetite (OR 2.043, 95% CI 1.788-2.034; reference: reduction or no change in appetite; P<.001). From 2019 to 2022, 51.29% (11,917/23,234) of the respondents experienced increased persistent stress or recurrent anxiety or depressed mood; 44.38% (10,311/23,234) stayed up late more often. Increased persistent stress or recurrent anxiety or depressed mood was associated with physical activity (OR 0.421, 95% CI 0.398-0.447; P<.001) and appetite (OR 1.601, 95% CI 1.483-1.728; P<.001). Conclusions: The pandemic was associated with overweight and obesity for HCWs due to changes in lifestyle behaviors, especially reduced physical activity and increased appetite related to increased persistent stress or recurrent anxiety or depressed mood caused by excessive workload. An integrated approach is needed to address overweight and obesity and lifestyle changes among HCWs by releasing negative psychoemotional conditions through workload reduction in future stressful events. %M 39657182 %R 10.2196/50754 %U https://www.i-jmr.org/2024/1/e50754 %U https://doi.org/10.2196/50754 %U http://www.ncbi.nlm.nih.gov/pubmed/39657182 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e56680 %T Communal Load Sharing of Miscarriage Experiences: Thematic Analysis of Social Media Community Support %A Dubbelman,Julia %A Ooms,Jonelle %A Havgry,Laura %A Simonse,Lianne %+ Department of Design, Organization, and Strategy, Faculty of Industrial Design Engineering, Delft University of Technology, Landbergstraat 15, Delft, 2628 CE, Netherlands, 31 616844170, L.W.L.Simonse@tudelft.nl %K miscarriage %K miscarriage grief %K online health communities %K thematic analysis %K social support %K communal load sharing %K peer-to-peer support %D 2024 %7 10.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Miscarriage is a common experience, affecting 15% of recognized pregnancies, but societal ignorance and taboos often downplay the mental distress and personal impact following a miscarriage. Emerging stories on social media in which women express their miscarriage grief are breaking such taboos. Research in the area of online health communities is increasingly focused on studying how people share their health experiences on social media. However, a clear understanding on the social support involved in this type of sharing of health experiences is lacking. Objective: This study explored the use of Instagram in sharing miscarriage experiences, guided by the following research question: How is social community support given to women who share their miscarriage experiences on social media? Considering that social media is increasingly used as a source of social support, in this study, we chose Instagram as the social media platform. The purpose of this research was to create a better understanding of how social media provides support in expressing personal miscarriage experiences and how people engage with such posts. Methods: This study used a qualitative inductive research method in which a phenomenological strategy and thematic analysis were followed to create a comprehensive understanding of the social community support phenomenon. The dataset was established from a sample of 258 Instagram posts and 736 comments collected over a period of 6 months after initial posts and from 6 different women. These data were categorized and clustered through a thematic analysis. Results: Three themes were identified: (1) storytelling of emotional turmoil and grief after miscarriage, (2) sharing positivity amidst miscarriage grief, and (3) mentioning personal medical information about miscarriage. Theme 1 represents the emotional experience of women who have had a miscarriage. It encompasses the initial posts that included miscarriage storytelling that express deep grief and mental distress and the emotional impact on both the posters and the commenters. Theme 2 highlights the importance of finding moments of joy and positivity in the midst of mental distress and pain. The posts shared with the online community convey a sense of moving forward and a refusal to let grief become the defining aspect of one’s life. Theme 3 focuses on sharing medical and practical advice. This theme includes posts and comments about medications, in vitro fertilization procedures, hospital experiences, and personal physical symptoms. Conclusions: As an overarching theme for this social support phenomenon, we introduce the term communal load sharing to describe the therapeutic role of social media in helping women cope with miscarriage by providing a platform for sharing similar experiences, breaking social taboos, and fostering load sharing. %M 39656509 %R 10.2196/56680 %U https://www.jmir.org/2024/1/e56680 %U https://doi.org/10.2196/56680 %U http://www.ncbi.nlm.nih.gov/pubmed/39656509 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e63132 %T Ecological Momentary Assessment of Self-Harm Thoughts and Behaviors: Systematic Review of Constructs From the Integrated Motivational-Volitional Model %A Winstone,Lizzy %A Heron,Jon %A John,Ann %A Kirtley,Olivia J %A Moran,Paul %A Muehlenkamp,Jennifer %A O'Connor,Rory C %A Mars,Becky %+ Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PN, United Kingdom, 44 0117 928 7279, lizzy.winstone@bristol.ac.uk %K integrated motivational-volitional model %K IMV model %K ecological momentary assessment %K suicidal and nonsuicidal self-harm thoughts and behaviors %D 2024 %7 9.12.2024 %9 Review %J JMIR Ment Health %G English %X Background: The integrated motivational-volitional model (IMV) is one of the leading theoretical models of suicidal thoughts and behavior. There has been a recent proliferation in the assessment of suicidal and nonsuicidal self-harm thoughts and behaviors (SHTBs) in daily life. Objective: This systematic review synthesized evidence from ecological momentary assessment (EMA) studies in the SHTB literature to address the following questions: (1) Which constructs in the IMV model have been assessed using EMA, and how have they been assessed? (2) Do different constructs from the IMV model fluctuate in daily life? (3) What is the relationship between the different IMV constructs and SHTBs in daily life? Methods: Consistent with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted systematic searches of 5 databases—Web of Science, Embase, MEDLINE, PsycINFO, and Europe PMC Preprints—from inception to March 26, 2024. Results: Our searches resulted in the inclusion and narrative synthesis of 53 studies across 58 papers. A total of 15 IMV constructs were measured using EMA across the included papers. The most frequently measured constructs were thwarted belongingness (24/58, 41% of the papers), future thinking (20/58, 34% of the papers), and perceived burdensomeness (16/58, 28% of the papers). The least frequently measured constructs were humiliation, social problem-solving, mental imagery, and perceived capability for suicide. None of the included papers measured memory biases, goals, norms, or resilience using EMA. Comparison of intraclass correlation coefficients (45/58, 78% of the papers) revealed moderate but inconsistent within-person variance across all the examined constructs. We found evidence (39/58, 67% of the papers) of concurrent associations between almost all constructs and SHTBs in daily life, with some evidence that entrapment, shame, rumination, thwarted belongingness, hopelessness, social support, and impulsivity are additionally associated with SHTBs in lagged (ie, longitudinal) relationships. Conclusions: Comparisons were hindered by variation in methodology, including the populations studied, EMA sampling scheme, operationalization of IMV constructs and SHTBs, and statistical approach used. Our findings suggest that EMA studies are a useful methodology for examining risk factors for SHTBs; however, more research is needed for some IMV constructs. Quality assessment suggested several areas for improvement in the reporting of EMA studies in this field. Trial Registration: PROSPERO CRD42022349514; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=349514 %M 39652869 %R 10.2196/63132 %U https://mental.jmir.org/2024/1/e63132 %U https://doi.org/10.2196/63132 %U http://www.ncbi.nlm.nih.gov/pubmed/39652869 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e59426 %T Co-Designing the MOSAIC mHealth App With Breast Cancer Survivors: User-Centered Design Approach %A Nuseibeh,Betsey Zenk %A Johns,Shelley A %A Shih,Patrick C %A Lewis,Gregory F %A Gowan,Tayler M %A Jordan,Evan J %+ School of Public Health, Indiana University, 1025 East Seventh Street, Bloomington, IN, 47405, United States, 1 5132255577, bznuseib@iu.edu %K breast cancer survivors %K acceptance and commitment therapy %K mHealth app %K user-centered design %K depression %K anxiety %K therapy %K app %K breast cancer %K expert %K designer %K psychosocial %K need %K co-design %K MOSAIC %K mobile acceptance and commitment therapy stress intervention %K interviews %D 2024 %7 9.12.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Breast cancer is the world’s most prevalent cancer. Although the 5-year survival rate for breast cancer in the United States is 91%, the stress and uncertainty of survivorship can often lead to symptoms of depression and anxiety. With nearly half of breast cancer survivors living with stress and symptoms of depression and anxiety, there are a significant number of unmet supportive care needs. New and potentially scalable approaches to meeting these supportive care needs are warranted. Objective: This study aimed to engage breast cancer survivors and acceptance and commitment therapy (ACT) content experts in user-centered design (UCD) to develop a mobile health app (MOSAIC [Mobile Acceptance and Commitment Therapy Stress Intervention]) using stress intervention strategies. Methods: We held 5 UCD sessions with 5 breast cancer survivors, 3 ACT content experts, 2 user experience design experts, and 1 stress expert facilitator over the course of 10 weeks. The sessions were developed to lead the 10 co-designers through the 5-step UCD process (eg, problem identification, solution generation, convergence, prototyping, and debriefing and evaluation). Following the fifth session, a prototype was generated and evaluated by the 5 breast cancer survivors and 3 ACT experts using the System Usability Scale, Acceptability E-scale, and a brief set of semistructured interview questions. Results: The 10 co-designers were present for each of the 5 co-design sessions. Co-designers identified 5 design characteristics: simple entry with use reminders (behavioral nudges), a manageable number of intervention choices, highly visual content, skill-building exercises, and social support. A total of 4 features were also identified as critical to the use of the tool: an ACT and breast cancer–specific onboarding process, clean navigation tools, clear organization of the interventions, and once-per-week behavioral nudges. These requirements created the foundation for the app prototype. The 5 breast cancer survivors and 3 ACT co-designers evaluated the app prototype for 1 week, using an Android smartphone. They rated the app as usable (mean 79.29, SD 19.83) on the System Usability Scale (a priori mean cutoff score=68) and acceptable (mean 24.28, SD 2.77) on the Acceptability E-scale (a priori mean cutoff score=24). Conclusions: Through the UCD process, we created an ACT app prototype with 5 breast cancer survivors, 3 ACT experts, and 2 UCD designers. The next step in our research is to continue the assessment and refining of the prototype with additional breast cancer survivors. Future work will pilot-test the app to examine the feasibility of a large-scale, randomized control trial. Studies will enroll increasingly diverse breast cancer survivors to broaden the generalizability of findings. %R 10.2196/59426 %U https://formative.jmir.org/2024/1/e59426 %U https://doi.org/10.2196/59426 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e55635 %T Dynamic Bidirectional Associations Between Global Positioning System Mobility and Ecological Momentary Assessment of Mood Symptoms in Mood Disorders: Prospective Cohort Study %A Lee,Ting-Yi %A Chen,Ching-Hsuan %A Chen,I-Ming %A Chen,Hsi-Chung %A Liu,Chih-Min %A Wu,Shu-I %A Hsiao,Chuhsing Kate %A Kuo,Po-Hsiu %+ Department of Public Health and Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Room 521, No 17, Xuzhou Road, Taipei, 10055, Taiwan, 886 2 33668015, phkuo@ntu.edu.tw %K ecological momentary assessment %K digital phenotyping %K GPS mobility %K bipolar disorder %K major depressive disorder %K GPS %K global positioning system %K mood disorders %K assessment %K depression %K anxiety %K digital phenotype %K smartphone app %K technology %K behavioral changes %K patient %K monitoring %D 2024 %7 6.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Although significant research has explored the digital phenotype in mood disorders, the time-lagged and bidirectional relationship between mood and global positioning system (GPS) mobility remains relatively unexplored. Leveraging the widespread use of smartphones, we examined correlations between mood and behavioral changes, which could inform future scalable interventions and personalized mental health monitoring. Objective: This study aims to investigate the bidirectional time lag relationships between passive GPS data and active ecological momentary assessment (EMA) data collected via smartphone app technology. Methods: Between March 2020 and May 2022, we recruited 45 participants (mean age 42.3 years, SD 12.1 years) who were followed up for 6 months: 35 individuals diagnosed with mood disorders referred by psychiatrists and 10 healthy control participants. This resulted in a total of 5248 person-days of data. Over 6 months, we collected 2 types of smartphone data: passive data on movement patterns with nearly 100,000 GPS data points per individual and active data through EMA capturing daily mood levels, including fatigue, irritability, depressed, and manic mood. Our study is limited to Android users due to operating system constraints. Results: Our findings revealed a significant negative correlation between normalized entropy (r=–0.353; P=.04) and weekly depressed mood as well as between location variance (r=–0.364; P=.03) and depressed mood. In participants with mood disorders, we observed bidirectional time-lagged associations. Specifically, changes in homestay were positively associated with fatigue (β=0.256; P=.03), depressed mood (β=0.235; P=.01), and irritability (β=0.149; P=.03). A decrease in location variance was significantly associated with higher depressed mood the following day (β=–0.015; P=.009). Conversely, an increase in depressed mood was significantly associated with reduced location variance the next day (β=–0.869; P<.001). These findings suggest a dynamic interplay between mood symptoms and mobility patterns. Conclusions: This study demonstrates the potential of utilizing active EMA data to assess mood levels and passive GPS data to analyze mobility behaviors, with implications for managing disease progression in patients. Monitoring location variance and homestay can provide valuable insights into this process. The daily use of smartphones has proven to be a convenient method for monitoring patients’ conditions. Interventions should prioritize promoting physical movement while discouraging prolonged periods of staying at home. %M 39642364 %R 10.2196/55635 %U https://www.jmir.org/2024/1/e55635 %U https://doi.org/10.2196/55635 %U http://www.ncbi.nlm.nih.gov/pubmed/39642364 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e56407 %T Text Messaging to Extend School-Based Suicide Prevention: Pilot Randomized Controlled Trial %A Pisani,Anthony R %A Wyman,Peter A %A Cero,Ian %A Kelberman,Caroline %A Gurditta,Kunali %A Judd,Emily %A Schmeelk-Cone,Karen %A Mohr,David %A Goldston,David %A Ertefaie,Ashkan %+ Department of Psychiatry, University of Rochester Medical Center, University of Rochester, 301 Crittenden Blvd, Rochester, NY, 14627, United States, 1 585 507 7177, anthony_pisani@urmc.rochester.edu %K suicide prevention %K text messaging %K self-violence %K self-harm %K suicidal behavior %K randomized controlled trial %K adolescent %K teenager %K student %K school %K United States %K Text4Strength %K help-seeking attitude %K coping %K awareness %K depression %K mood disorder %K mental health %D 2024 %7 6.12.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide is the third-leading cause of death among US adolescents aged 10-19 years, and about 10% attempt suicide each year. School-based universal prevention may reduce youth suicidal behavior. Sources of Strength uses a peer leader network diffusion model to promote healthy norms across a school population. A key challenge within schoolwide programs is reaching a large and diverse array of students, especially those less engaged with their peers. Motivated by this challenge, we developed and field-tested Text4Strength—a program of automated text messages targeting help-seeking attitudes and norms, social coping resources, and emotion regulation skills. Objective: This study conducted a pilot randomized controlled trial of Text4Strength in 1 high school as an extension of an ongoing schoolwide program (Sources of Strength), to test its impact on targets that have the potential to reduce suicidal behavior. Methods: Students at an upstate New York high school (N=223) received 1-2 text messages per week for 9 weeks, targeting strategies for coping with difficult feelings and experiences through clarifying emotions and focusing on positive affect concepts, awareness, and strengthening of youth-adult relationships; and positive help-seeking norms, skills, and resources. Surveys were administered at baseline, immediately post intervention and 3 months after texting ended. We measured proximal intervention targets (methods of coping during stressful events, ability to make sense of their own emotions, feelings of powerlessness during emotion management and recovery, relations with trusted adults at school, and help-seeking behaviors), symptoms and suicide ideation, and student replies to messages. Results: No significant effects were observed for any outcome at either follow-up time point. Results showed that if there is a true (but undetected) intervention effect, it is small. Students with fewer friend nominations did not interact any more or less with the text messages. Exploratory moderation analyses observed no interaction between the intervention condition and the number of friends or baseline suicide ideation at any time point. Conclusions: In contrast to a promising previous field test, these results suggest that Text4Strength is unlikely to have impacted the outcomes of interest and that undetected moderate or large effects can be ruled out with high confidence. Although motivated by the need to reach more isolated students, students with fewer friends did not engage more or show a greater effect than other participants. This study was conducted in a single high school that was already implementing Sources of Strength, so the bar for showing a distinct effect from texting alone was high. Many further channels for reaching youth through private messaging remain unexplored. Alternative delivery systems should be investigated, such as embedding messaging in gaming chat systems and other media. More sophisticated systems drawing on chatbots may also achieve better outcomes. Trial Registration: ClinicalTrials.gov NCT03145363; https://clinicaltrials.gov/study/NCT03145363 %M 39642360 %R 10.2196/56407 %U https://mental.jmir.org/2024/1/e56407 %U https://doi.org/10.2196/56407 %U http://www.ncbi.nlm.nih.gov/pubmed/39642360 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e49927 %T Machine Learning–Based Suicide Risk Prediction Model for Suicidal Trajectory on Social Media Following Suicidal Mentions: Independent Algorithm Validation %A Kaminsky,Zachary %A McQuaid,Robyn J %A Hellemans,Kim GC %A Patterson,Zachary R %A Saad,Mysa %A Gabrys,Robert L %A Kendzerska,Tetyana %A Abizaid,Alfonso %A Robillard,Rebecca %+ University of Ottawa Institute of Mental Health Research at The Royal, 1145 Carling Avenue, Ottawa, ON, K1Z 7K4, Canada, 1 6137226521 ext 7003, Zachary.Kaminsky@theroyal.ca %K suicide %K prediction %K social media %K machine learning %K suicide risk model %K validation %K prediction %K natural language processing %K suicide risk %K Twitter %K suicidal ideation %K suicidal mention %D 2024 %7 5.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Previous efforts to apply machine learning–based natural language processing to longitudinally collected social media data have shown promise in predicting suicide risk. Objective: Our primary objective was to externally validate our previous machine learning algorithm, the Suicide Artificial Intelligence Prediction Heuristic (SAIPH), against external survey data in 2 independent cohorts. A second objective was to evaluate the efficacy of SAIPH as an indicator of changing suicidal ideation (SI) over time. The tertiary objective was to use SAIPH to evaluate factors important for improving or worsening suicidal trajectory on social media following suicidal mention. Methods: Twitter (subsequently rebranded as X) timeline data from a student survey cohort and COVID-19 survey cohort were scored using SAIPH and compared to SI questions on the Beck Depression Inventory and the Self-Report version of the Quick Inventory of Depressive Symptomatology in 159 and 307 individuals, respectively. SAIPH was used to evaluate changing SI trajectory following suicidal mentions in 2 cohorts collected using the Twitter application programming interface. Results: An interaction of the mean SAIPH score derived from 12 days of Twitter data before survey completion and the average number of posts per day was associated with quantitative SI metrics in each cohort (student survey cohort interaction β=.038, SD 0.014; F4,94=3.3, P=.01; and COVID-19 survey cohort interaction β=.0035, SD 0.0016; F4,493=2.9, P=.03). The slope of average daily SAIPH scores was associated with the change in SI scores within longitudinally followed individuals when evaluating periods of 2 weeks or less (ρ=0.27, P=.04). Using SAIPH as an indicator of changing SI, we evaluated SI trajectory in 2 cohorts with suicidal mentions, which identified that those with responses within 72 hours exhibit a significant negative association of the SAIPH score with time in the 3 weeks following suicidal mention (ρ=–0.52, P=.02). Conclusions: Taken together, our results not only validate the association of SAIPH with perceived stress, SI, and changing SI over time but also generate novel methods to evaluate the effects of social media interactions on changing suicidal trajectory. %M 39637380 %R 10.2196/49927 %U https://www.jmir.org/2024/1/e49927 %U https://doi.org/10.2196/49927 %U http://www.ncbi.nlm.nih.gov/pubmed/39637380 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e60461 %T Acceptability, User Satisfaction, and Feasibility of an App-Based Support Service During the COVID-19 Pandemic in a Psychiatric Outpatient Setting: Prospective Longitudinal Observational Study %A Golsong,Konstanze %A Kaufmann,Luisa %A Baldofski,Sabrina %A Kohls,Elisabeth %A Rummel-Kluge,Christine %+ Department of Psychiatry and Psychotherapy, University of Leipzig Medical Center, Haus 13, Semmelweisstraße 10, Leipzig, Germany, 49 341 9724464, Christine.Rummel-Kluge@medizin.uni-leipzig.de %K mental health %K eHealth %K app %K health care %K app-based support %K psychiatric symptoms %K mobile phone %K COVID-19 %D 2024 %7 4.12.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Patients with mental disorders often have difficulties maintaining a daily routine, which can lead to exacerbated symptoms. It is known that apps can help manage mental health in a low-threshold way and can be used in therapeutic settings to complement existing therapies. Objective: The aim of this study was to evaluate the acceptability, usability, and feasibility of an app-based support service specifically developed for outpatients with severe mental disorders in addition to regular face-to-face therapy during the COVID-19 pandemic. Methods: Patients in a psychiatric outpatient department at a German university hospital were invited to use an app-based support service designed transdiagnostically for mental disorders for 4 weeks. The app included 7 relaxation modules, consisting of video, audio, and psychoeducational text; ecological momentary assessment–like questionnaires on daily mood answered via a visual smiley-face scale; and an activity button to record and encourage daily activities. Standardized questionnaires at baseline (T0; preintervention time point) and after 4 weeks (T2; postintervention time point) were analyzed. Feedback via the smiley-face scale was provided after using the app components (T1; during the intervention). Measures included depressive symptoms, quality of life, treatment credibility and expectancy, and satisfaction. Furthermore, participation rates, use of app modules and the activity button, and daily mood and the provided feedback were analyzed (T2). Results: In total, 57 patients participated in the study, and the data of 38 (67%) were analyzed; 17 (30%) dropped out. Satisfaction with the app was high, with 53% (30/57) of the participants stating being rather satisfied or satisfied. Furthermore, 79% (30/38) of completers stated they would be more likely or were definitely likely to use an app-based support service again and recommend it. Feasibility and acceptability were high, with nearly half (18/38, 47%) of the completers trying relaxation modules and 71% (27/38) regularly responding to the ecological momentary assessment–like questionnaire between 15 and 28 times (mean 19.91, SD 7.57 times). The activity button was used on average 12 (SD 15.72) times per completer, and 58% (22/38) felt “definitely” or “rather” encouraged to perform the corresponding activities. Depressive symptomatology improved significantly at the postintervention time point (P=.02). Quality of life showed a nonsignificant increase in the physical, psychological, and social domains (P=.59, P=.06, and P=.42, respectively) and a significant improvement in the environment domain (P=.004). Treatment credibility and expectancy scores were moderate and significantly decreased at T2 (P=.02 and P<.001, respectively). Posttreatment expectancy scores were negatively associated with posttreatment depressive symptomatology (r=–0.36; P=.03). Conclusions: App-based programs seem to be an accessible tool for stabilizing patients with severe mental disorders, supporting them in maintaining a daily routine, complementing existing face-to-face treatments, and overall helping respond to challenging situations such as the COVID-19 pandemic. %M 39630503 %R 10.2196/60461 %U https://formative.jmir.org/2024/1/e60461 %U https://doi.org/10.2196/60461 %U http://www.ncbi.nlm.nih.gov/pubmed/39630503 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e66430 %T Psychedelic Art and Implications for Mental Health: Randomized Pilot Study %A Peng,Mary L %A Monin,Joan %A Ovchinnikova,Polina %A Levi,Amanda %A McCall,Terika %+ Department of Orthopedics and Sports Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, United States, 1 (617) 355 6021, marypeng@hms.harvard.edu %K digital art %K mental health %K psychedelic art %K well-being %K pilot trial %K digital health tool %K art therapy %D 2024 %7 3.12.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Psychedelic art (PA) emerged in the 1960s during the psychedelic era; then characterized by visuals induced by the ingestion of psychedelic drugs, it is now an art form known for its vibrant colors, distorted forms, and intricate patterns. Building upon the existing research on art viewing as an effective means to improving physiological and psychological well-being, viewing PA is postulated to evoke positive emotions and provide a meditative experience, contributing to improved mental well-being. Objective: This study aims to investigate how digitally rendered PA influences viewers’ perceived emotional, mental, and physical states compared to imagery of natural scenery, offering insights into potential applications in mental health care and well-being. Methods: Overall, 102 participants age 18 to 35 years were randomly assigned to either the experimental group viewing 300 seconds of PA imagery (50/102, 49%) or the control group viewing 300 seconds of scenic imagery (52/102, 51%), after which every participant completed a survey that gathered qualitative data on the perceived impact of viewing their given imagery on their physical, mental, and emotional states through open-ended questions. Thematic analysis was conducted to identify the patterns of experiences reported by the participants. Results: Qualitative analysis unveiled a greater intensity and diversity of emotional, mental, and physical impacts induced by PA compared to natural scenery, including the sense of relaxation and peace, anxiety and stress alleviation, joy, thrill and sense of euphoria, sensations of awe and wonder, hypnotizing effect, holistic meditative effect, provocation of creative thoughts, induced hyperawareness of bodily states, and transitions from induced overstimulation or anxious thoughts to feelings of calmness. Conclusions: The preliminary findings of this study suggest that PA is a rich and complex form of visual art that has the potential to facilitate healing and promote well-being and mental health. PA presents promising avenues for integration into mental health care, therapeutic practices, digital health, health care environment, and medical research. %M 39626224 %R 10.2196/66430 %U https://formative.jmir.org/2024/1/e66430 %U https://doi.org/10.2196/66430 %U http://www.ncbi.nlm.nih.gov/pubmed/39626224 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e56874 %T Predicting and Monitoring Symptoms in Patients Diagnosed With Depression Using Smartphone Data: Observational Study %A Ikäheimonen,Arsi %A Luong,Nguyen %A Baryshnikov,Ilya %A Darst,Richard %A Heikkilä,Roope %A Holmen,Joel %A Martikkala,Annasofia %A Riihimäki,Kirsi %A Saleva,Outi %A Isometsä,Erkki %A Aledavood,Talayeh %+ Department of Computer Science, Aalto University, Konemiehentie 2, Espoo, 02150, Finland, 358 449750110, arsi.ikaheimonen@aalto.fi %K data analysis %K digital phenotyping %K digital behavioral data %K depression symptoms %K depression monitoring %K mHealth %K mobile health %K smartphone %K mobile phone %D 2024 %7 3.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Clinical diagnostic assessments and the outcome monitoring of patients with depression rely predominantly on interviews by professionals and the use of self-report questionnaires. The ubiquity of smartphones and other personal consumer devices has prompted research into the potential of data collected via these devices to serve as digital behavioral markers for indicating the presence and monitoring of the outcome of depression. Objective: This paper explores the potential of using behavioral data collected with smartphones to detect and monitor depression symptoms in patients diagnosed with depression. Specifically, it investigates whether this data can accurately classify the presence of depression, as well as monitor the changes in depressive states over time. Methods: In a prospective cohort study, we collected smartphone behavioral data for up to 1 year. The study consists of observations from 164 participants, including healthy controls (n=31) and patients diagnosed with various depressive disorders: major depressive disorder (MDD; n=85), MDD with comorbid borderline personality disorder (n=27), and major depressive episodes with bipolar disorder (n=21). Data were labeled based on depression severity using 9-item Patient Health Questionnaire (PHQ-9) scores. We performed statistical analysis and used supervised machine learning on the data to classify the severity of depression and observe changes in the depression state over time. Results: Our correlation analysis revealed 32 behavioral markers associated with the changes in depressive state. Our analysis classified patients who are depressed with an accuracy of 82% (95% CI 80%-84%) and change in the presence of depression with an accuracy of 75% (95% CI 72%-76%). Notably, the most important smartphone features for classifying depression states were screen-off events, battery charge levels, communication patterns, app usage, and location data. Similarly, for predicting changes in depression state, the most important features were related to location, battery level, screen, and accelerometer data patterns. Conclusions: The use of smartphone digital behavioral markers to supplement clinical evaluations may aid in detecting the presence and changes in severity of symptoms of depression, particularly if combined with intermittent use of self-report of symptoms. %M 39626241 %R 10.2196/56874 %U https://www.jmir.org/2024/1/e56874 %U https://doi.org/10.2196/56874 %U http://www.ncbi.nlm.nih.gov/pubmed/39626241 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 13 %N %P e53248 %T Predicting Depressive Symptoms Using GPS-Based Regional Data in Germany With the CORONA HEALTH App During the COVID-19 Pandemic: Cross-Sectional Study %A Edler,Johanna-Sophie %A Winter,Michael %A Steinmetz,Holger %A Cohrdes,Caroline %A Baumeister,Harald %A Pryss,Rüdiger %+ Mental Health Research Unit, Department of Epidemiology and Health Monitoring, Robert Koch Institute, PO Box 650261, Berlin, 12101, Germany, 49 1723842979, johannasophie.edler@gmail.com %K depression %K COVID-19 %K mobile phone %K geographic information systems %K GPS-based data %K mobile applications %K mental health %D 2024 %7 3.12.2024 %9 Original Paper %J Interact J Med Res %G English %X Background: Numerous studies have been conducted to predict depressive symptoms using passive smartphone data, mostly integrating the GPS signal as a measure of mobility. Environmental factors have been identified as correlated with depressive symptoms in specialized studies both before and during the pandemic. Objective: This study combined a data-based approach using passive smartphone data to predict self-reported depressive symptoms with a wide range of GPS-based environmental factors as predictors. Methods: The CORONA HEALTH app was developed for the purpose of data collection, and this app enabled the collection of both survey and passive data via smartphone. After obtaining informed consent, we gathered GPS signals at the time of study participation and evaluated depressive symptoms in 249 Android users with the Patient Health Questionnaire-9. The only GPS-based data collected were the participants’ location at the time of the questionnaire, which was used to assign participants to the nearest district for linking regional sociodemographic data. Data collection took place from July 2020 to February 2021, coinciding with the COVID-19 pandemic. Using GPS data, each dataset was linked to a wide variety of data on regional sociodemographic, geographic, and economic characteristics describing the respondent’s environment, which were derived from a publicly accessible database from official German statistical offices. Moreover, pandemic-specific predictors such as the current pandemic phase or the number of new regional infections were matched via GPS. For the prediction of individual depressive symptoms, we compared 3 models (ie, ridge, lasso, and elastic net regression) and evaluated the models using 10-fold cross-validation. Results: The final elastic net regression model showed the highest explained variance (R2=0.06) and reduced the dataset from 121 to 9 variables, the 3 main predictors being current COVID-19 infections in the respective district, the number of places in nursing homes, and the proportion of fathers receiving parental benefits. The number of places in nursing homes refers to the availability of care facilities for the elderly, which may indicate regional population characteristics that influence mental health. The proportion of fathers receiving parental benefits reflects family structure and work-life balance, which could impact stress and mental well-being during the pandemic. Conclusions: Passive data describing the environment contributed to the prediction of individual depressive symptoms and revealed regional risk and protective factors that may be of interest without their inclusion in routine assessments being costly. %M 39625745 %R 10.2196/53248 %U https://www.i-jmr.org/2024/1/e53248 %U https://doi.org/10.2196/53248 %U http://www.ncbi.nlm.nih.gov/pubmed/39625745 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e63195 %T Dynamic Simulation Models of Suicide and Suicide-Related Behaviors: Systematic Review %A Gariepy,Genevieve %A Zahan,Rifat %A Osgood,Nathaniel D %A Yeoh,Benjamin %A Graham,Eva %A Orpana,Heather %+ Centre for Surveillance and Applied Research, Public Health Agency of Canada, 785 Carling Avenue, Ottawa, ON, K1A 0K9, Canada, 1 6139527608, genevieve.gariepy@phac-aspc.gc.ca %K suicide %K agent-based modeling %K complex system %K complexity science %K discrete-event simulation %K dynamic modeling %K microsimulation %K system dynamics %K systems science %K qualitative study %K dynamic simulation %K database %K depression %K mental state %K systematic review %K stress %D 2024 %7 2.12.2024 %9 Review %J JMIR Public Health Surveill %G English %X Background: Suicide remains a public health priority worldwide with over 700,000 deaths annually, ranking as a leading cause of death among young adults. Traditional research methodologies have often fallen short in capturing the multifaceted nature of suicide, focusing on isolated risk factors rather than the complex interplay of individual, social, and environmental influences. Recognizing these limitations, there is a growing recognition of the value of dynamic simulation modeling to inform suicide prevention planning. Objective: This systematic review aims to provide a comprehensive overview of existing dynamic models of population-level suicide and suicide-related behaviors, and to summarize their methodologies, applications, and outcomes. Methods: Eight databases were searched, including MEDLINE, Embase, PsycINFO, Scopus, Compendex, ACM Digital Library, IEEE Xplore, and medRxiv, from inception to July 2023. We developed a search strategy in consultation with a research librarian. Two reviewers independently conducted the title and abstract and full-text screenings including studies using dynamic modeling methods (eg, System Dynamics and agent-based modeling) for suicide or suicide-related behaviors at the population level, and excluding studies on microbiology, bioinformatics, pharmacology, nondynamic modeling methods, and nonprimary modeling reports (eg, editorials and reviews). Reviewers extracted the data using a standardized form and assessed the quality of reporting using the STRESS (Strengthening the Reporting of Empirical Simulation Studies) guidelines. A narrative synthesis was conducted for the included studies. Results: The search identified 1574 studies, with 22 studies meeting the inclusion criteria, including 15 System Dynamics models, 6 agent-based models, and 1 microsimulation model. The studies primarily targeted populations in Australia and the United States, with some focusing on hypothetical scenarios. The models addressed various interventions ranging from specific clinical and health service interventions, such as mental health service capacity increases, to broader social determinants, including employment programs and reduction in access to means of suicide. The studies demonstrated the utility of dynamic models in identifying the synergistic effects of combined interventions and understanding the temporal dynamics of intervention impacts. Conclusions: Dynamic modeling of suicide and suicide-related behaviors, though still an emerging area, is expanding rapidly, adapting to a range of questions, settings, and contexts. While the quality of reporting was overall adequate, some studies lacked detailed reporting on model transparency and reproducibility. This review highlights the potential of dynamic modeling as a tool to support decision-making and to further our understanding of the complex dynamics of suicide and its related behaviors. Trial Registration: PROSPERO CRD42022346617; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=346617 %M 39622024 %R 10.2196/63195 %U https://publichealth.jmir.org/2024/1/e63195 %U https://doi.org/10.2196/63195 %U http://www.ncbi.nlm.nih.gov/pubmed/39622024 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e54941 %T Digital Interventions for Symptoms of Borderline Personality Disorder: Systematic Review and Meta-Analysis %A Lindsay,Julia A B %A McGowan,Niall M %A Henning,Thomas %A Harriss,Eli %A Saunders,Kate E A %+ Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Ln, Oxford, OX3 7JX, United Kingdom, 44 01865613196, julia.lindsay@psych.ox.ac.uk %K borderline personality disorder %K BPD %K digital intervention %K digital health %K digital therapeutics %K persuasive system design %K systematic review %K meta-analysis %K suicidal ideation %K paranoia %K single symptom %K mental health %K behavior change %K treatment %K effectiveness %K symptom %K suicide %K mobile phone %D 2024 %7 29.11.2024 %9 Review %J J Med Internet Res %G English %X Background: Borderline personality disorder (BPD) is a mental health condition with insufficient care availability worldwide. Digital mental health interventions could reduce this treatment gap. Persuasive system design (PSD) is a conceptual framework outlining elements of digital interventions that support behavior change. Objective: This systematic review aims to characterize digital interventions targeting BPD symptoms, assess treatment efficacy, and identify its association with intervention features, including PSD elements. Methods: A systematic review of automated digital interventions targeting symptoms of BPD was conducted. Eligible studies recruited participants aged ≥18 years, based on a diagnosis of BPD or one of its common comorbidities, or as healthy volunteers. OVID Embase, OVID MEDLINE, OVID PsycINFO, and the Cochrane Central Register for Controlled Trials were searched on July 19, 2022, and February 28, 2023. Intervention characteristics were tabulated. A meta-analysis of randomized controlled trials (RCTs) determined treatment effects separately for each core symptom of BPD using Hedges g. Associations between the treatment effect and intervention features, including PSD elements, were assessed by subgroup analysis (Cochran Q test). Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for RCTs and the National Institutes of Health Quality Assessment Tool for pre-post studies. Results: A total of 40 (0.47%) publications out of 8520 met the inclusion criteria of this review, representing 6611 participants. Studies comprised examinations of 38 unique interventions, of which 32 (84%) were RCTs. Synthesis found that included interventions had the following transdiagnostic treatment targets: severity of BPD symptoms (4/38, 11%), suicidal ideation (17/38, 45%), paranoia (5/38, 13%), nonsuicidal self-injury (5/38, 13%), emotion regulation (4/38, 11%), and anger (3/38, 8%). Common therapeutic approaches were based on dialectical behavioral therapy (8/38, 21%), cognitive behavioral therapy (6/38, 16%), or both (5/38, 13%). Meta-analysis found significant effects of digital intervention for both symptoms of paranoia (Hedges g=–0.52, 95% CI –0.86 to –0.18; P=.01) and suicidal ideation (Hedges g=–0.13, 95% CI –0.25 to –0.01; P=.03) but not overall BPD symptom severity (Hedges g=–0.17, 95% CI –0.42 to 0.10; P=.72). Subgroup analysis of suicidal ideation interventions found that evidence-based treatments such as cognitive behavioral therapy and dialectical behavior therapy were significantly more effective than alternative modalities (Cochran Q=4.87; P=.03). The degree of human support was not associated with the treatment effect. Interventions targeting suicidal ideation that used reminders, offered self-monitoring, and encouraged users to rehearse behaviors were associated with a greater reduction in ideation severity. Conclusions: Evidence suggests that digital interventions may reduce the symptoms of suicidal ideation and paranoia and that the design of digital interventions may impact the efficacy of treatments targeting suicidal ideation. These results support the use of transdiagnostic digital interventions for paranoia and suicidal ideation. Trial Registration: PROSPERO CRD42022358270; https://tinyurl.com/3mz7uc7k %R 10.2196/54941 %U https://www.jmir.org/2024/1/e54941 %U https://doi.org/10.2196/54941 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e56951 %T Evaluating the Impact of a Daylight-Simulating Luminaire on Mood, Agitation, Rest-Activity Patterns, and Social Well-Being Parameters in a Care Home for People With Dementia: Cohort Study %A Turley,Kate %A Rafferty,Joseph %A Bond,Raymond %A Mulvenna,Maurice %A Ryan,Assumpta %A Crawford,Lloyd %K digital health %K dementia %K dynamic lighting %K sensors %K circadian rhythm %K daylight %K wellbeing %K mood %K agitation %K sleep %K social wellbeing %K care home %K older adults %K elderly %K cardiac %K psychological %K monitoring %D 2024 %7 29.11.2024 %9 %J JMIR Mhealth Uhealth %G English %X Background: Living with a diagnosis of dementia can involve managing certain behavioral and psychological symptoms. Alongside cognitive decline, this cohort expresses a suppression in melatonin production which can negatively influence their alignment of sleep or wake timings with the 24 hour day and night cycle. As a result, their circadian rhythms become disrupted. Since daylight has the capacity to stimulate the circadian rhythm and humans spend approximately 90% of their time indoors, research has shifted toward the use of indoor lighting to achieve this same effect. This type of lighting is programmed in a daylight-simulating manner; mimicking the spectral changes of the sun throughout the day. As such, this paper focuses on the use of a dynamic lighting and sensing technology used to support the circadian rhythm, behavioral and psychological symptoms, and well-being of people living with dementia. Objective: This study aimed to understand how dynamic lighting, as opposed to static lighting, may impact the well-being of those who are living with dementia. Methods: An ethically approved trial was conducted within a care home for people with dementia. Data were collected in both quantitative and qualitative formats using environmentally deployed radar sensing technology and the validated QUALIDEM (Quality of Life for People With Dementia) well-being scale, respectively. An initial 4 weeks of static baseline lighting was used before switching out for 12 weeks of dynamic lighting. Metrics were collected for 11 participants on mood, social interactions, agitation, sense of feeling, and sleep and rest-activity over a period of 16 weeks. Results: Dynamic lighting showed significant improvement with a moderate effect size in well-being parameters including positive affect (P=.03), social isolation (P=.048), and feeling at home (P=.047) after 5‐10 weeks of dynamic lighting exposure. The results also highlight statistically significant improvements in rest-activity–related parameters of interdaily stability (P<.001), intradaily variation (P<.001), and relative amplitude (P=.03) from baseline to weeks 5‐10, with the effect propagating for interdaily stability at weeks 10‐16 as well (P<.001). Nonsignificant improvements are also noted for sleep metrics with a small effect size; however, the affect in agitation does not reflect this improvement. Conclusions: Dynamic lighting has the potential to support well-being in dementia, with seemingly stronger influence in earlier weeks where the dynamic lighting initially follows the static lighting contrast, before proceeding to aggregate as marginal gains over time. Future longitudinal studies are recommended to assess the additional impact that varying daylight availability throughout the year may have on the measured parameters. %R 10.2196/56951 %U https://mhealth.jmir.org/2024/1/e56951 %U https://doi.org/10.2196/56951 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e63262 %T Moving Toward Meaningful Evaluations of Monitoring in e-Mental Health Based on the Case of a Web-Based Grief Service for Older Mourners: Mixed Methods Study %A Brandl,Lena %A Jansen-Kosterink,Stephanie %A Brodbeck,Jeannette %A Jacinto,Sofia %A Mooser,Bettina %A Heylen,Dirk %K e-mental health %K digital mental health service %K mental health %K digital health %K internet intervention %K monitoring mental health %K monitor %K e-coach %K coaching %K grieve %K mourn %K old %K affective states %K artificial intelligence %K predictive %K repeatedly measured predictors in regression %K fuzzy cognitive map %K algorithm %K AI %D 2024 %7 28.11.2024 %9 %J JMIR Form Res %G English %X Background: Artificial intelligence (AI) tools hold much promise for mental health care by increasing the scalability and accessibility of care. However, current development and evaluation practices of AI tools limit their meaningfulness for health care contexts and therefore also the practical usefulness of such tools for professionals and clients alike. Objective: The aim of this study is to demonstrate the evaluation of an AI monitoring tool that detects the need for more intensive care in a web-based grief intervention for older mourners who have lost their spouse, with the goal of moving toward meaningful evaluation of AI tools in e-mental health. Method: We leveraged the insights from three evaluation approaches: (1) the F1-score evaluated the tool’s capacity to classify user monitoring parameters as either in need of more intensive support or recommendable to continue using the web-based grief intervention as is; (2) we used linear regression to assess the predictive value of users’ monitoring parameters for clinical changes in grief, depression, and loneliness over the course of a 10-week intervention; and (3) we collected qualitative experience data from e-coaches (N=4) who incorporated the monitoring in their weekly email guidance during the 10-week intervention. Results: Based on n=174 binary recommendation decisions, the F1-score of the monitoring tool was 0.91. Due to minimal change in depression and loneliness scores after the 10-week intervention, only 1 linear regression was conducted. The difference score in grief before and after the intervention was included as a dependent variable. Participants’ (N=21) mean score on the self-report monitoring and the estimated slope of individually fitted growth curves and its standard error (ie, participants’ response pattern to the monitoring questions) were used as predictors. Only the mean monitoring score exhibited predictive value for the observed change in grief (R2=1.19, SE 0.33; t16=3.58, P=.002). The e-coaches appreciated the monitoring tool as an opportunity to confirm their initial impression about intervention participants, personalize their email guidance, and detect when participants’ mental health deteriorated during the intervention. Conclusions: The monitoring tool evaluated in this paper identified a need for more intensive support reasonably well in a nonclinical sample of older mourners, had some predictive value for the change in grief symptoms during a 10-week intervention, and was appreciated as an additional source of mental health information by e-coaches who supported mourners during the intervention. Each evaluation approach in this paper came with its own set of limitations, including (1) skewed class distributions in prediction tasks based on real-life health data and (2) choosing meaningful statistical analyses based on clinical trial designs that are not targeted at evaluating AI tools. However, combining multiple evaluation methods facilitates drawing meaningful conclusions about the clinical value of AI monitoring tools for their intended mental health context. %R 10.2196/63262 %U https://formative.jmir.org/2024/1/e63262 %U https://doi.org/10.2196/63262 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 13 %N %P e57050 %T Relationship Between Depression and Falls Among Nursing Home Residents: Integrative Review %A Matos Queirós,Alcina %A von Gunten,Armin %A Rosselet Amoussou,Joëlle %A Lima,Andreia Maria %A Martins,Maria Manuela %A Verloo,Henk %+ Departement of Health and Social Welfare, Lausanne University Hospital and University of Lausanne, Avenue des Casernes 2, Lausanne, 1014, Switzerland, 41 799134061, alcinaqueiros@hotmail.com %K depression %K falls %K nursing home %K nursing home resident %K cross-sectional study %K cohort study %K integrative review %K fall risk %K older adults %D 2024 %7 28.11.2024 %9 Review %J Interact J Med Res %G English %X Background: Depression is a highly prevalent psychopathological condition among older adults, particularly those institutionalized in nursing homes (NHs). Unfortunately, it is poorly identified and diagnosed. NH residents are twice as likely to fall as community-dwelling older adults. There is a need for more knowledge about the mechanisms and relationships between depression and falls. Objective: This study aims to identify, analyze, and synthesize research on the relationships between depression and falls among NH residents. Methods: A literature search was conducted in October 2023 in the following bibliographic databases: MEDLINE ALL Ovid, Embase, CINAHL with Full Text EBSCO, APA PsycInfo Ovid, Web of Science Core Collection, the Cochrane Database of Systematic Reviews Wiley, and ProQuest Dissertations & Theses A&I. Clinical trials were searched for in the Cochrane Central Register of Controlled Trials Wiley, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. Additional searches were performed using Google Scholar, the DART-Europe E-theses Portal, and backward citation tracking. The Newcastle-Ottawa Scale and the Appraisal tool for Cross-Sectional Studies were used to evaluate study quality. Results: The review included 7 quantitative studies published in 7 different countries from 3 continents; of these, 6 (86%) were cross-sectional studies, and 1 (14%) was a prospective cohort study. Results suggested high frequencies of depressive symptoms and falls among older adults living in NHs, and depressive symptoms were considered a risk factor for falls. The 15-item and 10-item versions of the Geriatric Depression Scale were the most commonly used measurement tools, followed by the Cornell Scale for Depression in Dementia and the Resident Assessment Instrument-Minimum Data Set 2.0. The prevalence of depression was heterogeneous, varying from 21.5% to 47.7% of NH residents. The studies used heterogeneous descriptions of a fall, and some considered the risk of falls, recurrent fallers, and near falls in their data. The prevalence of fallers was disparate, varying from 17.2% to 63.1%. Of the 7 retained studies, 6 (86%) reported a relationship between depression and falls or the risk of falls. Among the 19 other risk factors identified in the review as being associated with falls among NH residents were a history of falls in the last 180 days, >1 fall in the past 12 months, and respiratory illnesses. Conclusions: There is a paucity of research examining falls among older adults with depressive symptoms in NHs. These findings should alert nurses to the need to consider depression as a risk factor in their work to prevent falls. More research is needed to gain a comprehensive understanding of fall risk among NH residents with depressive symptoms. International Registered Report Identifier (IRRID): RR2-10.2196/46995 %M 39608784 %R 10.2196/57050 %U https://www.i-jmr.org/2024/1/e57050 %U https://doi.org/10.2196/57050 %U http://www.ncbi.nlm.nih.gov/pubmed/39608784 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e63732 %T A Personalized, Transdiagnostic Smartphone App (Mello) Targeting Repetitive Negative Thinking for Depression and Anxiety: Qualitative Analysis of Young People’s Experience %A Valentine,Lee %A Arnold,Chelsea %A Nicholas,Jennifer %A Castagnini,Emily %A Malouf,Jessi %A Alvarez-Jimenez,Mario %A Bell,Imogen H %+ Orygen, 35 Poplar Rd, Melbourne, 3052, Australia, 61 9966 9100, lee.valentine@orygen.org.au %K repetitive negative thinking %K rumination %K anxiety %K depression %K mobile app %K just-in-time adaptive interventions %K youth mental health %K adolescent %K mobile phone %D 2024 %7 27.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: The increasing rates of mental health challenges among young people highlight an urgent need for accessible and effective treatment. However, current mental health systems face unprecedented demand, leaving most young people globally with unmet mental health needs. Smartphones present a promising solution to this issue by offering in-the-moment support through innovative just-in-time adaptive interventions, which provide support based on real-time data. Objective: This study explores young people’s experiences with Mello, a just-in-time adaptive intervention that focuses on the transdiagnostic mechanism of repetitive negative thinking (RNT), a significant factor contributing to youth depression and anxiety. Methods: Semistructured qualitative interviews were conducted with 15 participants aged 16 to 25 years, all of whom had previously participated in a pilot randomized controlled trial of Mello. Of the 15 participants, 9 (60%) identified as women, 4 (27%) as men (including 1 transgender man), and 2 (13%) as nonbinary. Interviews focused on participants’ experiences with the Mello app, factors influencing engagement, perceived benefits and limitations, and suggestions for future improvements. Thematic analysis was used to analyze the data. Results: The analysis identified three superordinate themes: Mello as a tool for intentional reflection; doing therapy your own way; and barriers to engagement during low mood, anxiety, and RNT. Theme 1 explored young people’s experiences of how the app facilitated active management of negative thoughts and supported the development of reflective habits, contrasting with their typical strategies of avoidance or resistance. Theme 2 highlighted the value of the app’s self-guided nature, with a particular focus on its flexibility and accessibility, particularly when compared to traditional face-to-face therapy. Finally, theme 3 addressed barriers to engagement, particularly during emotionally difficult times, with participants reporting feeling “stuck” in their negative thoughts. To mitigate these challenges, participants suggested incorporating gamification elements, such as progress-tracking visuals, to enhance motivation and increase engagement with the app. Conclusions: Our findings underscored the value of Mello in promoting intentional engagement and reflection with RNT, consistent with prior research that emphasizes the effectiveness of tailored interventions. Although some users valued the self-guided nature of the application, others encountered difficulties with motivation. Future research should explore strategies to enhance engagement for young people with low mood and motivation, such as co-design methodologies, advanced personalization features, and gamification techniques. %M 39602793 %R 10.2196/63732 %U https://www.jmir.org/2024/1/e63732 %U https://doi.org/10.2196/63732 %U http://www.ncbi.nlm.nih.gov/pubmed/39602793 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e62715 %T Efficacy of a Mobile App–Based Behavioral Intervention (DRIVEN) to Help Individuals With Unemployment-Related Emotional Distress Return to Work: Protocol for a Randomized Controlled Trial %A Danielson,Elizabeth C %A Saturday,Mystie %A Leonard,Sarah %A Levit,Alexandra %A Graham,Andrea K %A Marquez,Melissa %A Alperin,Keith %A Shankman,Stewart A %A Griffith,James W %+ Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL, 60637, United States, 1 7737023858, james.griffith@bsd.uchicago.edu %K unemployment %K wellness %K depression %K job stress %K job distress %K career coaching %K coaching %K mhealth %K ehealth %K job-seeking %K mobile app %K behavioral intervention %K %D 2024 %7 26.11.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Employment plays an important role in the maintenance of mental and physical health. Losing a job creates emotional distress, which can, in turn, interfere with effective job seeking. Thus, a program for job seekers that provides support for both the logistics of job seeking as well as emotional distress may help people find employment and improve emotional well-being. Objective: This study aims to test the efficacy of the 6-week intervention for job seekers in a randomized controlled trial. Methods: This is a parallel-assignment randomized control trial comparing a 6-week return-to-work intervention versus job seeking as usual for a stratified sample of job seekers (n=150). The intervention will be delivered through a mobile phone app and scheduled video counseling sessions with a job coach. Assessments will be taken weekly during the intervention as well as 8 and 16 weeks later. The intervention and control group procedures will be administered remotely, allowing the study to take place in several regions of the United States. Eligible participants will be adults aged 18 to 65 years, currently unemployed, and actively searching for work. Participants will be recruited from 7 major metropolitan areas in the United States using online advertisements on Craigslist. The primary outcome measure is the Job Search Behavior Scale, which has 2 subscales, preparatory job search behavior and active job search behavior. Employment status will also be assessed throughout the trial. A mixed-model regression analysis will be used to compare job searching behavior in the intervention group versus the control group. A time-to-event analysis (ie, survival analysis) will be used to compare employment status in the 2 experimental groups. Secondary outcomes will also be evaluated, including job search self-efficacy and mental health-related outcomes such as anxiety and depression. Results: This study started on August 7, 2023, and as of June 2024, we have enrolled 140 participants. Enrollment began in August 2023 and will conclude by October 2024. Half of the participants (75/150, 50%) will be assigned to the intervention arm while the other half (75/150, 50%) will be assigned to the control arm, job seeking as usual. Conclusions: The findings from this study will determine the efficacy of a mobile app–based intervention that uses both job training and psychological techniques on job seeking and employment outcomes. This first trial of Distress Return-to-Work Intervention (DRIVEN) will provide important information about blended support techniques for unemployed individuals, determine the usefulness of mobile apps to address large-scale mental health outcomes, and improve our understanding of the relationship between depression and unemployment status. Trial Registration: ClinicalTrials.gov NCT06026280; https://clinicaltrials.gov/study/NCT06026280 International Registered Report Identifier (IRRID): DERR1-10.2196/62715 %M 39589786 %R 10.2196/62715 %U https://www.researchprotocols.org/2024/1/e62715 %U https://doi.org/10.2196/62715 %U http://www.ncbi.nlm.nih.gov/pubmed/39589786 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e59585 %T Ten Myths About the Effect of Social Media Use on Well-Being %A Hall,Jeffrey A %+ Department of Communication Studies, University of Kansas, Bailey Hall, 1440 Jayhawk Boulevard, Lawrence, KS, 66045, United States, 1 7858641082, hallj@ku.edu %K social media %K well-being %K health promotion %K depressive disorder %K depression %K anxiety %K adolescent %K mental health %D 2024 %7 25.11.2024 %9 Viewpoint %J J Med Internet Res %G English %X This viewpoint reviews the empirical evidence regarding the association between social media use and well-being, including life satisfaction and affective well-being, and the association between social media use and ill-being, including loneliness, anxiety, and depressive symptomology. To frame this discussion, this viewpoint will present 10 widely believed myths about social media, each drawn from popular discourse on the topic. In rebuttal, this viewpoint will offer a warranted claim supported by the research. The goal is to bring popular beliefs into dialogue with state-of-the-art quantitative social scientific evidence. It is the intention of this viewpoint to provide a more accurate and nuanced claim to challenge each myth. This viewpoint will bring attention to the importance of using rigorous scientific evidence to inform public debates about social media use and well-being, especially among adolescents and young adults. %M 39586087 %R 10.2196/59585 %U https://www.jmir.org/2024/1/e59585 %U https://doi.org/10.2196/59585 %U http://www.ncbi.nlm.nih.gov/pubmed/39586087 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e57415 %T Exploring the Effects of Variety and Amount of Mindfulness Practices on Depression, Anxiety, and Stress Symptoms: Longitudinal Study on a Mental Health–Focused eHealth System for Patients With Breast or Prostate Cancer %A Malandrone,Francesca %A Urru,Sara %A Berchialla,Paola %A Rossini,Pierre Gilbert %A Oliva,Francesco %A Bianchi,Silvia %A Ottaviano,Manuel %A Gonzalez-Martinez,Sergio %A Carli,Vladimir %A Valenza,Gaetano %A Scilingo,Enzo Pasquale %A Carletto,Sara %A Ostacoli,Luca %K depression %K anxiety %K stress %K internet-based %K mental health %K mindfulness %K breast cancer %K prostate cancer %K cancer-related mental distress %K emotional distress %K psychological distress %K mindfulness-based interventions %K MBI %K e-MBI %K dispositional mindfulness %K self-compassion %K mental wellbeing %K mobile phone %D 2024 %7 21.11.2024 %9 %J JMIR Ment Health %G English %X Background: Patients with cancer often face depression and anxiety, and mindfulness-based interventions, including internet-based versions, can effectively reduce these symptoms and improve their quality of life. This study aims to investigate the impact of internet-based mindfulness-based interventions (e-MBIs) on anxiety, depression, and stress symptoms in patients with prostate or breast cancer. Objective: The primary aims are to assess the association between the amount and variety of e-MBI practices and symptom reduction. Second, this study aims to examine how baseline information such as sociodemographic characteristics, dispositional mindfulness (DM), and dispositional self-compassion (DSC) correlate with both app usage and symptom reduction. Methods: Participants included 107 patients with cancer (68 women with breast cancer and 38 men with prostate cancer) enrolled in a hospital setting. They were assigned to the intervention group of the NEVERMIND project, using the e-BMI module via the NEVERMIND app. A longitudinal design involved Pearson correlation analysis to determine the relationship between the amount and duration of e-MBI practices. Linear regression analysis was conducted to gauge the dose-response effect, evaluating the impact of DM and DSC on depression, anxiety, and stress. Negative binomial regression was conudcted to study sociodemographic factors’ influence on the amount of practice in e-MBIs. Results: The participants with more diverse and sustained mindfulness practices experienced significant reductions in depression, anxiety, and stress. A high correlation (0.94) between e-MBI practices and symptom reduction was also highlighted. Male, married, and highly educated patients were more likely to engage in mindfulness. Even if DM and DSC did not impact the amount or variety of practices correlated, they were correlated with symptom reduction, showing that higher levels were associated with significant reductions in depression, anxiety, and stress. Conclusions: While more e-MBI practice is linked to reduced anxiety, depression, and stress, this study emphasizes the crucial role of variety of practice over amount. DM and DSC are key in shaping intervention effectiveness and may act as protectors against psychological distress. Using app log data, our research provides a unique perspective on e-MBI impact, contributing to cancer care understanding and guiding future studies. %R 10.2196/57415 %U https://mental.jmir.org/2024/1/e57415 %U https://doi.org/10.2196/57415 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e53236 %T Investigating the Effectiveness of Technology-Based Distal Interventions for Postpartum Depression and Anxiety: Systematic Review and Meta-Analysis %A Brocklehurst,Sarah P %A Morse,Alyssa R %A Cruwys,Tegan %A Batterham,Philip J %A Leach,Liana %A Robertson,Alysia M %A Sahib,Aseel %A Burke,Colette T %A Nguyen,Jessica %A Calear,Alison L %+ Centre for Mental Health Research, The Australian National University, 63 Eggleston Road, Acton, Canberra, 2601, Australia, 61 2 6125 8406, alison.calear@anu.edu.au %K postpartum %K depression %K anxiety %K birth %K adoptive %K parents %K mobile phone %D 2024 %7 19.11.2024 %9 Review %J J Med Internet Res %G English %X Background: Postpartum anxiety and depression are common in new parents. While effective interventions exist, they are often delivered in person, which can be a barrier for some parents seeking help. One approach to overcoming these barriers is the delivery of evidence-based self-help interventions via websites, smartphone apps, and other digital media. Objective: This study aims to evaluate the effectiveness of technology-based distal interventions in reducing or preventing symptoms of postpartum depression or anxiety in male and female birth and adoptive parents, explore the effectiveness of technology-based distal interventions in increasing social ties, and determine the level of adherence to and satisfaction with technology-based distal interventions. Methods: A systematic review and series of meta-analyses were conducted. Three electronic bibliographic databases (PsycINFO, PubMed, and Cochrane Library) were searched for randomized controlled trials evaluating technology-based distal interventions for postpartum depression or anxiety in birth and adoptive parents. Searches were updated on August 1, 2023, before conducting the final meta-analyses. Data on trial characteristics, effectiveness, adherence, satisfaction, and quality were extracted. Screening and data extraction were conducted by 2 reviewers. Risk of bias was assessed using the Joanna Briggs Institute quality rating scale for randomized controlled trials. Studies were initially synthesized qualitatively. Where possible, studies were also quantitatively synthesized through 5 meta-analyses. Results: Overall, 18 articles met the inclusion criteria for the systematic review, with 14 (78%) providing sufficient data for a meta-analysis. A small significant between-group effect on depression favored the intervention conditions at the postintervention (Cohen d=–0.28, 95% CI –0.41 to –0.15; P<.001) and follow-up (Cohen d=–0.27, 95% CI –0.52 to –0.02; P=.03) time points. A small significant effect on anxiety also favored the intervention conditions at the postintervention time point (Cohen d=–0.29, 95% CI –0.48 to –0.10; P=.002), with a medium effect at follow-up (Cohen d=–0.47, 95% CI –0.88 to –0.05; P=.03). The effect on social ties was not significant at the postintervention time point (Cohen d=0.04, 95% CI –0.12 to 0.21; P=.61). Effective interventions tended to be web-based cognitive behavioral therapy programs with reminders. Adherence varied considerably between studies, whereas satisfaction tended to be high for most studies. Conclusions: Technology-based distal interventions are effective in reducing symptoms of postpartum depression and anxiety in birth mothers. Key limitations of the reviewed evidence include heterogeneity in outcome measures, studies being underpowered to detect modest effects, and the exclusion of key populations from the evidence base. More research needs to be conducted with birth fathers and adoptive parents to better ascertain the effectiveness of interventions in these populations, as well as to further assess the effect of technology-based distal interventions on social ties. Trial Registration: PROSPERO CRD42021290525; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=290525 %M 39561361 %R 10.2196/53236 %U https://www.jmir.org/2024/1/e53236 %U https://doi.org/10.2196/53236 %U http://www.ncbi.nlm.nih.gov/pubmed/39561361 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e56166 %T Online Depression Communities as a Complementary Approach to Improving the Attitudes of Patients With Depression Toward Medication Adherence: Cross-Sectional Survey Study %A Chen,Runnan %A Fu,Xiaorong %A Liu,Mochi %A Liao,Ke %A Bai,Lifei %+ Department of Marketing, School of Business Administration, Southwestern University of Finance and Economics, 555 Liutai Road, Chengdu, 611130, China, 86 13981916682, fuxr@swufe.edu.cn %K online depression communities %K attitudes %K institution-generated content %K user-generated content %K perceived social support %K antidepressants %K hopelessness %K cross-sectional study %K China %K health care system %K online health community %K depression %K medication adherence %K social support %K health care practitioner %K peer support %D 2024 %7 19.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Lack of adherence to prescribed medication is common among patients with depression in China, posing serious challenges to the health care system. Online health communities have been found to be effective in enhancing patient compliance. However, empirical evidence supporting this effect in the context of depression treatment is absent, and the influence of online health community content on patients’ attitudes toward medication adherence is also underexplored. Objective: This study aims to explore whether online depression communities (ODCs) can help ameliorate the problem of poor medication taking among patients with depression. Drawing on the stimulus-organism-response and feelings-as-information theories, we established a research model to examine the influence of useful institution-generated content (IGC) and positive user-generated content (UGC) on attitudes toward medication adherence when combined with the mediating role of perceived social support, perceived value of antidepressants, and the moderating role of hopelessness. Methods: A cross-sectional questionnaire survey method was used in this research. Participants were recruited from various Chinese ODCs, generating data for a main study and 2 robustness checks. Hierarchical multiple regression analyses and bootstrapping analyses were adopted as the primary methods to test the hypotheses. Results: We received 1515 valid responses in total, contributing to 5 different datasets: model IGC (n=353, 23.3%), model UGC (n=358, 23.63%), model IGC+UGC (n=270, 17.82%), model IGC-B (n=266, 17.56%), and model UGC-B (n=268, 17.69%). Models IGC and UGC were used for the main study. Model IGC+UGC was used for robustness check A. Models IGC-B and UGC-B were used for robustness check B. Useful IGC and positive UGC were proven to have positive impact on the attitudes of patients with depression toward medication adherence through the mediations of perceived social support and perceived value of antidepressants. The findings corroborated the role of hopelessness in weakening or even negating the positive effects of ODC content on the attitudes of patients with depression toward medication adherence. Conclusions: This study provides the first empirical evidence demonstrating the relationship between ODC content and attitudes toward medication adherence, through which we offer a novel solution to the problem of poor medication adherence among patients with depression in China. Our findings also provide suggestions about how to optimize this new approach—health care practitioners should generate online content that precisely matches the informational needs of patients with depression, and ODC service providers should endeavor to regulate the community atmosphere. Nonetheless, we warn that ODC interventions cannot be used as the only approach to addressing the problem of poor medication taking among patients with severe depressive symptoms. %M 39561355 %R 10.2196/56166 %U https://www.jmir.org/2024/1/e56166 %U https://doi.org/10.2196/56166 %U http://www.ncbi.nlm.nih.gov/pubmed/39561355 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e62725 %T Assessing Digital Phenotyping for App Recommendations and Sustained Engagement: Cohort Study %A Dwyer,Bridget %A Flathers,Matthew %A Burns,James %A Mikkelson,Jane %A Perlmutter,Elana %A Chen,Kelly %A Ram,Nanik %A Torous,John %+ Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02115, United States, 1 6176676700, jtorous@bidmc.harvard.edu %K engagement %K mental health %K digital phenotype %K pilot study %K phenotyping %K smartphone sensors %K anxiety %K sleep %K fitness %K depression %K qualitative %K app recommendation %K app use %K mobile phone %D 2024 %7 19.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Low engagement with mental health apps continues to limit their impact. New approaches to help match patients to the right app may increase engagement by ensuring the app they are using is best suited to their mental health needs. Objective: This study aims to pilot how digital phenotyping, using data from smartphone sensors to infer symptom, behavioral, and functional outcomes, could be used to match people to mental health apps and potentially increase engagement Methods: After 1 week of collecting digital phenotyping data with the mindLAMP app (Beth Israel Deaconess Medical Center), participants were randomly assigned to the digital phenotyping arm, receiving feedback and recommendations based on those data to select 1 of 4 predetermined mental health apps (related to mood, anxiety, sleep, and fitness), or the control arm, selecting the same apps but without any feedback or recommendations. All participants used their selected app for 4 weeks with numerous metrics of engagement recorded, including objective screentime measures, self-reported engagement measures, and Digital Working Alliance Inventory scores. Results: A total of 82 participants enrolled in the study; 17 (21%) dropped out of the digital phenotyping arm and 18 (22%) dropped out from the control arm. Across both groups, few participants chose or were recommended the insomnia or fitness app. The majority (39/47, 83%) used a depression or anxiety app. Engagement as measured by objective screen time and Digital Working Alliance Inventory scores were higher in the digital phenotyping arm. There was no correlation between self-reported and objective metrics of app use. Qualitative results highlighted the importance of habit formation in sustained app use. Conclusions: The results suggest that digital phenotyping app recommendation is feasible and may increase engagement. This approach is generalizable to other apps beyond the 4 apps selected for use in this pilot, and practical for real-world use given that the study was conducted without any compensation or external incentives that may have biased results. Advances in digital phenotyping will likely make this method of app recommendation more personalized and thus of even greater interest. %M 39560976 %R 10.2196/62725 %U https://formative.jmir.org/2024/1/e62725 %U https://doi.org/10.2196/62725 %U http://www.ncbi.nlm.nih.gov/pubmed/39560976 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e63298 %T Cultural Adaptation and User Satisfaction of an Internet-Delivered Cognitive Behavioral Program for Depression and Anxiety Among College Students in Two Latin American Countries: Focus Group Study With Potential Users and a Cross-Sectional Questionnaire Study With Actual Users %A Albor,Yesica %A González,Noé %A Benjet,Corina %A Salamanca-Sanabria,Alicia %A Hernández-de la Rosa,Cristiny %A Eslava-Torres,Viridiana %A García-Alfaro,María Carolina %A Melchor-Audirac,Andrés %A Montoya-Montero,Laura Itzel %A Suárez,Karla %+ Center for Research in Global Mental Health, Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Calzada México-Xochimilco 101, San Lorenzo Huipulco, Tlalpan, Mexico City, 14370, Mexico, 52 5541605332, cbenjet@gmail.com %K culturally competent care %K mental health %K digital health %K student health services %K Colombia %K Mexico %K SilverCloud %K anxiety %K depression %D 2024 %7 15.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: To scale up mental health care in low-resource settings, digital interventions must consider cultural fit. Despite the findings that culturally adapted digital interventions have greater effectiveness, there is a lack of empirical evidence of interventions that have been culturally adapted or their adaptation documented. Objective: This study aimed to document the cultural adaptation of the SilverCloud Health Space from Depression and Anxiety program for university students in Colombia and Mexico and evaluate user satisfaction with the adapted program. Methods: A mixed methods process was based on Cultural Sensitivity and Ecological Validity frameworks. In phase 1, the research team added culturally relevant content (eg, expressions, personal stories, photos) for the target population to the intervention. In phase 2, potential users (9 university students) first evaluated the vignettes and photos used throughout the program. We calculated median and modal responses. They then participated in focus groups to evaluate and assess the cultural appropriateness of the materials. Their comments were coded into the 8 dimensions of the Ecological Validity Framework. Phase 3 consisted of choosing the vignettes most highly rated by the potential users and making modifications to the materials based on the student feedback. In the final phase, 765 actual users then engaged with the culturally adapted program and rated their satisfaction with the program. We calculated the percentage of users who agreed or strongly agreed that the modules were interesting, relevant, useful, and helped them attain their goals. Results: The potential users perceived the original vignettes as moderately genuine, or true, which were given median scores between 2.5 and 3 (out of a possible 4) and somewhat identified with the situations presented in the vignettes given median scores between 1.5 and 3. The majority of comments or suggestions for modification concerned language (126/218, 57.5%), followed by concepts (50/218, 22.8%). Much less concerned methods (22/218, 10%), persons (9/218, 4.1%), context (5/218, 2.3%), or content (2/218, 0.9%). There were no comments about metaphors or goals. Intervention materials were modified based on these results. Of the actual users who engaged with the adapted version of the program, 87.7%-96.2% of them agreed or strongly agreed that the modules were interesting, relevant, useful, and helped them to attain their goals. Conclusions: We conclude that the adapted version is satisfactory for this population based on the focus group discussions and the satisfaction scores. Conducting and documenting such cultural adaptations and involving the users in the cultural adaptation process will likely improve the effectiveness of digital mental health interventions in low- and middle-income countries and culturally diverse contexts. %M 39546799 %R 10.2196/63298 %U https://formative.jmir.org/2024/1/e63298 %U https://doi.org/10.2196/63298 %U http://www.ncbi.nlm.nih.gov/pubmed/39546799 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e53768 %T Use of Random Forest to Predict Adherence in an Online Intervention for Depression Using Baseline and Early Usage Data: Model Development and Validation on Retrospective Routine Care Log Data %A Wenger,Franziska %A Allenhof,Caroline %A Schreynemackers,Simon %A Hegerl,Ulrich %A Reich,Hanna %+ Clinic for Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Goethe University Frankfurt, Heinrich-Hoffmann-Str. 10, Frankfurt am Main, 60528, Germany, 49 3412238744, franziska.wenger@deutsche-depressionshilfe.de %K depression %K adherence %K machine learning %K digital interventions %K random forest %K iFightDepression %K iFD %K online intervention %D 2024 %7 15.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Online interventions, such as the iFightDepression (iFD) tool, are increasingly recognized as effective alternatives to traditional face-to-face psychotherapy or pharmacotherapy for treating depression. However, particularly when used outside of study settings, low adherence rates and the resulting diminished benefits of the intervention can limit their effectiveness. Understanding the factors that predict adherence would allow for early, tailored interventions for individuals at risk of nonadherence, thereby enhancing user engagement and optimizing therapeutic outcomes. Objective: This study aims to develop and evaluate a random forest model that predicts adherence to the iFD tool to identify users at risk of noncompletion. The model was based on characteristics collected during baseline and the first week of the intervention in patients with depression. Methods: Log data from 4187 adult patients who registered for the iFD tool between October 1, 2016, and May 5, 2022, and provided informed consent were statistically analyzed. The resulting data set was divided into training (2932/4187, 70%) and test (1255/4187, 30%) sets using a randomly stratified split. The training data set was utilized to train a random forest model aimed at predicting each user’s adherence at baseline, based on the hypothesized predictors: age, self-reported gender, expectations of the intervention, current or previous depression treatments, confirmed diagnosis of depression, baseline 9-item Patient Health Questionnaire (PHQ-9) score, accompanying guide profession, and usage behavior within the first week. After training, the random forest model was evaluated on the test data set to assess its predictive performance. The importance of each variable in predicting adherence was analyzed using mean decrease accuracy, mean decrease Gini, and Shapley Additive Explanations values. Results: Of the 4187 patients evaluated, 1019 (24.34%) were classified as adherent based on our predefined definition. An initial random forest model that relied solely on sociodemographic and clinical predictors collected at baseline did not yield a statistically significant adherence prediction. However, after incorporating each patient’s usage behavior during the first week, we achieved a significant prediction of adherence (P<.001). Within this prediction, the model achieved an accuracy of 0.82 (95% CI 0.79-0.84), an F1-score of 0.53, an area under the curve of 0.83, and a specificity of 0.94 for predicting nonadherent users. The key predictors of adherence included logs, word count on the first workshop’s worksheet, and time spent on the tool, all measured during the first week. Conclusions: Our results highlight that early engagement, particularly usage behavior during the first week of the online intervention, is a far greater predictor of adherence than any sociodemographic or clinical factors. Therefore, analyzing usage behavior within the first week and identifying nonadherers through the algorithm could be beneficial for tailoring interventions aimed at improving user adherence. This could include follow-up calls or face-to-face discussions, optimizing resource utilization in the process. %M 39546342 %R 10.2196/53768 %U https://formative.jmir.org/2024/1/e53768 %U https://doi.org/10.2196/53768 %U http://www.ncbi.nlm.nih.gov/pubmed/39546342 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e65994 %T Comprehensive Symptom Prediction in Inpatients With Acute Psychiatric Disorders Using Wearable-Based Deep Learning Models: Development and Validation Study %A Hong,Minseok %A Kang,Ri-Ra %A Yang,Jeong Hun %A Rhee,Sang Jin %A Lee,Hyunju %A Kim,Yong-gyom %A Lee,KangYoon %A Kim,HongGi %A Lee,Yu Sang %A Youn,Tak %A Kim,Se Hyun %A Ahn,Yong Min %+ Department of Neuropsychiatry, Seoul National University Hospital, 101 Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea, 82 2 2072 2450, aym@snu.ac.kr %K digital phenotype %K mental health monitoring %K smart hospital %K clinical decision support system %K multitask learning %K wearable sensor %K local validation %K mental health facility %K deep learning %D 2024 %7 13.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Assessing the complex and multifaceted symptoms of patients with acute psychiatric disorders proves to be significantly challenging for clinicians. Moreover, the staff in acute psychiatric wards face high work intensity and risk of burnout, yet research on the introduction of digital technologies in this field remains limited. The combination of continuous and objective wearable sensor data acquired from patients with deep learning techniques holds the potential to overcome the limitations of traditional psychiatric assessments and support clinical decision-making. Objective: This study aimed to develop and validate wearable-based deep learning models to comprehensively predict patient symptoms across various acute psychiatric wards in South Korea. Methods: Participants diagnosed with schizophrenia and mood disorders were recruited from 4 wards across 3 hospitals and prospectively observed using wrist-worn wearable devices during their admission period. Trained raters conducted periodic clinical assessments using the Brief Psychiatric Rating Scale, Hamilton Anxiety Rating Scale, Montgomery-Asberg Depression Rating Scale, and Young Mania Rating Scale. Wearable devices collected patients’ heart rate, accelerometer, and location data. Deep learning models were developed to predict psychiatric symptoms using 2 distinct approaches: single symptoms individually (Single) and multiple symptoms simultaneously via multitask learning (Multi). These models further addressed 2 problems: within-subject relative changes (Deterioration) and between-subject absolute severity (Score). Four configurations were consequently developed for each scale: Single-Deterioration, Single-Score, Multi-Deterioration, and Multi-Score. Data of participants recruited before May 1, 2024, underwent cross-validation, and the resulting fine-tuned models were then externally validated using data from the remaining participants. Results: Of the 244 enrolled participants, 191 (78.3%; 3954 person-days) were included in the final analysis after applying the exclusion criteria. The demographic and clinical characteristics of participants, as well as the distribution of sensor data, showed considerable variations across wards and hospitals. Data of 139 participants were used for cross-validation, while data of 52 participants were used for external validation. The Single-Deterioration and Multi-Deterioration models achieved similar overall accuracy values of 0.75 in cross-validation and 0.73 in external validation. The Single-Score and Multi-Score models attained overall R² values of 0.78 and 0.83 in cross-validation and 0.66 and 0.74 in external validation, respectively, with the Multi-Score model demonstrating superior performance. Conclusions: Deep learning models based on wearable sensor data effectively classified symptom deterioration and predicted symptom severity in participants in acute psychiatric wards. Despite lower computational costs, Multi models demonstrated equivalent or superior performance to Single models, suggesting that multitask learning is a promising approach for comprehensive symptom prediction. However, significant variations were observed across wards, which present a key challenge for developing clinical decision support systems in acute psychiatric wards. Future studies may benefit from recurring local validation or federated learning to address generalizability issues. %R 10.2196/65994 %U https://www.jmir.org/2024/1/e65994 %U https://doi.org/10.2196/65994 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e59329 %T Collaborative Care to Improve Quality of Life for Anxiety and Depression in Posttraumatic Epilepsy (CoCarePTE): Protocol for a Randomized Hybrid Effectiveness-Implementation Trial %A Munger Clary,Heidi M %A Snively,Beverly M %A Cagle,Christian %A Kennerly,Richard %A Kimball,James N %A Alexander,Halley B %A Brenes,Gretchen A %A Moore,Justin B %A Hurley,Robin A %+ Department of Neurology, Wake Forest University School of Medicine, 1 Medical Center Blvd., Winston-Salem, NC, 27157, United States, 1 3367167110, hmungerc@wakehealth.edu %K integrated care %K mental health %K seizures %K psychiatric comorbidity %K neurology clinic %K epilepsy %D 2024 %7 13.11.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Anxiety and depression in people with epilepsy are common and associated with poor outcomes; yet, they often go untreated due to poor mental health specialist access. Collaborative care is an integrated care model with a strong evidence base in primary care and medical settings, but it has not been evaluated in neurology clinics. Evaluating implementation outcomes when translating evidence-based interventions to new clinical settings to inform future scaling and incorporation into real-world practice is important. Objective: The Collaborative Care for Posttraumatic Epilepsy (CoCarePTE) trial aims to evaluate the effectiveness (improvement in emotional quality of life) and implementation of a collaborative care intervention for people with anxiety or depressive symptoms and posttraumatic epilepsy. Methods: CoCarePTE is a 2-site, randomized, single-blind, hybrid type 1 effectiveness-implementation trial that will randomize 60 adults to receive either neurology-based collaborative care or usual care. Adults receiving neurological care at participating centers with anxiety or depressive symptoms and a history of at least mild traumatic brain injury before epilepsy onset will be enrolled. The collaborative care intervention is a 24-week stepped-care model with video or telephone calls every 2 weeks by a care manager for measurement-based anxiety and depression care, seizure care monitoring, and brief therapy intervention delivery. This is supplemented by antidepressant prescribing recommendations by psychiatrists for neurologists via case conferences and care manager–facilitated team communication. In step 2 of the intervention, individuals with <50% symptom reduction by 10 weeks will receive an added 8-session remote cognitive behavioral therapy program. The study is powered to detect a moderate improvement in emotional quality of life. As a hybrid type 1 trial, effectiveness is the primary focus, with the primary outcome being a change in emotional quality of life at 6 months in the intervention group compared to control. Secondary effectiveness outcomes are 6-month changes in depression, anxiety, and overall quality of life. Implementation outcomes, including fidelity, acceptability, feasibility, and appropriateness, are evaluated before implementation and at 3 months. The primary effectiveness analysis will compare changes in emotional quality of life scores from baseline to 6 months between the intervention and control arms using multiple linear regression modeling, adjusting for study site and using an intent-to-treat approach. Results: Enrollment commenced in 2023, with modifications in the inclusion and exclusion made after the first 6 enrollees due to slow recruitment. Enrollment is expected to continue at least into early 2025. Conclusions: The CoCarePTE trial is novel in its use of a hybrid effectiveness-implementation design to evaluate an evidence-based mental health intervention in epilepsy, and by incorporating seizure care into a collaborative care model. If a significant improvement in emotional quality of life is found in the intervention group compared to usual care, this would support next step scaling or clinical implementation. Trial Registration: ClinicalTrials.gov NCT05353452; https://www.clinicaltrials.gov/study/NCT05353452 International Registered Report Identifier (IRRID): DERR1-10.2196/59329 %M 39535875 %R 10.2196/59329 %U https://www.researchprotocols.org/2024/1/e59329 %U https://doi.org/10.2196/59329 %U http://www.ncbi.nlm.nih.gov/pubmed/39535875 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e56765 %T Influence of Psychological Stress on the Response to Periodontal Treatment: Protocol for a Systematic Review %A Vargas Villafuerte,Kelly R %A Palucci Vieira,Luiz H %A Oliveira Santos,Karina %+ Grupo de Investigación en Salud Integral Humana (GISIH), Facultad de Ciencias de la Salud, Universidad César Vallejo (UCV), Av. Argentina 1795 - Campus Callao, Lima, 07001, Peru, 51 2024342 ext 1, kvargasvi@ucv.edu.pe %K periodontal disease %K periodontal therapy %K integral health %K oral health %K evidence-based %K periodontitis %K inflammatory diseases %K inflammatory response %K anxiety %K stress %K depression %K periodontal health %D 2024 %7 12.11.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: The interaction between stress and periodontal treatment is a topic of growing interest. It stands out as a field of research that sheds light on the complexity of oral health in individuals subjected to high levels of emotional stress. Objective: This paper aims to provide a protocol for a systematic review to examine the scientific evidence related to the influence of psychological stress on the response to periodontal treatment. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will be followed, and the study is based on a formulation of PECO (Participants, Exposure, Comparators, and Outcomes) questions. This systematic review will involve a literature search covering studies published from January 2000 to May 2024. It will include searching the PubMed, Web of Science, EBSCOHost, Scopus, and ProQuest databases to identify relevant studies. After selection, data extraction and quality assessment (using the Ottawa-Newcastle Scale) of the included studies will be carried out. The objective is to integrate high-quality evidence on how psychological stress impacts the outcomes of periodontal treatment. Depending on the number and methodological consistency of included studies, the results may be presented by meta-analysis or qualitative synthesis. Results: The current stage of the study consists of selecting studies for the systematic review as outlined by this protocol. The search, screening, and data extraction began in January 2024. The final results are expected by July 2024, with final manuscript submission planned for November 2024. Conclusions: This review will help clarify how psychological factors, such as stress, influence the results of periodontal treatment, providing valuable guidelines for future research and helping clinicians make decisions about the best treatment options for patients. Trial Registration: Open Science Framework (OSF) Registries qfs6p; https://osf.io/qfs6p International Registered Report Identifier (IRRID): PRR1-10.2196/56765 %M 39531258 %R 10.2196/56765 %U https://www.researchprotocols.org/2024/1/e56765 %U https://doi.org/10.2196/56765 %U http://www.ncbi.nlm.nih.gov/pubmed/39531258 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e64540 %T Preliminary Feasibility of a Novel Mind-Body Program to Prevent Persistent Concussion Symptoms Among Young Adults With Anxiety: Nonrandomized Open Pilot Study %A Becker,Molly Elizabeth %A Stratton Levey,Nadine %A Yeh,Gloria Y %A Giacino,Joseph %A Iverson,Grant %A Silverberg,Noah %A Parker,Robert A %A McKinnon,Ellen %A Siravo,Caitlin %A Shah,Priyanca %A Vranceanu,Ana-Maria %A Greenberg,Jonathan %+ Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, 1 Bowdoin Square, Suite 648, Boston, MA, 02114, United States, 1 6176439402, jgreenberg5@mgh.harvard.edu %K concussions %K mind-body %K preventions %K young adults %K feasibility %K persistence %K open pilot %K mind-body program %K preliminary feasibility %K mild traumatic brain injuries %K United States %K adults %K psychological factors %K mind-body interventions %D 2024 %7 8.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Concussions are common, particularly among young adults, and often are associated with persistent, debilitating, and hard-to-treat symptoms. Anxiety and concussion symptoms often amplify each other, and growing evidence indicates that anxiety plays a key role in symptoms persistence after concussion. Targeting anxiety early after concussion may be a promising means of helping prevent persistent concussion symptoms in this population. We developed the Toolkit for Optimal Recovery after Concussion (TOR-C), the first mind-body program tailored for young adults with a recent concussion and anxiety, aiming to prevent persistent concussion symptoms. Objective: This study aims to conduct an open pilot of TOR-C to test preliminary feasibility, signal of change in measures, and treatment perceptions. Methods: Five young adults (aged 18-24 years) attended 4 weekly one-on-one live video sessions with a clinician. Participants completed questionnaires measuring treatment targets (ie, pain catastrophizing, mindfulness, fear avoidance, limiting behaviors, and all-or-nothing behaviors) and outcomes (ie, postconcussive symptoms, physical function, anxiety, depression, and pain) at baseline, immediately following the intervention, and 3 months after intervention completion. At the conclusion of the program, participants attended a qualitative interview and provided feedback about the program to help optimize study content and procedures. Results: Feasibility markers were excellent for credibility and expectancy (5/5, 100% of participants scored above the credibility and expectancy scale midpoint), client satisfaction (4/5, 80% of participants scored above the Client Satisfaction Questionnaire midpoint), therapist adherence (97% adherence), acceptability of treatment (5/5, 100% of participants attended 3 or more sessions), adherence to homework (87% home practice completion), and feasibility of assessments (no measures fully missing). The feasibility of recruitment was good (5/7, 71% of eligible participants agreed to participate). There were preliminary signals of improvements from pre-post comparisons in treatment targets (d=0.72-2.20) and outcomes (d=0.41-1.38), which were sustained after 3 months (d=0.38-2.74 and d=0.71-1.63 respectively). Exit interviews indicated overall positive perceptions of skills and highlighted barriers (eg, busyness) and facilitators (eg, accountability) to engagement. Conclusions: TOR-C shows preliminary feasibility, is associated with a signal of improvement in treatment targets and outcomes, and has the potential to support recovery from concussion. The quantitative findings along with the qualitative feedback obtained from the exit interviews will help optimize TOR-C in preparation for an upcoming randomized controlled trial of TOR-C versus an active control condition of health education for concussion recovery. International Registered Report Identifier (IRRID): RR2-10.2196/25746 %M 39514283 %R 10.2196/64540 %U https://formative.jmir.org/2024/1/e64540 %U https://doi.org/10.2196/64540 %U http://www.ncbi.nlm.nih.gov/pubmed/39514283 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e56201 %T Facilitating Thought Progression to Reduce Depressive Symptoms: Randomized Controlled Trial %A Yatziv,Shai-Lee %A Pedrelli,Paola %A Baror,Shira %A DeCaro,Sydney Ann %A Shachar,Noam %A Sofer,Bar %A Hull,Sunday %A Curtiss,Joshua %A Bar,Moshe %+ The Leslie and Susan Gonda Brain Science Center, Bar- Ilan University Building number 901, Ramat-Gan, 5290002, Israel, 972 35317795, moshe.bar@biu.ac.il %K depression %K cognitive neuroscience %K facilitating thought progression %K FTP %K mobile phone %K digital health %K gamification %K depression symptoms %K randomized controlled trial %K RCT %K app %K depressive disorder %K web-based platforms %K effectiveness %D 2024 %7 7.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: The constant rise in the prevalence of major depressive disorder calls for new, effective, and accessible interventions that can rapidly and effectively reach a wide range of audiences. Recent developments in the digital health domain suggest that dedicated online platforms may potentially address this gap. Focusing on targeting ruminative thought, a major symptomatic hallmark of depression, in this study we hypothesized that delivering a digital health–based intervention designed to systematically facilitate thought progression would substantially alleviate depression. Objective: The study aims to investigate the efficacy of a novel digital intervention on the reduction of depressive symptoms. This intervention was designed as an easy-to-use gamified app specifically aimed to facilitate thought progression through intense practicing of associative, semantically broad, fast, and creative thought patterns. Methods: A randomized clinical trial was conducted, comparing changes in depression symptoms between participants who used the app in the intervention group (n=74) and waitlist control group (n=27) over the course of 8 weeks. All participants filled out a battery of clinical questionnaires to assess the severity of depression at baseline and 4 and 8 weeks after starting the study. These primarily included the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Patient Health Questionnaire-9 as well as the Positive Affect Negative Affect Scale-Negative Affect Score, Ruminative Response Scale, and Symptoms of Depression Questionnaire. Additional questionnaires were implemented to assess anxiety, positive affect, anhedonia, and quality of life. Results: The results indicate that across multiple clinical measurements, participants in the intervention group who played the gamified app showed greater and faster improvement in depressive symptoms compared with their waitlist control counterparts. The difference between the groups in MADRS improvement was –7.01 points (95% CI –10.72 to –3.29; P<.001; Cohen d=0.67). Furthermore, the difference in improvement between groups persisted up to 4 weeks posttrial (MADRS differences at week 12: F49,2=6.62; P=.003; ηp2=0.21). At the end of the trial, participants who played the app showed high interest in continuing using the app. Conclusions: The results demonstrate that a gamified app designed to facilitate thought progression is associated with improvement in depressive symptoms. Given its innovative and accessibility features, this gamified method aiming to facilitate thought progression may successfully complement traditional treatments for depression in the future, providing a safe and impactful way to enhance the lives of individuals experiencing depression and anxiety. Trial Registration: ClinicalTrials.gov NCT05685758; https://clinicaltrials.gov/study/NCT05685758 %M 39350528 %R 10.2196/56201 %U https://www.jmir.org/2024/1/e56201 %U https://doi.org/10.2196/56201 %U http://www.ncbi.nlm.nih.gov/pubmed/39350528 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e48696 %T Predictors of Engagement in Multiple Modalities of Digital Mental Health Treatments: Longitudinal Study %A Nowels,Molly Aideen %A McDarby,Meghan %A Brody,Lilla %A Kleiman,Evan %A Sagui Henson,Sara %A Castro Sweet,Cynthia %A Kozlov,Elissa %+ Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, 525 E 68th St, New York, NY, 10065, United States, 1 212 746 4888, mon2007@med.cornell.edu %K digital health %K mental health %K health care benefit %K prediction %K technology %K digital mental health %K employer-based %K teletherapy %K coaching %K utilization %K mobile phone %D 2024 %7 7.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Technology-enhanced mental health platforms may serve as a pathway to accessible and scalable mental health care; specifically, those that leverage stepped care models have the potential to address many barriers to patient care, including low mental health literacy, mental health provider shortages, perceived acceptability of care, and equitable access to evidence-based treatment. Driving meaningful engagement in care through these platforms remains a challenge. Objective: This study aimed to examine predictors of engagement in self-directed digital mental health services offered as part of an employer-based mental health benefit that uses a technology-enabled care platform. Methods: Using a prospective, longitudinal design, we examined usage data from employees who had access to an employer-sponsored mental health care benefit. Participants had access to a digital library of mental health resources, which they could use at any time, including daily exercises, interactive programs, podcasts, and mindfulness exercises. Coaching and teletherapy were also available to. The outcome was engagement with the self-directed digital mental health resources, measured by the number of interactions. Poisson regression models included sociodemographic characteristics, patient activation, mental health literacy, well-being, PHQ-9 and GAD-7 scores at baseline, primary concern for engaging in treatment, and the use of coaching or teletherapy sessions. Results: In total 950 individuals enrolled in the study, with 38% using any self-directed digital mental health resources. Approximately 44% of the sample did not use the app during the study period. Those using both self-directed digital and 1:1 modalities made up about one-quarter of the sample (235/950, 24.7%). Those using only coaching or therapy (170/950, 17.9%) and those using only self-directed digital mental health resources (126/950, 13.3%) make up the rest. At baseline, these groups statistically significantly differed on age, PHQ-9, GAD-7, MHLS, and primary concern. Receipt of coaching and teletherapy was associated with the number of self-directed digital mental health resources interactions in adjusted Poisson regression modeling. Use of any coach visit was associated with 82% (rate ratio [RR] 1.82, 95% CI 1.63-2.03) more self-directed digital mental health resource interactions while use of any teletherapy session was associated with 80% (RR 1.80, 95% CI 1.55-2.07) more digital mental health resources interactions (both P<.001). Each additional year of age was associated with increased digital mental health resources interactions (RR 1.04, 95% CI (1.03-1.05), and women had 23% more self-directed digital resources interactions than men (RR 1.23, 95% CI 1.09-1.39). Conclusions: Our key finding was that the use of coaching or teletherapy was associated with increased self-directed digital mental health resource use. Higher self-directed digital resource engagement among those receiving coaching or therapy may be a result of provider encouragement. On the other hand, when a participant engages with 1 modality in the platform, they may be more likely to begin engaging with others, becoming “super users” of all resources. %R 10.2196/48696 %U https://www.jmir.org/2024/1/e48696 %U https://doi.org/10.2196/48696 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e58127 %T Mobile Apps for the Personal Safety of At-Risk Children and Youth: Scoping Review %A Bowen-Forbes,Camille %A Khondaker,Tilovatul %A Stafinski,Tania %A Hadizadeh,Maliheh %A Menon,Devidas %+ Health Technology and Policy Unit, School of Public Health, Edmonton Clinic Health Academy, 11405 St 87 Avenue NW, Edmonton, AB, T6G 1C9, Canada, 1 587 712 2086, bowenfor@ualberta.ca %K children %K youth %K personal safety apps %K smartphones %K mobile apps %K violence %K bullying %K suicide prevention %K youth support %K homeless support %K mobile phone %D 2024 %7 5.11.2024 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Personal safety is a widespread public health issue that affects people of all demographics. There is a growing interest in the use of mobile apps for enhancing personal safety, particularly for children and youth at risk, who are among the most vulnerable groups in society. Objective: This study aims to explore what is known about the use of mobile apps for personal safety among children and youth identified to be “at risk.” Methods: A scoping review following published methodological guidelines was conducted. In total, 5 databases (Scopus, SocINDEX, PsycINFO, Compendex, and Inspec Archive) were searched for relevant scholarly articles published between January 2005 and October 2023. The gray literature was searched using Google and Google Scholar search engines. The results were reported using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. For summarizing the features and users’ experiences of the apps, a published framework for evaluating the quality of mobile health apps for youth was used. Results: A total of 1986 articles were identified, and 41 (2.1%) were included in the review. Nine personal safety apps were captured and categorized into 4 groups based on the goals of the apps, as follows: dating and sexual violence prevention (n=4, 44% of apps), bullying and school violence prevention (n=2, 22% of apps), self-harm and suicide prevention (n=2, 22% of apps), and homeless youth support (n=1, 11% of apps). Of the 41 articles, 25 (61%) provided data solely on app descriptions and features, while the remaining 16 (39%) articles provided data on app evaluations and descriptions. Outcomes focused on app engagement, users’ experiences, and effectiveness. Four articles reported on app use, 3 (75%) of which reported relatively high app use. Data on users’ experience were obtained from 13 studies. In general, participants found the app features to be easy to use and useful as educational resources and personal safety tools. Most of the views were positive. Negative perceptions included redundancy of app features and a lack of usefulness. Five apps were evaluated for effectiveness (n=2, 40% dating and sexual violence prevention; n=2, 40% self-harm and suicide prevention; and n=1, 20% bullying and school violence prevention) and were all associated with a statistically significant reduction (P=.001 to .048) in harm or risk to participants at the 95% CI. Conclusions: Although many personal safety apps are available, few studies have specifically evaluated those designed for youth. However, the evidence suggests that mobile safety apps generally appear to be beneficial for reducing harm to at-risk children and youth without any associated adverse events. Recommendations for future research have been made to strengthen the evidence and increase the availability of effective personal safety apps for children and youth. %M 39499918 %R 10.2196/58127 %U https://mhealth.jmir.org/2024/1/e58127 %U https://doi.org/10.2196/58127 %U http://www.ncbi.nlm.nih.gov/pubmed/39499918 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 13 %N %P e55067 %T Screening for Depression Using Natural Language Processing: Literature Review %A Teferra,Bazen Gashaw %A Rueda,Alice %A Pang,Hilary %A Valenzano,Richard %A Samavi,Reza %A Krishnan,Sridhar %A Bhat,Venkat %+ Unity Health Toronto, St. Michael’s Hospital, Interventional Psychiatry Program, 193 Yonge Street, 6-012, Toronto, ON, M5B 1M4, Canada, 1 4163604000 ext 76404, venkat.bhat@utoronto.ca %K depression %K natural language processing %K NLP %K sentiment analysis %K machine learning %K deep learning %K transformer-based models %K large language models %K cross-cultural %K research domain criteria %K RDoC %D 2024 %7 4.11.2024 %9 Review %J Interact J Med Res %G English %X Background: Depression is a prevalent global mental health disorder with substantial individual and societal impact. Natural language processing (NLP), a branch of artificial intelligence, offers the potential for improving depression screening by extracting meaningful information from textual data, but there are challenges and ethical considerations. Objective: This literature review aims to explore existing NLP methods for detecting depression, discuss successes and limitations, address ethical concerns, and highlight potential biases. Methods: A literature search was conducted using Semantic Scholar, PubMed, and Google Scholar to identify studies on depression screening using NLP. Keywords included “depression screening,” “depression detection,” and “natural language processing.” Studies were included if they discussed the application of NLP techniques for depression screening or detection. Studies were screened and selected for relevance, with data extracted and synthesized to identify common themes and gaps in the literature. Results: NLP techniques, including sentiment analysis, linguistic markers, and deep learning models, offer practical tools for depression screening. Supervised and unsupervised machine learning models and large language models like transformers have demonstrated high accuracy in a variety of application domains. However, ethical concerns related to privacy, bias, interpretability, and lack of regulations to protect individuals arise. Furthermore, cultural and multilingual perspectives highlight the need for culturally sensitive models. Conclusions: NLP presents opportunities to enhance depression detection, but considerable challenges persist. Ethical concerns must be addressed, governance guidance is needed to mitigate risks, and cross-cultural perspectives must be integrated. Future directions include improving interpretability, personalization, and increased collaboration with domain experts, such as data scientists and machine learning engineers. NLP’s potential to enhance mental health care remains promising, depending on overcoming obstacles and continuing innovation. %M 39496145 %R 10.2196/55067 %U https://www.i-jmr.org/2024/1/e55067 %U https://doi.org/10.2196/55067 %U http://www.ncbi.nlm.nih.gov/pubmed/39496145 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e59490 %T Interaction Effects Between Low Self-Control and Meaning in Life on Internet Gaming Disorder Symptoms and Functioning in Chinese Adolescents: Cross-Sectional Latent Moderated Structural Equation Modeling Study %A Fong,Ted CT %A Cui,Kunjie %A Yip,Paul SF %+ Research Institute of Social Development, Southwestern University of Finance and Economics, No. 555 Liutai Road, Wenjiang District, Chengdu, 611100, China, 86 17512828565, cuikunjie@swufe.edu.cn %K Chinese %K impulsivity %K interaction effects %K internet gaming disorder %K latent moderation %K meaning in life %K self-control %K temper %D 2024 %7 4.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet gaming disorder (IGD) is an emerging behavioral addiction with mental health implications among adolescents. Low self-control is an established risk factor of IGD. Few studies have, however, examined the moderating role of meaning in life (MIL) on the relationships between low self-control and IGD symptoms and functioning. Objective: This study aimed to examine the effects of low self-control and MIL and their interaction effects on IGD symptoms and family and school functioning in a structural equation model. Methods: A sample of 2064 adolescents (967, 46.9% male; mean age 14.6 years) was recruited by multistage cluster random sampling from 5 middle schools in Sichuan, China, in 2022. The participants completed a self-report questionnaire with validated measures on low self-control, presence of MIL, search for MIL, IGD symptoms, school commitment, and family functioning. Construct validity, measurement invariance, and structural invariance of the measures were evaluated by confirmatory factor analysis across sex. Structural equation modeling was conducted to examine the indirect effects of low self-control and MIL on family and school functioning through IGD symptoms. Latent moderated structural equation modeling was performed to examine the interaction effects between low self-control and MIL on IGD symptoms, school commitment, and family functioning. Results: All scales showed satisfactory model fit and scalar measurement invariance by sex. Males showed significantly greater IGD symptoms and lower levels of self-control (Cohen d=0.25-1.20, P<.001) than females. IGD symptoms were significantly and positively associated with impulsivity (β=.20, P=.01), temper (β=.25, P<.001), and search for meaning (β=.11, P=.048) and significantly and negatively associated with presence of meaning (β=–.21, P<.001). Presence of MIL and impulsivity showed a significant and negative interaction effect (β=–.11, SE .05; P=.03) on IGD symptoms. The positive effect of impulsivity on IGD symptoms was stronger among adolescents with low presence of MIL than those with high presence of MIL. Temper showed significant and positive interaction effects with presence of MIL (β=.08, SE .04; P=.03) and search for MIL (β=.08, SE .04; P=.04) on family functioning. The negative effects of temper on family functioning were stronger among adolescents with low levels of MIL than among those with high levels of MIL. Conclusions: This study provides the first findings on the interaction effects between low self-control and presence of MIL and search for MIL on IGD symptoms and functioning among a large sample of adolescents in rural China. The results have implications for targeted interventions to help male adolescents with lower self-control and presence of meaning. %M 39496163 %R 10.2196/59490 %U https://www.jmir.org/2024/1/e59490 %U https://doi.org/10.2196/59490 %U http://www.ncbi.nlm.nih.gov/pubmed/39496163 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51875 %T The Relation Between Passively Collected GPS Mobility Metrics and Depressive Symptoms: Systematic Review and Meta-Analysis %A Terhorst,Yannik %A Knauer,Johannes %A Philippi,Paula %A Baumeister,Harald %+ Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University Ulm, Lise-Meitner-Str. 16, Ulm, 89081, Germany, 49 7315032820, yannik.terhorst@uni-ulm.de %K smart sensing %K digital phenotyping %K depression %K GPS %K global positioning system %K meta-analysis %K mobile phone %K depressive symptoms %K smartphone %K systematic review %K depressive disorders %K treatment %K mental disorder %K mental health %K wearable %D 2024 %7 1.11.2024 %9 Review %J J Med Internet Res %G English %X Background: The objective, unobtrusively collected GPS features (eg, homestay and distance) from everyday devices like smartphones may offer a promising augmentation to current assessment tools for depression. However, to date, there is no systematic and meta-analytical evidence on the associations between GPS features and depression. Objective: This study aimed to investigate the between-person and within-person correlations between GPS mobility and activity features and depressive symptoms, and to critically review the quality and potential publication bias in the field. Methods: We searched MEDLINE, PsycINFO, Embase, CENTRAL, ACM, IEEE Xplore, PubMed, and Web of Science to identify eligible articles focusing on the correlations between GPS features and depression from December 6, 2022, to March 24, 2023. Inclusion and exclusion criteria were applied in a 2-stage inclusion process conducted by 2 independent reviewers (YT and JK). To be eligible, studies needed to report correlations between wearable-based GPS variables (eg, total distance) and depression symptoms measured with a validated questionnaire. Studies with underage persons and other mental health disorders were excluded. Between- and within-person correlations were analyzed using random effects models. Study quality was determined by comparing studies against the STROBE (Strengthening the Reporting of Observational studies in Epidemiology) guidelines. Publication bias was investigated using Egger test and funnel plots. Results: A total of k=19 studies involving N=2930 participants were included in the analysis. The mean age was 38.42 (SD 18.96) years with 59.64% (SD 22.99%) of participants being female. Significant between-person correlations between GPS features and depression were identified: distance (r=–0.25, 95% CI –0.29 to –0.21), normalized entropy (r–0.17, 95% CI –0.29 to –0.04), location variance (r–0.17, 95% CI –0.26 to –0.04), entropy (r=–0.13, 95% CI –0.23 to –0.04), number of clusters (r=–0.11, 95% CI –0.18 to –0.03), and homestay (r=0.10, 95% CI 0.00 to 0.19). Studies reporting within-correlations (k=3) were too heterogeneous to conduct meta-analysis. A deficiency in study quality and research standards was identified: all studies followed exploratory observational designs, but no study referenced or fully adhered to the international guidelines for reporting observational studies (STROBE). A total of 79% (k=15) of the studies were underpowered to detect a small correlation (r=.20). Results showed evidence for potential publication bias. Conclusions: Our results provide meta-analytical evidence for between-person correlations of GPS mobility and activity features and depression. Hence, depression diagnostics may benefit from adding GPS mobility and activity features as an integral part of future assessment and expert tools. However, confirmatory studies for between-person correlations and further research on within-person correlations are needed. In addition, the methodological quality of the evidence needs to improve. Trial Registration: OSF Registeries cwder; https://osf.io/cwder %M 39486026 %R 10.2196/51875 %U https://www.jmir.org/2024/1/e51875 %U https://doi.org/10.2196/51875 %U http://www.ncbi.nlm.nih.gov/pubmed/39486026 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e60317 %T Digital Youth and Family Engagement Program for Adolescents Who Receive Outpatient Mental Health Services: Qualitative Evaluation %A Ramirez,Ana %A Kramer,Justin %A Hazim,Katrina %A Roberge,Jason %+ Department of Anthropology, University of North Carolina at Chapel Hill, 207 E Cameron Aveue Chapel Hill, NC 27599-3115, Chapel Hill, NC, 27599, United States, 1 9199621243, ana_ramirez@unc.edu %K telemedicine %K telepsychiatry %K adolescents %K mental health %K psychiatry %K coaching %K qualitative assessment %K patient satisfaction %K family engagement %K depression %K anxiety %K suicidal ideation %D 2024 %7 31.10.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Incidents of depression, anxiety, and suicidal ideation among adolescents have increased in recent years. Mental health interventions tailored to adolescents and families need to consider mechanisms for increasing enrollment and sustaining program engagement. A telephone-based, health coach intervention for adolescents and families was implemented at a Southeastern US health system with the goals of improving psychiatric appointment attendance, medication adherence, reduction in emergency department visits, and assisting with crisis management (“Youth and Family Engagement” [YFE] program). Objective: This study aims to explore patients’ and parents’ perceptions of a mental health program and the factors that impact enrollment and sustained engagement. Methods: Semistructured interviews were conducted with adolescent patients (n=9, 56%), parents (n=11, 92%), and clinicians who placed patient referrals (n=6, 100%). Interviews were in English (participants: 19/26, 73%) or Spanish (parents: 7/11, 64%), depending upon participants’ preference. Interviews explored perceptions of the YFE program, experiences working with health coaches, suggestions for program changes, and program goals. The data were analyzed using inductive coding methodologies, with thematic analysis used to organize emergent themes. Two qualitatively trained researchers, one bilingual in English and Spanish, facilitated all data collection and collaboratively performed data analysis. Results: The YFE program’s structure was often mentioned as promoting engagement, with telephone appointments and health coaches’ ability to accommodate inflexible work or school schedules alleviating participation barriers. Skills learned from health coaches were frequently referenced, with adolescents generally citing internal processes, such as positive thinking and mindfulness. Parents discussed behaviors relative to their children, such as improvements with discipline, setting boundaries, and improved parent-child communication. Many participants discussed the importance of health coaches assisting families in navigating social systems, such as accessing resources (eg, housing) and navigating school processes (eg, individualized educational plans), with clinicians suggesting an increased emphasis on adolescents’ nutrition and engagement in primary care. Spanish-speaking parents highlighted numerous advantages of working with bilingual health coaches, emphasizing both enhanced communication and cultural understanding. They specifically noted the coaches’ ability to grasp their lived experiences and challenges as immigrants in the United States, which significantly enriched their participation in the program. Conclusions: Prioritizing convenient engagement for adolescents and families may be important for sustained program participation, as inflexible schedules and competing priorities pose barriers to traditional appointments. Future programs should carefully consider health coach–participant relationships, specifically cultural competency, providing services in native languages, and assisting families with wraparound care, as these may be crucial to sustained engagement. %M 39481102 %R 10.2196/60317 %U https://formative.jmir.org/2024/1/e60317 %U https://doi.org/10.2196/60317 %U http://www.ncbi.nlm.nih.gov/pubmed/39481102 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e58409 %T Automated Real-Time Tool for Promoting Crisis Resource Use for Suicide Risk (ResourceBot): Development and Usability Study %A Coppersmith,Daniel DL %A Bentley,Kate H %A Kleiman,Evan M %A Jaroszewski,Adam C %A Daniel,Merryn %A Nock,Matthew K %+ Department of Psychology, Harvard University, 33 Kirkland St, Cambridge, MA, 02138, United States, 1 617 495 3800, dcoppersmith@g.harvard.edu %K suicidal thoughts %K suicidal behaviors %K ecological momentary assessment %K crisis resources %K real-time tool %K self-report %K psychoeducation %K app %D 2024 %7 31.10.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Real-time monitoring captures information about suicidal thoughts and behaviors (STBs) as they occur and offers great promise to learn about STBs. However, this approach also introduces questions about how to monitor and respond to real-time information about STBs. Given the increasing use of real-time monitoring, there is a need for novel, effective, and scalable tools for responding to suicide risk in real time. Objective: The goal of this study was to develop and test an automated tool (ResourceBot) that promotes the use of crisis services (eg, 988) in real time through a rule-based (ie, if-then) brief barrier reduction intervention. Methods: ResourceBot was tested in a 2-week real-time monitoring study of 74 adults with recent suicidal thoughts. Results: ResourceBot was deployed 221 times to 36 participants. There was high engagement with ResourceBot (ie, 87% of the time ResourceBot was deployed, a participant opened the tool and submitted a response to it), but zero participants reported using crisis services after engaging with ResourceBot. The most reported reasons for not using crisis services were beliefs that the resources would not help, wanting to handle things on one’s own, and the resources requiring too much time or effort. At the end of the study, participants rated ResourceBot with good usability (mean of 75.6 out of 100) and satisfaction (mean of 20.8 out of 32). Conclusions: This study highlights both the possibilities and challenges of developing effective real-time interventions for suicide risk and areas for refinement in future work. %M 39481100 %R 10.2196/58409 %U https://mental.jmir.org/2024/1/e58409 %U https://doi.org/10.2196/58409 %U http://www.ncbi.nlm.nih.gov/pubmed/39481100 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e56950 %T The Impact of Different Types of Social Media Use on the Mental Health of UK Adults: Longitudinal Observational Study %A Yu,Yue %A Dykxhoorn,Jennifer %A Plackett,Ruth %+ Research Department of Primary Care and Population Health, University College London, Rowland Hill Street, London, NW3 2PF, United Kingdom, 44 203108309, ruth.plackett.15@ucl.ac.uk %K social media %K mental health %K depression %K anxiety %K mental disorders %K cohort studies %K United Kingdom %K longitudinal observational study %D 2024 %7 30.10.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Previous studies have explored the association between social media use and mental health among adolescents. However, few studies using nationally representative longitudinal data have explored this relationship for adults and how the effect might change depending on how people use social media. Objective: This study investigated the longitudinal relationship between the frequency of viewing and posting on social media and mental health problems among UK adults. Methods: This study included 15,836 adults (aged 16 years and older) who participated in Understanding Society, a UK longitudinal survey. Social media use was measured with questions about the frequency of viewing social media and posting on social media in Understanding Society Wave 11 (2019-2021). We explored viewing and posting separately, as well as a combined exposure: (1) high viewing, high posting; (2) high viewing, low posting; (3) low viewing, high posting; and (4) low viewing, low posting. Mental health problems were measured in Wave 12 (2020-2022) using the General Health Questionnaire (GHQ-12), a validated scale for identifying symptoms of common mental health problems, where higher scores indicated more mental health problems (0 to 36). Unadjusted and adjusted linear regression models were estimated for viewing social media and posting on social media, adjusting for the baseline GHQ score, gender, age, ethnicity, employment, and education. We found no evidence for effect modification by gender and age so overall associations were reported. Results: In our adjusted models, we found no evidence of an association between the frequency of viewing social media and mental health problems in the following year. We found that adults who posted daily on social media had more mental health problems than those who never posted on social media, corresponding to a 0.35-point increase in GHQ score (β=0.35, 95% CI 0.01-0.68; P=.04). When we considered both social media behaviors, we found that those who frequently viewed and posted on social media scored 0.31 points higher on the GHQ score (β=0.31, 95% CI 0.04-0.58; P=.03) in the following year compared to those who rarely viewed or posted on social media. Conclusions: We found that a high frequency of posting on social media was associated with increased mental health problems a year later. However, we did not find evidence of a similar association based on the frequency of viewing social media content. This provides evidence that some types of active social media use (ie, posting) have a stronger link to mental health outcomes than some types of passive social media use (viewing). These results highlighted that the relationship between social media use and mental health is complex, and more research is needed to understand the mechanisms underlying these patterns to inform targeted interventions and policies. %M 39476374 %R 10.2196/56950 %U https://www.jmir.org/2024/1/e56950 %U https://doi.org/10.2196/56950 %U http://www.ncbi.nlm.nih.gov/pubmed/39476374 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51269 %T Digital Phenotypes of Mobile Keyboard Backspace Rates and Their Associations With Symptoms of Mood Disorder: Algorithm Development and Validation %A Liu,Qimin %A Ning,Emma %A Ross,Mindy K %A Cladek,Andrea %A Kabir,Sarah %A Barve,Amruta %A Kennelly,Ellyn %A Hussain,Faraz %A Duffecy,Jennifer %A Langenecker,Scott A %A Nguyen,Theresa M %A Tulabandhula,Theja %A Zulueta,John %A Demos,Alexander P %A Leow,Alex %A Ajilore,Olusola %+ Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, Boston, MA, 02215, United States, 1 6173532000, qiminliu@bu.edu %K keyboard typing %K passive sensing %K digital phenotyping %K mood disorder %K mixture model %K phenotypes %K mobile keyboard %K smartphone %K keyboard data %K monitoring %K clinical decision-making %K depression %K mania, mobile phone %D 2024 %7 29.10.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Passive sensing through smartphone keyboard data can be used to identify and monitor symptoms of mood disorders with low participant burden. Behavioral phenotyping based on mobile keystroke data can aid in clinical decision-making and provide insights into the individual symptoms of mood disorders. Objective: This study aims to derive digital phenotypes based on smartphone keyboard backspace use among 128 community adults across 2948 observations using a Bayesian mixture model. Methods: Eligible study participants completed a virtual screening visit where all eligible participants were instructed to download the custom-built BiAffect smartphone keyboard (University of Illinois). The BiAffect keyboard unobtrusively captures keystroke dynamics. All eligible and consenting participants were instructed to use this keyboard exclusively for up to 4 weeks of the study in real life, and participants’ compliance was checked at the 2 follow-up visits at week 2 and week 4. As part of the research protocol, every study participant underwent evaluations by a study psychiatrist during each visit. Results: We found that derived phenotypes were associated with not only the diagnoses and severity of depression and mania but also specific individual symptoms. Using a linear mixed-effects model with random intercepts accounting for the nested data structure from daily data, the backspace rates on the continuous scale did not differ between participants in the healthy control and in the mood disorders groups (P=.11). The 3-class model had mean backspace rates of 0.112, 0.180, and 0.268, respectively, with a SD of 0.048. In total, 3 classes, respectively, were estimated to comprise 37.5% (n=47), 54.4% (n=72), and 8.1% (n=9) of the sample. We grouped individuals into Low, Medium, and High backspace rate groups. Individuals with unipolar mood disorder were predominantly in the Medium group (n=54), with some in the Low group (n=27) and a few in the High group (n=6). The Medium group, compared with the Low group, had significantly higher ratings of depression (b=2.32, P=.008). The High group was not associated with ratings of depression with (P=.88) or without (P=.27) adjustment for medication and diagnoses. The High group, compared with the Low group, was associated with both nonzero ratings (b=1.91, P=.02) and higher ratings of mania (b=1.46, P<.001). The High group, compared with the Low group, showed significantly higher odds of elevated mood (P=.03), motor activity (P=.04), and irritability (P<.05). Conclusions: This study demonstrates the promise of mobile typing kinematics in mood disorder research and practice. Monitoring a single mobile typing kinematic feature, that is, backspace rates, through passive sensing imposes a low burden on the participants. Based on real-life keystroke data, our derived digital phenotypes from this single feature can be useful for researchers and practitioners to distinguish between individuals with and those without mood disorder symptoms. %M 39471368 %R 10.2196/51269 %U https://www.jmir.org/2024/1/e51269 %U https://doi.org/10.2196/51269 %U http://www.ncbi.nlm.nih.gov/pubmed/39471368 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 13 %N %P e49660 %T Blended Psychological Therapy for the Treatment of Psychological Disorders in Adult Patients: Systematic Review and Meta-Analysis %A Ferrao Nunes-Zlotkowski,Kelly %A Shepherd,Heather L %A Beatty,Lisa %A Butow,Phyllis %A Shaw,Joanne Margaret %+ Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology, The University of Sydney, Rm 311B Level 3 Griffith Taylor (A19), Manning Road, Sydney, NSW 2006, Australia, 61 2 9351 3761, joanne.shaw@sydney.edu.au %K systematic review %K blended psychological therapy %K blended care %K face-to-face %K online %K psychological intervention %K intervention design %K digital care %K digital mental health %K psychological disorder %D 2024 %7 29.10.2024 %9 Review %J Interact J Med Res %G English %X Background: Blended therapy (BT) combines digital with face-to-face psychological interventions. BT may improve access to treatment, therapy uptake, and adherence. However, research is scarce on the structure of BT models. Objective: We synthesized the literature to describe BT models used for the treatment of psychological disorders in adults. We investigated whether BT structure, content, and ratio affected treatment efficacy, uptake, and adherence. We also conducted meta-analyses to examine treatment efficacy in intervention-control dyads and associations between treatment outcomes versus BT model structure. Methods: PsycINFO, CINAHL, Embase, ProQuest, and MEDLINE databases were searched. Eligibility criteria included articles published in English till March 2023 that described digital and face-to-face elements as part of an intervention plan for treating psychological disorders in adult patients. We developed a coding framework to characterize the BT interventions. A meta-analysis was conducted to calculate effect size (ES; Cohen d and 95% CIs) regarding pre- and posttreatment outcomes in depression and anxiety versus BT structure. The review was registered with PROSPERO and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Searches identified 8436 articles, and data were extracted from 29 studies. BT interventions were analyzed and classified according to mode of interaction between digital and face-to-face components (integrated vs sequential), role of the components (core vs supplementary), component delivery (alternate vs case-by-case), and digital materials assignment mode (standardized vs personalized). Most BT interventions (n=24) used a cognitive behavioral therapy approach for anxiety or depression treatment. Mean rates of uptake (91%) and adherence (81%) were reported across individual studies. BT interventions were more effective or noninferior to treatment as usual, with large spread in the data and a moderate to large ES in the treatment of depression (n=9; Cohen d=–1.1, 95% CI –0.6 to –1.6, P<.001, and z score=–4.3). A small, nonsignificant ES was found for anxiety outcomes (n=5; Cohen d=–0.1, 95% CI –0.3 to 0.05, P=.17, and z score=–1.4). Higher ESs were found in blended interventions with supplementary design (depression: n=11, Cohen d=–0.75, 95% CI –0.56 to –0.95; anxiety: n=8, Cohen d=–0.9, 95% CI –0.6 to –1.2); fewer (≤6) face-to-face sessions (depression: n=9, Cohen d=–0.7, 95% CI –0.5 to –0.9; anxiety: n=7, Cohen d=–0.8, 95% CI –0.3 to –1.3); and a lower ratio (≤50%) of face-to-face versus digital sessions (depression: n=5, Cohen d=–0.8, 95% CI –0.6 to –1.1; anxiety: n=4, Cohen d=–0.8, 95% CI 0.006 to –1.6). Conclusions: This study confirmed integrated BT models as feasible to deliver. We found BT to be effective in depression treatment, but anxiety treatment results were nonsignificant. Future studies assessing outcomes across different psychological disorders and therapeutic approaches are required. Trial Registration: PROSPERO CRD42021258977; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=258977 %M 39470720 %R 10.2196/49660 %U https://www.i-jmr.org/2024/1/e49660 %U https://doi.org/10.2196/49660 %U http://www.ncbi.nlm.nih.gov/pubmed/39470720 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e55531 %T Internet-Based Social Connections of Black American College Students in Pre–COVID-19 and Peri–COVID-19 Pandemic Periods: Network Analysis %A Lee,Eun %A Kim,Heejun %A Esener,Yildiz %A McCall,Terika %+ Department of Scientific Computing, Pukyong National University, 45, Yongso-ro, Nam-gu, Busan, 48513, Republic of Korea, 82 10 7356 7890, eunlee@pknu.ac.kr %K COVID-19 pandemic %K college students %K Black American %K African American %K social network analysis %K social media %K mental health %K depression %D 2024 %7 28.10.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: A global-scale pandemic, such as the COVID-19 pandemic, greatly impacted communities of color. Moreover, physical distancing recommendations during the height of the COVID-19 pandemic negatively affected people’s sense of social connection, especially among young individuals. More research is needed on the use of social media and communication about depression, with a specific focus on young Black Americans. Objective: This paper aims to examine whether there are any differences in social-networking characteristics before and during the pandemic periods (ie, pre–COVID-19 pandemic vs peri–COVID-19 pandemic) among the students of historically black colleges and universities (HBCUs). For the study, the researchers focus on the students who have posted a depression-related tweet or have retweeted such posts on their timeline and also those who have not made such tweets. This is done to understand the collective patterns of both groups. Methods: This paper analyzed the social networks on Twitter (currently known as X; X Corp) of HBCU students through comparing pre–COVID-19 and peri–COVID-19 pandemic data. The researchers quantified the structural properties, such as reciprocity, homophily, and communities, to test the differences in internet-based socializing patterns between the depression-related and non–depression related groups for the 2 periods. Results: During the COVID-19 pandemic period, the group with depression-related tweets saw an increase in internet-based friendships, with the average number of friends rising from 1194 (SD 528.14) to 1371 (SD 824.61; P<.001). Their mutual relationships strengthened (reciprocity: 0.78-0.8; P=.01), and they showed higher assortativity with other depression-related group members (0.6-0.7; P<.001). In a network with only HBCU students, internet-based and physical affiliation memberships aligned closely during the peri–COVID-19 pandemic period, with membership entropy decreasing from 1.0 to 0.5. While users without depression-related tweets engaged more on the internet with other users who shared physical affiliations, those who posted depression-related tweets maintained consistent entropy levels (modularity: 0.75-0.76). Compared with randomized networks before and during the COVID-19 pandemic (P<.001), the users also exhibited high homophily with other members who posted depression-related tweets. Conclusions: The findings of this study provided insight into the social media activities of HBCU students’ social networks and communication about depression on social media. Future social media interventions focused on the mental health of Black college students may focus on providing resources to students who communicate about depression. Efforts aimed at providing relevant resources and information to internet-based communities that share institutional affiliation may enhance access to social support, particularly for those who may not proactively seek assistance. This approach may contribute to increased social support for individuals within these communities, especially those with a limited social capacity. %M 39467280 %R 10.2196/55531 %U https://www.jmir.org/2024/1/e55531 %U https://doi.org/10.2196/55531 %U http://www.ncbi.nlm.nih.gov/pubmed/39467280 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e52609 %T Acceptability of Digital Mental Health Interventions for Depression and Anxiety: Systematic Review %A Lau,Carrie K Y %A Saad,Anthony %A Camara,Bettina %A Rahman,Dia %A Bolea-Alamanac,Blanca %+ Department of Psychiatry, Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada, 1 647 331 2707, Blanca.BoleaAlamanac@wchospital.ca %K acceptability %K mental health %K depression %K anxiety %K mobile app %K internet %K mobile phone %K mobile health %K mHealth %K digital health %D 2024 %7 28.10.2024 %9 Review %J J Med Internet Res %G English %X Background: Depression and anxiety disorders are common, and treatment often includes psychological interventions. Digital health interventions, delivered through technologies such as web-based programs and mobile apps, are increasingly used in mental health treatment. Acceptability, the extent to which an intervention is viewed positively, has been identified as contributing to patient adherence and engagement with digital health interventions. Acceptability, therefore, impacts the benefit derived from using digital health interventions in treatment. Understanding the acceptability of digital mental health interventions among patients with depression or anxiety disorders is essential to maximize the effectiveness of their treatment. Objective: This review investigated the acceptability of technology-based interventions among patients with depression or anxiety disorders. Methods: A systematic review was performed based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PROSPERO (International Prospective Register of Systematic Reviews) guidelines. We searched PubMed, Web of Science, and Ovid in May 2022. Studies were included if they evaluated digital interventions for the treatment of depression or anxiety disorders and investigated their acceptability among adult patients. Studies were excluded if they targeted only specific populations (eg, those with specific physical health conditions), investigated acceptability in healthy individuals or patients under the age of 18 years, involved no direct interaction between patients and technologies, used technology only as a platform for traditional care (eg, videoconferencing), had patients using technologies only in clinical or laboratory settings, or involved virtual reality technologies. Acceptability outcome data were narratively synthesized by the direction of acceptability using vote counting. Included studies were evaluated using levels of evidence from the Oxford Centre for Evidence-Based Medicine. The risk of bias was assessed using a tool designed for this review and GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Results: A total of 143 articles met the inclusion criteria, comprising 67 (47%) articles on interventions for depression, 65 (45%) articles on interventions for anxiety disorders, and 11 (8%) articles on interventions for both. Overall, 90 (63%) were randomized controlled trials, 50 (35%) were other quantitative studies, and 3 (2%) were qualitative studies. Interventions used web-based programs, mobile apps, and computer programs. Cognitive behavioral therapy was the basis of 71% (102/143) of the interventions. Digital mental health interventions were generally acceptable among patients with depression or anxiety disorders, with 88% (126/143) indicating positive acceptability, 8% (11/143) mixed results, and 4% (6/143) insufficient information to categorize the direction of acceptability. The available research evidence was of moderate quality. Conclusions: Digital mental health interventions seem to be acceptable to patients with depression or anxiety disorders. Consistent use of validated measures for acceptability would enhance the quality of evidence. Careful design of acceptability as an evaluation outcome can further improve the quality of evidence and reduce the risk of bias. Trial Registration: Open Science Framework Y7MJ4; https://doi.org/10.17605/OSF.IO/SPR8M %M 39466300 %R 10.2196/52609 %U https://www.jmir.org/2024/1/e52609 %U https://doi.org/10.2196/52609 %U http://www.ncbi.nlm.nih.gov/pubmed/39466300 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e59119 %T The Evaluation of a Web-Based Intervention (Deprexis) to Decrease Depression and Restore Functioning in Veterans: Protocol for a Randomized Controlled Trial %A Pearson,Rahel %A Beevers,Christopher G %A Mignogna,Joseph %A Benzer,Justin %A Pfeiffer,Paul N %A Post,Edward %A Creech,Suzannah K %+ Veterans Integrated Service Network 17 Center of Excellence for Research on Returning War Veterans, Central Texas Veterans Affairs Healthcare System, 4800 Memorial Drive (151C), Waco, TX, 76711, United States, 1 254 297 5155, rahel.pearson@va.gov %K depression %K eHealth %K mental health %K randomized controlled trial %K RCT %K mobile phone %D 2024 %7 24.10.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depressive symptoms are common in veterans, and the presence of these symptoms increases disability as well as suicidal thoughts and behaviors. However, there is evidence that these symptoms often go untreated. Intervening before symptoms become severe and entrenched is related to better long-term outcomes, including improved functioning and less disease chronicity. Computer-delivered interventions may be especially appropriate for those veterans with mild to moderate depressive symptoms, because these interventions can require fewer resources and have lower barriers to access and thus have potential for wider reach. Despite this potential, there is a dearth of research examining computerized interventions for depressive symptoms in veteran samples. Objective: The aim of this study is to evaluate the efficacy of Deprexis (GAIA AG), a computerized intervention for depressive symptoms and related functional impairment. Methods: Veterans will be recruited through the US Department of Veterans Affairs electronic medical record and through primary care and specialty clinics. First, qualitative interviews will be completed with a small subset of veterans (n=16-20) to assess the acceptability of treatment procedures. Next, veterans (n=132) with mild to moderate depressive symptoms will be randomly assigned to the fully automated Deprexis intervention or a treatment-as-usual control group. The primary outcomes will be self-reported depressive symptoms and various dimensions of psychosocial functioning. Results: This project was funded in May 2024, and data collection will be conducted between October 2024 and April 2029. Overall, 4 participants have been recruited as of the submission of the manuscript, and data analysis is expected in June 2029, with initial results expected in November 2029. Conclusions: This study will provide initial evidence for the efficacy of self-guided, computerized interventions for depressive symptoms and functional impairment in veterans. If effective, these types of interventions could improve veteran access to low-resource psychosocial treatments. Trial Registration: ClinicalTrials.gov NCT06217198; https://www.clinicaltrials.gov/study/NCT06217198 International Registered Report Identifier (IRRID): PRR1-10.2196/59119 %M 39446432 %R 10.2196/59119 %U https://www.researchprotocols.org/2024/1/e59119 %U https://doi.org/10.2196/59119 %U http://www.ncbi.nlm.nih.gov/pubmed/39446432 %0 Journal Article %@ 2563-3570 %I JMIR Publications %V 5 %N %P e58357 %T Enhancing Suicide Risk Prediction With Polygenic Scores in Psychiatric Emergency Settings: Prospective Study %A Lee,Younga Heather %A Zhang,Yingzhe %A Kennedy,Chris J %A Mallard,Travis T %A Liu,Zhaowen %A Vu,Phuong Linh %A Feng,Yen-Chen Anne %A Ge,Tian %A Petukhova,Maria V %A Kessler,Ronald C %A Nock,Matthew K %A Smoller,Jordan W %+ Psychiatric & Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St, 6th Floor, Boston, MA, 02114, United States, 1 617 724 0835, jsmoller@mgh.harvard.edu %K polygenic risk score %K suicide risk prediction %K suicide attempt %K predictive algorithms %K genomics %K genotypes %K electronic health record %K machine learning %D 2024 %7 23.10.2024 %9 Original Paper %J JMIR Bioinform Biotech %G English %X Background: Despite growing interest in the clinical translation of polygenic risk scores (PRSs), it remains uncertain to what extent genomic information can enhance the prediction of psychiatric outcomes beyond the data collected during clinical visits alone. Objective: This study aimed to assess the clinical utility of incorporating PRSs into a suicide risk prediction model trained on electronic health records (EHRs) and patient-reported surveys among patients admitted to the emergency department. Methods: Study participants were recruited from the psychiatric emergency department at Massachusetts General Hospital. There were 333 adult patients of European ancestry who had high-quality genotype data available through their participation in the Mass General Brigham Biobank. Multiple neuropsychiatric PRSs were added to a previously validated suicide prediction model in a prospective cohort enrolled between February 4, 2015, and March 13, 2017. Data analysis was performed from July 11, 2022, to August 31, 2023. Suicide attempt was defined using diagnostic codes from longitudinal EHRs combined with 6-month follow-up surveys. The clinical risk score for suicide attempt was calculated from an ensemble model trained using an EHR-based suicide risk score and a brief survey, and it was subsequently used to define the baseline model. We generated PRSs for depression, bipolar disorder, schizophrenia, suicide attempt, and externalizing traits using a Bayesian polygenic scoring method for European ancestry participants. Model performance was evaluated using area under the receiver operator curve (AUC), area under the precision-recall curve, and positive predictive values. Results: Of the 333 patients (n=178, 53.5% male; mean age 36.8, SD 13.6 years; n=333, 100% non-Hispanic and n=324, 97.3% self-reported White), 28 (8.4%) had a suicide attempt within 6 months. Adding either the schizophrenia PRS or all PRSs to the baseline model resulted in the numerically highest discrimination (AUC 0.86, 95% CI 0.73-0.99) compared to the baseline model (AUC 0.84, 95% Cl 0.70-0.98). However, the improvement in model performance was not statistically significant. Conclusions: In this study, incorporating genomic information into clinical prediction models for suicide attempt did not improve patient risk stratification. Larger studies that include more diverse participants are required to validate whether the inclusion of psychiatric PRSs in clinical prediction models can enhance the stratification of patients at risk of suicide attempts. %M 39442166 %R 10.2196/58357 %U https://bioinform.jmir.org/2024/1/e58357 %U https://doi.org/10.2196/58357 %U http://www.ncbi.nlm.nih.gov/pubmed/39442166 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e54275 %T Meal Timing and Depression Among Chinese Children and Adolescents: Cross-Sectional Study %A Li,Huilun %A Lu,Zhaohui %A Zhang,Erliang %A Zhang,Jie %A Cui,Shuheng %A Takahashi,Masaki %A Xiang,Mi %K mental health %K meal timing %K chrononutrition %K depression %K mhealth %K meal time %K children %K adolescent %K cross-sectional study %K China %K schedule of meal %K metabolic disorder %K correlation %K survey %K breakfast skipping %K food intake %K daily eating %K analysis %K logistic regression %D 2024 %7 23.10.2024 %9 %J JMIR Public Health Surveill %G English %X Background: Depression in children and adolescents is a rising concern in China. Dietary behavior is a critical determinant of mental health. Meal timing, or the schedule of meal consumption, has been related to several metabolic disorders. However, the effect of meal timing on mental health is scarce, particularly in children and adolescents who are in a critical period of physical and psychological development. Objective: This research examined the relationship between meal timing and depression in children and adolescents in China. Methods: Children and adolescents from grades 1 to 9 were recruited from 16 districts in Shanghai, China, from January 3 to January 21, 2020. Ten schools attended the study. A survey was distributed to the students and their parents to collect demographic and health-related information. Depression was measured by the Children’s Depression Inventory-Short Form. Breakfast consumption was analyzed as a binary outcome. Participants were defined as breakfast consumers if they never skipped breakfast during the week. They were otherwise defined as breakfast skippers if they skipped breakfast at least once per week. A similar categorization was applied to analyze food intake proximal to bed. Daily eating windows were calculated using the last food intake time frame—the first food intake time frame. Participants were classified into eating window groups of less than 10 hours, 10-12 hours, and more than 12 hours. A logistic regression model was used to compute the odds ratio (OR) and 95% CI. Results: A total of 6874 participants were included in the analysis. Participants who skipped breakfast were associated with a 2.70 times higher occurrence of depression (OR 2.70, 95% CI 2.24‐3.26; P<.001). The prevalence of depression was 1.28 times higher in participants who ate before bed than in those who never ate before bed (OR 1.28, 95% CI 1.08‐1.50; P<.001). The occurrence of depression was 1.37 times higher if the eating time window was shorter than 10 hours (OR 1.37, 95% CI 1.08‐1.73; P=.009) and 1.23 times higher if the eating time window was longer than 12 hours (OR 1.23, 95% CI 1.01‐1.50; P=.004). The lowest occurrence of depression was observed at 11.5 hours. Subgroup analysis showed that such relationships remained significant in adolescents aged 10 years or older. In children, only skipping breakfast was associated with a higher odds of depression (OR 2.77, 95% CI 1.94‐3.96; P<.001). Conclusions: Breakfast skipping and eating before bed significantly increase the occurrence of depression. The optimal daily eating window to lower the occurrence of depression is 11.5 hours in children and adolescents. Daily eating windows longer than 12 hours or shorter than 10 hours are associated with an elevated occurrence of depression. Current findings advocate evidence-based dietary strategies to prevent and treat depression in children and adolescents. %R 10.2196/54275 %U https://publichealth.jmir.org/2024/1/e54275 %U https://doi.org/10.2196/54275 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51710 %T Association Between School-Related Google Trends Search Volume and Suicides Among Children and Adolescents in Japan During 2016-2020: Retrospective Observational Study With a Time-Series Analysis %A Arai,Takahiro %A Tsubaki,Hiroe %A Wakano,Ayako %A Shimizu,Yasuyuki %+ School of Management and Information Sciences, Tama University, 4-1-1 Hijirigaoka, Tama City, Tokyo, 206-0022, Japan, 81 42 337 7149, arai.t@keio.jp %K adolescent %K children %K COVID-19 %K Google Trends %K internet %K Japan %K monitoring %K suicide %K surveillance %K time series analysis %D 2024 %7 21.10.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is the leading cause of death among children and adolescents in Japan. Internet search volume may be useful in detecting suicide risk. However, few studies have shown an association between suicides attempted by children and adolescents and their internet search volume. Objective: This study aimed to examine the relationship between the number of suicides and the volume of school-related internet searches to identify the search terms that could serve as the leading indicators of suicide prevention among children and adolescents. Methods: We used data on weekly suicides attempted by elementary, middle, and high school students in Japan from 2016 to 2020, provided by the National Police Agency. Internet search volume was weekly data for 20 school-related terms obtained from Google Trends. Granger causality and cross-correlation analysis were performed to estimate the temporal back-and-forth and lag between suicide deaths and search volume for the related terms. Results: The search queries “I do not want to go to school” and “study” showed Granger causality with suicide incidences. The cross-correlation analysis showed significant positive correlations in the range of –2 to 2 for “I do not want to go to school” (highest value at time lag 0, r=0.28), and –1 to 2 for “study” (highest value at time lag –1, r=0.18), indicating that the search volume increased as the number of suicides increased. Furthermore, during the COVID-19 pandemic period (January-December 2020), the search trend for “I do not want to go to school,” unlike “study,” was highly associated with suicide frequency. Conclusions: Monitoring the volume of internet searches for “I do not want to go to school” could be useful for the early detection of suicide risk among children and adolescents and for optimizing web-based helpline displays. %M 39432900 %R 10.2196/51710 %U https://www.jmir.org/2024/1/e51710 %U https://doi.org/10.2196/51710 %U http://www.ncbi.nlm.nih.gov/pubmed/39432900 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e43954 %T Data Visualization Preferences in Remote Measurement Technology for Individuals Living With Depression, Epilepsy, and Multiple Sclerosis: Qualitative Study %A Simblett,Sara %A Dawe-Lane,Erin %A Gilpin,Gina %A Morris,Daniel %A White,Katie %A Erturk,Sinan %A Devonshire,Julie %A Lees,Simon %A Zormpas,Spyridon %A Polhemus,Ashley %A Temesi,Gergely %A Cummins,Nicholas %A Hotopf,Matthew %A Wykes,Til %A , %+ Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, United Kingdom, 44 02078480762, sara.simblett@kcl.ac.uk %K mHealth %K qualitative %K technology %K depression %K epilepsy %K multiple sclerosis %K wearables %K devices %K smartphone apps %K application %K feedback %K users %K data %K data visualization %K mobile phone %D 2024 %7 18.10.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Remote measurement technology (RMT) involves the use of wearable devices and smartphone apps to measure health outcomes in everyday life. RMT with feedback in the form of data visual representations can facilitate self-management of chronic health conditions, promote health care engagement, and present opportunities for intervention. Studies to date focus broadly on multiple dimensions of service users’ design preferences and RMT user experiences (eg, health variables of perceived importance and perceived quality of medical advice provided) as opposed to data visualization preferences. Objective: This study aims to explore data visualization preferences and priorities in RMT, with individuals living with depression, those with epilepsy, and those with multiple sclerosis (MS). Methods: A triangulated qualitative study comparing and thematically synthesizing focus group discussions with user reviews of existing self-management apps and a systematic review of RMT data visualization preferences. A total of 45 people participated in 6 focus groups across the 3 health conditions (depression, n=17; epilepsy, n=11; and MS, n=17). Results: Thematic analysis validated a major theme around design preferences and recommendations and identified a further four minor themes: (1) data reporting, (2) impact of visualization, (3) moderators of visualization preferences, and (4) system-related factors and features. Conclusions: When used effectively, data visualizations are valuable, engaging components of RMT. Easy to use and intuitive data visualization design was lauded by individuals with neurological and psychiatric conditions. Apps design needs to consider the unique requirements of service users. Overall, this study offers RMT developers a comprehensive outline of the data visualization preferences of individuals living with depression, epilepsy, and MS. %M 39423366 %R 10.2196/43954 %U https://www.jmir.org/2024/1/e43954 %U https://doi.org/10.2196/43954 %U http://www.ncbi.nlm.nih.gov/pubmed/39423366 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51110 %T Exploring the Role of Mobile Apps for Insomnia in Depression: Systematic Review %A Chiu,Yi-Hang %A Lee,Yen-Fen %A Lin,Huang-Li %A Cheng,Li-Chen %+ Department of Information and Finance Management, National Taipei University of Technology, Number 1, Section 3, Zhongxiao East Road, Da’an District, Taipei City, 10608, Taiwan, 886 2771 2171 ext 6720, lijen.cheng@gmail.com %K depression %K insomnia %K chatbots %K conversational agents %K medical apps %K systematic review %K technical aspects %K PRISMA %D 2024 %7 18.10.2024 %9 Review %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has profoundly affected mental health, leading to an increased prevalence of depression and insomnia. Currently, artificial intelligence (AI) and deep learning have thoroughly transformed health care–related mobile apps, offered more effective mental health support, and alleviated the psychological stress that may have emerged during the pandemic. Early reviews outlined the use of mobile apps for dealing with depression and insomnia separately. However, there is now an urgent need for a systematic evaluation of mobile apps that address both depression and insomnia to reveal new applications and research gaps. Objective: This study aims to systematically review and evaluate mobile apps targeting depression and insomnia, highlighting their features, effectiveness, and gaps in the current research. Methods: We systematically searched PubMed, Scopus, and Web of Science for peer-reviewed journal articles published between 2017 and 2023. The inclusion criteria were studies that (1) focused on mobile apps addressing both depression and insomnia, (2) involved young people or adult participants, and (3) provided data on treatment efficacy. Data extraction was independently conducted by 2 reviewers. Title and abstract screening, as well as full-text screening, were completed in duplicate. Data were extracted by a single reviewer and verified by a second reviewer, and risk of bias assessments were completed accordingly. Results: Of the initial 383 studies we found, 365 were excluded after title, abstract screening, and removal of duplicates. Eventually, 18 full-text articles met our criteria and underwent full-text screening. The analysis revealed that mobile apps related to depression and insomnia were primarily utilized for early detection, assessment, and screening (n=5 studies); counseling and psychological support (n=3 studies); and cognitive behavioral therapy (CBT; n=10 studies). Among the 10 studies related to depression, our findings showed that chatbots demonstrated significant advantages in improving depression symptoms, a promising development in the field. Additionally, 2 studies evaluated the effectiveness of mobile apps as alternative interventions for depression and sleep, further expanding the potential applications of this technology. Conclusions: The integration of AI and deep learning into mobile apps, particularly chatbots, is a promising avenue for personalized mental health support. Through innovative features, such as early detection, assessment, counseling, and CBT, these apps significantly contribute toward improving sleep quality and addressing depression. The reviewed chatbots leveraged advanced technologies, including natural language processing, machine learning, and generative dialog, to provide intelligent and autonomous interactions. Compared with traditional face-to-face therapies, their feasibility, acceptability, and potential efficacy highlight their user-friendly, cost-effective, and accessible nature with the aim of enhancing sleep and mental health outcomes. %M 39423009 %R 10.2196/51110 %U https://www.jmir.org/2024/1/e51110 %U https://doi.org/10.2196/51110 %U http://www.ncbi.nlm.nih.gov/pubmed/39423009 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e60502 %T Clinical Effects of Asynchronous Provider-Guided Practice Sessions During Blended Care Therapy for Anxiety and Depression: Pragmatic Retrospective Cohort Study %A Espel-Huynh,Hallie M %A Wang,Lu %A Lattie,Emily G %A Wickham,Robert E %A Varra,Alethea %A Chen,Connie E %A Lungu,Anita %A Lee,Jennifer L %+ Lyra Health, 270 East Lane, Burlingame, CA, 94010, United States, 1 (877) 505 7147, hespel-huynh@lyrahealth.com %K anxiety %K depression %K blended care therapy %K guided practice sessions %K mental health care %K digital mental health %K psychotherapy outcomes %D 2024 %7 18.10.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Blended care therapy models are intended to increase the efficiency and effectiveness of evidence-based psychotherapy by combining synchronous and asynchronous components of care. Objective: This retrospective cohort study evaluated the clinical effects of synchronous video therapy sessions and asynchronous guided practice session elements on anxiety and depression in a blended care therapy program, with a novel focus on asynchronous provider feedback messages. Methods: Participants were adults (N=33,492) with clinical symptoms of anxiety (Generalized Anxiety Disorder 7-item scale [GAD-7] score of ≥8) and depression (Patient Health Questionnaire 9-item scale [PHQ-9] score of ≥10) at intake. Symptom trajectories were evaluated via individual growth curve models. Time-varying covariates evaluated effects of synchronous video session attendance and the presence or absence of each asynchronous guided practice session element occurring within 7 days and 8-14 days prior to each clinical outcome assessment. Guided practice session elements included client digital lesson completion, client digital exercise completion, and feedback messages sent by providers. Results: Approximately 86.6% (29,012/33,492) of clients met criteria for clinical improvement by end of care (median 6, IQR 4-8 synchronous sessions). Synchronous video session attendance and client digital lesson completion in the past 7 days and in the past 8-14 days were each uniquely and significantly associated with lower GAD-7 scores (video session effects: bsession7=–0.82, bsession8-14=–0.58, P values<.001; digital lesson effects: blesson7=–0.18, blesson8-14=–0.26, P values <.001) and PHQ-9 scores (video session effects: bsession7=–0.89, bsession8-14=–0.67, P values <.001; digital lesson effects: blesson7=–0.12, blesson8-14=–0.30, P values <.001). Client digital exercise completion in the past 8-14 days was significantly associated with lower GAD-7 scores (bexercise8-14=–0.10; P<.001) but exercise completion in the 7 days prior to clinical outcome assessment was not (bexercise7=0.00; P=.89). Exercise completion in the past 7 days was significantly associated with lower PHQ-9 scores (bexercise7=–0.16; P<.001) but exercise completion in the past 8-14 days was not (bexercise8-14=–0.05; P=.09). Provider feedback messaging in the past 7 days and in the past 8-14 days was significantly associated with lower GAD-7 and PHQ-9 scores, respectively (GAD-7: bfeedback7=–0.12, P<.001; bfeedback8-14=–0.07, P=.004; PHQ-9: bfeedback7=–0.15, P<.001; bfeedback8-14=–0.08, P=.01). Conclusions: Provider feedback between synchronous therapy sessions provided significant benefit for symptom reduction, beyond the effects of client digital engagement and synchronous video sessions. When guided practice sessions are well integrated into care, blended care therapy provides meaningful improvements upon the traditional, synchronous session–only therapy model. Provider guidance and feedback for clients between synchronous sessions support more efficient and effective mental health care overall. %M 39422996 %R 10.2196/60502 %U https://www.jmir.org/2024/1/e60502 %U https://doi.org/10.2196/60502 %U http://www.ncbi.nlm.nih.gov/pubmed/39422996 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e57294 %T A French-Language Web-Based Intervention Targeting Prolonged Grief Symptoms in People Who Are Bereaved and Separated: Randomized Controlled Trial %A Debrot,Anik %A Efinger,Liliane %A Kheyar,Maya %A Pomini,Valentino %A Berthoud,Laurent %+ Institute of Psychology, Faculty of Social and Political Sciences, University of Lausanne, Géopolis, Rue de la Mouline 11, Lausanne, 1015, Switzerland, 41 216923239, anik.debrot@unil.ch %K web-based interventions %K randomized controlled trial %K grief %K bereavement %K separation %K guidance %D 2024 %7 16.10.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Losing a loved one, through death or separation, counts among the most stressful life events and is detrimental to health and well-being. About 15% of people show clinically significant difficulties coping with such an event. Web-based interventions (WBIs) are effective for a variety of mental health disorders, including prolonged grief. However, no validated WBI is available in French for treating prolonged grief symptoms. Objective: This study aimed to compare the efficacy and adherence rates of 2 WBIs for prolonged grief symptoms following the loss of a loved one through death or romantic separation. Methods: LIVIA 2.0 was developed relying on theoretical and empirical findings on bereavement processes and WBIs, and is compared with LIVIA 1, which has already demonstrated its efficacy. We conducted a randomized controlled trial and provided on-demand guidance to participants. Outcomes were assessed through web-based questionnaires before the intervention, after the intervention (12 weeks later), and at follow-up (24 weeks later). Primary outcomes were grief symptoms, depressive symptoms, and well-being. Secondary outcomes were anxiety symptoms, grief coping strategies, aspects related to self-identity, and program satisfaction. Results: In total, 62 participants were randomized (intent-to-treat [ITT] sample), 29 (47%) in LIVIA 2.0 (active arm) and 33 (53%) in LIVIA 1 (control arm). The dropout rate was 40% (37/62), and 10 participants were removed due to exclusion criteria, leading to a final per-protocol sample of 27 (44%) completers who differed from noncompleters only based on reporting fewer anxiety symptoms (t60=3.03; P=.004). Participants who are separated reported more grief symptoms (t60=2.22; P=.03) and attachment anxiety (t60=2.26; P=.03), compared to participants who are bereaved. There were pre-post within-group differences for both programs in the ITT sample, with significant reductions in grief (Cohen d=−0.90), depressive symptoms (Cohen d=−0.31), and centrality of the loss (Cohen d=−0.45). The same pattern was observed in the per-protocol sample, with the exception that anxiety symptoms also significantly diminished (Cohen d=−0.45). No difference was found in efficacy between the 2 programs (all P>.33). Participants (ITT sample) reported overall high levels of program satisfaction (mean 3.18, SD 0.54; over a maximum of 4). Effect stability was confirmed at the 6-month follow-up for all outcomes, with an improvement in self-concept clarity. Conclusions: The 2 grief-related WBIs were effective in reducing grief, depressive and anxiety symptoms for participants who are bereaved or separated. The analyses did not reveal any pre-post between-group differences, suggesting that the innovations brought to LIVIA 2.0 did not significantly affect the outcome. However, caution is warranted with the interpretation of the results given the limited power of the sample, which only allows the detection of medium effect sizes. Trial Registration: ClinicalTrials.gov NCT05219760; https://clinicaltrials.gov/study/NCT05219760 International Registered Report Identifier (IRRID): RR2-10.2196/39026 %M 39412869 %R 10.2196/57294 %U https://formative.jmir.org/2024/1/e57294 %U https://doi.org/10.2196/57294 %U http://www.ncbi.nlm.nih.gov/pubmed/39412869 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e52354 %T Internet Search Activity for Intentional Self-Harm Forums After a High-Profile News Publication: Interrupted Time Series Analysis %A Kelsall,Nora Clancy %A Gimbrone,Catherine %A Olfson,Mark %A Gould,Madelyn %A Shaman,Jeffrey %A Keyes,Katherine %+ Department of Epidemiology, Columbia University, 722 West 168th Street, Suite 724, New York, NY, 10032, United States, 1 212 304 5652, kmk2104@cumc.columbia.edu %K suicide risk %K suicide %K journalism %K media %K self-harm %K Google Trends %K websites %K mental health %K depression %K quality of life %K harmful information %D 2024 %7 15.10.2024 %9 Research Letter %J J Med Internet Res %G English %X Searches for “pro-suicide” websites in the United States peaked during the week a high-profile news story was published and remained elevated for 6 months afterward, highlighting the need to avoid mentioning specific sources of explicit suicide instructions in media publications. %M 39405095 %R 10.2196/52354 %U https://www.jmir.org/2024/1/e52354 %U https://doi.org/10.2196/52354 %U http://www.ncbi.nlm.nih.gov/pubmed/39405095 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e47251 %T Intervention to Improve Well-Being, Nutrition, and Physical Activity in Adults: Experimental Study %A Aubert,Morghane %A Clavel,Céline %A Le Scanff,Christine %A Martin,Jean-Claude %+ Laboratoire Interdisciplinaire des Sciences du Numérique, Campus Universitaire bâtiment 507, Rue du Belvédère, Orsay, 91400, France, 33 684216205, jean-claude.martin@lisn.fr %K mindfulness %K well-being %K affects %K nutrition %K physical activity %K intervention %K lifestyle habits %K mindfulness exercises %D 2024 %7 15.10.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Mindfulness improves well-being, improves emotional regulation, reduces impulses to eat, and is linked to increased physical activity. Mindfulness interventions usually focus on 1 aspect but do not offer an approach to holistically improving lifestyle. Objective: This study aims to address this gap by designing and evaluating a holistic mindfulness intervention. Methods: Committing to a 12-week intervention with 2-hour sessions without knowing whether you will enjoy it can be a hindrance for someone completely unfamiliar with mindfulness. For this reason, we decided to design a mindfulness intervention with short sessions over a reduced number of weeks. The aim is to enable novices to discover different aspects of mindfulness while at the same time offering a satisfactory practice for people who are already practicing mindfulness. We designed and evaluated a web-based mindfulness intervention in 5 sessions of 5 to 10 minutes each on well-being, diet, and physical activity to support a healthier lifestyle. The first 2 sessions focus on formal mindfulness meditation to enable novices to discover mindfulness and its main principles. Then there are 2 sessions about food. The first session about food aims to develop a sense of satisfaction with the food we eat and to focus our attention on new sensations. The second session about food aims to develop the ability to resist the lure of unhealthy foods. Finally, there is a session on physical activity. The aim is to develop a particular awareness of the body during movement, to increase satisfaction with physical activity, and to develop regular exercise. Results: In total, 32 participants completed the intervention. After the intervention, we observed decreases in negative affect, anxiety, and emotional distress, and an increase in dispositional mindfulness. There was no effect on reported healthy eating habits and physical activity habits. Few participants repeated the exercises as recommended. The majority of our participants were new to mindfulness. The majority of our participants reported being satisfied with the different sessions. A few minor difficulties were mentioned, mainly related to the environment in which the participants carried out the sessions. Only 1 session was less satisfactory for one-third of the participants. The session on resistance to unhealthy foods was formulated too strictly and the idea of banning certain foods was a hindrance for one-third of the participants. A reformulation is needed. Conclusions: The mindfulness exercises were well accepted and promoted a state of mindfulness. It would be interesting to provide easier technical access to the exercises via a mobile app so that they can be repeated easily. %M 39405102 %R 10.2196/47251 %U https://formative.jmir.org/2024/1/e47251 %U https://doi.org/10.2196/47251 %U http://www.ncbi.nlm.nih.gov/pubmed/39405102 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e57439 %T Smartphone Screen Time Characteristics in People With Suicidal Thoughts: Retrospective Observational Data Analysis Study %A Karas,Marta %A Huang,Debbie %A Clement,Zachary %A Millner,Alexander J %A Kleiman,Evan M %A Bentley,Kate H %A Zuromski,Kelly L %A Fortgang,Rebecca G %A DeMarco,Dylan %A Haim,Adam %A Donovan,Abigail %A Buonopane,Ralph J %A Bird,Suzanne A %A Smoller,Jordan W %A Nock,Matthew K %A Onnela,Jukka-Pekka %K smartphone %K mobile apps %K mobile health %K screen time %K suicidal thoughts and behavior %K suicidal %K app %K observational data %K data analysis study %K monitor %K survey %K psychiatric %K screen %K mental health %K feasibility %K suicidal ideation %K mobile phone %D 2024 %7 11.10.2024 %9 %J JMIR Mhealth Uhealth %G English %X Background: Smartphone-based monitoring in natural settings provides opportunities to monitor mental health behaviors, including suicidal thoughts and behaviors. To date, most suicidal thoughts and behaviors research using smartphones has primarily relied on collecting so-called “active” data, requiring participants to engage by completing surveys. Data collected passively from smartphone sensors and logs may offer an objectively measured representation of an individual’s behavior, including smartphone screen time. Objective: This study aims to present methods for identifying screen-on bouts and deriving screen time characteristics from passively collected smartphone state logs and to estimate daily smartphone screen time in people with suicidal thinking, providing a more reliable alternative to traditional self-report. Methods: Participants (N=126; median age 22, IQR 16-33 years) installed the Beiwe app (Harvard University) on their smartphones, which passively collected phone state logs for up to 6 months after discharge from an inpatient psychiatric unit (adolescents) or emergency department visit (adults). We derived daily screen time measures from these logs, including screen-on time, screen-on bout duration, screen-off bout duration, and screen-on bout count. We estimated the mean of these measures across age subgroups (adults and adolescents), phone operating systems (Android and iOS), and monitoring stages after the discharge (first 4 weeks vs subsequent weeks). We evaluated the sensitivity of daily screen time measures to changes in the parameters of the screen-on bout identification method. Additionally, we estimated the impact of a daylight time change on minute-level screen time using function-on-scalar generalized linear mixed-effects regression. Results: The median monitoring period was 169 (IQR 42‐169) days. For adolescents and adults, mean daily screen-on time was 254.6 (95% CI 231.4-277.7) and 271.0 (95% CI 252.2-289.8) minutes, mean daily screen-on bout duration was 4.233 (95% CI 3.565-4.902) and 4.998 (95% CI 4.455-5.541) minutes, mean daily screen-off bout duration was 25.90 (95% CI 20.09-31.71) and 26.90 (95% CI 22.18-31.66) minutes, and mean daily screen-on bout count (natural logarithm transformed) was 4.192 (95% CI 4.041-4.343) and 4.090 (95% CI 3.968-4.213), respectively; there were no significant differences between smartphone operating systems (all P values were >.05). The daily measures were not significantly different for the first 4 weeks compared to the fifth week onward (all P values were >.05), except average screen-on bout in adults (P value = .018). Our sensitivity analysis indicated that in the screen-on bout identification method, the cap on an individual screen-on bout duration has a substantial effect on the resulting daily screen time measures. We observed time windows with a statistically significant effect of daylight time change on screen-on time (based on 95% joint confidence intervals bands), plausibly attributable to sleep time adjustments related to clock changes. Conclusions: Passively collected phone logs offer an alternative to self-report measures for studying smartphone screen time characteristics in people with suicidal thinking. Our work demonstrates the feasibility of this approach, opening doors for further research on the associations between daily screen time, mental health, and other factors. %R 10.2196/57439 %U https://mhealth.jmir.org/2024/1/e57439 %U https://doi.org/10.2196/57439 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e55511 %T Predicting the Transition From Depression to Suicidal Ideation Using Facebook Data Among Indian-Bangladeshi Individuals: Protocol for a Cohort Study %A Turjo,Manoshi Das %A Mundada,Khushboo Suchit %A Haque,Nuzhat Jabeen %A Ahmed,Nova %+ North South University, Bashundhara, Dhaka, 1219, Bangladesh, 880 1701754745, manoshi.turjo@northsouth.edu %K human-computer interaction %K depression %K suicidal ideation %K mental health %K India %K Bangladesh %K Facebook %K major depressive disorder %K MDD %K 9-item Patient Health Questionnaire %K PHQ-9 %K natural language processing %K NLP %K machine learning %K ML %D 2024 %7 7.10.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide stands as a global public health concern with a pronounced impact, especially in low- and middle-income countries, where it remains largely unnoticed as a significant health concern, leading to delays in diagnosis and intervention. South Asia, in particular, has seen limited development in this area of research, and applying existing models from other regions is challenging due to cost constraints and the region’s distinct linguistics and behavior. Social media analysis, notably on platforms such as Facebook (Meta Platforms Inc), offers the potential for detecting major depressive disorder and aiding individuals at risk of suicidal ideation. Objective: This study primarily focuses on India and Bangladesh, both South Asian countries. It aims to construct a predictive model for suicidal ideation by incorporating unique, unexplored features along with masked content from both public and private Facebook profiles. Moreover, the research aims to fill the existing research gap by addressing the distinct challenges posed by South Asia’s unique behavioral patterns, socioeconomic conditions, and linguistic nuances. Ultimately, this research strives to enhance suicide prevention efforts in the region by offering a cost-effective solution. Methods: This quantitative research study will gather data through a web-based platform. Initially, participants will be asked a few demographic questions and to complete the 9-item Patient Health Questionnaire assessment. Eligible participants who provide consent will receive an email requesting them to upload a ZIP file of their Facebook data. The study will begin by determining whether Facebook is the primary application for the participants based on their active hours and Facebook use duration. Subsequently, the predictive model will incorporate a wide range of previously unexplored variables, including anonymous postings, and textual analysis features, such as captions, biographic information, group membership, preferred pages, interactions with advertisement content, and search history. The model will also analyze the use of emojis and the types of games participants engage with on Facebook. Results: The study obtained approval from the scientific review committee on October 2, 2023, and subsequently received institutional review committee ethical clearance on December 8, 2023. Our system is anticipated to automatically detect posts related to depression by analyzing the text and use pattern of the individual with the best accuracy possible. Ultimately, our research aims to have practical utility in identifying individuals who may be at risk of depression or in need of mental health support. Conclusions: This initiative aims to enhance engagement in suicidal ideation medical care in South Asia to improve health outcomes. It is set to be the first study to consider predicting participants’ primary social application use before analyzing their content to forecast behavior and mental states. The study holds the potential to revolutionize strategies and offer insights for scalable, accessible interventions while maintaining quality through comprehensive Facebook feature analysis. International Registered Report Identifier (IRRID): DERR1-10.2196/55511 %M 39374059 %R 10.2196/55511 %U https://www.researchprotocols.org/2024/1/e55511 %U https://doi.org/10.2196/55511 %U http://www.ncbi.nlm.nih.gov/pubmed/39374059 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e54751 %T Inclusion of Individuals With Lived Experiences in the Development of a Digital Intervention for Co-Occurring Depression and Cannabis Use: Mixed Methods Investigation %A Collins,Amanda C %A Bhattacharya,Sukanya %A Oh,Jenny Y %A Salzhauer,Abigail %A Taylor,Charles T %A Wolitzky-Taylor,Kate %A Aupperle,Robin L %A Budney,Alan J %A Jacobson,Nicholas C %+ Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, 46 Centerra Pkwy, Suite 300, Lebanon, NH, 03766, United States, 1 4693210607, amanda.c.collins@dartmouth.edu %K digital intervention %K depression %K cannabis use %K positive affect %K formative research %K app development %D 2024 %7 7.10.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Existing interventions for co-occurring depression and cannabis use often do not treat both disorders simultaneously and can result in higher rates of symptom relapse. Traditional in-person interventions are often difficult to obtain due to financial and time limitations, which may further prevent individuals with co-occurring depression and cannabis use from receiving adequate treatment. Digital interventions can increase the scalability and accessibility for these individuals, but few digital interventions exist to treat both disorders simultaneously. Targeting transdiagnostic processes of these disorders with a digital intervention—specifically positive valence system dysfunction—may yield improved access and outcomes. Objective: Recent research has highlighted a need for the inclusion of individuals with lived experiences to assist in the co-design of interventions to enhance scalability and relevance of an intervention. Thus, the purpose of this study is to describe the process of eliciting feedback from individuals with elevated depressed symptoms and cannabis use and co-designing a digital intervention, Amplification of Positivity—Cannabis Use Disorder (AMP-C), focused on improving positive valence system dysfunction in these disorders. Methods: Ten individuals who endorsed moderate to severe depressive symptoms and regular cannabis use (2-3×/week) were recruited online via Meta ads. Using a mixed methods approach, participants completed a 1-hour mixed methods interview over Zoom (Zoom Technologies Inc) where they gave their feedback and suggestions for the development of a mental health app, based on an existing treatment targeting positive valence system dysfunction, for depressive symptoms and cannabis use. The qualitative approach allowed for a broader investigation of participants’ wants and needs regarding the engagement and scalability of AMP-C, and the quantitative approach allowed for specific ratings of intervention components to be potentially included. Results: Participants perceived the 13 different components of AMP-C as overall helpful (mean 3.9-4.4, SD 0.5-1.1) and interesting (mean 4.0-4.9, SD 0.3-1.1) on a scale from 1 (not at all) to 5 (extremely). They gave qualitative feedback for increasing engagement in the app, including adding a social component, using notifications, and being able to track their symptoms and progress over time. Conclusions: This study highlights the importance of including individuals with lived experiences in the development of interventions, including digital interventions. This inclusion resulted in valuable feedback and suggestions for improving the proposed digital intervention targeting the positive valence system, AMP-C, to better match the wants and needs of individuals with depressive symptoms and cannabis use. %M 39374076 %R 10.2196/54751 %U https://formative.jmir.org/2024/1/e54751 %U https://doi.org/10.2196/54751 %U http://www.ncbi.nlm.nih.gov/pubmed/39374076 %0 Journal Article %@ 2564-1891 %I JMIR Publications %V 4 %N %P e58201 %T Detection and Characterization of Online Substance Use Discussions Among Gamers: Qualitative Retrospective Analysis of Reddit r/StopGaming Data %A Le,Nicolette %A McMann,Tiana %A Yang,Luning %A Li,Zhuoran %A Cuomo,Raphael E %A Mackey,Tim K %+ Global Health Program, Department of Anthropology, University of California San Diego, 9500 Gilman Drive, MC: 0505, La Jolla, CA, 92093, United States, 1 9514914161, tmackey@ucsd.edu %K internet gaming disorder %K gaming disorder %K substance use %K alcohol use %K nicotine use %K stimulants %K gaming %K internet gaming %K video games %K addiction %K addiction medicine %K digital mental health %K reddit %D 2024 %7 2.10.2024 %9 Original Paper %J JMIR Infodemiology %G English %X Background: Video games have rapidly become mainstream in recent decades, with over half of the US population involved in some form of digital gaming. However, concerns regarding the potential harms of excessive, disordered gaming have also risen. Internet gaming disorder (IGD) has been proposed as a tentative psychiatric disorder that requires further study by the American Psychological Association (APA) and is recognized as a behavioral addiction by the World Health Organization. Substance use among gamers has also become a concern, with caffeinated or energy drinks and prescription stimulants commonly used for performance enhancement. Objective: This study aimed to identify substance use patterns and health-related concerns among gamers among a population of Reddit users. Methods: We used the public streaming Reddit application programming interface to collect and analyze all posts from the popular subreddit, r/StopGaming. From this corpus of posts, we filtered the dataset for keywords associated with common substances that may be used to enhance gaming performance. We then applied an inductive coding approach to characterize substance use behaviors, gaming genres, and physical and mental health concerns. Potential disordered gaming behavior was also identified using the tentative IGD guidelines proposed by the APA. A chi-square test of independence was used to assess the association between gaming disorder and substance use characteristics, and multivariable logistic regression was used to analyze whether mental health discussion or the mention of any substance with sufficient sample size was significantly associated with IGD. Results: In total, 10,551 posts were collected from Reddit from June 2017 to December 2022. After filtering the dataset for substance-related keywords, 1057 were included for further analysis, of which 286 mentioned both gaming and the use of ≥1 substances. Among the 286 posts that discussed both gaming and substance use, the most mentioned substances were alcohol (n=132), cannabis (n=104), and nicotine (n=48), while the most mentioned genres were role-playing games (n=120), shooters (n=90), and multiplayer online battle arenas (n=43). Self-reported behavior that aligned with the tentative guidelines for IGD was identified in 66.8% (191/286) posts. More than half, 62.9% (180/286) of the posts, discussed a health issue, with the majority (n=144) cited mental health concerns. Common mental health concerns discussed were depression and anxiety. There was a significant association between IGD and substance use (P<.001; chi-square test), and there were significantly increased odds of IGD among those who self-reported substance use (odds ratio 2.29, P<.001) and those who discussed mental health (odds ratio 1.64, P<.03). Conclusions: As gaming increasingly becomes highly prevalent among various age groups and demographics, a better understanding of the interplay and convergence among disordered gaming, substance use, and negative health impacts can inform the development of interventions to mitigate risks and promote healthier gaming habits. %M 39357050 %R 10.2196/58201 %U https://infodemiology.jmir.org/2024/1/e58201 %U https://doi.org/10.2196/58201 %U http://www.ncbi.nlm.nih.gov/pubmed/39357050 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e52130 %T Brief Peer-Supported Web-Based Skills Training in Affective and Interpersonal Regulation (BPS webSTAIR) for Trauma-Exposed Veterans in the Community: Randomized Controlled Trial %A Ong,Laura E %A Speicher,Sarah %A Villasenor,Diana %A Kim,Jamie %A Jacobs,Adam %A Macia,Kathryn S %A Cloitre,Marylene %+ National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Health Care System, 425 First Street, Unit 3004, Palo Alto, CA, 94105, United States, 1 6504935000, Marylene.Cloitre@va.gov %K posttraumatic stress disorder %K PTSD %K depression %K depressive symptoms %K veterans %K veterans health %K mHealth %K mobile health %K peer support %K peer-to-peer %K transdiagnostic %K mental health %K mental health services %K community %K emotion regulation %K interpersonal regulation %K mHealth program %D 2024 %7 2.10.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Peer-supported mobile health (mHealth) programs hold the promise of providing a low-burden approach to increasing access to care and improving mental health. While peer support has been shown to improve engagement in care, there is limited investigation into the impact of peers on symptom outcomes. Trauma-exposed populations frequently endure co-occurring posttraumatic stress and depressive symptoms as well as difficulties in day-to-day functioning. This study evaluated the potential benefits of a peer-supported, transdiagnostic mHealth program on symptom outcomes and functioning. Objective: This randomized controlled trial tested the effectiveness of Brief Peer-Supported (BPS) web-based Skills Training in Affective and Interpersonal Regulation (webSTAIR), a 6-module transdiagnostic digital program derived from Skills Training in Affective and Interpersonal Regulation and compared to waitlist control in a community sample of veterans who screened positive for either posttraumatic stress disorder (PTSD) or depression. Methods: A total of 178 veterans were enrolled in this study using a 2:1 randomization scheme with 117 assigned to BPS webSTAIR and 61 assigned to waitlist control. PTSD and depressive symptoms as well as emotion regulation and psychosocial functioning were assessed at pretreatment, posttreatment, and 8-week follow-up time points. Mixed-effects models were used to assess change in outcome measures across time points. Exploratory analyses were conducted to determine whether the type and number of peer interactions influenced outcomes. Results: Significant interaction effects were observed for all outcomes such that participants randomized to BPS webSTAIR reported significantly greater improvement at the posttreatment time point compared to waitlist control with moderate effect sizes for PTSD (d=0.48), depression (d=0.64), emotion regulation (d=0.61), and functional impairment (d=0.61); gains were maintained at 8-week follow-up. An initial cohort of participants who were required to engage with a peer coach to progress through the modules interacted more frequently with peers but completed fewer modules compared to a later cohort for whom peer engagement was optional. Overall, those who completed more modules reported greater improvement in all outcomes. Conclusions: BPS webSTAIR was effective in improving PTSD and depression symptoms, emotion regulation, and psychosocial functioning in community veterans. Peer-supported, transdiagnostic mHealth programs may be a particularly efficient, effective, and low-burden approach to improving mental health among trauma-exposed populations. Investigation of peer-supported programs among other populations is necessary to evaluate the generalizability of the findings. Analyses comparing peer support that was required versus optional indicated that some veterans may not need or want peer support. Future research should evaluate how best to deliver peer support and for whom it is most beneficial. If successful, peer-supported tech programs may increase the Veteran Affairs workforce as well as improve veteran mental health services and outcomes. Trial Registration: ClinicalTrials.gov NCT04286165; https://clinicaltrials.gov/study/NCT04286165 %M 39012722 %R 10.2196/52130 %U https://www.jmir.org/2024/1/e52130 %U https://doi.org/10.2196/52130 %U http://www.ncbi.nlm.nih.gov/pubmed/39012722 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e56355 %T Self-Care Program as a Tool for Alleviating Anxiety and Loneliness and Promoting Satisfaction With Life in High School Students and Staff: Randomized Survey Study %A Iyer,Priya %A Iyer,Lina %A Carter,Nicole %A Iyer,Ranjani %A Stirling,Amy %A Priya,Lakshmi %A Sriraman,Ushma %+ Department of Education, Heartfulness Institute, 2200 Goldenrod Ln, San Ramon, CA, 94582, United States, 1 2482559635, ranjani.heartfulness@gmail.com %K Heartfulness, anxiety, loneliness, high school, satisfaction with life %K self-care %K develop %K stress %K stress management %K effectiveness %K life satisfaction %K students %K student %K support %K web-based program %K time management %K educational %K mental health %K tool %K tools %D 2024 %7 30.9.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: The COVID-19 global pandemic has led to a marked increase in anxiety levels, significantly affecting the well-being of individuals worldwide. In response to this growing concern, interventions aimed at enhancing social-emotional skills and promoting mental health are more crucial than ever. Objective: This global study aimed to examine the effectiveness of a self-care program on anxiety, loneliness, and satisfaction with life in high school students and staff in a randomized, waitlist control trial with baseline and postintervention assessments. Methods: The 4-week web-based self-care program, offered by the Heartfulness Institute, is designed to develop social-emotional skills through stress management and self-observation. The web-based program was a positive intervention that offered support to the students and staff to build specific skills, such as reflection, observation, positivity, time management, and goal setting. In this study, the sample consisted of a total of 203 high school students and staff randomized into a control waitlisted group (students: n=57 and staff: n=45) and a Heartfulness group (students: n=57 and staff: n=44) from 3 schools. Both the groups completed web-based surveys at weeks 0, 4, and 8, assessing their anxiety, loneliness, and satisfaction with life scores using Generalized Anxiety Disorder-7 Scale (GAD-7 and Severity Measure for Generalized Anxiety Disorder—Child Age 11-17), Satisfaction With Life scale (SWLS) and Satisfaction With Life Scale-Child (SWLS-C), and the University of California, Los Angeles (UCLA) Loneliness Scale. Survey responses were each individually analyzed using repeated measures ANOVA. Results: The study received institutional review board approval on February 3, 2022. Participant recruitment lasted from the approval date until March 30, 2022. The 4-week program for the Heartfulness group started on April 4, 2024. There was a significant 3-way interaction among time, group, and school showing a decrease in anxiety and loneliness scores and an increase in satisfaction-with-life scores (P<.05). In students in the Heartfulness group, there was strong evidence to suggest a significant mean difference in GAD-7, SWLS, and UCLA scores between week 0 and week 4 at all schools (P<.001). In staff in the Heartfulness group, there was strong evidence to suggest a significant mean difference in GAD-7, SWLS, and UCLA scores between week 0 and week 4 at all schools (P<.001). Conclusions: The pandemic brought severe educational and social changes that triggered a decline in mental health in schools. This study showed the effectiveness of noninvasive self-care tools used digitally to significantly decrease anxiety and loneliness scores and increase satisfaction of life scores in the participants. Trial Registration: ClinicalTrials.gov NCT05874232; https://clinicaltrials.gov/ct2/show/NCT05874232 %M 39047180 %R 10.2196/56355 %U https://formative.jmir.org/2024/1/e56355 %U https://doi.org/10.2196/56355 %U http://www.ncbi.nlm.nih.gov/pubmed/39047180 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e55500 %T Digital Psychotherapies for Adults Experiencing Depressive Symptoms: Systematic Review and Meta-Analysis %A Omylinska-Thurston,Joanna %A Aithal,Supritha %A Liverpool,Shaun %A Clark,Rebecca %A Moula,Zoe %A Wood,January %A Viliardos,Laura %A Rodríguez-Dorans,Edgar %A Farish-Edwards,Fleur %A Parsons,Ailsa %A Eisenstadt,Mia %A Bull,Marcus %A Dubrow-Marshall,Linda %A Thurston,Scott %A Karkou,Vicky %+ School of Health and Society, University of Salford, Frederick Road Campus, Broad Street, Manchester, M6 6PU, United Kingdom, 44 0161 295 0000, j.omylinska-thurston1@salford.ac.uk %K digital psychotherapies %K depression %K adults %K systematic review %K meta-analysis %K mobile phone %D 2024 %7 30.9.2024 %9 Review %J JMIR Ment Health %G English %X Background: Depression affects 5% of adults and it is a major cause of disability worldwide. Digital psychotherapies offer an accessible solution addressing this issue. This systematic review examines a spectrum of digital psychotherapies for depression, considering both their effectiveness and user perspectives. Objective: This review focuses on identifying (1) the most common types of digital psychotherapies, (2) clients’ and practitioners’ perspectives on helpful and unhelpful aspects, and (3) the effectiveness of digital psychotherapies for adults with depression. Methods: A mixed methods protocol was developed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search strategy used the Population, Intervention, Comparison, Outcomes, and Study Design (PICOS) framework covering 2010 to 2024 and 7 databases were searched. Overall, 13 authors extracted data, and all aspects of the review were checked by >1 reviewer to minimize biases. Quality appraisal was conducted for all studies. The clients’ and therapists’ perceptions on helpful and unhelpful factors were identified using qualitative narrative synthesis. Meta-analyses of depression outcomes were conducted using the standardized mean difference (calculated as Hedges g) of the postintervention change between digital psychotherapy and control groups. Results: Of 3303 initial records, 186 records (5.63%; 160 studies) were included in the review. Quantitative studies (131/160, 81.8%) with a randomized controlled trial design (88/160, 55%) were most common. The overall sample size included 70,720 participants (female: n=51,677, 73.07%; male: n=16,779, 23.73%). Digital interventions included “stand-alone” or non–human contact interventions (58/160, 36.2%), “human contact” interventions (11/160, 6.8%), and “blended” including stand-alone and human contact interventions (91/160, 56.8%). What clients and practitioners perceived as helpful in digital interventions included support with motivation and accessibility, explanation of task reminders, resources, and learning skills to manage symptoms. What was perceived as unhelpful included problems with usability and a lack of direction or explanation. A total of 80 studies with 16,072 participants were included in the meta-analysis, revealing a moderate to large effect in favor of digital psychotherapies for depression (Hedges g=–0.61, 95% CI –0.75 to –0.47; Z=–8.58; P<.001). Subgroup analyses of the studies with different intervention delivery formats and session frequency did not have a statistically significant effect on the results (P=.48 and P=.97, respectively). However, blended approaches revealed a large effect size (Hedges g=–0.793), while interventions involving human contact (Hedges g=–0.42) or no human contact (Hedges g=–0.40) had slightly smaller effect sizes. Conclusions: Digital interventions for depression were found to be effective regardless of format and frequency. Blended interventions have larger effect size than those involving human contact or no human contact. Digital interventions were helpful especially for diverse ethnic groups and young women. Future research should focus on understanding the sources of heterogeneity based on intervention and population characteristics. Trial Registration: PROSPERO CRD42021238462; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=238462 %M 39348177 %R 10.2196/55500 %U https://mental.jmir.org/2024/1/e55500 %U https://doi.org/10.2196/55500 %U http://www.ncbi.nlm.nih.gov/pubmed/39348177 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e57362 %T The Most Effective Interventions for Classification Model Development to Predict Chat Outcomes Based on the Conversation Content in Online Suicide Prevention Chats: Machine Learning Approach %A Salmi,Salim %A Mérelle,Saskia %A Gilissen,Renske %A van der Mei,Rob %A Bhulai,Sandjai %+ Research Department, 113 Suicide Prevention, Paasheuvelweg 25, Amsterdam, 1105 BP, Netherlands, 31 640673474, s.salmi@113.nl %K suicide %K suicidality %K suicide prevention %K helpline %K suicide helpline %K classification %K interpretable AI %K explainable AI %K conversations %K BERT %K bidirectional encoder representations from transformers %K machine learning %K artificial intelligence %K large language models %K LLM %K natural language processing %D 2024 %7 26.9.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: For the provision of optimal care in a suicide prevention helpline, it is important to know what contributes to positive or negative effects on help seekers. Helplines can often be contacted through text-based chat services, which produce large amounts of text data for use in large-scale analysis. Objective: We trained a machine learning classification model to predict chat outcomes based on the content of the chat conversations in suicide helplines and identified the counsellor utterances that had the most impact on its outputs. Methods: From August 2021 until January 2023, help seekers (N=6903) scored themselves on factors known to be associated with suicidality (eg, hopelessness, feeling entrapped, will to live) before and after a chat conversation with the suicide prevention helpline in the Netherlands (113 Suicide Prevention). Machine learning text analysis was used to predict help seeker scores on these factors. Using 2 approaches for interpreting machine learning models, we identified text messages from helpers in a chat that contributed the most to the prediction of the model. Results: According to the machine learning model, helpers’ positive affirmations and expressing involvement contributed to improved scores of the help seekers. Use of macros and ending the chat prematurely due to the help seeker being in an unsafe situation had negative effects on help seekers. Conclusions: This study reveals insights for improving helpline chats, emphasizing the value of an evocative style with questions, positive affirmations, and practical advice. It also underscores the potential of machine learning in helpline chat analysis. %M 39326039 %R 10.2196/57362 %U https://mental.jmir.org/2024/1/e57362 %U https://doi.org/10.2196/57362 %U http://www.ncbi.nlm.nih.gov/pubmed/39326039 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e56691 %T Long-Term Effects of Internet-Based Cognitive Behavioral Therapy on Depression Prevention Among University Students: Randomized Controlled Factorial Trial %A Nakagami,Yukako %A Uwatoko,Teruhisa %A Shimamoto,Tomonari %A Sakata,Masatsugu %A Toyomoto,Rie %A Yoshida,Kazufumi %A Luo,Yan %A Shiraishi,Nao %A Tajika,Aran %A Sahker,Ethan %A Horikoshi,Masaru %A Noma,Hisashi %A Iwami,Taku %A Furukawa,Toshi A %K iCBT %K depression prevention %K student mental health %K factorial randomized controlled trial %K mobile phone %D 2024 %7 24.9.2024 %9 %J JMIR Ment Health %G English %X Background: Internet-based cognitive behavioral therapy (iCBT) shows promise in the prevention of depression. However, the specific iCBT components that contribute to its effectiveness remain unclear. Objective: We aim to evaluate the effects of iCBT components in preventing depression among university students. Methods: Using a smartphone cognitive behavioral therapy (CBT) app, we randomly allocated university students to the presence or absence of 5 different iCBT components: self-monitoring, behavioral activation, cognitive restructuring, assertiveness training, and problem-solving. The active intervention lasted 8 weeks but the app remained accessible through the follow-up. The primary outcome was the onset of a major depressive episode (MDE) between baseline and the follow-up after 52 weeks, as assessed with the computerized World Health Organization Composite International Diagnostic Interview. Secondary outcomes included changes in the 9-item Patient Health Questionnaire, 7-item General Anxiety Disorder, and CBT Skills Scale. Results: During the 12-month follow-up, 133 of 1301 (10.22%) participants reported the onset of an MDE. There were no significant differences in the incidence of MDEs between the groups with or without each component (hazard ratios ranged from 0.85, 95% CI 0.60‐1.20, for assertiveness training to 1.26, 95% CI 0.88‐1.79, for self-monitoring). Furthermore, there were no significant differences in the changes on the 9-item Patient Health Questionnaire, 7-item General Anxiety Disorder, or for CBT Skills Scale between component allocation groups. However, significant reductions in depression and anxiety symptoms were observed among all participants at the 52-week follow-up. Conclusions: In this study, we could not identify any specific iCBT components that were effective in preventing depression or the acquisition of CBT skills over the 12-month follow-up period, but all participants with and without intervention of each iCBT component demonstrated significant improvements in depressive and anxiety symptoms. Further research is needed to explore the potential impact of frequency of psychological assessments, nonspecific intervention effects, natural change in the mental state, and the baseline depression level. Trial Registration: UMINCTR UMIN000031307; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000035735 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-018-2719-z %R 10.2196/56691 %U https://mental.jmir.org/2024/1/e56691 %U https://doi.org/10.2196/56691 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e53101 %T Dose-Response Associations of Internet Use Time and Internet Addiction With Depressive Symptoms Among Chinese Children and Adolescents: Cross-Sectional Study %A Li,Juanjuan %A Sun,Weidi %A Luo,Zeyu %A Liu,Yi %A Huang,Xuanyin %A Jiang,Denan %A Li,Shuting %A Meng,Jia %A Gu,Fang %A Zhang,Ronghua %A Song,Peige %K internet use %K internet addiction %K depression %K children %K adolescents %K China %K depressive symptoms %D 2024 %7 23.9.2024 %9 %J JMIR Public Health Surveill %G English %X Background: Children’s lives are increasingly mediated by digital technologies, yet evidence regarding the associations between internet use and depression is far from comprehensive and remains unclear. Objective: This study aimed to investigate the dose-response association between internet use, including use time and addiction behaviors, and depressive symptoms among children and adolescents in Zhejiang Province. Methods: Data were collected from a school-based health survey China Common Disease and Risk Factor Surveillance Among Students, encompassing 21,336 students in Zhejiang Province. The daily internet use time, internet addiction (IA) behaviors, and depressive symptoms were assessed with questionnaires. Logistic regression models were used to explore the associations of internet use time and IA behaviors with depressive symptoms among children and adolescents. Restricted cubic spline curves were used to determine the dose-response associations. Results: A total of 6225 (29.2%) students had depressive symptoms. Compared to those reporting no internet use, boys using the internet for >2 hours/day (odds ratio [OR] 1.53, 95% CI 1.34‐1.74) and girls using internet for 1.1‐2 hours/day (OR 1.22, 95% CI 1.06‐1.39) and >2 hours/day (OR 1.70, 95% CI 1.50‐1.93) were at higher risks of depressive symptoms. A significant J-shaped association was identified between internet use time and depressive symptoms among children and adolescents, especially in boys and primary school students (nonlinear P values were .006, .003, and <.001, respectively). Increased IA behaviors were associated with a higher odd of depressive symptoms (1 IA behavior: OR 2.01, 95% CI 1.83‐2.21; 2 IA behaviors: 2.91, 95% CI 2.57‐3.29; and ≥3 IA behaviors: 4.72, 95% CI 4.26‐5.22). A positive nonlinear association between the number of IA behaviors and depressive symptoms was found in total population, girls, and primary school students (nonlinear P values were .02, .002, .007, respectively). Conclusions: Findings suggested that excessive internet use time and IA behaviors were significantly associated with an increased risk of depressive symptoms, highlighting the importance of interventions to regulate and educate about adequate internet use during childhood and adolescence. %R 10.2196/53101 %U https://publichealth.jmir.org/2024/1/e53101 %U https://doi.org/10.2196/53101 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e58162 %T Talk Time Differences Between Interregional and Intraregional Calls to a Crisis Helpline: Statistical Analysis %A Turkington,Robin %A Potts,Courtney %A Mulvenna,Maurice %A Bond,Raymond %A O'Neill,Siobhán %A Ennis,Edel %A Hardcastle,Katie %A Scowcroft,Elizabeth %A Moore,Ciaran %A Hamra,Louise %K crisis helplines %K call duration %K mental health %K suicide %K suicidal %K suicide prevention %K population-based %K help-seeking behavior %K Samaritans %K UK %K telephony %K telephone %K telephones %K one-way analysis %K call %K calls %K talk time %K support %K talk time differences %D 2024 %7 19.9.2024 %9 %J JMIR Ment Health %G English %X Background: National suicide prevention strategies are general population-based approaches to prevent suicide by promoting help-seeking behaviors and implementing interventions. Crisis helplines are one of the suicide prevention resources available for public use, where individuals experiencing a crisis can talk to a trained volunteer. Samaritans UK operates on a national scale, with a number of branches located within each of the United Kingdom’s 4 countries or regions. Objectives: The aim of this study was to identify any differences in call duration across the helpline service in order to determine whether service varied interregionally and intraregionally and to determine the impact of calls answered in the same region as the caller, compared with calls answered in a different region on the duration of calls made from landlines to Samaritans UK. Methods: Calls may be routed by Samaritans, wherein the telephony system sends the call to the next available volunteer, irrespective of location; therefore, individuals may be routed to a branch within the same region as the caller’s current region (intraregional calls) or routed to a branch that is in a different region from that of the caller’s current region (interregional calls). The origin of calls by region was identified using the landline prefix of the anonymized caller identifier, along with the region of the destination branch (as branch details are recorded in the call details record). First, a Levene’s test of homogeneity of variance was carried out for each condition, that is, England calls and Scotland calls. Thereafter, for each condition, a one-way ANOVA or one-way analysis of means was carried out to evaluate any significant differences in call duration. Results: ANOVA results showed that there are significant differences in call durations between intraregional calls and interregional calls (P<.001). Across all conditions within this study, callers stayed on the phone for a shorter period of time when routed to a branch that is within the same region as the call origin than if they were put through to a branch within a different region than the call origin. Conclusions: Statistical analyses showed that there were significant differences between interregional and intraregional calls. On average, callers to crisis helplines stayed on the phone for a shorter period of time if they were routed to a branch within the same region in which the call originated than if they were routed to a branch in a different region of origin. The findings from this study have practical applications, which may allow crisis helplines to manage their resources more effectively and improve caller satisfaction with the service. %R 10.2196/58162 %U https://mental.jmir.org/2024/1/e58162 %U https://doi.org/10.2196/58162 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e48439 %T Association Between Internet Gaming Disorder and Suicidal Ideation Mediated by Psychosocial Resources and Psychosocial Problems Among Adolescent Internet Gamers in China: Cross-Sectional Study %A Yu,Yanqiu %A Wu,Anise M S %A Fong,Vivian W I %A Zhang,Jianxin %A Li,Ji-bin %A Lau,Joseph T F %+ Public Mental Health Center, School of Mental Health, Wenzhou Medical University, Ouhai District, Wenzhou, 325000, China, 86 57786689810, jlau@cuhk.edu.hk %K internet gaming disorder %K suicidal ideation %K adolescents %K mediation %K structural equation modelling %K resilience %K loneliness %K social support %K social anxiety %D 2024 %7 19.9.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Adolescent internet gaming disorder (IGD) was associated with severe harm, including suicidal ideation. While suicidal ideation was predictive of completed suicides, further research is required to clarify the association between IGD and suicidal ideation among adolescents, as well as the mechanisms involved. Objective: This study aimed to investigate the understudied association between IGD and suicidal ideation, as well as novel mechanisms associated with it, among Chinese adolescent internet gamers through psychosocial coping resources and psychosocial problems. Methods: An anonymous, self-administered, cross-sectional survey was conducted among secondary school students who had played internet games in the past year in Guangzhou and Chengdu, China (from October 2019 to January 2020). In total, 1693 adolescent internet gamers were included in this study; the mean age was 13.48 (SD 0.80) years, and 60% (n=1016) were males. IGD was assessed by the 9-item Internet Gaming Disorder Checklist of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]), while a single item assessed suicidal ideation: “Have you ever considered committing suicide in the past 12 months?” Univariate and multivariate logistic regression associations were conducted to test the significance and directions of the potential factors for suicidal ideation. The mediation mechanism was examined by structural equation modeling. Results: Among all participants, the prevalence of IGD and suicidal ideation was 16.95% (287/1693) and 43.06% (729/1693), respectively. IGD cases were 2.42 times more likely than non-IGD cases to report suicidal ideation (adjusted odds ratio [OR] 2.42, 95% CI 1.73-3.37). Other significant factors of suicidal ideation included psychosocial coping resources (resilience and social support, both adjusted OR 0.97, 95% CI 0.96-0.98) and psychosocial problems (social anxiety: adjusted OR 1.07, 95% CI 1.05-1.09; loneliness, adjusted OR 1.13, 95% CI 1.10-1.16). The association between IGD and suicidal ideation was partially mediated by 3 indirect paths, including (1) the 2-step path that IGD reduced psychosocial coping resources, which in turn increased suicidal ideation; (2) the 2-step path that IGD increased psychosocial problems, which in turn increased suicidal ideation; and (3) the 3-step path that IGD reduced psychosocial coping resources which then increased psychosocial problems, which in turn increased suicidal ideation, with effect sizes of 10.7% (indirect effect/total effect: 0.016/0.15), 30.0% (0.05/0.15), and 13.3% (0.02/0.15), respectively. The direct path remained statistically significant. Conclusions: IGD and suicidal ideation were alarmingly prevalent. Evidently and importantly, IGD was a significant risk factor for suicidal ideation. The association was partially explained by psychosocial coping resources of resilience and social support and psychosocial problems of social anxiety and loneliness. Longitudinal studies are needed to confirm the findings. Pilot randomized controlled trials are recommended to evaluate the effectiveness of interventions in reducing suicidal ideation by reducing IGD, improving psychosocial coping resources, and reducing psychosocial problems investigated in this study. %M 39298753 %R 10.2196/48439 %U https://games.jmir.org/2024/1/e48439 %U https://doi.org/10.2196/48439 %U http://www.ncbi.nlm.nih.gov/pubmed/39298753 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e51366 %T Engagement, Acceptability, and Effectiveness of the Self-Care and Coach-Supported Versions of the Vira Digital Behavior Change Platform Among Young Adults at Risk for Depression and Obesity: Pilot Randomized Controlled Trial %A Weiner,Lauren S %A Crowley,Ryann N %A Sheeber,Lisa B %A Koegler,Frank H %A Davis,Jon F %A Wells,Megan %A Funkhouser,Carter J %A Auerbach,Randy P %A Allen,Nicholas B %+ Ksana Health, 2288 Alder Street, Eugene, OR, 97405, United States, 1 541 912 2883, lauren.weiner@ksanahealth.com %K depression %K behavioral activation %K digital health %K mental health %K behavior change %K mobile sensing %K anxiety %K health coaching %K mobile phone %D 2024 %7 19.9.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Adolescence and early adulthood are pivotal stages for the onset of mental health disorders and the development of health behaviors. Digital behavioral activation interventions, with or without coaching support, hold promise for addressing risk factors for both mental and physical health problems by offering scalable approaches to expand access to evidence-based mental health support. Objective: This 2-arm pilot randomized controlled trial evaluated 2 versions of a digital behavioral health product, Vira (Ksana Health Inc), for their feasibility, acceptability, and preliminary effectiveness in improving mental health in young adults with depressive symptoms and obesity risk factors. Methods: A total of 73 participants recruited throughout the United States were randomly assigned to use Vira either as a self-guided product (Vira Self-Care) or with support from a health coach (Vira+Coaching) for 12 weeks. The Vira smartphone app used passive sensing of behavioral data related to mental health and obesity risk factors (ie, activity, sleep, mobility, and language patterns) and offered users personalized insights into patterns of behavior associated with their daily mood. Participants completed self-reported outcome measures at baseline and follow-up (12 weeks). All study procedures were completed via digital communications. Results: Both versions of Vira showed strong user engagement, acceptability, and evidence of effectiveness in improving mental health and stress. However, users receiving coaching exhibited more sustained engagement with the platform and reported greater reductions in depression (Cohen d=0.45, 95% CI 0.10-0.82) and anxiety (Cohen d=0.50, 95% CI 0.13-0.86) compared to self-care users. Both interventions also resulted in reduced stress (Vira+Coaching: Cohen d=–1.05, 95% CI –1.57 to –-0.50; Vira Self-Care: Cohen d=–0.78, 95% CI –1.33 to –0.23) and were perceived as useful and easy to use. Coached users also reported reductions in sleep-related impairment (Cohen d=–0.51, 95% CI –1.00 to –0.01). Moreover, participants increased their motivation for and confidence in making behavioral changes, with greater improvements in confidence among coached users. Conclusions: An app-based intervention using passive mobile sensing to track behavior and deliver personalized insights into behavior-mood associations demonstrated feasibility, acceptability, and preliminary effectiveness for reducing depressive symptoms and other mental health problems in young adults. Future directions include (1) optimizing the interventions, (2) conducting a fully powered trial that includes an active control condition, and (3) testing mediators and moderators of outcome effects. Trial Registration: ClinicalTrials.gov NCT05638516; https://clinicaltrials.gov/study/NCT05638516 %M 39298763 %R 10.2196/51366 %U https://mental.jmir.org/2024/1/e51366 %U https://doi.org/10.2196/51366 %U http://www.ncbi.nlm.nih.gov/pubmed/39298763 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e54617 %T Using Large Language Models to Detect Depression From User-Generated Diary Text Data as a Novel Approach in Digital Mental Health Screening: Instrument Validation Study %A Shin,Daun %A Kim,Hyoseung %A Lee,Seunghwan %A Cho,Younhee %A Jung,Whanbo %+ Department of Psychiatry, Anam Hospital, Korea University, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea, 82 1093649735, rune1018@gmail.com %K depression %K screening %K artificial intelligence %K digital health technology %K text data %D 2024 %7 18.9.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Depressive disorders have substantial global implications, leading to various social consequences, including decreased occupational productivity and a high disability burden. Early detection and intervention for clinically significant depression have gained attention; however, the existing depression screening tools, such as the Center for Epidemiologic Studies Depression Scale, have limitations in objectivity and accuracy. Therefore, researchers are identifying objective indicators of depression, including image analysis, blood biomarkers, and ecological momentary assessments (EMAs). Among EMAs, user-generated text data, particularly from diary writing, have emerged as a clinically significant and analyzable source for detecting or diagnosing depression, leveraging advancements in large language models such as ChatGPT. Objective: We aimed to detect depression based on user-generated diary text through an emotional diary writing app using a large language model (LLM). We aimed to validate the value of the semistructured diary text data as an EMA data source. Methods: Participants were assessed for depression using the Patient Health Questionnaire and suicide risk was evaluated using the Beck Scale for Suicide Ideation before starting and after completing the 2-week diary writing period. The text data from the daily diaries were also used in the analysis. The performance of leading LLMs, such as ChatGPT with GPT-3.5 and GPT-4, was assessed with and without GPT-3.5 fine-tuning on the training data set. The model performance comparison involved the use of chain-of-thought and zero-shot prompting to analyze the text structure and content. Results: We used 428 diaries from 91 participants; GPT-3.5 fine-tuning demonstrated superior performance in depression detection, achieving an accuracy of 0.902 and a specificity of 0.955. However, the balanced accuracy was the highest (0.844) for GPT-3.5 without fine-tuning and prompt techniques; it displayed a recall of 0.929. Conclusions: Both GPT-3.5 and GPT-4.0 demonstrated relatively reasonable performance in recognizing the risk of depression based on diaries. Our findings highlight the potential clinical usefulness of user-generated text data for detecting depression. In addition to measurable indicators, such as step count and physical activity, future research should increasingly emphasize qualitative digital expression. %M 39292502 %R 10.2196/54617 %U https://www.jmir.org/2024/1/e54617 %U https://doi.org/10.2196/54617 %U http://www.ncbi.nlm.nih.gov/pubmed/39292502 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e45530 %T Messenger Use and Video Calls as Correlates of Depressive and Anxiety Symptoms: Results From the Corona Health App Study of German Adults During the COVID-19 Pandemic %A Edler,Johanna-Sophie %A Terhorst,Yannik %A Pryss,Rüdiger %A Baumeister,Harald %A Cohrdes,Caroline %+ Mental Health Research Unit, Department of Epidemiology and Health Monitoring, Robert Koch Institute, PO Box 650261, Berlin, 12101, Germany, 49 30187542692, cohrdesc@rki.de %K passive data %K depression %K anxiety %K predicting mental health %K mobile phone %D 2024 %7 16.9.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Specialized studies have shown that smartphone-based social interaction data are predictors of depressive and anxiety symptoms. Moreover, at times during the COVID-19 pandemic, social interaction took place primarily remotely. To appropriately test these objective data for their added value for epidemiological research during the pandemic, it is necessary to include established predictors. Objective: Using a comprehensive model, we investigated the extent to which smartphone-based social interaction data contribute to the prediction of depressive and anxiety symptoms, while also taking into account well-established predictors and relevant pandemic-specific factors. Methods: We developed the Corona Health App and obtained participation from 490 Android smartphone users who agreed to allow us to collect smartphone-based social interaction data between July 2020 and February 2021. Using a cross-sectional design, we automatically collected data concerning average app use in terms of the categories video calls and telephony, messenger use, social media use, and SMS text messaging use, as well as pandemic-specific predictors and sociodemographic covariates. We statistically predicted depressive and anxiety symptoms using elastic net regression. To exclude overfitting, we used 10-fold cross-validation. Results: The amount of variance explained (R2) was 0.61 for the prediction of depressive symptoms and 0.57 for the prediction of anxiety symptoms. Of the smartphone-based social interaction data included, only messenger use proved to be a significant negative predictor of depressive and anxiety symptoms. Video calls were negative predictors only for depressive symptoms, and SMS text messaging use was a negative predictor only for anxiety symptoms. Conclusions: The results show the relevance of smartphone-based social interaction data in predicting depressive and anxiety symptoms. However, even taken together in the context of a comprehensive model with well-established predictors, the data only add a small amount of value. %M 39283658 %R 10.2196/45530 %U https://www.jmir.org/2024/1/e45530 %U https://doi.org/10.2196/45530 %U http://www.ncbi.nlm.nih.gov/pubmed/39283658 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e52293 %T A Suicide Prevention Digital Technology for Individuals Experiencing an Acute Suicide Crisis in Emergency Departments: Naturalistic Observational Study of Real-World Acceptability, Feasibility, and Safety %A Dimeff,Linda A %A Koerner,Kelly %A Heard,Kandi %A Ruork,Allison K %A Kelley-Brimer,Angela %A Witterholt,Suzanne T %A Lardizabal,Mary Beth %A Clubb,Joseph R %A McComish,Julie %A Waghray,Arpan %A Dowdy,Roger %A Asad-Pursley,Sara %A Ilac,Maria %A Lawrence,Hannah %A Zhou,Frank %A Beadnell,Blair %+ Evidence-Based Practice Institute, 9450 SW Gemini Dr, PMB 68735, Beaverton, OR, 97008-7105, United States, 1 253 765 0455, linda.dimeff@jasprhealth.com %K suicide %K emergency department %K ED %K digital technology %K suicide prevention best practices %K individual %K particular %K suicide prevention %K evidence-based intervention %K Emergency department %K hospital %K vulnerable population %K Jaspr Health %K psychiatric %K psychiatrist %K care %K safety %D 2024 %7 16.9.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Emergency departments (EDs) are the front line in providing suicide care. Expert consensus recommends the delivery of several suicide prevention evidence-based interventions for individuals with acute suicidal ideation in the ED. ED personnel demands and staff shortages compromise delivery and contribute to long wait times and unnecessary hospitalization. Digital technologies can play an important role in helping EDs deliver suicide care without placing further demands on the care team if their use is safe to patients in a routine care context. Objective: This study evaluates the safety and effectiveness of an evidence-based digital technology (Jaspr Health) designed for persons with acute suicidal ideation seeking psychiatric crisis ED services when used as part of routine ED-based suicide care. This study deployed Jaspr Health for real-world use in 2 large health care systems in the United States and aimed to evaluate (1) how and whether Jaspr Health could be safely and effectively used outside the context of a researcher-facilitated clinical trial, and (2) that Jaspr’s use would be associated with improved patient agitation and distress. Methods: Under the auspices of a nonsignificant risk device study, ED patients with acute suicidal ideation (N=962) from 2 health care systems representing 10 EDs received access to Jaspr Health as part of their routine suicide care. Primary outcome measures included how many eligible patients were assigned Jaspr Health, which modules were assigned and completed, and finally, the number of adverse events reported by patients or by medical staff. Secondary outcome measures were patient agitation, distress, and satisfaction. Results: The most frequent modules assigned were Comfort and Skills (98% of users; n=942) and lethal means assessment (90% of patient users; n=870). Patient task completion rates for all modules ranged from 51% to 79%. No adverse events were reported, suggesting that digital technologies can be safely used for people seeking ED-based psychiatric services. Statistically significant (P<.001) reductions in agitation and distress were reported after using the app. Average patient satisfaction ratings by site were 7.81 (SD 2.22) and 7.10 (SD 2.65), with 88.8% (n=325) and 84% (n=90) of patients recommending the app to others. Conclusions: Digital technologies such as Jaspr Health may be safely and effectively integrated into existing workflows to help deliver evidence-based suicide care in EDs. These findings hold promise for the use of digital technologies in delivering evidence-based care to other vulnerable populations in complex environments. %M 39283664 %R 10.2196/52293 %U https://formative.jmir.org/2024/1/e52293 %U https://doi.org/10.2196/52293 %U http://www.ncbi.nlm.nih.gov/pubmed/39283664 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e44368 %T Psychological Health and Wellness and the Impact of a Supportive Text Messaging Program (Wellness4MDs) Among Physicians and Medical Learners in Canada: Protocol for a Longitudinal Study %A Shalaby,Reham %A Agyapong,Belinda %A Dias,Raquel %A Obuobi-Donkor,Gloria %A Adu,Medard K %A Spicer,Sharron %A Yanchar,Natalie L %A Agyapong,Vincent I O %+ Department of Psychiatry, Faculty of Medicine, Dalhousie University, 5909 Veterans Memorial Lane, 8th Floor, Abbie J. Lane Memorial Building QEII Health Sciences Centre, Halifax, NS, B3H 2E2, Canada, 1 780 215 7771, agyapong@ualberta.ca %K wellness %K doctors %K Canada %K depression %K burnout %K anxiety %K supportive text messages %K eHealth %D 2024 %7 16.9.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Burnout, anxiety, and depression continue to affect physicians, postgraduate medical trainees, and medical students globally and in Canada particularly after the COVID-19 pandemic. Objective: The primary goal of this project is to design, implement, monitor, and evaluate a daily supportive SMS text messaging program (Wellness4MDs, Global Psychological e-Health Foundation). The program aims to reduce the prevalence and severity of burnout, anxiety, and depression symptoms among physicians, postgraduate medical trainees, and medical students in Canada. Methods: This longitudinal study represents a multistakeholder, mixed methods, multiyear implementation science project. Project evaluation will be conducted through a quantitative prospective longitudinal approach using a paired sample comparison, a naturalistic cross-sectional controlled design, and satisfaction surveys. Prevalence estimates for psychological problems would be based on baseline data from self-completed validated rating scales. Additional data will be collected at designated time points for paired comparison. Outcome measures will be assessed using standardized rating scales, including the Maslach Burnout Inventory for burnout symptoms, the 9-item Patient Health Questionnaire for depression symptoms, the 7-item Generalized Anxiety Disorder scale for anxiety symptoms, and the World Health Organization–Five Well-Being Index. Results: The project launched in the last quarter of 2023, and program evaluation results will become available within 36 months. The Wellness4MDs program is expected to reduce the prevalence and severity of psychological problems among physicians in Canada and achieve high subscriber satisfaction. Conclusions: The results from the Wellness4MDs project evaluation will provide key information regarding the effectiveness of daily supportive SMS text messages and links to mental health resources on these mental health parameters in Canadian physicians, postgraduate trainees, and medical students. Information will be useful for informing policy and decision-making concerning psychological interventions for physicians in Canada. International Registered Report Identifier (IRRID): PRR1-10.2196/44368 %M 39283660 %R 10.2196/44368 %U https://www.researchprotocols.org/2024/1/e44368 %U https://doi.org/10.2196/44368 %U http://www.ncbi.nlm.nih.gov/pubmed/39283660 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e58791 %T Digital Interventions for Reducing Loneliness and Depression in Korean College Students: Mixed Methods Evaluation %A Kang,Boyoung %A Hong,Munpyo %+ Sungkyunkwan University, 25-2, Sungkyunkwan-ro, Jongno-gu, Seoul, 03063, Republic of Korea, 82 2 740 1770, bykang2015@gmail.com %K loneliness %K depression %K digital interventions %K college students %K mental health %K mixed methods evaluation %K Woebot %K Happify %D 2024 %7 12.9.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: The COVID-19 pandemic has exacerbated the prevalence of loneliness and depression among college students. Digital interventions, such as Woebot (Woebot Health, Inc) and Happify (Twill Inc), have shown promise in alleviating these symptoms. Objective: This study aims to investigate the effectiveness and acceptability of Woebot and Happify in reducing loneliness and depression among college students after the COVID-19 pandemic. Methods: A mixed methods approach was used over 4 months. A total of 63 participants aged 18 to 27 years from Sungkyunkwan University in Seoul, South Korea, were initially recruited, with an inclusion criterion of University of California, Los Angeles (UCLA) Loneliness Scale score ≥34. The final sample consisted of 27 participants due to attrition. Participants were randomly assigned to Woebot (15/27, 55%); Happify (9/27, 33%); or a control group using Bondee (Metadream), a metaverse social network messenger app (3/27, 11%). Quantitative measures (UCLA Loneliness Scale and Patient Health Questionnaire-9) and qualitative assessments (user feedback and focused interviews) were used. Results: Although mean decreases in loneliness and depression were observed in the control and intervention groups after the intervention, the differences between the control and intervention groups were not statistically significant (UCLA Loneliness: P=.67; Patient Health Questionnaire-9: P=.35). Qualitative data indicated user satisfaction, with suggestions for improved app effectiveness and personalization. Conclusions: Despite limitations, this study highlights the potential of well-designed digital interventions in alleviating college students’ loneliness and depression. The findings contribute to the growing body of research on accessible digital mental health tools and underscore the importance of comprehensive support systems. Further research with larger and more diverse samples is needed to better understand the effectiveness and optimization of such interventions. Trial Registration: Clinical Research Information Service KCT0009449; https://bit.ly/4d2e4Bu %M 39264705 %R 10.2196/58791 %U https://formative.jmir.org/2024/1/e58791 %U https://doi.org/10.2196/58791 %U http://www.ncbi.nlm.nih.gov/pubmed/39264705 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e57343 %T Community Health Workers as Mental Health Paraprofessionals: Protocol for a Mixed-Methods Pilot Feasibility Study %A Moyce,Sally %A Crawford,Cassidy %+ College of Health and Human Development, Montana State University, PO Box 173560, Bozeman, MT, 59717, United States, 1 970 846 8424, cassacrawford8@gmail.com %K behavioral activation %K community health workers %K implementation science %K Latino %K mental health provider shortage area %K pilot study %K evidence-based treatments %D 2024 %7 12.9.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Community health workers (CHWs) are effective in delivering behavioral activation (BA), especially in low-resource settings. In an area with a lack of Spanish-speaking mental health counselors, such as southwest Montana, CHWs can provide needed care. Objective: The goal of this pilot study protocol is to test the feasibility, acceptability, and preliminary efficacy of a model of care that engages CHWs as providers of BA. Methods: We will train 2 CHWs in BA methodology. We will enroll 20 participants who screen positive for depression in a 12-week telephone intervention for BA. Preliminary efficacy will be tested in pre- and postscores of the Beck Depression Inventory and semistructured interviews. Feasibility and acceptability will be measured through participant retention and treatment adherence. The Therapeutic Alliance with Clinician Scale will be used to measure the strength of the therapeutic relationship. Descriptive statistics will measure alliances and repeated measures ANOVA will measure trends and changes in depression scores. Results: Enrollment began in October 2023. A total of 12 participants completed at least 10 BA sessions and all study measures by the time the study concluded in May 2024. In August 2024, data analysis occurred with an anticipated manuscript to be submitted for publication in October 2024. Conclusions: Results from this study will inform future studies into the implementation of an evidence-based mental health intervention in a limited resource setting for Latino people with limited English proficiency. International Registered Report Identifier (IRRID): DERR1-10.2196/57343 %M 39264699 %R 10.2196/57343 %U https://www.researchprotocols.org/2024/1/e57343 %U https://doi.org/10.2196/57343 %U http://www.ncbi.nlm.nih.gov/pubmed/39264699 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e54005 %T Assessment of a Pilot Program for Remote Support on Mental Health for Young Physicians in Rural Settings in Peru: Mixed Methods Study %A De la Cruz-Torralva,Kelly %A Escobar-Agreda,Stefan %A Riega López,Pedro %A Amaro,James %A Reategui-Rivera,C Mahony %A Rojas-Mezarina,Leonardo %+ Unidad de Telesalud, Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Av Grau 755, Cercado de Lima, 15001, Peru, 51 619 7000 ext 4650, priegal@unmsm.edu.pe %K telemedicine %K screening %K treatment %K mental health %K suicide %K depression %K anxiety %K alcoholism %K physicians %K rural areas %K Peru %D 2024 %7 10.9.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Telemedicine-based interventions show promise in addressing mental health issues among rural populations, yet evidence regarding their impact among the health care workforce in these contexts remains limited. Objective: This study aimed to evaluate the characteristics and the responses and perceptions of recently graduated physicians who work in rural areas of Peru as part of the Servicio Rural Urbano Marginal en Salud (Rural-Urban Marginal Health Service [SERUMS], in Spanish) toward a telehealth intervention to provide remote orientation and accompaniment in mental health. Methods: A mixed methods study was carried out involving physicians who graduated from the Universidad Nacional Mayor de San Marcos and participated in the Mental Health Accompaniment Program (MHAP) from August 2022 to February 2023. This program included the assessment of mental health conditions via online forms, the dissemination of informational materials through a website, and, for those with moderate or high levels of mental health issues, the provision of personalized follow-up by trained personnel. Quantitative analysis explored the mental health issues identified among physicians, while qualitative analysis, using semistructured interviews, examined their perceptions of the services provided. Results: Of 75 physicians initially enrolled to the MHAP, 30 (41.6%) opted to undergo assessment and use the services. The average age of the participants was 26.8 (SD 1.9) years, with 17 (56.7%) being female. About 11 (36.7%) reported have current or previous mental health issues, 17 (56.7%) indicating some level of depression, 14 (46.7%) indicated some level of anxiety, 5 (16.6%) presenting a suicidal risk, and 2 (6.7%) attempted suicide during the program. Physicians who did not use the program services reported a lack of advertising and related information, reliance on personal mental health resources, or neglect of symptoms. Those who used the program expressed a positive perception regarding the services, including evaluation and follow-up, although some faced challenges accessing the website. Conclusions: The MHAP has been effective in identifying and managing mental health problems among SERUMS physicians in rural Peru, although it faced challenges related to access and participation. The importance of mental health interventions in this context is highlighted, with recommendations to improve accessibility and promote self-care among participants. %M 39255480 %R 10.2196/54005 %U https://formative.jmir.org/2024/1/e54005 %U https://doi.org/10.2196/54005 %U http://www.ncbi.nlm.nih.gov/pubmed/39255480 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e56650 %T Digital Mental Health Interventions for Alleviating Depression and Anxiety During Psychotherapy Waiting Lists: Systematic Review %A Huang,Sijia %A Wang,Yiyue %A Li,Gen %A Hall,Brian J %A Nyman,Thomas J %+ School of Psychology and Clinical Language Sciences, University of Reading, Earley, Reading, RG6 6ET, United Kingdom, 44 1189875123, t.nyman@reading.ac.uk %K digital health %K digital technology %K digital intervention %K digital interventions %K waiting list %K digital mental health intervention %K DMHI %K digital mental health interventions %K DMHIs %K digital mental health %K mental health intervention %K mental health interventions %K mental health %K mental illness %K mental disease %K mental diseases %K mental illnesses %K depression %K depressed %K major depressive disorder %K MDD %K depressive disorder %K depressive %K anxiety %K anxious %K self-guided %K self-guidance %K self-mediated %K self-mediation %K systematic review %K systematic reviews %K mood disorder %K therapy %K tele-therapy %K web-based therapy %D 2024 %7 10.9.2024 %9 Review %J JMIR Ment Health %G English %X Background: Depression and anxiety have become increasingly prevalent across the globe. The rising need for treatment and the lack of clinicians has resulted in prolonged waiting times for patients to receive their first session. Responding to this gap, digital mental health interventions (DMHIs) have been found effective in treating depression and anxiety and are potentially promising pretreatments for patients who are awaiting face-to-face psychotherapy. Nevertheless, whether digital interventions effectively alleviate symptoms for patients on waiting lists for face-to-face psychotherapy remains unclear. Objective: This review aimed to synthesize the effectiveness of DMHIs for relieving depression and anxiety symptoms of patients on waiting lists for face-to-face therapy. This review also investigated the features, perceived credibility, and usability of DMHIs during waiting times. Methods: In this systematic review, we searched PubMed, PsycINFO, Cochrane, and Web of Science for research studies investigating the effectiveness of DMHIs in reducing either depression or anxiety symptoms among individuals waiting for face-to-face psychotherapy. The search was conducted in June 2024, and we have included the studies that met the inclusion criteria and were published before June 6, 2024. Results: Of the 9267 unique records identified, 8 studies met the eligibility criteria and were included in the systematic review. Five studies were randomized controlled trials (RCTs), and 3 studies were not. Among the RCTs, we found that digital interventions reduced depression and anxiety symptoms, but the majority of interventions were not more effective compared to the control groups where participants simply waited or received a self-help book. For the non-RCTs, the interventions also reduced symptoms, but without control groups, the interpretation of the findings is limited. Finally, participants in the included studies perceived the digital interventions to be credible and useful, but high dropout rates raised concerns about treatment adherence. Conclusions: Due to the lack of effective interventions among the reviewed studies, especially among the RCTs, our results suggest that waiting list DMHIs are not more effective compared to simply waiting or using a self-help book. However, more high-quality RCTs with larger sample sizes are warranted in order to draw a more robust conclusion. Additionally, as this review revealed concerns regarding the high dropout rate in digital interventions, future studies could perhaps adopt more personalized and human-centered functions in interventions to increase user engagement, with the potential to increase treatment adherence and effectiveness. %M 39255015 %R 10.2196/56650 %U https://mental.jmir.org/2024/1/e56650 %U https://doi.org/10.2196/56650 %U http://www.ncbi.nlm.nih.gov/pubmed/39255015 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e59003 %T Comparing Email Versus Text Messaging as Delivery Platforms for Supporting Patients With Major Depressive Disorder: Noninferiority Randomized Controlled Trial %A Adu,Medard K %A Eboreime,Oghenekome %A Shalaby,Reham %A Eboreime,Ejemai %A Agyapong,Belinda %A da Luz Dias,Raquel %A Sapara,Adegboyega O %A Agyapong,Vincent I O %+ Department of Psychiatry, Faculty of Medicine, Dalhousie University, 5909 Veterans Memorial Lane, 8th Floor, Abbie J Lane Memorial Building, QEII Health Sciences Centre, Halifax, NS, B3H 2E2, Canada, 1 17802157771, vn602367@dal.ca %K major depressive disorder %K Text4Support %K SMS text messaging %K email messaging %K digital health %K mental health %K mobile phone %K depressive disorder %K health communication %K global health %K treatments %K patient %K text messaging-based %K cognitive behavioral therapy %K communication %K effectiveness %K mental health support %K digital intervention %K digital interventions %K mental health care %K well-being %K depression symptoms %D 2024 %7 9.9.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: The prevalence of major depressive disorder (MDD) poses significant global health challenges, with available treatments often insufficient in achieving remission for many patients. Digital health technologies, such as SMS text messaging–based cognitive behavioral therapy, offer accessible alternatives but may not reach all individuals. Email communication presents a secure avenue for health communication, yet its effectiveness compared to SMS text messaging in providing mental health support for patients with MDD remains uncertain. Objective: This study aims to compare the efficacy of email versus SMS text messaging as delivery platforms for supporting patients with MDD, addressing a critical gap in understanding optimal digital interventions for mental health care. Methods: A randomized noninferiority pilot trial was conducted, comparing outcomes for patients receiving 6-week daily supportive messages via email with those receiving messages via SMS text message. This duration corresponds to a minimum of 180 days of message delivery. The supportive messages maintained consistent length and structure across both delivery methods. Participants (N=66) were recruited from the Access 24/7 clinic in Edmonton, Alberta, among those who were diagnosed with MDD. The outcomes were measured at baseline and 6 months after enrollment using the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and the World Health Organization Well-Being Index (WHO-5). Results: Most of the participants were females (n=43, 65%), aged between 26 and 40 years (n=34, 55%), had high school education (n=35, 58%), employed (n=33, 50%), and single (n=24, 36%). Again, most participants had had no history of any major physical illness (n=56, 85%) and (n=61, 92%) responded “No” to having a history of admission for treatment of mood disorders. There was no statistically significant difference in the mean changes in PHQ-9, GAD-7, and WHO-5 scores between the email and SMS text messaging groups (mean difference, 95% CI: –1.90, 95% CI –6.53 to 2.74; 5.78, 95% CI –1.94 to 13.50; and 11.85, 95% CI –3.81 to 27.51), respectively. Both supportive modalities showed potential in reducing depressive symptoms and improving quality of life. Conclusions: The study’s findings suggest that both email and SMS text messaging interventions have equivalent effectiveness in reducing depression symptoms among individuals with MDD. As digital technology continues to evolve, harnessing the power of multiple digital platforms for mental health interventions can significantly contribute to bridging the existing treatment gaps and improving the overall well-being of individuals with depressive conditions. Further research is needed with a larger sample size to confirm and expand upon these findings. Trial Registration: ClinicalTrials.gov NCT04638231; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8552095/ %M 39250182 %R 10.2196/59003 %U https://formative.jmir.org/2024/1/e59003 %U https://doi.org/10.2196/59003 %U http://www.ncbi.nlm.nih.gov/pubmed/39250182 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e56402 %T Harnessing Innovative Technologies to Train Nurses in Suicide Safety Planning With Hospital Patients: Formative Acceptability Evaluation of an eLearning Continuing Education Training %A Darnell,Doyanne %A Pierson,Andria %A Tanana,Michael J %A Dorsey,Shannon %A Boudreaux,Edwin D %A Areán,Patricia A %A Comtois,Katherine Anne %+ Department of Psychiatry & Behavioral Sciences, University of Washington, 325 9th Ave, Box 359911, Seattle, WA, 98104, United States, 1 12067449108, darnelld@uw.edu %K suicide prevention %K hospital %K training %K e-learning %K artificial intelligence %K AI %K task-shifting %K quality assessment %K fidelity %K acceptability %K feasibility %K eLearning %K suicide %K quality %K innovative %K nurse %K education training %K safety planning %K pilot study %K virtual patient %K web-based %K role-play %K microcounseling skills %K United States %D 2024 %7 6.9.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Suicide is the 12th leading cause of death in the United States. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill building are resource intensive and difficult to implement. Novel computer technologies harnessing artificial intelligence are now available, which hold promise for increasing the feasibility of providing trainees opportunities across a range of continuing education contexts to engage in skills practice with constructive feedback on performance. Objective: This pilot study aims to evaluate the feasibility and acceptability of an eLearning training in suicide safety planning among nurses serving patients admitted to a US level 1 trauma center for acute or intensive care. The training included a didactic portion with demonstration, practice of microcounseling skills with a web-based virtual patient (Client Bot Emily), role-play with a patient actor, and automated coding and feedback on general counseling skills based on the role-play via a web-based platform (Lyssn Advisor). Secondarily, we examined learning outcomes of knowledge, confidence, and skills in suicide safety planning descriptively. Methods: Acute and intensive care nurses were recruited between November 1, 2021, and May 31, 2022, to participate in a formative evaluation using pretraining, posttraining, and 6-month follow-up surveys, as well as observation of the nurses’ performance in delivering suicide safety planning via standardized patient role-plays over 6 months and rated using the Safety Plan Intervention Rating Scale. Nurses completed the System Usability Scale after interacting with Client Bot Emily and reviewing general counseling scores based on their role-play via Lyssn Advisor. Results: A total of 18 nurses participated in the study; the majority identified as female (n=17, 94%) and White (n=13, 72%). Of the 17 nurses who started the training, 82% (n=14) completed it. On average, the System Usability Scale score for Client Bot Emily was 70.3 (SD 19.7) and for Lyssn Advisor was 65.4 (SD 16.3). On average, nurses endorsed a good bit of knowledge (mean 3.1, SD 0.5) and confidence (mean 2.9, SD 0.5) after the training. After completing the training, none of the nurses scored above the expert-derived cutoff for proficiency on the Safety Plan Intervention Rating Scale (≥14); however, on average, nurses were above the cutoffs for general counseling skills per Lyssn Advisor (empathy: mean 4.1, SD 0.6; collaboration: mean 3.6, SD 0.7). Conclusions: Findings suggest the completion of the training activities and use of novel technologies within this context are feasible. Technologic modifications may enhance the training acceptability and utility, such as increasing the virtual patient conversational abilities and adding automated coding capability for specific suicide safety planning skills. International Registered Report Identifier (IRRID): RR2-10.2196/33695 %M 39239987 %R 10.2196/56402 %U https://formative.jmir.org/2024/1/e56402 %U https://doi.org/10.2196/56402 %U http://www.ncbi.nlm.nih.gov/pubmed/39239987 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e56396 %T Breaking Down Barriers to a Suicide Prevention Helpline: Web-Based Randomized Controlled Trial %A Van der Burgt,Margot C A %A Mérelle,Saskia %A Brinkman,Willem-Paul %A Beekman,Aartjan T F %A Gilissen,Renske %K barrier reduction intervention %K suicidal ideation %K self-help %K suicide prevention helpline %K randomized controlled trial %K help-seeking %K suicide %K RCT %K self-test %K effectiveness %K prevention %K middle-aged %K behavioral %K attitudinal %K website visitors %K website visitor %K website %K men %K suicide prevention %D 2024 %7 5.9.2024 %9 %J JMIR Ment Health %G English %X Background: Every month, around 3800 people complete an anonymous self-test for suicidal thoughts on the website of the Dutch suicide prevention helpline. Although 70% score high on the severity of suicidal thoughts, <10% navigate to the web page about contacting the helpline. Objective: This study aimed to test the effectiveness of a brief barrier reduction intervention (BRI) in motivating people with severe suicidal thoughts to contact the suicide prevention helpline, specifically in high-risk groups such as men and middle-aged people. Methods: We conducted a fully automated, web-based, randomized controlled trial. Respondents with severe suicidal thoughts and little motivation to contact the helpline were randomly allocated either to a brief BRI, in which they received a short, tailored message based on their self-reported barrier to the helpline (n=610), or a general advisory text (care as usual as the control group: n=612). Effectiveness was evaluated using both behavioral and attitudinal measurements. The primary outcome measure was the use of a direct link to contact the helpline after completing the intervention or control condition. Secondary outcomes were the self-reported likelihood of contacting the helpline and satisfaction with the received self-test. Results: In total, 2124 website visitors completed the Suicidal Ideation Attributes Scale and the demographic questions in the entry screening questionnaire. Among them, 1222 were randomized into the intervention or control group. Eventually, 772 respondents completed the randomized controlled trial (intervention group: n=369; control group: n=403). The most selected barrier in both groups was “I don’t think that my problems are serious enough.” At the end of the trial, 33.1% (n=122) of the respondents in the intervention group used the direct link to the helpline. This was not significantly different from the respondents in the control group (144/403, 35.7%; odds ratio 0.87, 95% CI 0.64‐1.18, P=.38). However, the respondents who received the BRI did score higher on their self-reported likelihood of contacting the helpline at a later point in time (B=0.22, 95% CI 0.12‐0.32, P≤.001) and on satisfaction with the self-test (B=0.27, 95% CI 0.01‐0.53, P=.04). For male and middle-aged respondents specifically, the results were comparable to that of the whole group. Conclusions: This trial was the first time the helpline was able to connect with high-risk website visitors who were hesitant to contact the helpline. Although the BRI could not ensure that those respondents immediately used the direct link to the helpline at the end of the trial, it is encouraging that respondents indicated that they were more likely to contact the helpline at a later point in time. In addition, this low-cost intervention provided greater insight into the perceived barriers to service. Follow-up research should be focused on identifying the added value of other components (eg, video or photo material) in the BRI and increasing its effectiveness, especially for men and middle-aged people. Trial Registration: ClinicalTrials.gov NCT05458830; https://clinicaltrials.gov/study/NCT05458830 International Registered Report Identifier (IRRID): RR2-10.2196/41078 %R 10.2196/56396 %U https://mental.jmir.org/2024/1/e56396 %U https://doi.org/10.2196/56396 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e58259 %T Natural Language Processing for Depression Prediction on Sina Weibo: Method Study and Analysis %A Zhang,Zhenwen %A Zhu,Jianghong %A Guo,Zhihua %A Zhang,Yu %A Li,Zepeng %A Hu,Bin %K depression %K social media %K natural language processing %K deep learning %K mental health %K statistical analysis %K linguistic analysis %K Sina Weibo %K risk prediction %K mood analysis %D 2024 %7 4.9.2024 %9 %J JMIR Ment Health %G English %X Background: Depression represents a pressing global public health concern, impacting the physical and mental well-being of hundreds of millions worldwide. Notwithstanding advances in clinical practice, an alarming number of individuals at risk for depression continue to face significant barriers to timely diagnosis and effective treatment, thereby exacerbating a burgeoning social health crisis. Objective: This study seeks to develop a novel online depression risk detection method using natural language processing technology to identify individuals at risk of depression on the Chinese social media platform Sina Weibo. Methods: First, we collected approximately 527,333 posts publicly shared over 1 year from 1600 individuals with depression and 1600 individuals without depression on the Sina Weibo platform. We then developed a hierarchical transformer network for learning user-level semantic representations, which consists of 3 primary components: a word-level encoder, a post-level encoder, and a semantic aggregation encoder. The word-level encoder learns semantic embeddings from individual posts, while the post-level encoder explores features in user post sequences. The semantic aggregation encoder aggregates post sequence semantics to generate a user-level semantic representation that can be classified as depressed or nondepressed. Next, a classifier is employed to predict the risk of depression. Finally, we conducted statistical and linguistic analyses of the post content from individuals with and without depression using the Chinese Linguistic Inquiry and Word Count. Results: We divided the original data set into training, validation, and test sets. The training set consisted of 1000 individuals with depression and 1000 individuals without depression. Similarly, each validation and test set comprised 600 users, with 300 individuals from both cohorts (depression and nondepression). Our method achieved an accuracy of 84.62%, precision of 84.43%, recall of 84.50%, and F1-score of 84.32% on the test set without employing sampling techniques. However, by applying our proposed retrieval-based sampling strategy, we observed significant improvements in performance: an accuracy of 95.46%, precision of 95.30%, recall of 95.70%, and F1-score of 95.43%. These outstanding results clearly demonstrate the effectiveness and superiority of our proposed depression risk detection model and retrieval-based sampling technique. This breakthrough provides new insights for large-scale depression detection through social media. Through language behavior analysis, we discovered that individuals with depression are more likely to use negation words (the value of “swear” is 0.001253). This may indicate the presence of negative emotions, rejection, doubt, disagreement, or aversion in individuals with depression. Additionally, our analysis revealed that individuals with depression tend to use negative emotional vocabulary in their expressions (“NegEmo”: 0.022306; “Anx”: 0.003829; “Anger”: 0.004327; “Sad”: 0.005740), which may reflect their internal negative emotions and psychological state. This frequent use of negative vocabulary could be a way for individuals with depression to express negative feelings toward life, themselves, or their surrounding environment. Conclusions: The research results indicate the feasibility and effectiveness of using deep learning methods to detect the risk of depression. These findings provide insights into the potential for large-scale, automated, and noninvasive prediction of depression among online social media users. %R 10.2196/58259 %U https://mental.jmir.org/2024/1/e58259 %U https://doi.org/10.2196/58259 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e56957 %T Feasibility and Acceptability Study of a Culturally Adapted Web-Based Intervention to Reduce Suicidal Ideation for Syrian Asylum Seekers and Refugees in the United Kingdom: Protocol for a Mixed Methods Study %A Beuthin,Oliver %A Shahid,Sadiya %A Yu,Ly-Mee %A Bhui,Kamaldeep %+ Department of Psychiatry, University of Oxford, Linacre College, St Cross Road, Oxford, OX1 3JA, United Kingdom, 44 1865 618200, oliver.beuthin@linacre.ox.ac.uk %K cultural adaptation %K digital mental health %K suicidal ideation %K refugee mental health %K Syrian refugee %K experience-based co-design %K mental health %K suicide %K suicidal %K refugee %K immigrant %K ethnic minority %K asylum %K user experience %K cultural %K Syria %K Syrian %K refugees %K feasibility %K acceptability %K depression %K anxiety %K posttraumatic stress disorder %K United Kingdom %K Arabic-speaking %D 2024 %7 2.9.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: The war in Syria has displaced over 6.8 million people, more than any other conflict since the Second World War. As a result, Syrian asylum seekers and refugees have experienced several life-changing events, resulting in high rates of anxiety, depression, posttraumatic stress disorder, and suicidal ideation (SI). To address the treatment gap and reduce the burden of help-seeking, a web-based intervention to reduce SI developed for general populations was culturally adapted for and with Syrian asylum seekers and refugees in the United Kingdom. The study revealed the importance of understanding their lived experience with migration and the acculturative process in providing treatment for SI. This study will now assess the feasibility and acceptability of the culturally adapted intervention for this population. Objective: The first phase of the study will include recruiting participants and delivering the web-based intervention (1) to assess the feasibility of meeting recruitment goals and recruitment rates and (2) to assess the feasibility of outcome measures. The second phase of the study will include one-to-one semistructured interviews (1) to assess the suitability of the culturally adapted intervention in terms of recruitment and adherence rates and barriers and facilitators to engagement and (2) to assess the acceptability of the intervention in terms of its cultural relevance and appropriateness. Methods: This is a protocol for a single-group, noncontrolled, mixed methods feasibility and acceptability study of a culturally adapted web-based intervention to reduce SI for Syrian asylum seekers and refugees in the United Kingdom. The study will assess the feasibility of recruitment goals, recruitment rates, adherence rates, and outcome measures using individual participant tracking forms, which will be analyzed quantitatively. The suitability and acceptability of the intervention will be assessed using one-to-one semistructured interviews with 12 participants who completed the intervention, which will be analyzed qualitatively. Results: Recruitment began in February 2024 and will run until 30 participants are recruited to the study or until the end of July 2024. Thus far, 19 participants have provided informed consent, 16 were eligible and enrolled, and 12 have completed a postintervention interview. No data have been analyzed. The study, including the write-up period, is expected to end in December 2024. Conclusions: Despite experiencing several stressors related to forced displacement and high rates of mental health issues, access to treatment is still limited for Syrian asylum seekers and refugees in the United Kingdom. To address the treatment gap and reduce the burden of help-seeking, a web-based intervention to reduce SI was culturally adapted in collaboration with Syrian asylum seekers and refugees in the United Kingdom. This study will now assess the feasibility and acceptability of the intervention and culturally appropriate recruitment strategies. Trial Registration: ISRCTN ISRCTN11417025; https://www.isrctn.com/ISRCTN11417025 International Registered Report Identifier (IRRID): PRR1-10.2196/56957 %M 39222345 %R 10.2196/56957 %U https://www.researchprotocols.org/2024/1/e56957 %U https://doi.org/10.2196/56957 %U http://www.ncbi.nlm.nih.gov/pubmed/39222345 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e54252 %T Examining a Fully Automated Mobile-Based Behavioral Activation Intervention in Depression: Randomized Controlled Trial %A Santopetro,Nicholas %A Jones,Danielle %A Garron,Andrew %A Meyer,Alexandria %A Joyner,Keanan %A Hajcak,Greg %K digital intervention %K digital health %K digital application %K digital applications %K mobile health %K mHealth %K automation %K automate %K automated %K behavioral activation %K BA %K BA intervention %K depression %K depressed %K depressive %K depressive symptoms %K anhedonia %K anhedonia symptoms %K anxiety %K anxious %K anxiety symptoms %K adults %K adult %K psychiatry %K psych %K psychology %K major depressive disorder %K MDD %D 2024 %7 30.8.2024 %9 %J JMIR Ment Health %G English %X Background: Despite significant progress in our understanding of depression, prevalence rates have substantially increased in recent years. Thus, there is an imperative need for more cost-effective and scalable mental health treatment options, including digital interventions that minimize therapist burden. Objective: This study focuses on a fully automated digital implementation of behavioral activation (BA)—a core behavioral component of cognitive behavioral therapy for depression. We examine the efficacy of a 1-month fully automated SMS text message–based BA intervention for reducing depressive symptoms and anhedonia. Methods: To this end, adults reporting at least moderate current depressive symptoms (8-item Patient Health Questionnaire score ≥10) were recruited online across the United States and randomized to one of three conditions: enjoyable activities (ie, BA), healthy activities (ie, an active control condition), and passive control (ie, no contact). Participants randomized to enjoyable and healthy activities received daily SMS text messages prompting them to complete 2 activities per day; participants also provided a daily report on the number and enjoyment of activities completed the prior day. Results: A total of 126 adults (mean age 32.46, SD 7.41 years) with current moderate depressive symptoms (mean score 16.53, SD 3.90) were recruited. Participants in the enjoyable activities condition (BA; n=39) experienced significantly greater reductions in depressive symptoms compared to participants in the passive condition (n=46). Participants in both active conditions—enjoyable activities and healthy activities (n=41)—reported reduced symptoms of anxiety compared to those in the control condition. Conclusions: These findings provide preliminary evidence regarding the efficacy of a fully automated digital BA intervention for depression and anxiety symptoms. Moreover, reminders to complete healthy activities may be a promising intervention for reducing anxiety symptoms. Trial Registration: ClincalTrials.gov NCT06492824; https://clinicaltrials.gov/study/NCT06492824 %R 10.2196/54252 %U https://mental.jmir.org/2024/1/e54252 %U https://doi.org/10.2196/54252 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e52759 %T Association Between COVID-19 and Self-Harm: Nationwide Retrospective Ecological Spatiotemporal Study in Metropolitan France %A Baillet,Maëlle %A Wathelet,Marielle %A Lamer,Antoine %A Frévent,Camille %A Fovet,Thomas %A D'Hondt,Fabien %A Notredame,Charles-Edouard %A Vaiva,Guillaume %A Génin,Michael %K self-harm %K COVID-19 %K spatiotemporal analysis %K ecological regression %K data reuse %D 2024 %7 27.8.2024 %9 %J JMIR Public Health Surveill %G English %X Background: The COVID-19 pandemic has not been associated with increases in suicidal behavior at the national, regional, or county level. However, previous studies were not conducted on a finer scale or adjusted for ecological factors. Objective: Our objective was to assess the fine-scale spatiotemporal association between self-harm and COVID-19 hospitalizations, while considering ecological factors. Methods: Using the French national hospital discharge database, we extracted data on hospitalizations for self-harm of patients older than 10 years (from 2019 to 2021) or for COVID-19 (from 2020 to 2021) in metropolitan France. We first calculated monthly standardized incidence ratios (SIRs) for COVID-19 between March 2020 and December 2021, using a Besag, York, and Mollié spatiotemporal model. Next, we entered the SIRs into an ecological regression in order to test the association between hospital admissions for self-harm and those for COVID-19. Lastly, we adjusted for ecological variables with time lags of 0 to 6 months. Results: Compared with a smoothed SIR of ≤1, smoothed SIRs from 1 to 3, from 3 to 4, and greater than 4 for COVID-19 hospital admissions were associated with a subsequent increase in hospital admissions for self-harm, with a time lag of 2 to 4 months, 4 months, and 6 months, respectively. Conclusions: A high SIR for hospital admissions for COVID-19 was a risk factor for hospital admission for self-harm some months after the epidemic peaks. This finding emphasizes the importance of monitoring and seeking to prevent suicide attempts outside the epidemic peak periods. %R 10.2196/52759 %U https://publichealth.jmir.org/2024/1/e52759 %U https://doi.org/10.2196/52759 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e59560 %T Self-Administered Interventions Based on Natural Language Processing Models for Reducing Depressive and Anxiety Symptoms: Systematic Review and Meta-Analysis %A Villarreal-Zegarra,David %A Reategui-Rivera,C Mahony %A García-Serna,Jackeline %A Quispe-Callo,Gleni %A Lázaro-Cruz,Gabriel %A Centeno-Terrazas,Gianfranco %A Galvez-Arevalo,Ricardo %A Escobar-Agreda,Stefan %A Dominguez-Rodriguez,Alejandro %A Finkelstein,Joseph %+ Department of Biomedical Informatics, School of Medicine, University of Utah, 421 Wakara Way, Salt Lake City, UT, 84108, United States, 1 (801) 581 4080, mahony.reategui@utah.edu %K natural language processing %K depression %K anxiety %K systematic review %K artificial intelligence %K AI %D 2024 %7 21.8.2024 %9 Review %J JMIR Ment Health %G English %X Background: The introduction of natural language processing (NLP) technologies has significantly enhanced the potential of self-administered interventions for treating anxiety and depression by improving human-computer interactions. Although these advances, particularly in complex models such as generative artificial intelligence (AI), are highly promising, robust evidence validating the effectiveness of the interventions remains sparse. Objective: The aim of this study was to determine whether self-administered interventions based on NLP models can reduce depressive and anxiety symptoms. Methods: We conducted a systematic review and meta-analysis. We searched Web of Science, Scopus, MEDLINE, PsycINFO, IEEE Xplore, Embase, and Cochrane Library from inception to November 3, 2023. We included studies with participants of any age diagnosed with depression or anxiety through professional consultation or validated psychometric instruments. Interventions had to be self-administered and based on NLP models, with passive or active comparators. Outcomes measured included depressive and anxiety symptom scores. We included randomized controlled trials and quasi-experimental studies but excluded narrative, systematic, and scoping reviews. Data extraction was performed independently by pairs of authors using a predefined form. Meta-analysis was conducted using standardized mean differences (SMDs) and random effects models to account for heterogeneity. Results: In all, 21 articles were selected for review, of which 76% (16/21) were included in the meta-analysis for each outcome. Most of the studies (16/21, 76%) were recent (2020-2023), with interventions being mostly AI-based NLP models (11/21, 52%); most (19/21, 90%) delivered some form of therapy (primarily cognitive behavioral therapy: 16/19, 84%). The overall meta-analysis showed that self-administered interventions based on NLP models were significantly more effective in reducing both depressive (SMD 0.819, 95% CI 0.389-1.250; P<.001) and anxiety (SMD 0.272, 95% CI 0.116-0.428; P=.001) symptoms compared to various control conditions. Subgroup analysis indicated that AI-based NLP models were effective in reducing depressive symptoms (SMD 0.821, 95% CI 0.207-1.436; P<.001) compared to pooled control conditions. Rule-based NLP models showed effectiveness in reducing both depressive (SMD 0.854, 95% CI 0.172-1.537; P=.01) and anxiety (SMD 0.347, 95% CI 0.116-0.578; P=.003) symptoms. The meta-regression showed no significant association between participants’ mean age and treatment outcomes (all P>.05). Although the findings were positive, the overall certainty of evidence was very low, mainly due to a high risk of bias, heterogeneity, and potential publication bias. Conclusions: Our findings support the effectiveness of self-administered NLP-based interventions in alleviating depressive and anxiety symptoms, highlighting their potential to increase accessibility to, and reduce costs in, mental health care. Although the results were encouraging, the certainty of evidence was low, underscoring the need for further high-quality randomized controlled trials and studies examining implementation and usability. These interventions could become valuable components of public health strategies to address mental health issues. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42023472120; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023472120 %M 39167795 %R 10.2196/59560 %U https://mental.jmir.org/2024/1/e59560 %U https://doi.org/10.2196/59560 %U http://www.ncbi.nlm.nih.gov/pubmed/39167795 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e53794 %T Skill Enactment Among University Students Using a Brief Video-Based Mental Health Intervention: Mixed Methods Study Within a Randomized Controlled Trial %A Jackson,Hayley M %A Batterham,Philip J %A Calear,Alison L %A Ohan,Jeneva L %A Farrer,Louise M %+ Centre for Mental Health Research, National Centre for Epidemiology and Population Health, The Australian National University, 63 Eggleston Road, Acton ACT, 2601, Australia, 61 416913323, hayley.jackson@anu.edu.au %K university students %K young people %K internet %K computer-assisted therapy %K engagement %K skill enactment %K depression %K anxiety %K randomized controlled trial %K mobile phone %D 2024 %7 21.8.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental health problems are common among university students, yet many students do not seek professional help. Digital mental health interventions can increase students’ access to support and have been shown to be effective in preventing and treating mental health problems. However, little is known about the extent to which students implement therapeutic skills from these programs in everyday life (ie, skill enactment) or about the impact of skill enactment on outcomes. Objective: This study aims to assess the effects of a low-intensity video-based intervention, Uni Virtual Clinic Lite (UVC-Lite), in improving skill enactment relative to an attention-control program (primary aim) and examine whether skill enactment influences symptoms of depression and anxiety (secondary aim). The study also qualitatively explored participants’ experiences of, and motivations for, engaging with the therapeutic techniques. Methods: We analyzed data from a randomized controlled trial testing the effectiveness of UVC-Lite for symptoms of depression and anxiety among university students with mild to moderate levels of psychological distress. Participants were recruited from universities across Australia and randomly assigned to 6 weeks of self-guided use of UVC-Lite (243/487, 49.9%) or an attention-control program (244/487, 50.1%). Quantitative data on skill enactment, depression, and anxiety were collected through baseline, postintervention, and 3- and 6-month follow-up surveys. Qualitative data were obtained from 29 intervention-group participants through open-ended questions during postintervention surveys (n=17, 59%) and semistructured interviews (n=12, 41%) after the intervention period concluded. Results: Mixed model repeated measures ANOVA demonstrated that the intervention did not significantly improve skill enactment (F3,215.36=0.50; P=.68). Skill enactment was also not found to influence change in symptoms of depression (F3,241.10=1.69; P=.17) or anxiety (F3,233.71=1.11; P=.35). However, higher levels of skill enactment were associated with lower symptom levels among both intervention and control group participants across time points (depression: F1,541.87=134.61; P<.001; anxiety: F1,535.11=73.08; P<.001). Inductive content analysis confirmed low levels of skill enactment among intervention group participants. Participants were motivated to use techniques and skills that were perceived to be personally relevant, easily integrated into daily life, and that were novel or had worked for them in the past. Conclusions: The intervention did not improve skill enactment or mental health among students with mild to moderate psychological distress. Low adherence impacted our ability to draw robust conclusions regarding the intervention’s impact on outcomes. Factors influencing skill enactment differed across individuals, suggesting that it may be necessary to tailor therapeutic skills and engagement strategies to the individual user. Theoretically informed research involving collaboration with end users is needed to understand the processes underlying skill enactment in digital mental health interventions. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12621000375853; https://tinyurl.com/7b9ar54r %M 39167783 %R 10.2196/53794 %U https://mental.jmir.org/2024/1/e53794 %U https://doi.org/10.2196/53794 %U http://www.ncbi.nlm.nih.gov/pubmed/39167783 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e56960 %T Evaluating the Efficacy of a Digital Therapeutic (CT-152) as an Adjunct to Antidepressant Treatment in Adults With Major Depressive Disorder: Protocol for the MIRAI Remote Study %A Rothman,Brian %A Slomkowski,Mary %A Speier,Austin %A Rush,A John %A Trivedi,Madhukar H %A Lawson,Erica %A Fahmy,Michael %A Carpenter,Daniel %A Chen,Dalei %A Forbes,Ainslie %+ Otsuka Pharmaceutical Development & Commercialization, Inc, 508 Carnegie Center Dr, Princeton, NJ, 08540, United States, 1 609 524 6788, brian.rothman@otsuka-us.com %K adherence %K digital placebo %K sham control %K cognitive-emotional training %K Emotional Faces Memory Task %K mobile phone %D 2024 %7 20.8.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Major depressive disorder (MDD) is common worldwide and can be highly disabling. People with MDD face many barriers to treatment and may not experience full symptom relief even when treated. Therefore, new treatment modalities are needed for MDD. Digital therapeutics (DTx) may provide people with MDD an additional treatment option. Objective: This study aimed to describe a phase 3 remote, multicenter, randomized, masked, sham-controlled trial evaluating the efficacy of a smartphone app–based DTx (CT-152) in adult participants diagnosed with MDD, used as an adjunct to antidepressant therapy (ADT). Methods: Participants aged 22-64 years with a current primary diagnosis of MDD and an inadequate response to ADT were included. Participants were randomized 1:1 to CT-152 or a sham DTx. CT-152 is a smartphone app–based DTx that delivers a cognitive-emotional and behavioral therapeutic intervention. The core components of CT-152 are the Emotional Faces Memory Task exercises, brief lessons to learn and apply key therapeutic skills, and SMS text messaging to reinforce lessons and encourage engagement with the app. The sham DTx is a digital working memory exercise with emotionally neutral stimuli designed to match CT-152 for time and attention. Participants took part in the trial for up to 13 weeks. The trial included a screening period of up to 3 weeks, a treatment period of 6 weeks, and an extension period of 4 weeks to assess the durability of the effect. Sites and participants had the option of an in-person or remote screening visit; the remaining trial visits were remote. Efficacy was evaluated using the Montgomery-Åsberg Depression Rating Scale, the Generalized Anxiety Disorder-7, Clinical Global Impression–Severity scale, the Patient Health Questionnaire-9, and the World Health Organization Disability Assessment Schedule 2.0. The durability of the effect was evaluated with the Montgomery-Åsberg Depression Rating Scale and Generalized Anxiety Disorder-7 scale. Adverse events were also assessed. Satisfaction, measured by the Participant and Healthcare Professional Satisfaction Scales, and health status, measured by the EQ-5D-5L, were summarized using descriptive statistics. Results: This study was initiated in February 2021 and had a primary completion date in October 2022. Conclusions: This represents the methodological design for the first evaluation of CT-152 as an adjunct to ADT. This study protocol is methodologically robust and incorporates many aspects of conventional pivotal pharmaceutical phase 3 trial design, such as randomization and safety end points. Novel considerations included the use of a sham comparator, masking considerations for visible app content, and outcome measures relevant to DTx. The rigor of this methodology will provide a more comprehensive understanding of the effectiveness of CT-152. Trial Registration: ClinicalTrials.gov NCT04770285; https://clinicaltrials.gov/study/NCT04770285 International Registered Report Identifier (IRRID): RR1-10.2196/56960 %M 39163592 %R 10.2196/56960 %U https://www.researchprotocols.org/2024/1/e56960 %U https://doi.org/10.2196/56960 %U http://www.ncbi.nlm.nih.gov/pubmed/39163592 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e56319 %T Developing a Guided Web App for Postpartum Depression Symptoms: User-Centered Design Approach %A Franco,Pamela %A Olhaberry,Marcia %A Muzard,Antonia %A Harismendy,Ángeles %A Kelders,Saskia %+ Centre for eHealth & Well-being Research, Department of Psychology, Health & Technology, University of Twente, Drienerlolaan 5, Enschede, 7522 NB, Netherlands, 31 0 534899180, s.m.kelders@utwente.nl %K internet-based intervention %K postpartum depression %K user-centered development %K perinatal mental health %K user-centered design %K mobile phone %D 2024 %7 19.8.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Psychological internet-based interventions have shown promise in preventing and treating perinatal depression, but their effectiveness can be hindered by low user engagement. This challenge often arises from a misalignment between technology attributes, user needs, and context. A user-centered, iterative approach involving all stakeholders is recommended. Objective: In this paper, we aimed to develop a user-friendly psychological internet-based intervention aimed at addressing the symptoms of perinatal depression through an iterative, user-centered approach. Methods: The development process followed the Center for eHealth Research and Disease Management Roadmap phases of contextual inquiry, value specification, and design. It involved a comprehensive literature review, 2 surveys, 10 focus groups, 5 usability interviews, and 1 technical pilot. Results: The contextual inquiry revealed a demand for accessible interventions for perinatal mental health, with internet-based solutions seen as viable options. Insights from the literature influenced intervention content and features. Stakeholders’ openness to the intervention became evident during this phase, along with the integration of the first set of values. Initially, we assessed the broader perinatal context to identify the optimal period for the intervention. On the basis of the findings and practical considerations, we decided to specifically target postpartum depression symptoms. The value specification phase further defined the central values and translated them into requirements. In the design phase, feedback was obtained on the user experience of an early digital prototype and on the prototype’s final version. The resulting intervention, named Mamá, te entiendo (“Mom, I get you”), is a guided web app based on cognitive behavioral therapy principles, integrating elements from attachment and mentalization theories. It aims to reduce depressive symptoms in women during the first months postpartum and consists of 6 core sequential modules, along with 3 additional modules, including 5 case examples illustrating depressive symptoms and therapeutic techniques. The intervention provides homework exercises and offers users the opportunity to receive feedback from an e-coach through the web app. Conclusions: This study emphasizes the importance of a user-centered and iterative development process for psychological internet-based interventions. This process helps clarify user needs and provides valuable feedback on service design and quality, ultimately having the potential to enhance the utility and, presumably, the effectiveness of the intervention. The Discussion section shares valuable insights from the project, such as the value of the requirement sessions. %M 39159447 %R 10.2196/56319 %U https://formative.jmir.org/2024/1/e56319 %U https://doi.org/10.2196/56319 %U http://www.ncbi.nlm.nih.gov/pubmed/39159447 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e59699 %T Impact of an Online Discussion Forum on Self-Guided Internet-Delivered Cognitive Behavioral Therapy for Public Safety Personnel: Randomized Trial %A McCall,Hugh C %A Hadjistavropoulos,Heather D %+ Department of Psychology, University of Regina, 3737 Wascana Pkwy, Regina, SK, S4S 0A2, Canada, 1 306 585 5133, Heather.Hadjistavropoulos@uregina.ca %K internet %K cognitive behavioral therapy %K forum %K persuasive design %K generalized anxiety disorder %K major depressive disorder %K posttraumatic stress disorder %K public safety personnel %D 2024 %7 14.8.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet-delivered cognitive behavioral therapy (ICBT) is an effective and accessible treatment for various mental health concerns. ICBT has shown promising treatment outcomes among public safety personnel (PSP), who experience high rates of mental health problems and face barriers to accessing other mental health services. Client engagement and clinical outcomes are better in ICBT with therapist guidance, but ICBT is easier to implement on a large scale when it is self-guided. Therefore, it is important to identify strategies to improve outcomes and engagement in self-guided ICBT and other self-guided digital mental health interventions. One such strategy is the use of online discussion forums to provide ICBT clients with opportunities for mutual social support. Self-guided interventions accompanied by online discussion forums have shown excellent treatment outcomes, but there is a need for research experimentally testing the impact of online discussion forums in ICBT. Objective: We aimed to evaluate a transdiagnostic, self-guided ICBT intervention tailored specifically for PSP (which had not previously been assessed), assess the impact of adding a therapist-moderated online discussion forum on outcomes, and analyze participants’ feedback to inform future research and implementation efforts. Methods: In this randomized trial, we randomly assigned participating PSP (N=107) to access an 8-week transdiagnostic, self-guided ICBT course with or without a built-in online discussion forum. Enrollment and participation were entirely web-based. We assessed changes in depression, anxiety, and posttraumatic stress as well as several secondary outcome measures (eg, treatment engagement and satisfaction) using questionnaires at the pre-enrollment, 8-week postenrollment, and 20-week postenrollment time points. Mixed methods analyses included multilevel modeling and qualitative content analysis. Results: Participants engaged minimally with the forum, creating 9 posts. There were no differences in treatment outcomes between participants who were randomly assigned to access the forum (56/107, 52.3%) and those who were not (51/107, 47.7%). Across conditions, participants who reported clinically significant symptoms during enrollment showed large and statistically significant reductions in symptoms (P<.05 and d>0.97 in all cases). Participants also showed good treatment engagement and satisfaction, with 43% (46/107) of participants fully completing the intervention during the course of the study and 96% (79/82) indicating that the intervention was worth their time. Conclusions: Previous research has shown excellent clinical outcomes for self-guided ICBT accompanied by discussion forums and good engagement with those forums. Although clinical outcomes in our study were excellent across conditions, engagement with the forum was poor, in contrast to previous research. We discuss several possible interpretations of this finding (eg, related to the population under study or the design of the forum). Our findings highlight a need for more research evaluating the impact of online discussion forums and other strategies for improving outcomes and engagement in self-guided ICBT and other digital mental health interventions. Trial Registration: ClinicalTrials.gov NCT05145582; https://clinicaltrials.gov/study/NCT05145582 %M 39141899 %R 10.2196/59699 %U https://www.jmir.org/2024/1/e59699 %U https://doi.org/10.2196/59699 %U http://www.ncbi.nlm.nih.gov/pubmed/39141899 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e51932 %T Evaluating the Effects of a Self-Help Mobile Phone App on Worry and Rumination Experienced by Young Adults: Randomized Controlled Trial %A Edge,Daniel %A Watkins,Edward %A Newbold,Alexandra %A Ehring,Thomas %A Frost,Mads %A Rosenkranz,Tabea %+ Mood Disorders Centre, School of Psychology, University of Exeter, Washington Singer Building Perry Road, Washington Singer Laboratories, Exeter, EX4 4QG, United Kingdom, 44 01392724621, de292@exeter.ac.uk %K worry %K rumination %K repetitive negative thinking %K prevention-mechanism %K well-being %K depression %K anxiety %K mobile-based interventions %K mobile phone %K mobile health application %K app %K application %D 2024 %7 13.8.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Delivery of preventative interventions via mobile phone apps offers an effective and accessible way to address the global priority of improving the mental health of adolescents and young adults. A proven risk factor for anxiety and depression is elevated worry and rumination, also known as repetitive negative thinking (RNT). Objective: This was a prevention mechanism trial that aimed to investigate whether an RNT-targeting self-help mobile phone app (MyMoodCoach) reduces worry and rumination in young adults residing in the United Kingdom. A secondary objective was to test whether the app reduces symptoms of anxiety and depression and improves well-being. Methods: A web-based, single-blind, 2-arm parallel-group randomized controlled trial was conducted with 236 people aged between 16 and 24 years, who self-reported high levels of worry or rumination. Eligible participants were randomized to an active intervention group (usual practice, plus up to 6 weeks of using the RNT-targeting mobile app, n=119) or a waitlist control group (usual practice with no access to the app until after 6 weeks, n=117). The primary outcome was changes in worry and rumination 6 weeks after randomization. Secondary outcomes included changes in well-being and symptoms of anxiety and depression after 6 weeks and changes in all measures after 12 weeks. Results: Participants randomly allocated to use the RNT-targeting self-help app showed significantly lower levels of rumination (mean difference –2.92, 95% CI –5.57 to –0.28; P=.03; ηp2=0.02) and worry (mean difference –3.97, 95% CI –6.21 to –1.73; P<.001; ηp2=0.06) at 6-week follow-up, relative to the waitlist control. Similar differences were observed for well-being (P<.001), anxiety (P=.03), and depression (P=.04). The waitlist control group also showed improvement when given access to the app after 6 weeks. Improvements observed in the intervention group after 6 weeks of using the app were maintained at the 12-week follow-up point. Conclusions: The MyMoodCoach app had a significant positive effect on worry and rumination, well-being, anxiety, and depression in young adults, relative to waitlist controls, providing proof-of-principle that an unguided self-help app can effectively reduce RNT. This app, therefore, has potential for the prevention of anxiety and depression although longer-term effects on incidence need to be directly evaluated. Trial Registration: ClinicalTrials.gov NCT04950257; https://www.clinicaltrials.gov/ct2/show/NCT04950257 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-021-03536-0 %M 39137411 %R 10.2196/51932 %U https://mhealth.jmir.org/2024/1/e51932 %U https://doi.org/10.2196/51932 %U http://www.ncbi.nlm.nih.gov/pubmed/39137411 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 7 %N %P e51570 %T Development and Implementation of Postdischarge Text Messages to Adolescents With Suicidal Thoughts and Behaviors Through Caring Contacts: Implementation Study %A Thomas,Glenn V %A Camacho,Elena %A Masood,Fatimah A %A Huang,Yungui %A Valleru,Jahnavi %A Bridge,Jeffrey A %A Ackerman,John %+ Behavioral Health Services, Nationwide Children’s Hospital, 444 Butterfly Gardens Dr., 2nd Fl., Columbus, OH, 43215, United States, 1 6143550814, John.Ackerman@nationwidechildrens.org %K mental health %K suicide prevention %K adolescent %K caring contacts %K mHealth %K Zero Suicide %K quality improvement %K care transitions %K safety plan %K behavioral health %K mobile phone %D 2024 %7 13.8.2024 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Youth suicide is a pressing public health concern, and transitions in care after a suicidal crisis represent a period of elevated risk. Disruptions in continuity of care and emotional support occur frequently. “Caring contacts” validating messages post discharge have the potential to enhance connections with patients and have been shown to improve outcomes. More recently, positive outcomes have been noted using caring contact text messages (SMS and MMS), which hold promise for engaging patients in a pediatric setting, but there are few studies describing the large-scale implementation of such an approach. Objective: This study aims to describe the process of developing and implementing automated caring contacts within a quality improvement framework, using a standardized series of supportive texts and images, for adolescents discharged from high-acuity programs at a large midwestern pediatric hospital. We describe lessons learned, including challenges and factors contributing to success. Methods: We implemented the caring contacts intervention in 3 phases. Phase 1 entailed developing supportive statements and images designed to promote hope, inclusivity, and connection in order to create 2 sets of 8 text messages and corresponding images. Phase 2 included piloting caring contacts manually in the hospital’s Psychiatric Crisis Department and Inpatient Psychiatry Unit and assessing the feasibility of implementation in other services, as well as developing workflows and addressing legal considerations. Phase 3 consisted of implementing an automated process to scale within 4 participating hospital services and integrating enrollment into the hospital’s electronic medical records. Process outcome measures included staff compliance with approaching and enrolling eligible patients and results from an optional posttext survey completed by participants. Results: Compliance data are presented for 4062 adolescent patients eligible for caring contacts. Overall, 88.65% (3601/4062) of eligible patients were approached, of whom 52.43% (1888/3601) were enrolled. In total, 94.92% (1792/1888) of enrolled participants completed the program. Comparisons of the patients eligible, approached, enrolled, and completed are presented. Primary reasons for eligible patients declining include not having access to a mobile phone (686/1705, 40.23%) and caregivers preferring to discuss the intervention at a later time (754/1705, 44.22%). The majority of patients responding to the optional posttext survey reported that the texts made them feel moderately to very hopeful (219/264, 83%), supported (232/264, 87.9%), that peers would be helped by these texts (243/264, 92%), and that they would like to keep receiving texts given the option (227/264, 86%). Conclusions: This study describes the successful implementation of automated postdischarge caring contacts texts to scale with an innovative use of images and demonstrates how a quality improvement methodology resulted in a more effective and efficient process. This paper also highlights the potential for technology to enhance care for at-risk youth and create more accessible, inclusive, and sustainable prevention strategies. %M 39137019 %R 10.2196/51570 %U https://pediatrics.jmir.org/2024/1/e51570 %U https://doi.org/10.2196/51570 %U http://www.ncbi.nlm.nih.gov/pubmed/39137019 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 13 %N %P e53672 %T Debate and Dilemmas Regarding Generative AI in Mental Health Care: Scoping Review %A Xian,Xuechang %A Chang,Angela %A Xiang,Yu-Tao %A Liu,Matthew Tingchi %+ Department of Communication, Faculty of Social Sciences, University of Macau, University Avenue, Taipa, Macau SAR, 999078, China, 86 88228991, wychang@um.edu.mo %K generative artificial intelligence %K GAI %K ChatGPT %K mental health %K scoping review %K artificial intelligence %K depression %K anxiety %K generative adversarial network %K GAN %K variational autoencoder %K VAE %D 2024 %7 12.8.2024 %9 Review %J Interact J Med Res %G English %X Background: Mental disorders have ranked among the top 10 prevalent causes of burden on a global scale. Generative artificial intelligence (GAI) has emerged as a promising and innovative technological advancement that has significant potential in the field of mental health care. Nevertheless, there is a scarcity of research dedicated to examining and understanding the application landscape of GAI within this domain. Objective: This review aims to inform the current state of GAI knowledge and identify its key uses in the mental health domain by consolidating relevant literature. Methods: Records were searched within 8 reputable sources including Web of Science, PubMed, IEEE Xplore, medRxiv, bioRxiv, Google Scholar, CNKI and Wanfang databases between 2013 and 2023. Our focus was on original, empirical research with either English or Chinese publications that use GAI technologies to benefit mental health. For an exhaustive search, we also checked the studies cited by relevant literature. Two reviewers were responsible for the data selection process, and all the extracted data were synthesized and summarized for brief and in-depth analyses depending on the GAI approaches used (traditional retrieval and rule-based techniques vs advanced GAI techniques). Results: In this review of 144 articles, 44 (30.6%) met the inclusion criteria for detailed analysis. Six key uses of advanced GAI emerged: mental disorder detection, counseling support, therapeutic application, clinical training, clinical decision-making support, and goal-driven optimization. Advanced GAI systems have been mainly focused on therapeutic applications (n=19, 43%) and counseling support (n=13, 30%), with clinical training being the least common. Most studies (n=28, 64%) focused broadly on mental health, while specific conditions such as anxiety (n=1, 2%), bipolar disorder (n=2, 5%), eating disorders (n=1, 2%), posttraumatic stress disorder (n=2, 5%), and schizophrenia (n=1, 2%) received limited attention. Despite prevalent use, the efficacy of ChatGPT in the detection of mental disorders remains insufficient. In addition, 100 articles on traditional GAI approaches were found, indicating diverse areas where advanced GAI could enhance mental health care. Conclusions: This study provides a comprehensive overview of the use of GAI in mental health care, which serves as a valuable guide for future research, practical applications, and policy development in this domain. While GAI demonstrates promise in augmenting mental health care services, its inherent limitations emphasize its role as a supplementary tool rather than a replacement for trained mental health providers. A conscientious and ethical integration of GAI techniques is necessary, ensuring a balanced approach that maximizes benefits while mitigating potential challenges in mental health care practices. %M 39133916 %R 10.2196/53672 %U https://www.i-jmr.org/2024/1/e53672 %U https://doi.org/10.2196/53672 %U http://www.ncbi.nlm.nih.gov/pubmed/39133916 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e57038 %T Characterization of Psychopathology in Latin American Adolescents Using a Web-Based Screening Tool: Cross-Sectional Study %A Campos,Susana %A Nuñez,Daniel %A Pérez,J Carola %A Robinson,Jo %+ Center of Cognitive Sciences, Faculty of Psychology, University of Talca, Avenida Lircay s/n, Talca, 3460000, Chile, 56 712201782, dnunez@utalca.cl %K web-based screening %K adolescents %K psychopathology %K suicidal ideation %K early detection %K detection %K screening %K teens %K youths %K suicide %K mental health %K screening tool %K Latin American %K Latino %K psychiatric %K psychiatric symptoms %K psychological risk %D 2024 %7 8.8.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Mental health problems and suicide ideation are common in adolescents. Early detection of these issues could prevent the escalation of mental health–related symptoms in the long term. Moreover, characterizing different profiles of prevalent symptoms in conjunction with emotional regulation strategies could guide the design of specific interventions. The use of web-based screening (WBS) tools has been regarded as a suitable strategy to timely detect symptomatology while improving the appeal, cost, timeliness, and reach of detection in young populations. However, the evidence regarding the accuracy of these approaches is not fully conclusive. Objective: The study aims (1) to examine the capability of a WBS to identify adolescents with psychiatric symptoms and suicidality and (2) to characterize the mental health profiles of a large sample of adolescents using WBS. Methods: A total of 1599 Latin American Spanish-speaking adolescents (mean age 15.56, SD 1.34 years), consisting of 47.3% (n=753) female, 98.5% Chilean (n=1570), and 1.5% Venezuelan (n=24) participants, responded to a mental health WBS. A randomized subsample of participants also responded to the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). McNemar χ2 and receiver-operating characteristic curves tested the detection accuracy of WBS contrasted with the MINI-KID. Latent profile analyses explored the symptomatic and emotional regulation profiles of participants. Results: Both measures showed an adequate level of agreement (area under the curve per symptom domain ranging from 0.70 to 0.89); however, WBS yielded a higher prevalence than MINI-KID for all psychiatric symptoms, except suicide ideation and depression. Latent profile analyses yielded 4 profiles—one of them presented elevated psychopathological symptoms, constituting 11% of the sample (n=175). Rumination (odds ratio [OR] 130.15, 95% CI 51.75-439.89; P<.001), entrapment (OR 96.35, 95% CI 29.21-317.79; P<.001), and defeat (OR 156.79, 95% CI 50.45-487.23; P<.001) contributed significantly to the prediction of latent profile memberships, while cognitive reappraisal did not contribute to the prediction of any latent profile memberships, and expressive suppression was only associated to profile-2 membership. Conclusions: WBS is acceptable for the timely detection of adolescents at risk of mental health conditions. Findings from the symptomatic and emotional regulation profiles highlight the need for comprehensive assessments and differential interventions. %M 39116425 %R 10.2196/57038 %U https://formative.jmir.org/2024/1/e57038 %U https://doi.org/10.2196/57038 %U http://www.ncbi.nlm.nih.gov/pubmed/39116425 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e48907 %T Identifying Reddit Users at a High Risk of Suicide and Their Linguistic Features During the COVID-19 Pandemic: Growth-Based Trajectory Model %A Yan,Yifei %A Li,Jun %A Liu,Xingyun %A Li,Qing %A Yu,Nancy Xiaonan %+ Department of Social and Behavioural Sciences, City University of Hong Kong, Tat Chee Avenue, Kowloon, HKSAR, P. R. China, Hong Kong, 000, China (Hong Kong), 852 34429436, nancy.yu@cityu.edu.hk %K COVID-19 pandemic %K Reddit %K suicide risk %K trajectory %D 2024 %7 8.8.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide has emerged as a critical public health concern during the COVID-19 pandemic. With social distancing measures in place, social media has become a significant platform for individuals expressing suicidal thoughts and behaviors. However, existing studies on suicide using social media data often overlook the diversity among users and the temporal dynamics of suicide risk. Objective: By examining the variations in post volume trajectories among users on the r/SuicideWatch subreddit during the COVID-19 pandemic, this study aims to investigate the heterogeneous patterns of change in suicide risk to help identify social media users at high risk of suicide. We also characterized their linguistic features before and during the pandemic. Methods: We collected and analyzed post data every 6 months from March 2019 to August 2022 for users on the r/SuicideWatch subreddit (N=6163). A growth-based trajectory model was then used to investigate the trajectories of post volume to identify patterns of change in suicide risk during the pandemic. Trends in linguistic features within posts were also charted and compared, and linguistic markers were identified across the trajectory groups using regression analysis. Results: We identified 2 distinct trajectories of post volume among r/SuicideWatch subreddit users. A small proportion of users (744/6163, 12.07%) was labeled as having a high risk of suicide, showing a sharp and lasting increase in post volume during the pandemic. By contrast, most users (5419/6163, 87.93%) were categorized as being at low risk of suicide, with a consistently low and mild increase in post volume during the pandemic. In terms of the frequency of most linguistic features, both groups showed increases at the initial stage of the pandemic. Subsequently, the rising trend continued in the high-risk group before declining, while the low-risk group showed an immediate decrease. One year after the pandemic outbreak, the 2 groups exhibited differences in their use of words related to the categories of personal pronouns; affective, social, cognitive, and biological processes; drives; relativity; time orientations; and personal concerns. In particular, the high-risk group was discriminant in using words related to anger (odds ratio [OR] 3.23, P<.001), sadness (OR 3.23, P<.001), health (OR 2.56, P=.005), achievement (OR 1.67, P=.049), motion (OR 4.17, P<.001), future focus (OR 2.86, P<.001), and death (OR 4.35, P<.001) during this stage. Conclusions: Based on the 2 identified trajectories of post volume during the pandemic, this study divided users on the r/SuicideWatch subreddit into suicide high- and low-risk groups. Our findings indicated heterogeneous patterns of change in suicide risk in response to the pandemic. The high-risk group also demonstrated distinct linguistic features. We recommend conducting real-time surveillance of suicide risk using social media data during future public health crises to provide timely support to individuals at potentially high risk of suicide. %M 39115925 %R 10.2196/48907 %U https://www.jmir.org/2024/1/e48907 %U https://doi.org/10.2196/48907 %U http://www.ncbi.nlm.nih.gov/pubmed/39115925 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e46823 %T Using Discrete-Event Simulation to Model Web-Based Crisis Counseling Service Operation: Evaluation Study %A Chiang,Byron %A Law,Yik Wa %A Yip,Paul Siu Fai %+ Centre of Suicide Research and Prevention, University of Hong Kong, 2/F, The Hong Kong Jockey Club Building for Interdisciplinary Research, 5 Sassoon Rd, Pokfulam, Hong Kong, China (Hong Kong), 852 2831 5232, sfpyip@hku.hk %K discrete-event simulation %K community operational research %K queuing %K web-based counseling %K service management %K repeat users %D 2024 %7 7.8.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: According to the Organisation for Economic Co-operation and Development, its member states experienced worsening mental health during the COVID-19 pandemic, leading to an increase of 60% to 1000% in digital counseling access. Hong Kong, too, witnessed a surge in demand for crisis intervention services during the pandemic, attracting both nonrepeat and repeat service users during the process. As a result of the continuing demand, platforms offering short-term emotional support are facing an efficiency challenge in managing caller responses. Objective: This aim of this paper was to assess the queuing performance of a 24-hour text-based web-based crisis counseling platform using a Python-based discrete-event simulation (DES) model. The model evaluates the staff combinations needed to meet demand and informs service priority decisions. It is able to account for unbalanced and overlapping shifts, unequal simultaneous serving capacities among custom worker types, time-dependent user arrivals, and the influence of user type (nonrepeat users vs repeat users) and suicide risk on service durations. Methods: Use and queue statistics by user type and staffing conditions were tabulated from past counseling platform database records. After calculating the data distributions, key parameters were incorporated into the DES model to determine the supply-demand equilibrium and identify potential service bottlenecks. An unobserved-components time-series model was fitted to make 30-day forecasts of the arrival rate, with the results piped back to the DES model to estimate the number of workers needed to staff each work shift, as well as the number of repeat service users encountered during a service operation. Results: The results showed a marked increase (from 3401/9202, 36.96% to 5042/9199, 54.81%) in the overall conversion rate after the strategic deployment of human resources according to the values set in the simulations, with an 85% chance of queuing users receiving counseling service within 10 minutes and releasing an extra 39.57% (3631/9175) capacity to serve nonrepeat users at potential risk. Conclusions: By exploiting scientifically informed data models with DES, nonprofit web-based counseling platforms, even those with limited resources, can optimize service capacity strategically to manage service bottlenecks and increase service uptake. %M 39110974 %R 10.2196/46823 %U https://formative.jmir.org/2024/1/e46823 %U https://doi.org/10.2196/46823 %U http://www.ncbi.nlm.nih.gov/pubmed/39110974 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e59826 %T Beyond Step Count: Are We Ready to Use Digital Phenotyping to Make Actionable Individual Predictions in Psychiatry? %A Ortiz,Abigail %A Mulsant,Benoit H %+ Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, 8th Floor, 250 College Street, Toronto, ON, M5T 1R8, Canada, 1 416 979 6948, benoit.mulsant@utoronto.ca %K digital phenotype %K digital phenotyping %K prediction %K predictions %K mental health %K mental illness %K mental illnesses %K mental disorder %K mental disorders %K US National Institute of Mental Health %K NIMH %K psychiatry %K psychiatrist %K psychiatrists %D 2024 %7 5.8.2024 %9 Viewpoint %J J Med Internet Res %G English %X Some models for mental disorders or behaviors (eg, suicide) have been successfully developed, allowing predictions at the population level. However, current demographic and clinical variables are neither sensitive nor specific enough for making individual actionable clinical predictions. A major hope of the “Decade of the Brain” was that biological measures (biomarkers) would solve these issues and lead to precision psychiatry. However, as models are based on sociodemographic and clinical data, even when these biomarkers differ significantly between groups of patients and control participants, they are still neither sensitive nor specific enough to be applied to individual patients. Technological advances over the past decade offer a promising approach based on new measures that may be essential for understanding mental disorders and predicting their trajectories. Several new tools allow us to continuously monitor objective behavioral measures (eg, hours of sleep) and densely sample subjective measures (eg, mood). The promise of this approach, referred to as digital phenotyping, was recognized almost a decade ago, with its potential impact on psychiatry being compared to the impact of the microscope on biological sciences. However, despite the intuitive belief that collecting densely sampled data (big data) improves clinical outcomes, recent clinical trials have not shown that incorporating digital phenotyping improves clinical outcomes. This viewpoint provides a stepwise development and implementation approach, similar to the one that has been successful in the prediction and prevention of cardiovascular disease, to achieve clinically actionable predictions in psychiatry. %M 39102686 %R 10.2196/59826 %U https://www.jmir.org/2024/1/e59826 %U https://doi.org/10.2196/59826 %U http://www.ncbi.nlm.nih.gov/pubmed/39102686 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e52536 %T Decomposition Analysis of Depressive Symptom Differences Among Older Adults With Hypertension Between Urban and Rural Areas: Cross-Sectional Study %A Yuan,Lei %A Jiang,Qinqin %A Liu,Yuqing %A Liu,Yijun %A Du,Maolin %A Sun,Jinhai %A Li,Meina %K depression %K older %K hypertension %K Fairlie decomposition %K China %K older adult %K elderly %D 2024 %7 1.8.2024 %9 %J JMIR Public Health Surveill %G English %X Background: Hypertension is the most prevalent chronic disease among China’s older population, which comprises a growing proportion of the overall demographic. Older individuals with chronic diseases have a higher risk of developing depressive symptoms than their healthy counterparts, as evidenced in China’s older population, where patients with hypertension exhibit varying rates of depression depending on residing in urban or rural areas. Objective: This study aimed to investigate factors influencing and contributing to the disparities in depressive symptoms among older urban and rural patients with hypertension in China. Methods: We used a cross-sectional study design and derived data from the 8th Chinese Longitudinal Health Longevity Survey of 2018. The Fairlie model was applied to analyze the factors contributing to disparities in depressive symptoms between urban and rural older populations with hypertension. Results: The sample size for this study was 5210, and 12.8% (n=669) of participants exhibited depressive symptoms. The proportions of depressive symptoms in rural and urban areas were 14.1% (n=468) and 10.7% (n=201), respectively. In rural areas, years of education (1-6 years: odds ratio [OR] 0.68, 95% CI 1.10-1.21; ≥7 years: OR 0.47, 95% CI 0.24-0.94), alcohol consumption (yes: OR 0.52, 95% CI 0.29-0.93), exercise (yes: OR 0.78, 95% CI 0.56-1.08), and sleep duration (6.0-7.9 hours: OR 0.29, 95% CI 0.17-0.52; 8.0-9.9 hours: OR 0.24, 95% CI 0.13-0.43; ≥10.0 hours: OR 0.22, 95% CI 0.11-0.41) were protective factors against depressive symptoms in older adults with hypertension, while gender (female: OR 1.94, 95% CI 1.33-2.81), self-reported income status (poor: OR 3.07, 95% CI 2.16-4.37), and activities of daily living (ADL) dysfunction (mild: OR 1.69, 95% CI 1.11-2.58; severe: OR 3.03, 95% CI 1.46-6.32) were risk factors. In urban areas, age (90-99 years: OR 0.37, 95% CI 0.16-0.81; ≥100 years: OR 0.19, 95% CI 0.06-0.66), exercise (yes: OR 0.33, 95% CI 0.22-0.51), and sleep duration (6.0-7.9 hours: OR 0.27, 95% CI 0.10-0.71; 8.0-9.9 hours: OR 0.16, 95% CI 0.06-0.44; ≥10.0 hours: OR 0.18, 95% CI 0.06-0.57) were protective factors, while years of education (1-6 years: OR 1.91, 95% CI 1.05-3.49), self-reported income status (poor: OR 2.94, 95% CI 1.43-6.08), and ADL dysfunction (mild: OR 2.38, 95% CI 1.39-4.06; severe: OR 3.26, 95% CI 1.21-8.76) were risk factors. The Fairlie model revealed that 91.61% of differences in depressive symptoms could be explained by covariates, including years of education (contribution 63.1%), self-reported income status (contribution 13.2%), exercise (contribution 45.7%), sleep duration (contribution 20.8%), ADL dysfunction (contribution −9.6%), and comorbidities (contribution −22.9%). Conclusions: Older patients with hypertension in rural areas had more depressive symptoms than their counterparts residing in urban areas, which could be explained by years of education, self-reported income status, exercise, sleep duration, ADL dysfunction, and comorbidities. Factors influencing depressive symptoms had similarities regarding exercise, sleep duration, self-reported income status, and ADL dysfunction as well as differences regarding age, gender, years of education, and alcohol consumption. %R 10.2196/52536 %U https://publichealth.jmir.org/2024/1/e52536 %U https://doi.org/10.2196/52536 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e53562 %T Automated Behavioral Coding to Enhance the Effectiveness of Motivational Interviewing in a Chat-Based Suicide Prevention Helpline: Secondary Analysis of a Clinical Trial %A Pellemans,Mathijs %A Salmi,Salim %A Mérelle,Saskia %A Janssen,Wilco %A van der Mei,Rob %+ Department of Mathematics, Vrije Universiteit Amsterdam, De Boelelaan 1111, Amsterdam, 1081 HV, Netherlands, 31 20 5987700, m.j.pellemans@vu.nl %K motivational interviewing %K behavioral coding %K suicide prevention %K artificial intelligence %K effectiveness %K counseling %K support tool %K online help %K mental health %D 2024 %7 1.8.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: With the rise of computer science and artificial intelligence, analyzing large data sets promises enormous potential in gaining insights for developing and improving evidence-based health interventions. One such intervention is the counseling strategy motivational interviewing (MI), which has been found effective in improving a wide range of health-related behaviors. Despite the simplicity of its principles, MI can be a challenging skill to learn and requires expertise to apply effectively. Objective: This study aims to investigate the performance of artificial intelligence models in classifying MI behavior and explore the feasibility of using these models in online helplines for mental health as an automated support tool for counselors in clinical practice. Methods: We used a coded data set of 253 MI counseling chat sessions from the 113 Suicide Prevention helpline. With 23,982 messages coded with the MI Sequential Code for Observing Process Exchanges codebook, we trained and evaluated 4 machine learning models and 1 deep learning model to classify client- and counselor MI behavior based on language use. Results: The deep learning model BERTje outperformed all machine learning models, accurately predicting counselor behavior (accuracy=0.72, area under the curve [AUC]=0.95, Cohen κ=0.69). It differentiated MI congruent and incongruent counselor behavior (AUC=0.92, κ=0.65) and evocative and nonevocative language (AUC=0.92, κ=0.66). For client behavior, the model achieved an accuracy of 0.70 (AUC=0.89, κ=0.55). The model’s interpretable predictions discerned client change talk and sustain talk, counselor affirmations, and reflection types, facilitating valuable counselor feedback. Conclusions: The results of this study demonstrate that artificial intelligence techniques can accurately classify MI behavior, indicating their potential as a valuable tool for enhancing MI proficiency in online helplines for mental health. Provided that the data set size is sufficiently large with enough training samples for each behavioral code, these methods can be trained and applied to other domains and languages, offering a scalable and cost-effective way to evaluate MI adherence, accelerate behavioral coding, and provide therapists with personalized, quick, and objective feedback. %M 39088244 %R 10.2196/53562 %U https://www.jmir.org/2024/1/e53562 %U https://doi.org/10.2196/53562 %U http://www.ncbi.nlm.nih.gov/pubmed/39088244 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e52683 %T Secular Trends in Depressive Symptoms in Adolescents in Yunnan, Southwest China From Before COVID-19 to During the COVID-19 Pandemic: Longitudinal, Observational Study %A Yang,Yunjuan %A Zha,Shun %A Li,Tunan %+ Public Health School, Xi'an Jiaotong University, NO.76 Yanta West Road, Xi, 710061, China, 86 13116290467, yncdcyyj@126.com %K COVID-19 exposure %K depressive symptom %K adolescent %K epidemic trend %K prevalence %K observational study %K epidemic %K COVID-19 %K depression %K symptoms %K teen %K youth %K China %K mental health %K psychological %K logistic regression %K lifestyle intervention %D 2024 %7 31.7.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Yunnan province borders Myanmar, Laos, and Vietnam, giving it one of the longest borders in China. We aimed to determine the trends in prevalence and impact of COVID-19 on depressive symptoms among adolescents (12-18 years) from 2018 to 2022 in Yunnan, southwest China. Objective: We evaluated the impact of the COVID-19 epidemic on adolescents’ mental health, with the aim of reducing the effect of psychological emergency syndrome and promoting healthy, happy adolescent growth. Methods: This longitudinal, observational study used Students’ Health Survey data on adolescents’ depressive symptoms from 2018 to 2022 (before and during COVID-19) in Yunnan. We used multistage, stratified sampling in 3 prefectures in 2018 and 16 prefectures from 2019 to 2022. In each prefecture, the study population was classified by gender and residence (urban or rural), and each group was of equal size. Depressive symptoms were diagnosed based on Center for Epidemiological Studies Depression Scale (CES-D) scores. We used ANOVA to assess the differences in mean CES-D scores stratified by gender, age, residence, grade, and ethnicity. Chi-square tests were used to compare depressive symptoms by different variables. For comparability, the age-standard and gender-standard population prevalences were calculated using the 2010 China Census as the standard population. The association between COVID-19 and the risk of a standardized prevalence of depressive symptoms was identified using unconditional logistic regression analysis. Results: The standardized prevalence of depressive symptoms for all participants was 32.98%: 28.26% in 2018, 30.89% in 2019, 29.81% in 2020, 28.77% in 2021, 36.33% in 2022. The prevalences were 30.49% before COVID-19,29.29% in early COVID-19, and 36.33% during the COVID-19 pandemic. Compared with before COVID-19, the risks of depressive symptoms were 0.793 (95% CI 0.772-0.814) times higher in early COVID-19 and 1.071 (95% CI 1.042-1.100) times higher than during COVID-19. The average annual increase in depressive symptoms was 1.61%. During the epidemic, the prevalence of depressive symptoms in girls (36.87%) was higher than that in boys (28.64%), and the acceleration rate of girls was faster than that of boys. The prevalences of depressive symptoms and acceleration rates by age group were as follows: 27.14% and 1.09% (12-13 years), 33.99% and 1.8% (14-15 years), 36.59% and 1.65% (16-18 years). Prevalences did not differ between Han (32.89%) and minority (33.10%) populations. However, the acceleration rate was faster for the former than for the latter. The rate for senior high school students was the highest (34.94%). However, the acceleration rate for vocational high school students was the fastest (2.88%), followed by that for junior high school students (2.32%). Rural residents (35.10%) had a higher prevalence and faster acceleration than urban residents (30.16%). Conclusions: From 2018 to 2022, there was a significant, continuous increase in the prevalence of depressive symptoms among adolescents in Yunnan, China, especially during the COVID-19 pandemic. This represents an emergency public health problem that should be given more attention. Effective, comprehensive psychological and lifestyle intervention measures should be used to reduce the prevalence of mental health issues in adolescents. %M 39083344 %R 10.2196/52683 %U https://publichealth.jmir.org/2024/1/e52683 %U https://doi.org/10.2196/52683 %U http://www.ncbi.nlm.nih.gov/pubmed/39083344 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e54288 %T Measuring Population-Level Adolescent Mental Health Using a Single-Item Indicator of Experiences of Sadness and Hopelessness: Cross-Sectional Study %A Verlenden,Jorge %A Pampati,Sanjana %A Heim Viox,Melissa %A Brener,Nancy %A Licitis,Laima %A Dittus,Patricia %A Ethier,Kathleen %+ Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Chamblee Campus, 4770 Buford Highway, Atlanta, GA, 30341, United States, 1 404 498 6018, nlx7@cdc.gov %K adolescents %K mental health %K surveillance %K teens %K sadness %K hopelessness %D 2024 %7 26.7.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Population-level monitoring of adolescent mental health is a critical public health activity used to help define local, state, and federal priorities. The Youth Risk Behavior Surveillance System includes a single-item measure of experiences of sadness or hopelessness as an indicator of risk to mental health. In 2021, 42% of high school students reported having felt sad or hopeless for 2 weeks or more during the past 12 months. The high prevalence of US high school students with this experience has been highlighted in recent studies and media reports. Objective: This study seeks to examine associations between this single-item measure of experiences of sadness or hopelessness with other indicators of poor mental health including frequent mental distress and depressive symptoms. Methods: We analyzed survey data from a national sample of 737 adolescents aged 15-19 years as a part of the Teen and Parent Surveys of Health. Participants were recruited from AmeriSpeak, a probability-based panel designed to be representative of the US household population. Feeling sad or hopeless was operationalized as a “yes” response to the item, “During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?” Unadjusted and adjusted prevalence ratios (aPRs) were calculated to examine associations between the single-item measure of having felt sad or hopeless almost every day for 2 weeks with moderate to severe depressive symptoms, frequent mental distress, and functional limitation due to poor mental health. Adjusted models controlled for age, race and ethnicity, sex assigned at birth, and sexual identity. Results: Overall, 17.3% (unweighted: 138/735) of adolescents reported that they felt sad or hopeless for 2 weeks or more during the past 12 months, 30.2% (unweighted: 204/716) reported moderate to severe depressive symptoms, 18.4% (unweighted: 126/732) reported frequent mental distress, and 15.4% (unweighted: 107/735) reported functional limitation due to poor mental health. After adjusting for demographics, adolescents who reported that they felt sad or hopeless for 2 weeks or more were 3.3 times as likely to report moderate to severe depressive symptoms (aPR 3.28, 95% CI 2.39-4.50), 4.8 times as likely to indicate frequent mental distress (aPR 4.75, 95% CI 2.92-7.74), and 7.8 times as likely to indicate mental health usually or always interfered with their ability to do things (aPR 7.78, 95% CI 4.88-12.41). Conclusions: Associations between having felt sad or hopeless for 2 weeks or more and moderate to severe depressive symptoms, frequent mental distress, and functional limitation due to poor mental health suggest the single-item indicator may represent relevant symptoms associated with poor mental health and be associated with unmet health needs. Findings suggest the single-item indicator provides a population-level snapshot of adolescent experiences of poor mental health. %M 39059010 %R 10.2196/54288 %U https://formative.jmir.org/2024/1/e54288 %U https://doi.org/10.2196/54288 %U http://www.ncbi.nlm.nih.gov/pubmed/39059010 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e53404 %T Association Between Prosuicide Website Searches Through Google and Suicide Death in the United States From 2010 to 2021: Lagged Time-Series Analysis %A Kelsall,Nora Clancy %A Gimbrone,Catherine %A Olfson,Mark %A Gould,Madelyn S %A Shaman,Jeffrey %A Keyes,Katherine %+ Department of Epidemiology, Columbia University, 722 West 168th Street, Room 733, New York, NY, 10032, United States, 1 2023600113, nk3067@cumc.columbia.edu %K pro-suicide forum %K suicide %K google search %K social media %K online forum %K internet search %K death %K United States %K suicide death %K forum %K analysis %K association %K poisoning %K suffocation %D 2024 %7 26.7.2024 %9 Original Paper %J J Med Internet Res %G English %X Background:  The rate of suicide death has been increasing, making understanding risk factors of growing importance. While exposure to explicit suicide-related media, such as description of means in news reports or sensationalized fictional portrayal, is known to increase population suicide rates, it is not known whether prosuicide website forums, which often promote or facilitate information about fatal suicide means, are related to change in suicide deaths overall or by specific means. Objective:  This study aimed to estimate the association of the frequency of Google searches of known prosuicide web forums and content with death by suicide over time in the United States, by age, sex, and means of death. Methods:  National monthly Google search data for names of common prosuicide websites between January 2010 and December 2021 were extracted from Google Health Trends API (application programming interface). Suicide deaths were identified using the CDC (Centers for Disease Control and Prevention) National Vital Statistics System (NVSS), and 3 primary means of death were identified (poisoning, suffocation, and firearm). Distributed lag nonlinear models (DLNMs) were then used to estimate the lagged association between the number of Google searches on suicide mortality, stratified by age, sex, and means, and adjusted for month. Sensitivity analyses, including using autoregressive integrated moving average (ARIMA) modeling approaches, were also conducted. Results:  Months in the United States in which search rates for prosuicide websites increased had more documented deaths by intentional poisoning and suffocation among both adolescents and adults. For example, the risk of poisoning suicide among youth and young adults (age 10-24 years) was 1.79 (95% CI 1.06-3.03) times higher in months with 22 searches per 10 million as compared to 0 searches. The risk of poisoning suicide among adults aged 25-64 was 1.10 (95% CI 1.03-1.16) times higher 1 month after searches reached 9 per 10 million compared with 0 searches. We also observed that increased search rates were associated with fewer youth suicide deaths by firearms with a 3-month time lag for adolescents. These models were robust to sensitivity tests. Conclusions:  Although more analysis is needed, the findings are suggestive of an association between increased prosuicide website access and increased suicide deaths, specifically deaths by poisoning and suffocation. These findings emphasize the need to further investigate sites containing potentially dangerous information and their associations with deaths by suicide, as they may affect vulnerable individuals. %M 39059004 %R 10.2196/53404 %U https://www.jmir.org/2024/1/e53404 %U https://doi.org/10.2196/53404 %U http://www.ncbi.nlm.nih.gov/pubmed/39059004 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e57938 %T Changes in the Frequency of Actions Associated With Mental Health During Online Treatment: Analysis of Demographic and Clinical Factors %A Bisby,Madelyne %A Staples,Lauren %A Dear,Blake %A Titov,Nickolai %+ MindSpot Clinic, MQ Health, Macquarie University, 16 University Avenue, Sydney, 2109, Australia, 61 298508724, madelyne.bisby@mq.edu.au %K anxiety %K depression %K daily actions %K treatments %K personalization %K mental health %K digital treatment %K analysis %K clinical factors %K questionnaire %K depression symptoms %K anxiety symptoms %K patients %K Australian %K Australia %K digital psychology service %K psychology %K symptom severity %K severity %D 2024 %7 25.7.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Specific daily actions (eg, goal setting, meaningful activities) are associated with mental health. Performing specific daily actions at a higher frequency is associated with significantly lower baseline symptoms of depression and anxiety, as well as better psychological treatment outcomes for depression and anxiety. Objective: This study explored how the frequency of specific daily actions associated with mental health may differ prior to, during, and following treatment according to demographic and clinical characteristics. Methods: Using a sample of 448 patients from an Australian national digital psychology service, we examined baseline differences in daily action frequency and changes in daily action frequency during a digital psychological treatment according to demographic and clinical subgroups. A total of 5 specific types of daily actions were measured using the Things You Do Questionnaire: healthy thinking, meaningful activities, goals and plans, healthy habits, and social connections. Results: The frequency of daily actions differed according to employment status (largest P=.005) and educational level (largest P=.004). Daily action frequency was lower in those participants with more severe or chronic depression or anxiety symptoms (largest P=.004). Participants reported larger increases in how often they did these daily actions from baseline to midtreatment compared to mid- to posttreatment. Depression duration (P=.01) and severity (P<.001) were associated with differences in how daily action frequency changed during treatment. Conclusions: The findings of this study support continued research exploring the relationship between daily actions and mental health, how this relationship might differ between individuals, and the clinical potential of supporting individuals to increase the frequency of daily actions to improve mental health. %M 39052998 %R 10.2196/57938 %U https://formative.jmir.org/2024/1/e57938 %U https://doi.org/10.2196/57938 %U http://www.ncbi.nlm.nih.gov/pubmed/39052998 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e58263 %T Digitally Enabled Peer Support and Social Health Platform for Vulnerable Adults With Loneliness and Symptomatic Mental Illness: Cohort Analysis %A Bravata,Dena %A Russell,Daniel %A Fellows,Annette %A Goldman,Ron %A Pace,Elizabeth %+ Center for Primary Care and Outcomes Research, Stanford University, 1840 Lexington Av, San Mateo, CA, 94402, United States, 1 4157065829, dbravata@gmail.com %K peer support %K social isolation %K loneliness %K depression %K depressive %K mental health %K anxiety %K quality of life %K isolation %K isolated %K online support %K digital health %K vulnerable %K race %K racial ethnic %K ethnicity %K gender %K socioeconomic %K demographic %D 2024 %7 24.7.2024 %9 Research Letter %J JMIR Form Res %G English %X This study prospectively evaluated the effects of digitally enabled peer support on mental health outcomes and estimated medical cost reductions among vulnerable adults with symptomatic depression, anxiety, and significant loneliness to address the mental health crisis in the United States. %M 38941568 %R 10.2196/58263 %U https://formative.jmir.org/2024/1/e58263 %U https://doi.org/10.2196/58263 %U http://www.ncbi.nlm.nih.gov/pubmed/38941568 %0 Journal Article %@ 2369-2960 %I %V 10 %N %P e48355 %T The Effect of Walking on Depressive and Anxiety Symptoms: Systematic Review and Meta-Analysis %A Xu,Zijun %A Zheng,Xiaoxiang %A Ding,Hanyue %A Zhang,Dexing %A Cheung,Peter Man-Hin %A Yang,Zuyao %A Tam,King Wa %A Zhou,Weiju %A Chan,Dicken Cheong-Chun %A Wang,Wenyue %A Wong,Samuel Yeung-Shan %K walking %K depression %K anxiety %K systematic review %K meta-analysis %D 2024 %7 23.7.2024 %9 %J JMIR Public Health Surveill %G English %X Background: Previous literature lacks summative information on the mental health benefits achieved from different forms of walking. Objective: The aim of this study was to assess the effectiveness of different forms of walking in reducing symptoms of depression and anxiety. Methods: This was a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the effects of walking on depressive and anxiety symptoms. MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, PsycINFO, Allied and Complementary Medicine Database (AMED), CINAHL, and Web of Science were searched on April 5, 2022. Two authors independently screened the studies and extracted the data. Random-effects meta-analysis was used to synthesize the data. Results were summarized as standardized mean differences (SMDs) with 95% CIs in forest plots. The risk of bias was assessed by using the Cochrane Risk of Bias tool. Results: This review included 75 RCTs with 8636 participants; 68 studies reported depressive symptoms, 39 reported anxiety symptoms, and 32 reported both as the outcomes. One study reported the results for adolescents and was not included in the meta-analysis. The pooled results for adults indicated that walking could significantly reduce depressive symptoms (RCTs: n=44; SMD −0.591, 95% CI −0.778 to −0.403; I2=84.8%; τ2=0.3008; P<.001) and anxiety symptoms (RCTs: n=26; SMD −0.446, 95% CI −0.628 to −0.265; I2=81.1%; τ2=0.1530; P<.001) when compared with the inactive controls. Walking could significantly reduce depressive or anxiety symptoms in most subgroups, including different walking frequency, duration, location (indoor or outdoor), and format (group or individual) subgroups (all P values were <.05). Adult participants who were depressed (RCTs: n=5; SMD −1.863, 95% CI −2.764 to −0.962; I2=86.4%; τ2=0.8929) and those who were not depressed (RCTs: n=39; SMD −0.442, 95% CI −0.604 to −0.280; I2=77.5%; τ2=0.1742) could benefit from walking effects on their depressive symptoms, and participants who were depressed could benefit more (P=.002). In addition, there was no significant difference between walking and active controls in reducing depressive symptoms (RCTs: n=17; SMD −0.126, 95% CI −0.343 to 0.092; I2=58%; τ2=0.1058; P=.26) and anxiety symptoms (14 RCTs, SMD −0.053, 95% CI −0.311 to 0.206, I2=67.7%, τ2=0.1421; P=.69). Conclusions: Various forms of walking can be effective in reducing symptoms of depression and anxiety, and the effects of walking are comparable to active controls. Walking can be adopted as an evidence-based intervention for reducing depression and anxiety. More evidence on the effect of low-intensity walking is needed in the future. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021247983; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=247983 %R 10.2196/48355 %U https://publichealth.jmir.org/2024/1/e48355 %U https://doi.org/10.2196/48355 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e54272 %T Technology-Assisted Mental Health Intervention Delivered by Frontline Workers at Community Doorsteps for Reducing Anxiety and Depression in Rural Pakistan: Protocol for the mPareshan Mixed Methods Implementation Trial %A Rabbani,Fauziah %A Nafis,Javeria %A Akhtar,Samina %A Khan,Muhammad Shahid %A Sayani,Saleem %A Siddiqui,Amna %A Siddiqi,Sameen %A Merali,Zul %+ Department of Community Health Sciences, Aga Khan University, Stadium Road, Karachi, 3500, Pakistan, 92 2134864864, fauziah.Rabbani@aku.edu %K anxiety %K depression %K feasibility %K mental health %K health workers %K mPareshan app %K implementation research %D 2024 %7 23.7.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is a dearth of specialized mental health workforce in low- and middle-income countries. Use of mobile technology by frontline community health workers (CHWs) is gaining momentum in Pakistan and needs to be explored as an alternate strategy to improve mental well-being. Objective: The aim of this study is to assess the feasibility, acceptability, and usefulness of an app-based counseling intervention delivered by government lady health workers (LHWs) to reduce anxiety and depression in rural Pakistan. Methods: Project mPareshan is a single-arm, pre- and posttest implementation research trial in Badin District, Sindh, using mixed methods of data collection executed in 3 phases (preintervention, intervention, and postintervention). In the preintervention phase, formative qualitative assessments through focus group discussions and in-depth interviews assess the acceptability and appropriateness of intervention through perceptions of all concerned stakeholders using a specific interview guide. A REDCap (Research Electronic Data Capture)-based baseline survey using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 Scale (GAD-7) determines the point prevalence of depression and anxiety among consenting men and women older than 18 years. Individuals with mild and moderate anxiety and depression are identified as screen positives (SPs) and are eligible for mPareshan app–based intervention. Mental health literacy of health workers is improved through customized training adapting the World Health Organization’s Mental Health Gap Action Programme guide 2.0. The intervention (mPareshan app) consists of tracking, counseling, and referral segments. The tracking segment facilitates participant consent and enrollment while the referral segment is used by LHWs to transfer severe cases to the next level of specialist care. Through the counseling segment, identified SPs are engaged during LHWs’ routine home visits in 6 face-to-face 20-minute counseling sessions over 6 months. Each session imparts psychoeducation through audiovisual aids, breathing exercises, and coping skills to reduce stress. Clinical and implementation outcomes include change in mean anxiety and depression scores and identification of facilitators and barriers in intervention uptake and rollout. Results: At the time of this submission (April 2024), we are analyzing the results of 366 individuals who participated in the baseline prevalence survey, the change in knowledge and skills of 72 health workers who took the mPareshan training, change in anxiety and depression scores of 98 SPs recruited for app-based counseling intervention, and perceptions of stakeholders pre- and postintervention gathered through 8 focus group discussions and 18 in-depth interviews. Conclusions: This trial will assess the feasibility of early home-based mental health screening, counseling, and prompt referrals by frontline health workers to reduce anxiety and depression in the community. The study findings will set the stage for integrating mental health into primary health care. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12622000989741; https://tinyurl.com/5n844c8z International Registered Report Identifier (IRRID): DERR1-10.2196/54272 %M 39042878 %R 10.2196/54272 %U https://www.researchprotocols.org/2024/1/e54272 %U https://doi.org/10.2196/54272 %U http://www.ncbi.nlm.nih.gov/pubmed/39042878 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e57804 %T Measurement of Daily Actions Associated With Mental Health Using the Things You Do Questionnaire–15-Item: Questionnaire Development and Validation Study %A Bisby,Madelyne A %A Jones,Michael P %A Staples,Lauren %A Dear,Blake %A Titov,Nickolai %+ MindSpot Clinic, MQ Health, Macquarie University, 16 University Avenue, Macquarie Park, 2109, Australia, 61 298508724, madelyne.bisby@mq.edu.au %K daily actions %K depression %K anxiety %K psychometric %K mental health %K questionnaire %K activities %K goals %K plans %K healthy habits %K habits %K psychometric %K treatment-seeking %K treatment %K confirmatory factor analysis %K survey %K adult %K adult %K assessment %K digital psychology service %K digital %K psychology %K depression symptoms %K anxiety symptoms %D 2024 %7 22.7.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: A large number of modifiable and measurable daily actions are thought to impact mental health. The “Things You Do” refers to 5 types of daily actions that have been associated with mental health: healthy thinking, meaningful activities, goals and plans, healthy habits, and social connections. Previous studies have reported the psychometric properties of the Things You Do Questionnaire (TYDQ)–21-item (TYDQ21). The 21-item version, however, has an uneven distribution of items across the 5 aforementioned factors and may be lengthy to administer on a regular basis. Objective: This study aimed to develop and evaluate a brief version of the TYDQ. To accomplish this, we identified the top 10 and 15 items on the TYDQ21 and then evaluated the performance of the 10-item and 15-item versions of the TYDQ in community and treatment-seeking samples. Methods: Using confirmatory factor analysis, the top 2 or 3 items were used to develop the 10-item and 15-item versions, respectively. Model fit, reliability, and validity were examined for both versions in 2 samples: a survey of community adults (n=6070) and adults who completed an assessment at a digital psychology service (n=14,878). Treatment responsivity was examined in a subgroup of participants (n=448). Results: Parallel analysis supported the 5-factor structure of the TYDQ. The brief (10-item and 15-item) versions were associated with better model fit than the 21-item version, as revealed by its comparative fit index, root-mean-square error of approximation, and Tucker-Lewis index. Configural, metric, and scalar invariance were supported. The 15-item version explained more variance in the 21-item scores than the 10-item version. Internal consistency was appropriate (eg, the 15-item version had a Cronbach α of >0.90 in both samples) and there were no marked differences between how the brief versions correlated with validated measures of depression or anxiety symptoms. The measure was responsive to treatment. Conclusions: The 15-item version is appropriate for use as a brief measure of daily actions associated with mental health while balancing brevity and clinical utility. Further research is encouraged to replicate our psychometric evaluation in other settings (eg, face-to-face services). Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12613000407796; https://tinyurl.com/2s67a6ps %M 39038286 %R 10.2196/57804 %U https://formative.jmir.org/2024/1/e57804 %U https://doi.org/10.2196/57804 %U http://www.ncbi.nlm.nih.gov/pubmed/39038286 %0 Journal Article %@ 2562-7600 %I JMIR Publications %V 7 %N %P e54810 %T Identifying Depression Through Machine Learning Analysis of Omics Data: Scoping Review %A Taylor,Brittany %A Hobensack,Mollie %A Niño de Rivera,Stephanie %A Zhao,Yihong %A Masterson Creber,Ruth %A Cato,Kenrick %+ School of Nursing, Columbia University, 560 W 168th St, New York, NY, 10032, United States, 1 2123424172, bt2542@cumc.columbia.edu %K machine learning %K depression %K omics %K review %K mental health %K nurses %D 2024 %7 19.7.2024 %9 Review %J JMIR Nursing %G English %X Background: Depression is one of the most common mental disorders that affects >300 million people worldwide. There is a shortage of providers trained in the provision of mental health care, and the nursing workforce is essential in filling this gap. The diagnosis of depression relies heavily on self-reported symptoms and clinical interviews, which are subject to implicit biases. The omics methods, including genomics, transcriptomics, epigenomics, and microbiomics, are novel methods for identifying the biological underpinnings of depression. Machine learning is used to analyze genomic data that includes large, heterogeneous, and multidimensional data sets. Objective: This scoping review aims to review the existing literature on machine learning methods for omics data analysis to identify individuals with depression, with the goal of providing insight into alternative objective and driven insights into the diagnostic process for depression. Methods: This scoping review was reported following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. Searches were conducted in 3 databases to identify relevant publications. A total of 3 independent researchers performed screening, and discrepancies were resolved by consensus. Critical appraisal was performed using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies. Results: The screening process identified 15 relevant papers. The omics methods included genomics, transcriptomics, epigenomics, multiomics, and microbiomics, and machine learning methods included random forest, support vector machine, k-nearest neighbor, and artificial neural network. Conclusions: The findings of this scoping review indicate that the omics methods had similar performance in identifying omics variants associated with depression. All machine learning methods performed well based on their performance metrics. When variants in omics data are associated with an increased risk of depression, the important next step is for clinicians, especially nurses, to assess individuals for symptoms of depression and provide a diagnosis and any necessary treatment. %M 39028994 %R 10.2196/54810 %U https://nursing.jmir.org/2024/1/e54810 %U https://doi.org/10.2196/54810 %U http://www.ncbi.nlm.nih.gov/pubmed/39028994 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e55094 %T Wearable Data From Subjects Playing Super Mario, Taking University Exams, or Performing Physical Exercise Help Detect Acute Mood Disorder Episodes via Self-Supervised Learning: Prospective, Exploratory, Observational Study %A Corponi,Filippo %A Li,Bryan M %A Anmella,Gerard %A Valenzuela-Pascual,Clàudia %A Mas,Ariadna %A Pacchiarotti,Isabella %A Valentí,Marc %A Grande,Iria %A Benabarre,Antoni %A Garriga,Marina %A Vieta,Eduard %A Young,Allan H %A Lawrie,Stephen M %A Whalley,Heather C %A Hidalgo-Mazzei,Diego %A Vergari,Antonio %+ School of Informatics, University of Edinburgh, Informatics Forum, 10 Crichton St, Newington, Edinburgh, EH89AB, United Kingdom, 44 131 651 5661, filippo.corponi@ed.ac.uk %K mood disorder %K time-series classification %K wearable %K personal sensing %K deep learning %K self-supervised learning %K transformer %D 2024 %7 17.7.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Personal sensing, leveraging data passively and near-continuously collected with wearables from patients in their ecological environment, is a promising paradigm to monitor mood disorders (MDs), a major determinant of the worldwide disease burden. However, collecting and annotating wearable data is resource intensive. Studies of this kind can thus typically afford to recruit only a few dozen patients. This constitutes one of the major obstacles to applying modern supervised machine learning techniques to MD detection. Objective: In this paper, we overcame this data bottleneck and advanced the detection of acute MD episodes from wearables’ data on the back of recent advances in self-supervised learning (SSL). This approach leverages unlabeled data to learn representations during pretraining, subsequently exploited for a supervised task. Methods: We collected open access data sets recording with the Empatica E4 wristband spanning different, unrelated to MD monitoring, personal sensing tasks—from emotion recognition in Super Mario players to stress detection in undergraduates—and devised a preprocessing pipeline performing on-/off-body detection, sleep/wake detection, segmentation, and (optionally) feature extraction. With 161 E4-recorded subjects, we introduced E4SelfLearning, the largest-to-date open access collection, and its preprocessing pipeline. We developed a novel E4-tailored transformer (E4mer) architecture, serving as the blueprint for both SSL and fully supervised learning; we assessed whether and under which conditions self-supervised pretraining led to an improvement over fully supervised baselines (ie, the fully supervised E4mer and pre–deep learning algorithms) in detecting acute MD episodes from recording segments taken in 64 (n=32, 50%, acute, n=32, 50%, stable) patients. Results: SSL significantly outperformed fully supervised pipelines using either our novel E4mer or extreme gradient boosting (XGBoost): n=3353 (81.23%) against n=3110 (75.35%; E4mer) and n=2973 (72.02%; XGBoost) correctly classified recording segments from a total of 4128 segments. SSL performance was strongly associated with the specific surrogate task used for pretraining, as well as with unlabeled data availability. Conclusions: We showed that SSL, a paradigm where a model is pretrained on unlabeled data with no need for human annotations before deployment on the supervised target task of interest, helps overcome the annotation bottleneck; the choice of the pretraining surrogate task and the size of unlabeled data for pretraining are key determinants of SSL success. We introduced E4mer, which can be used for SSL, and shared the E4SelfLearning collection, along with its preprocessing pipeline, which can foster and expedite future research into SSL for personal sensing. %M 39018100 %R 10.2196/55094 %U https://mhealth.jmir.org/2024/1/e55094 %U https://doi.org/10.2196/55094 %U http://www.ncbi.nlm.nih.gov/pubmed/39018100 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e43931 %T Identifying Person-Specific Drivers of Depression in Adolescents: Protocol for a Smartphone-Based Ecological Momentary Assessment and Passive Sensing Study %A Ng,Mei Yi %A Frederick,Jennifer A %A Fisher,Aaron J %A Allen,Nicholas B %A Pettit,Jeremy W %A McMakin,Dana L %+ Department of Psychology and Center for Children and Families, Florida International University, 11200 SW 8th St AHC4-457, Miami, FL, 33199, United States, 1 305 348 9920, meiyi.ng@fiu.edu %K adolescents %K depression %K idiographic assessment %K network modeling %K treatment personalization %K ecological momentary assessment %K mobile sensing %K digital phenotyping %K actigraphy %K smartphones %D 2024 %7 16.7.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Adolescence is marked by an increasing risk of depression and is an optimal window for prevention and early intervention. Personalizing interventions may be one way to maximize therapeutic benefit, especially given the marked heterogeneity in depressive presentations. However, empirical evidence that can guide personalized intervention for youth is lacking. Identifying person-specific symptom drivers during adolescence could improve outcomes by accounting for both developmental and individual differences. Objective: This study leverages adolescents’ everyday smartphone use to investigate person-specific drivers of depression and validate smartphone-based mobile sensing data against established ambulatory methods. We describe the methods of this study and provide an update on its status. After data collection is completed, we will address three specific aims: (1) identify idiographic drivers of dynamic variability in depressive symptoms, (2) test the validity of mobile sensing against ecological momentary assessment (EMA) and actigraphy for identifying these drivers, and (3) explore adolescent baseline characteristics as predictors of these drivers. Methods: A total of 50 adolescents with elevated symptoms of depression will participate in 28 days of (1) smartphone-based EMA assessing depressive symptoms, processes, affect, and sleep; (2) mobile sensing of mobility, physical activity, sleep, natural language use in typed interpersonal communication, screen-on time, and call frequency and duration using the Effortless Assessment of Risk States smartphone app; and (3) wrist actigraphy of physical activity and sleep. Adolescents and caregivers will complete developmental and clinical measures at baseline, as well as user feedback interviews at follow-up. Idiographic, within-subject networks of EMA symptoms will be modeled to identify each adolescent’s person-specific drivers of depression. Correlations among EMA, mobile sensor, and actigraph measures of sleep, physical, and social activity will be used to assess the validity of mobile sensing for identifying person-specific drivers. Data-driven analyses of mobile sensor variables predicting core depressive symptoms (self-reported mood and anhedonia) will also be used to assess the validity of mobile sensing for identifying drivers. Finally, between-subject baseline characteristics will be explored as predictors of person-specific drivers. Results: As of October 2023, 84 families were screened as eligible, of whom 70% (n=59) provided informed consent and 46% (n=39) met all inclusion criteria after completing baseline assessment. Of the 39 included families, 85% (n=33) completed the 28-day smartphone and actigraph data collection period and follow-up study visit. Conclusions: This study leverages depressed adolescents’ everyday smartphone use to identify person-specific drivers of adolescent depression and to assess the validity of mobile sensing for identifying these drivers. The findings are expected to offer novel insights into the structure and dynamics of depressive symptomatology during a sensitive period of development and to inform future development of a scalable, low-burden smartphone-based tool that can guide personalized treatment decisions for depressed adolescents. International Registered Report Identifier (IRRID): DERR1-10.2196/43931 %M 39012691 %R 10.2196/43931 %U https://www.researchprotocols.org/2024/1/e43931 %U https://doi.org/10.2196/43931 %U http://www.ncbi.nlm.nih.gov/pubmed/39012691 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51506 %T Needs Expressed in Peer-to-Peer Web-Based Interactions Among People With Depression and Anxiety Disorders Hospitalized in a Mental Health Facility: Mixed Methods Study %A Storman,Dawid %A Jemioło,Paweł %A Sawiec,Zuzanna %A Swierz,Mateusz Jan %A Antonowicz,Ewa %A Bala,Malgorzata M %A Prokop-Dorner,Anna %+ Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Kopernika 7, Kraków, 31-034, Poland, 48 124223720, dawid.storman@uj.edu.pl %K anxiety disorders %K depression %K peer-to-peer web-based interactions %K needs %K psychiatric hospitalization %D 2024 %7 12.7.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Hospitalization in psychiatric wards is a necessary step for many individuals experiencing severe mental health issues. However, being hospitalized can also be a stressful and unsettling experience. It is crucial to understand and address the various needs of hospitalized individuals with psychiatric disorders to promote their overall well-being and support their recovery. Objective: Our objectives were to identify and describe individual needs related to mental hospitals through peer-to-peer interactions on Polish web-based forums among individuals with depression and anxiety disorders and to assess whether these needs were addressed by peers. Methods: We conducted a search of web-based forums focused on depression and anxiety and selected samples of 160 and 176 posts, respectively, until we reached saturation. A mixed methods analysis that included an in-depth content analysis, the Pearson χ2 test, and φ coefficient was used to evaluate the posts. Results: The most frequently identified needs were the same for depression and anxiety forums and involved informational (105/160, 65.6% and 169/393, 43%, respectively), social life (17/160, 10.6% and 90/393, 22.9%, respectively), and emotional (9/160, 5.6% and 66/393, 16.8%, respectively) needs. The results show that there is no difference in the expression of needs between the analyzed forums. The needs were directly (42/47, 89% vs 98/110, 89.1% of times for depression and anxiety, respectively) and not fully (27/47, 57% vs 86/110, 78.2% of times for depression and anxiety, respectively) addressed by forum users. In quantitative analysis, we found that depression-related forums had more posts about the need for informational support and rectification, the expression of anger, and seeking professional support. By contrast, anxiety-related forums had more posts about the need for emotional support; social life; and information concerning medications, hope, and motivation. The most common co-occurrence of expressed needs was between sharing own experience and the need for professional support, with a strong positive association. The qualitative analysis showed that users join web-based communities to discuss their fears and questions about psychiatric hospitals. The posts revealed 4 mental and emotional representations of psychiatric hospitals: the hospital as an unknown place, the ambivalence of presumptions and needs, the negative representation of psychiatric hospitals, and the people associated with psychiatric hospitals. The tone of the posts was mostly negative, with discussions revolving around negative stereotypes; traumatic experiences; and beliefs that increased anxiety, shock, and fright and deterred users from hospitalization. Conclusions: Our study demonstrates that web-based forums can provide a platform for individuals with depression and anxiety disorders to express a wide range of needs. Most needs were addressed by peers but not sufficiently. Mental health professionals can benefit from these findings by gaining insights into the unique needs and concerns of their patients, thus allowing for more effective treatment and support. %R 10.2196/51506 %U https://www.jmir.org/2024/1/e51506 %U https://doi.org/10.2196/51506 %0 Journal Article %@ 2562-0959 %I JMIR Publications %V 7 %N %P e60686 %T Assessing the Relationship Between Vitiligo and Major Depressive Disorder Severity: Cross-Sectional Study %A Molla,Amr %A Jannadi,Raed %A Alayoubi,Hamza %A Altouri,Haya %A Balkhair,Maryam %A Hafez,Dareen %+ Department of Medicine, College of Medicine, Taibah University, Universities Road, P.O. Box: 344, Taibah, Madinah, 42353, Saudi Arabia, 966 504342992, molladerm@outlook.com %K vitiligo %K major depressive disorder (MDD) %K PHQ-9 %K Patient Health Questionnaire-9 %K depression severity %K Saudi Arabia %K cross-sectional study %D 2024 %7 12.7.2024 %9 Original Paper %J JMIR Dermatol %G English %X Background: Vitiligo, a common dermatological disorder in Saudi Arabia, is associated with significant psychological impacts. This study explores the relationship between vitiligo and the severity of major depressive disorder (MDD), highlighting the broader implications on mental health among affected individuals. Objective: We aim to assess the prevalence and predictors of depression among adult patients with vitiligo, and to examine the relationship between MDD severity and vitiligo. Methods: Using a cross-sectional design, the research used the vitiligo area severity index and the Patient Health Questionnaire-9 to measure the extent of vitiligo and depression severity, respectively. This study involved 340 diagnosed patients with vitiligo from various health care settings. Logistic and ordinal regression analysis were applied to evaluate the impact of sociodemographic variables and vitiligo types on MDD severity. Results: The prevalence of MDD was 58.8% (200/340) of participants. Depression severity varied notably: 18.2% (62/340) of patients experienced mild depression, 17.9% (61/340) moderate, 11.8% (40/340) moderately severe, and 10.9% (37/340) severe depression. Female patients had higher odds of severe depression than male patients (adjusted odds ratio [aOR] 3.14, 95% CI 1.93-5.1; P<.001). Age was inversely related to depression severity, with patients aged older than 60 years showing significantly lower odds (aOR 0.1, 95% CI 0.03-0.39; P<.001). Lower income was associated with higher depression severity (aOR 10.2, 95% CI 3.25-31.8; P<.001). Vitiligo types also influenced depression severity; vulgaris (aOR 5.3, 95% CI 2.6-10.9; P<.001) and acrofacial vitiligo (aOR 2.8, 95% CI 1.5-5.1; P<.001) were significantly associated with higher depression levels compared to focal vitiligo. Conclusions: The findings suggest that vitiligo contributes to an increased risk of severe depression, highlighting the need for integrated dermatological and psychological treatment approaches to address both the physical and mental health aspects of the disease. %M 38888950 %R 10.2196/60686 %U https://derma.jmir.org/2024/1/e60686 %U https://doi.org/10.2196/60686 %U http://www.ncbi.nlm.nih.gov/pubmed/38888950 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 13 %N %P e48396 %T The Association Between Depressive Symptoms and the Weekly Duration of Physical Activity Subset by Intensity and Domain: Population-Based, Cross-Sectional Analysis of the National Health and Nutrition Examination Survey From 2007 to 2018 %A Boparai,Josheil K %A Dunnett,Sarah %A Wu,Michelle %A Tassone,Vanessa K %A Duffy,Sophie F %A Zuluaga Cuartas,Valentina %A Chen,Ziming %A Jung,Hyejung %A Sabiston,Catherine M %A Lou,Wendy %A Bhat,Venkat %+ Interventional Psychiatry Program, St. Michael's Hospital, 193 Yonge Street, Floor Number 6-013, Toronto, ON, M5B1M8, Canada, 1 4163604000 ext 76404, venkat.bhat@utoronto.ca %K depressive disorder %K exercise %K physical activity intensity %K recreational physical activity %K work-related physical activity %K National Health and Nutrition Examination Survey %K NHANES %K nutrition surveys %K recreational activity %K physical activity %K depression %D 2024 %7 5.7.2024 %9 Original Paper %J Interact J Med Res %G English %X Background: Prior literature suggests a dose-response relationship between physical activity (PA) and depressive symptoms. The intensity and domain of PA are suggested to be critical to its protective effect against depression; however, existing literature has shown mixed results. Objective: The purpose of this population-based study is to examine the associations between depressive symptoms and weekly duration of (1) total PA and (2) PA subset by intensity, domain, or both. Methods: A cross-sectional analysis of National Health and Nutrition Examination Survey data from 2007 to 2018 was conducted using multivariable logistic and linear regression models and survey weights. Participants (N=29,730) were 20 years and older and completed the Physical Activity Questionnaire and Depression Screener. The primary outcome was the presence of depressive symptoms, and the secondary outcomes were cognitive-affective and somatic symptoms of depression. Results: Participants (N=29,730) had a weighted mean age of 47.62 (SD 16.99) years, and 15,133 (51.34%) were female. On average, participants without depressive symptoms engaged in 10.87 hours of total PA per week, whereas participants with depressive symptoms engaged in 8.82 hours (P<.001). No significant associations were seen between the weekly duration of total PA and depressive symptom odds, somatic, or cognitive-affective symptoms (all P>.05). Participants with an increased weekly duration of recreational PA had decreases in depressive symptom odds (adjusted odds ratio [aOR] 0.965, 95% CI 0.944-0.986) and in somatic (adjusted coefficient [aβ]=–0.016, 95% CI –0.022 to –0.009) and cognitive-affective (aβ=–0.015, 95% CI –0.023 to –0.007) symptoms. When recreational PA was subset by intensity, participants with an increased weekly duration of vigorous-intensity recreational PA had decreases in depressive symptom odds (aOR 0.926, 95% CI 0.883-0.972) and in somatic (aβ=–0.021, 95% CI –0.032 to –0.010) and cognitive-affective (aβ=–0.022, 95% CI –0.035 to –0.009) symptoms. However, significant associations were not seen for the weekly duration of work-related, moderate- or vigorous-intensity PAs (all P>.05). Conclusions: Findings suggest that recreational, not work-related PA is associated with reduced symptoms of depression. Future studies should explore the impact of the different types and contexts of PA on depressive symptomatology. %M 38968593 %R 10.2196/48396 %U https://www.i-jmr.org/2024/1/e48396 %U https://doi.org/10.2196/48396 %U http://www.ncbi.nlm.nih.gov/pubmed/38968593 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e52045 %T Bayesian Networks for Prescreening in Depression: Algorithm Development and Validation %A Maekawa,Eduardo %A Grua,Eoin Martino %A Nakamura,Carina Akemi %A Scazufca,Marcia %A Araya,Ricardo %A Peters,Tim %A van de Ven,Pepijn %+ Department of Electronic and Computer Engineering, University of Limerick, Plassey Park Road, Limerick, V94 T9PX, Ireland, 353 830150601, eduardo.maekawa@ul.ie %K Bayesian network %K target depressive symptomatology %K probabilistic machine learning %K stochastic gradient descent %K patient screening %K depressive symptom %K machine learning model %K machine learning %K survey %K prediction %K socioeconomic data sets %K utilization %K depression %K mental health %K digital mental health %K artificial intelligence %K AI %K prediction %K prediction modeling %K patient %K mood %K anxiety %K mood disorders %K mood disorder %K eHealth %K mobile health %K mHealth %K telehealth %D 2024 %7 4.7.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Identifying individuals with depressive symptomatology (DS) promptly and effectively is of paramount importance for providing timely treatment. Machine learning models have shown promise in this area; however, studies often fall short in demonstrating the practical benefits of using these models and fail to provide tangible real-world applications. Objective: This study aims to establish a novel methodology for identifying individuals likely to exhibit DS, identify the most influential features in a more explainable way via probabilistic measures, and propose tools that can be used in real-world applications. Methods: The study used 3 data sets: PROACTIVE, the Brazilian National Health Survey (Pesquisa Nacional de Saúde [PNS]) 2013, and PNS 2019, comprising sociodemographic and health-related features. A Bayesian network was used for feature selection. Selected features were then used to train machine learning models to predict DS, operationalized as a score of ≥10 on the 9-item Patient Health Questionnaire. The study also analyzed the impact of varying sensitivity rates on the reduction of screening interviews compared to a random approach. Results: The methodology allows the users to make an informed trade-off among sensitivity, specificity, and a reduction in the number of interviews. At the thresholds of 0.444, 0.412, and 0.472, determined by maximizing the Youden index, the models achieved sensitivities of 0.717, 0.741, and 0.718, and specificities of 0.644, 0.737, and 0.766 for PROACTIVE, PNS 2013, and PNS 2019, respectively. The area under the receiver operating characteristic curve was 0.736, 0.801, and 0.809 for these 3 data sets, respectively. For the PROACTIVE data set, the most influential features identified were postural balance, shortness of breath, and how old people feel they are. In the PNS 2013 data set, the features were the ability to do usual activities, chest pain, sleep problems, and chronic back problems. The PNS 2019 data set shared 3 of the most influential features with the PNS 2013 data set. However, the difference was the replacement of chronic back problems with verbal abuse. It is important to note that the features contained in the PNS data sets differ from those found in the PROACTIVE data set. An empirical analysis demonstrated that using the proposed model led to a potential reduction in screening interviews of up to 52% while maintaining a sensitivity of 0.80. Conclusions: This study developed a novel methodology for identifying individuals with DS, demonstrating the utility of using Bayesian networks to identify the most significant features. Moreover, this approach has the potential to substantially reduce the number of screening interviews while maintaining high sensitivity, thereby facilitating improved early identification and intervention strategies for individuals experiencing DS. %M 38963925 %R 10.2196/52045 %U https://mental.jmir.org/2024/1/e52045 %U https://doi.org/10.2196/52045 %U http://www.ncbi.nlm.nih.gov/pubmed/38963925 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e57103 %T Suicidal Ideation and Attempts Among Youth With Physical-Mental Comorbidity in Canada: Proposal for an Epidemiological Study %A Ferro,Mark A %A Chan,Christy K Y %A Browne,Dillon T %A Colman,Ian %A Dubin,Joel A %A Duncan,Laura %+ School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada, 1 519 888 4567, mark.ferro@uwaterloo.ca %K adolescents %K children %K chronic disease %K epidemiology %K mental health %K suicidality %D 2024 %7 4.7.2024 %9 Proposal %J JMIR Res Protoc %G English %X Background: Evidence suggests that having a chronic physical illness (CPI; eg, asthma, diabetes, and epilepsy) is an independent risk factor for suicidality (ie, suicidal ideation or attempts) among youth. Less is known about the mechanisms linking CPI and suicidality. Some evidence suggests that mental illness (eg, depression and anxiety) or neurodevelopmental disorder (eg, attention-deficit/hyperactivity disorder) mediates or moderates the CPI-suicidality association. Missing from the knowledge base is information on the association between having co-occurring CPI and mental illness or neurodevelopmental disorder (MIND) on youth suicidality. Objective: This study uses epidemiological data from the 2019 Canadian Health Survey of Children and Youth (CHSCY) to study the intersection of CPI, MIND, and suicidality in youth. We will estimate prevalence, identify predictors, and investigate psychosocial and service use outcomes for youth with CPI-MIND comorbidity versus other morbidity groups (ie, healthy, CPI only, and MIND only). Methods: Conducted by Statistics Canada, the CHSCY collected data from 47,850 children (aged 1-17 years) and their primary caregiving parent. Measures of youth CPI, MIND, family environment, and sociodemographics are available using youth and parent informants. Information on psychiatric services use is available via parent report and linkage to national administrative health data found in the National Ambulatory Care Reporting System and the Discharge Abstract Database, which allow the investigation of hospital-based mental health services (eg, emergency department visits, hospitalizations, and length of stay in hospital). Questions about suicidality were restricted to youths aged 15-17 years (n=6950), which form our analytic sample. Weighted regression-based analyses will account for the complex survey design. Results: Our study began in November 2023, funded by the American Foundation for Suicide Prevention (SRG-0-008-22). Access to the linked CHSCY microdata file was granted in May 2024. Initial examination of CHSCY data shows that approximately 20% (1390/6950) of youth have CPI, 7% (490/6950) have MIND, 7% (490/6950) seriously considered suicide in the past year, and 3% (210/6950) had attempted suicide anytime during their life. Conclusions: Findings will provide estimates of suicidality among youth with CPI-MIND comorbidity, which will inform intervention planning to prevent loss of life in this vulnerable population. Modeling correlates of suicidality will advance understanding of the relative and joint effects of factors at multiple levels—information needed to target prevention efforts and services. Understanding patterns of psychiatric service use is vital to understanding access and barriers to services. This will inform whether use matches need, identifying opportunities to advise policy makers about upstream resources to prevent suicidality. Importantly, findings will provide robust baseline of information on the link between CPI-MIND comorbidity and suicidality in youth, which can be used by future studies to address questions related to the impact of the COVID-19 pandemic and associated countermeasures in this vulnerable population of youth. International Registered Report Identifier (IRRID): DERR1-10.2196/57103 %M 38963692 %R 10.2196/57103 %U https://www.researchprotocols.org/2024/1/e57103 %U https://doi.org/10.2196/57103 %U http://www.ncbi.nlm.nih.gov/pubmed/38963692 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e56118 %T Motivational Variables as Moderating Effects of a Web-Based Mental Health Program for University Students: Secondary Analysis of a Randomized Controlled Trial %A Hanano,Maria %A Rith-Najarian,Leslie %A Gong-Guy,Elizabeth %A Chavira,Denise %+ University of California, Los Angeles, 405 Hilgard Ave, Los Angeles, CA, 90095, United States, 1 9493501523, mariahanano@g.ucla.edu %K web-based intervention %K internal motivation %K depression %K anxiety %K self-determination theory %K mental health %K university students %K university %K students %K web-based %K analysis %K randomized controlled trial %K self-guided %D 2024 %7 3.7.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Self-guided web-based interventions have the potential of addressing help-seeking barriers and symptoms common among university students, such as depression and anxiety. Unfortunately, self-guided interventions are also associated with less adherence, implicating motivation as a potential moderator for adherence and improvement for such interventions. Previous studies examining motivation as a moderator or predictor of improvement on web-based interventions have defined and measured motivation variably, producing conflicting results. Objective: This secondary analysis of data from a randomized controlled trial aimed to examine constructs of motivation as moderators of improvement for a self-guided 8-week web-based intervention in university students (N=1607). Methods: Tested moderators included internal motivation, external motivation, and confidence in treatment derived from the Treatment Motivation Questionnaire. The primary outcome was an improvement in depression and anxiety measured by the Depression Anxiety Stress Scale-21. Results: Piecewise linear mixed effects models showed that internal motivation significantly moderated symptom change for the intervention group (t1504=–2.94; P=.003) at average and high (+1 SD) motivation levels (t1507=–2.28; P=.02 and t1507=–4.05; P<.001, respectively). Significant results remained even after controlling for baseline severity. The results showed that confidence in treatment did not significantly moderate symptom change for the intervention group (t1504=1.44; P=.15). In this sample, only internal motivation was positively correlated with service initiation, intervention adherence, and intervention satisfaction. Conclusions: The combination of a web-based intervention and high or moderate internal motivation resulted in greater improvement in the total Depression Anxiety Stress Scale-21 score. These findings highlight the importance of conceptually differentiating motivation-related constructs when examining moderators of improvement. The results suggest that the combination of a web-based intervention and high or moderate internal motivation results in greater improvement. These findings highlight the importance of conceptually differentiating motivation-related constructs when examining moderators of improvement. To better understand the moderating role of internal motivation, future research is encouraged to replicate these findings in diverse samples as well as to examine related constructs such as baseline severity and adherence. Understanding these characteristics informs treatment strategies to maximize adherence and improvement when developing web-based interventions as well as allows services to be targeted to individuals likely to benefit from such interventions. Trial Registration: ClinicalTrials.gov NCT04361045; https://clinicaltrials.gov/study/NCT04361045 %M 38959024 %R 10.2196/56118 %U https://formative.jmir.org/2024/1/e56118 %U https://doi.org/10.2196/56118 %U http://www.ncbi.nlm.nih.gov/pubmed/38959024 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e49879 %T News Media Framing of Suicide Circumstances and Gender: Mixed Methods Analysis %A Foriest,Jasmine C %A Mittal,Shravika %A Kim,Eugenia %A Carmichael,Andrea %A Lennon,Natalie %A Sumner,Steven A %A De Choudhury,Munmun %+ School of Interactive Computing, Georgia Institute of Technology, 225 North Ave NW, Atlanta, GA, 30332, United States, 1 7064643658, jay@gatech.edu %K suicide %K framing %K disparities %K reporting guidelines %K gender %K stigma %K glorification %K glorify %K glorifying %K suicidal %K self harm %K suicides %K stigmatizing %K stigmatization %K disparities %K reporting %K news %K journalist %K journalists %K journalism %K machine learning %K NLP %K natural language processing %K LLM %K LLMs %K language model %K language models %K linguistic %K linguistics %K reporter %K reporters %K gender %K digital mental health %K mHealth %K media %D 2024 %7 3.7.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide is a leading cause of death worldwide. Journalistic reporting guidelines were created to curb the impact of unsafe reporting; however, how suicide is framed in news reports may differ by important characteristics such as the circumstances and the decedent’s gender. Objective: This study aimed to examine the degree to which news media reports of suicides are framed using stigmatized or glorified language and differences in such framing by gender and circumstance of suicide. Methods: We analyzed 200 news articles regarding suicides and applied the validated Stigma of Suicide Scale to identify stigmatized and glorified language. We assessed linguistic similarity with 2 widely used metrics, cosine similarity and mutual information scores, using a machine learning–based large language model. Results: News reports of male suicides were framed more similarly to stigmatizing (P<.001) and glorifying (P=.005) language than reports of female suicides. Considering the circumstances of suicide, mutual information scores indicated that differences in the use of stigmatizing or glorifying language by gender were most pronounced for articles attributing legal (0.155), relationship (0.268), or mental health problems (0.251) as the cause. Conclusions: Linguistic differences, by gender, in stigmatizing or glorifying language when reporting suicide may exacerbate suicide disparities. %M 38959061 %R 10.2196/49879 %U https://mental.jmir.org/2024/1/e49879 %U https://doi.org/10.2196/49879 %U http://www.ncbi.nlm.nih.gov/pubmed/38959061 %0 Journal Article %@ 2368-7959 %I %V 11 %N %P e56569 %T The Role of Humanization and Robustness of Large Language Models in Conversational Artificial Intelligence for Individuals With Depression: A Critical Analysis %A Ferrario,Andrea %A Sedlakova,Jana %A Trachsel,Manuel %K generative AI %K large language models %K large language model %K LLM %K LLMs %K machine learning %K ML %K natural language processing %K NLP %K deep learning %K depression %K mental health %K mental illness %K mental disease %K mental diseases %K mental illnesses %K artificial intelligence %K AI %K digital health %K digital technology %K digital intervention %K digital interventions %K ethics %D 2024 %7 2.7.2024 %9 %J JMIR Ment Health %G English %X Large language model (LLM)–powered services are gaining popularity in various applications due to their exceptional performance in many tasks, such as sentiment analysis and answering questions. Recently, research has been exploring their potential use in digital health contexts, particularly in the mental health domain. However, implementing LLM-enhanced conversational artificial intelligence (CAI) presents significant ethical, technical, and clinical challenges. In this viewpoint paper, we discuss 2 challenges that affect the use of LLM-enhanced CAI for individuals with mental health issues, focusing on the use case of patients with depression: the tendency to humanize LLM-enhanced CAI and their lack of contextualized robustness. Our approach is interdisciplinary, relying on considerations from philosophy, psychology, and computer science. We argue that the humanization of LLM-enhanced CAI hinges on the reflection of what it means to simulate “human-like” features with LLMs and what role these systems should play in interactions with humans. Further, ensuring the contextualization of the robustness of LLMs requires considering the specificities of language production in individuals with depression, as well as its evolution over time. Finally, we provide a series of recommendations to foster the responsible design and deployment of LLM-enhanced CAI for the therapeutic support of individuals with depression. %R 10.2196/56569 %U https://mental.jmir.org/2024/1/e56569 %U https://doi.org/10.2196/56569 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e59121 %T Characterizing Mental Health Status and Service Utilization in Chinese Americans With Type 2 Diabetes in New York City: Cross-Sectional Study %A Shi,Yun %A Wu,Bei %A Islam,Nadia %A Sevick,Mary Ann %A Shallcross,Amanda J %A Levy,Natalie %A Tamura,Kosuke %A Bao,Han %A Lieu,Ricki %A Xu,Xinyi %A Jiang,Yulin %A Hu,Lu %+ Center for Healthful Behavior Change, New York University Grossman School of Medicine, New York University Langone Health, 180 Madison Ave, 7th floor, New York, NY, 10016, United States, 1 6465013438, lu.hu@nyulangone.org %K mental health %K diabetes distress %K depression %K anxiety %K service utilization %K psychological distress %K type 2 diabetes %K diabetes %K United States %K mental health burden %K Chinese American %K cross-sectional %K telephone survey %K stress %K depressive symptoms %K mental health care %K mental health screening %D 2024 %7 2.7.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Emerging evidence indicates that individuals with type 2 diabetes (T2D) are more prone to mental health issues than the general population; however, there is a significant lack of data concerning the mental health burden in Chinese Americans with T2D. Objective: The aim of this study was to explore the comorbid mental health status, health-seeking behaviors, and mental service utilization among Chinese Americans with T2D. Methods: A cross-sectional telephone survey was performed among 74 Chinese Americans with T2D in New York City. We used standardized questionnaires to assess mental health status and to gather data on mental health–seeking behaviors and service utilization. Descriptive statistics were applied for data analysis. Results: A total of 74 Chinese Americans with T2D completed the survey. Most participants (mean age 56, SD 10 years) identified as female (42/74, 57%), were born outside the United States (73/74, 99%), and had limited English proficiency (71/74, 96%). Despite nearly half of the participants (34/74, 46%) reporting at least one mental health concern (elevated stress, depressive symptoms, and/or anxiety), only 3% (2/74) were currently using mental health services. Common reasons for not seeking care included no perceived need, lack of information about Chinese-speaking providers, cost, and time constraints. The cultural and language competence of the provider was ranked as the top factor related to seeking mental health care. Conclusions: Chinese Americans with T2D experience relatively high comorbid mental health concerns yet have low service utilization. Clinicians may consider team-based care to incorporate mental health screening and identify strategies to provide culturally and linguistically concordant mental health services to engage Chinese Americans with T2D. %M 38954806 %R 10.2196/59121 %U https://formative.jmir.org/2024/1/e59121 %U https://doi.org/10.2196/59121 %U http://www.ncbi.nlm.nih.gov/pubmed/38954806 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e55302 %T Longitudinal Assessment of Seasonal Impacts and Depression Associations on Circadian Rhythm Using Multimodal Wearable Sensing: Retrospective Analysis %A Zhang,Yuezhou %A Folarin,Amos A %A Sun,Shaoxiong %A Cummins,Nicholas %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Stewart,Callum %A Conde,Pauline %A Sankesara,Heet %A Laiou,Petroula %A Matcham,Faith %A White,Katie M %A Oetzmann,Carolin %A Lamers,Femke %A Siddi,Sara %A Simblett,Sara %A Vairavan,Srinivasan %A Myin-Germeys,Inez %A Mohr,David C %A Wykes,Til %A Haro,Josep Maria %A Annas,Peter %A Penninx,Brenda WJH %A Narayan,Vaibhav A %A Hotopf,Matthew %A Dobson,Richard JB %A , %+ Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, SGDP Centre, De Crespigny Park, Denmark Hill, London, SE5 8AF, United Kingdom, 44 7579856617, yuezhou.zhang@kcl.ac.uk %K circadian rhythm %K biological rhythms %K mental health %K major depressive disorder %K MDD %K wearable %K mHealth %K mobile health %K digital health %K monitoring %D 2024 %7 28.6.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Previous mobile health (mHealth) studies have revealed significant links between depression and circadian rhythm features measured via wearables. However, the comprehensive impact of seasonal variations was not fully considered in these studies, potentially biasing interpretations in real-world settings. Objective: This study aims to explore the associations between depression severity and wearable-measured circadian rhythms while accounting for seasonal impacts. Methods: Data were sourced from a large longitudinal mHealth study, wherein participants’ depression severity was assessed biweekly using the 8-item Patient Health Questionnaire (PHQ-8), and participants’ behaviors, including sleep, step count, and heart rate (HR), were tracked via Fitbit devices for up to 2 years. We extracted 12 circadian rhythm features from the 14-day Fitbit data preceding each PHQ-8 assessment, including cosinor variables, such as HR peak timing (HR acrophase), and nonparametric features, such as the onset of the most active continuous 10-hour period (M10 onset). To investigate the association between depression severity and circadian rhythms while also assessing the seasonal impacts, we used three nested linear mixed-effects models for each circadian rhythm feature: (1) incorporating the PHQ-8 score as an independent variable, (2) adding seasonality, and (3) adding an interaction term between season and the PHQ-8 score. Results: Analyzing 10,018 PHQ-8 records alongside Fitbit data from 543 participants (n=414, 76.2% female; median age 48, IQR 32-58 years), we found that after adjusting for seasonal effects, higher PHQ-8 scores were associated with reduced daily steps (β=–93.61, P<.001), increased sleep variability (β=0.96, P<.001), and delayed circadian rhythms (ie, sleep onset: β=0.55, P=.001; sleep offset: β=1.12, P<.001; M10 onset: β=0.73, P=.003; HR acrophase: β=0.71, P=.001). Notably, the negative association with daily steps was more pronounced in spring (β of PHQ-8 × spring = –31.51, P=.002) and summer (β of PHQ-8 × summer = –42.61, P<.001) compared with winter. Additionally, the significant correlation with delayed M10 onset was observed solely in summer (β of PHQ-8 × summer = 1.06, P=.008). Moreover, compared with winter, participants experienced a shorter sleep duration by 16.6 minutes, an increase in daily steps by 394.5, a delay in M10 onset by 20.5 minutes, and a delay in HR peak time by 67.9 minutes during summer. Conclusions: Our findings highlight significant seasonal influences on human circadian rhythms and their associations with depression, underscoring the importance of considering seasonal variations in mHealth research for real-world applications. This study also indicates the potential of wearable-measured circadian rhythms as digital biomarkers for depression. %M 38941600 %R 10.2196/55302 %U https://www.jmir.org/2024/1/e55302 %U https://doi.org/10.2196/55302 %U http://www.ncbi.nlm.nih.gov/pubmed/38941600 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e52773 %T Predicting the Population Risk of Suicide Using Routinely Collected Health Administrative Data in Quebec, Canada: Model-Based Synthetic Estimation Study %A Wang,JianLi %A Kharrat,Fatemeh Gholi Zadeh %A Gariépy,Geneviève %A Gagné,Christian %A Pelletier,Jean-François %A Massamba,Victoria Kubuta %A Lévesque,Pascale %A Mohammed,Mada %A Lesage,Alain %+ Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, 5790 University Ave, Halifax, NS, B3H 1V7, Canada, 1 9024736684, JianLi.Wang@dal.ca %K population risk prediction %K case-control %K development %K validation %K health administrative data %K suicide %K depression %K anxiety %K Quebec %K Canada %K mental health %K suicide prevention %K prevention %K adolescent %K adolescents %K teen %K teens %K teenager %K teenagers %K male %K female %D 2024 %7 28.6.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Suicide is a significant public health issue. Many risk prediction tools have been developed to estimate an individual’s risk of suicide. Risk prediction models can go beyond individual risk assessment; one important application of risk prediction models is population health planning. Suicide is a result of the interaction among the risk and protective factors at the individual, health care system, and community levels. Thus, policy and decision makers can play an important role in suicide prevention. However, few prediction models for the population risk of suicide have been developed. Objective: This study aims to develop and validate prediction models for the population risk of suicide using health administrative data, considering individual-, health system–, and community-level predictors. Methods: We used a case-control study design to develop sex-specific risk prediction models for suicide, using the health administrative data in Quebec, Canada. The training data included all suicide cases (n=8899) that occurred from January 1, 2002, to December 31, 2010. The control group was a 1% random sample of living individuals in each year between January 1, 2002, and December 31, 2010 (n=645,590). Logistic regression was used to develop the prediction models based on individual-, health care system–, and community-level predictors. The developed model was converted into synthetic estimation models, which concerted the individual-level predictors into community-level predictors. The synthetic estimation models were directly applied to the validation data from January 1, 2011, to December 31, 2019. We assessed the performance of the synthetic estimation models with four indicators: the agreement between predicted and observed proportions of suicide, mean average error, root mean square error, and the proportion of correctly identified high-risk regions. Results: The sex-specific models based on individual data had good discrimination (male model: C=0.79; female model: C=0.85) and calibration (Brier score for male model 0.01; Brier score for female model 0.005). With the regression-based synthetic models applied in the validation data, the absolute differences between the synthetic risk estimates and observed suicide risk ranged from 0% to 0.001%. The root mean square errors were under 0.2. The synthetic estimation model for males correctly predicted 4 of 5 high-risk regions in 8 years, and the model for females correctly predicted 4 of 5 high-risk regions in 5 years. Conclusions: Using linked health administrative databases, this study demonstrated the feasibility and the validity of developing prediction models for the population risk of suicide, incorporating individual-, health system–, and community-level variables. Synthetic estimation models built on routinely collected health administrative data can accurately predict the population risk of suicide. This effort can be enhanced by timely access to other critical information at the population level. %M 38941610 %R 10.2196/52773 %U https://publichealth.jmir.org/2024/1/e52773 %U https://doi.org/10.2196/52773 %U http://www.ncbi.nlm.nih.gov/pubmed/38941610 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e54030 %T Effects of Sound Interventions on the Mental Stress Response in Adults: Protocol for a Scoping Review %A Saskovets,Marina %A Liang,Zilu %A Piumarta,Ian %A Saponkova,Irina %+ Faculty of Engineering, Kyoto University of Advanced Science, 18 Yamanouchi Gotanda-cho, Ukyo-ku, Kyoto, 615-8577, Japan, 81 9049473689, vetryvody@gmail.com %K mental stress %K anxiety %K sound therapy %K music therapy %K voice-guided relaxation %K voice-guided meditation %K prosody %K paralanguage %K expressive sounds %K psychoacoustics %D 2024 %7 27.6.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Sound therapy methods have seen a surge in popularity, with a predominant focus on music among all types of sound stimulation. There is substantial evidence documenting the integrative impact of music therapy on psycho-emotional and physiological outcomes, rendering it beneficial for addressing stress-related conditions such as pain syndromes, depression, and anxiety. Despite these advancements, the therapeutic aspects of sound, as well as the mechanisms underlying its efficacy, remain incompletely understood. Existing research on music as a holistic cultural phenomenon often overlooks crucial aspects of sound therapy mechanisms, particularly those related to speech acoustics or the so-called “music of speech.” Objective: This study aims to provide an overview of empirical research on sound interventions to elucidate the mechanism underlying their positive effects. Specifically, we will focus on identifying therapeutic factors and mechanisms of change associated with sound interventions. Our analysis will compare the most prevalent types of sound interventions reported in clinical studies and experiments. Moreover, we will explore the therapeutic effects of sound beyond music, encompassing natural human speech and intermediate forms such as traditional poetry performances. Methods: This review adheres to the methodological guidance of the Joanna Briggs Institute and follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist for reporting review studies, which is adapted from the Arksey and O’Malley framework. Our search strategy encompasses PubMed, Web of Science, Scopus, and PsycINFO or EBSCOhost, covering literature from 1990 to the present. Among the different study types, randomized controlled trials, clinical trials, laboratory experiments, and field experiments were included. Results: Data collection began in October 2022. We found a total of 2027 items. Our initial search uncovered an asymmetry in the distribution of studies, with a larger number focused on music therapy compared with those exploring prosody in spoken interventions such as guided meditation or hypnosis. We extracted and selected papers using Rayyan software (Rayyan) and identified 41 eligible papers after title and abstract screening. The completion of the scoping review is anticipated by October 2024, with key steps comprising the analysis of findings by May 2024, drafting and revising the study by July 2024, and submitting the paper for publication in October 2024. Conclusions: In the next step, we will conduct a quality evaluation of the papers and then chart and group the therapeutic factors extracted from them. This process aims to unveil conceptual gaps in existing studies. Gray literature sources, such as Google Scholar, ClinicalTrials.gov, nonindexed conferences, and reference list searches of retrieved studies, will be added to our search strategy to increase the number of relevant papers that we cover. International Registered Report Identifier (IRRID): DERR1-10.2196/54030 %M 38935945 %R 10.2196/54030 %U https://www.researchprotocols.org/2024/1/e54030 %U https://doi.org/10.2196/54030 %U http://www.ncbi.nlm.nih.gov/pubmed/38935945 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e55747 %T Insights Derived From Text-Based Digital Media, in Relation to Mental Health and Suicide Prevention, Using Data Analysis and Machine Learning: Systematic Review %A Sweeney,Colm %A Ennis,Edel %A Mulvenna,Maurice D %A Bond,Raymond %A O'Neill,Siobhan %+ Department of Psychlogy, Ulster University, Cromore Rd, Coleraine, BT52 1SA, United Kingdom, 44 02870 123 456, Sweeney-C23@ulster.ac.uk %K mental health %K machine learning %K text analysis %K digital intervention %D 2024 %7 27.6.2024 %9 Review %J JMIR Ment Health %G English %X Background: Text-based digital media platforms have revolutionized communication and information sharing, providing valuable access to knowledge and understanding in the fields of mental health and suicide prevention. Objective: This systematic review aimed to determine how machine learning and data analysis can be applied to text-based digital media data to understand mental health and aid suicide prevention. Methods: A systematic review of research papers from the following major electronic databases was conducted: Web of Science, MEDLINE, Embase (via MEDLINE), and PsycINFO (via MEDLINE). The database search was supplemented by a hand search using Google Scholar. Results: Overall, 19 studies were included, with five major themes as to how data analysis and machine learning techniques could be applied: (1) as predictors of personal mental health, (2) to understand how personal mental health and suicidal behavior are communicated, (3) to detect mental disorders and suicidal risk, (4) to identify help seeking for mental health difficulties, and (5) to determine the efficacy of interventions to support mental well-being. Conclusions: Our findings show that data analysis and machine learning can be used to gain valuable insights, such as the following: web-based conversations relating to depression vary among different ethnic groups, teenagers engage in a web-based conversation about suicide more often than adults, and people seeking support in web-based mental health communities feel better after receiving online support. Digital tools and mental health apps are being used successfully to manage mental health, particularly through the COVID-19 epidemic, during which analysis has revealed that there was increased anxiety and depression, and web-based communities played a part in reducing isolation during the pandemic. Predictive analytics were also shown to have potential, and virtual reality shows promising results in the delivery of preventive or curative care. Future research efforts could center on optimizing algorithms to enhance the potential of text-based digital media analysis in mental health and suicide prevention. In addressing depression, a crucial step involves identifying the factors that contribute to happiness and using machine learning to forecast these sources of happiness. This could extend to understanding how various activities result in improved happiness across different socioeconomic groups. Using insights gathered from such data analysis and machine learning, there is an opportunity to craft digital interventions, such as chatbots, designed to provide support and address mental health challenges and suicide prevention. %M 38935419 %R 10.2196/55747 %U https://mental.jmir.org/2024/1/e55747 %U https://doi.org/10.2196/55747 %U http://www.ncbi.nlm.nih.gov/pubmed/38935419 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e48776 %T Investigating the Interrelationships Among Mental Health, Substance Use Disorders, and Suicidal Ideation Among Lesbian, Gay, and Bisexual Adults in the United States: Population-Based Statewide Survey Study %A Chan,Alex Siu Wing %A Tam,Hon Lon %A Wong,Florence Kwai Ching %A Wong,Gordon %A Leung,Lok Man %A Ho,Jacqueline Mei Chi %A Tang,Patrick Ming Kuen %A Yan,Elsie %+ Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, ELB704B, Hong Kong, 999077, China, 852 39439306, hltam@cuhk.edu.hk %K mental health %K adults %K lesbian, gay, and bisexual %K depression %K drug abuse %K drug dependence %K suicidality risk %K mental illness %D 2024 %7 25.6.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Mental health disparities have been documented among lesbian, gay, and bisexual (LGB) adults in the United States. Substance use disorders and suicidal ideation have been identified as important health concerns for this population. However, the interrelationships among these factors are not well understood. Objective: This study aims to investigate the interrelationships among mental health, substance use disorders, and suicidal ideation among LGB adults in the United States using a population-based statewide survey. Methods: Our study was an observational cross-sectional analysis, and the data for this study were collected from a sample of LGB adults who participated in the statewide survey. The survey collected information on mental health, substance use disorders, and suicidal ideation using validated measures. Descriptive statistics and inferential data analysis were conducted to explore the interrelationships among these factors. Results: The results showed that LGB adults who reported higher levels of depression and drug abuse and dependence also reported higher levels of suicidal tendency and mental illness. Inferential data analysis using χ2 tests revealed significant differences in depression score (χ22=458.241; P<.001), drug abuse and dependence score (χ22=226.946; P<.001), suicidal tendency score (χ22=67.795; P<.001), and mental illness score (χ22=363.722; P<.001) among the 3 sexual identity groups. Inferential data analysis showed significant associations between sexual identity and mental health outcomes, with bisexual individuals reporting the highest levels of depression, drug abuse and dependence, suicidal tendency, and mental illness. Conclusions: This study provides important insights into the interrelationships among mental health, substance use disorders, and suicidal ideation among LGB adults in the United States. The findings underscore the need for targeted interventions and research aimed at addressing the mental health needs of sexual minority populations. Future research should aim to better understand the underlying mechanisms driving these disparities and develop culturally sensitive and tailored interventions that meet the unique needs of LGB individuals. Reducing stigma and discrimination against sexual minority populations is also crucial to improving their mental health outcomes. %M 38916938 %R 10.2196/48776 %U https://publichealth.jmir.org/2024/1/e48776 %U https://doi.org/10.2196/48776 %U http://www.ncbi.nlm.nih.gov/pubmed/38916938 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e53162 %T Multicentric Assessment of a Multimorbidity-Adjusted Disability Score to Stratify Depression-Related Risks Using Temporal Disease Maps: Instrument Validation Study %A González-Colom,Rubèn %A Mitra,Kangkana %A Vela,Emili %A Gezsi,Andras %A Paajanen,Teemu %A Gál,Zsófia %A Hullam,Gabor %A Mäkinen,Hannu %A Nagy,Tamas %A Kuokkanen,Mikko %A Piera-Jiménez,Jordi %A Roca,Josep %A Antal,Peter %A Juhasz,Gabriella %A Cano,Isaac %+ Fundació de Recerca Clínic Barcelona - Institut d’Investigacions Biomèdiques August Pi i Sunyer, C/Rosselló 149-153, Barcelona, 08036, Spain, 34 932275707, rgonzalezc@recerca.clinic.cat %K health risk assessment %K multimorbidity %K disease trajectories %K major depressive disorder %D 2024 %7 24.6.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Comprehensive management of multimorbidity can significantly benefit from advanced health risk assessment tools that facilitate value-based interventions, allowing for the assessment and prediction of disease progression. Our study proposes a novel methodology, the Multimorbidity-Adjusted Disability Score (MADS), which integrates disease trajectory methodologies with advanced techniques for assessing interdependencies among concurrent diseases. This approach is designed to better assess the clinical burden of clusters of interrelated diseases and enhance our ability to anticipate disease progression, thereby potentially informing targeted preventive care interventions. Objective: This study aims to evaluate the effectiveness of the MADS in stratifying patients into clinically relevant risk groups based on their multimorbidity profiles, which accurately reflect their clinical complexity and the probabilities of developing new associated disease conditions. Methods: In a retrospective multicentric cohort study, we developed the MADS by analyzing disease trajectories and applying Bayesian statistics to determine disease-disease probabilities combined with well-established disability weights. We used major depressive disorder (MDD) as a primary case study for this evaluation. We stratified patients into different risk levels corresponding to different percentiles of MADS distribution. We statistically assessed the association of MADS risk strata with mortality, health care resource use, and disease progression across 1 million individuals from Spain, the United Kingdom, and Finland. Results: The results revealed significantly different distributions of the assessed outcomes across the MADS risk tiers, including mortality rates; primary care visits; specialized care outpatient consultations; visits in mental health specialized centers; emergency room visits; hospitalizations; pharmacological and nonpharmacological expenditures; and dispensation of antipsychotics, anxiolytics, sedatives, and antidepressants (P<.001 in all cases). Moreover, the results of the pairwise comparisons between adjacent risk tiers illustrate a substantial and gradual pattern of increased mortality rate, heightened health care use, increased health care expenditures, and a raised pharmacological burden as individuals progress from lower MADS risk tiers to higher-risk tiers. The analysis also revealed an augmented risk of multimorbidity progression within the high-risk groups, aligned with a higher incidence of new onsets of MDD-related diseases. Conclusions: The MADS seems to be a promising approach for predicting health risks associated with multimorbidity. It might complement current risk assessment state-of-the-art tools by providing valuable insights for tailored epidemiological impact analyses of clusters of interrelated diseases and by accurately assessing multimorbidity progression risks. This study paves the way for innovative digital developments to support advanced health risk assessment strategies. Further validation is required to generalize its use beyond the initial case study of MDD. %M 38913991 %R 10.2196/53162 %U https://www.jmir.org/2024/1/e53162 %U https://doi.org/10.2196/53162 %U http://www.ncbi.nlm.nih.gov/pubmed/38913991 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e48298 %T Improvement and Maintenance of Clinical Outcomes in a Digital Mental Health Platform: Findings From a Longitudinal Observational Real-World Study %A Roos,Lydia G %A Sagui-Henson,Sara J %A Castro Sweet,Cynthia %A Welcome Chamberlain,Camille E %A Smith,Brooke J %+ Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA, 90024, United States, 1 8435446005, lroos@mednet.ucla.edu %K digital mental health %K employee health %K depression %K anxiety %K well-being %K mobile phone %D 2024 %7 24.6.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Digital mental health services are increasingly being provided by employers as health benefit programs that can improve access to and remove barriers to mental health care. Stratified care models, in particular, offer personalized care recommendations that can offer clinically effective interventions while conserving resources. Nonetheless, clinical evaluation is needed to understand their benefits for mental health and their use in a real-world setting. Objective: This study aimed to examine the changes in clinical outcomes (ie, depressive and anxiety symptoms and well-being) and to evaluate the use of stratified blended care among members of an employer-sponsored digital mental health benefit. Methods: In a large prospective observational study, we examined the changes in depressive symptoms (9-item Patient Health Questionnaire), anxiety symptoms (7-item Generalized Anxiety Disorder scale), and well-being (5-item World Health Organization Well-Being Index) for 3 months in 509 participants (mean age 33.9, SD 8.7 years; women: n=312, 61.3%; men: n=175, 34.4%; nonbinary: n=22, 4.3%) who were newly enrolled and engaged in care with an employer-sponsored digital mental health platform (Modern Health Inc). We also investigated the extent to which participants followed the recommendations provided to them through a stratified blended care model. Results: Participants with elevated baseline symptoms of depression and anxiety exhibited significant symptom improvements, with a 37% score improvement in depression and a 29% score improvement in anxiety (P values <.001). Participants with baseline scores indicative of poorer well-being also improved over the study period (90% score improvement; P=.002). Furthermore, over half exhibited clinical improvement or recovery for depressive symptoms (n=122, 65.2%), anxiety symptoms (n=127, 59.1%), and low well-being (n=82, 64.6%). Among participants with mild or no baseline symptoms, we found high rates of maintenance for low depressive (n=297, 92.2%) and anxiety (n=255, 86.7%) symptoms and high well-being (n=344, 90.1%). In total, two-thirds of the participants (n=343, 67.4%) used their recommended care, 16.9% (n=86) intensified their care beyond their initial recommendation, and 15.7% (n=80) of participants underused care by not engaging with the highest level of care recommended to them. Conclusions: Participants with elevated baseline depressive or anxiety symptoms improved their mental health significantly from baseline to follow-up, and most participants without symptoms or with mild symptoms at baseline maintained their mental health over time. In addition, engagement patterns indicate that the stratified blended care model was efficient in matching individuals with the most effective and least costly care while also allowing them to self-determine their care and use combinations of services that best fit their needs. Overall, the results of this study support the clinical effectiveness of the platform for improving and preserving mental health and support the utility and effectiveness of stratified blended care models to improve access to and use of digitally delivered mental health services. %M 38913405 %R 10.2196/48298 %U https://mhealth.jmir.org/2024/1/e48298 %U https://doi.org/10.2196/48298 %U http://www.ncbi.nlm.nih.gov/pubmed/38913405 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e50503 %T Web-Based, Human-Guided, or Computer-Guided Transdiagnostic Cognitive Behavioral Therapy in University Students With Anxiety and Depression: Randomized Controlled Trial %A Koelen,Jurrijn %A Klein,Anke %A Wolters,Nine %A Bol,Eline %A De Koning,Lisa %A Roetink,Samantha %A Van Blom,Jorien %A Boutin,Bruno %A Schaaf,Jessica %A Grasman,Raoul %A Van der Heijde,Claudia Maria %A Salemink,Elske %A Riper,Heleen %A Karyotaki,Eirini %A Cuijpers,Pim %A Schneider,Silvia %A Rapee,Ronald %A Vonk,Peter %A Wiers,Reinout %+ Department of Developmental Psychology, University of Amsterdam, P.O.Box 15916, 1001 NK, Amsterdam, Netherlands, 31 20 5256842, r.w.h.j.wiers@uva.nl %K internet-based cognitive behavioral intervention %K iCBT %K university students %K transdiagnostic %K human guidance %K technological guidance %D 2024 %7 19.6.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Internet-based cognitive behavioral interventions (iCBTs) are efficacious treatments for depression and anxiety. However, it is unknown whether adding human guidance is feasible and beneficial within a large educational setting. Objective: This study aims to potentially demonstrate the superiority of 2 variants of a transdiagnostic iCBT program (human-guided and computer-guided iCBT) over care as usual (CAU) in a large sample of university students and the superiority of human-guided iCBT over computer-guided iCBT. Methods: A total of 801 students with elevated levels of anxiety, depression, or both from a large university in the Netherlands were recruited as participants and randomized to 1 of 3 conditions: human-guided iCBT, computer-guided iCBT, and CAU. The primary outcome measures were depression (Patient Health Questionnaire) and anxiety (Generalized Anxiety Disorder scale). Secondary outcomes included substance use–related problems (Alcohol Use Disorder Identification Test and Drug Abuse Screening Test—10 items). Linear mixed models were used to estimate the effects of time, treatment group, and their interactions (slopes). The primary research question was whether the 3 conditions differed in improvement over 3 time points (baseline, midtreatment, and after treatment) in terms of depression and anxiety symptoms. Results were analyzed according to the intention-to-treat principle using multiple imputation. Patients were followed exploratively from baseline to 6 and 12 months. Results: In both short-term and long-term analyses, the slopes for the 3 conditions did not differ significantly in terms of depression and anxiety, although both web-based interventions were marginally more efficacious than CAU over 6 months (P values between .02 and .03). All groups showed significant improvement over time (P<.001). For the secondary outcomes, only significant improvements over time (across and not between groups) were found for drug use (P<.001). Significant differences were found in terms of adherence, indicating that participants in the human-guided condition did more sessions than those in the computer-guided condition (P=.002). Conclusions: The transdiagnostic iCBT program offers a practical, feasible, and efficacious alternative to usual care to tackle mental health problems in a large university setting. There is no indication that human guidance should be preferred over technological guidance. The potential preference of human support also depends on the scale of implementation and cost-effectiveness, which need to be addressed in future trials. Trial Registration: International Clinical Trials Registry Platform NL7328/NTR7544; https://trialsearch.who.int/Trial2.aspx?TrialID=NL-OMON26795 %M 38896474 %R 10.2196/50503 %U https://mental.jmir.org/2024/1/e50503 %U https://doi.org/10.2196/50503 %U http://www.ncbi.nlm.nih.gov/pubmed/38896474 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e53966 %T Web-Based Mindfulness-Based Cognitive Therapy for Adults With a History of Depression: Protocol for a Randomized Controlled Trial %A Hooshmand Zaferanieh,Mohammad %A Shi,Lu %A Jindal,Meenu %A Chen,Liwei %A Zhang,Lingling %A Lopes,Snehal %A Jones,Karyn %A Wang,Yucheng %A Meggett,Kinsey %A Walker,Cari Beth %A Falgoust,Grace %A Zinzow,Heidi %+ University of South Carolina School of Medicine Greenville, 607 Grove Road, Greenville, SC, 29605, United States, 1 864 455 7992, hooshmam@email.sc.edu %K mindfulness-based cognitive therapy %K MBCT %K mindfulness-based interventions %K depression %K depressive symptoms %K virtual delivery %K mindfulness %K mental health %K depressive %K distress %K stress %K remote %K randomized %K controlled trial %K controlled trials %K RCT %K psychotherapy %K cognitive therapy %D 2024 %7 18.6.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression poses a major threat to public health with an increasing prevalence in the United States. Mindfulness-based interventions, such as mindfulness-based cognitive therapy (MBCT), are effective methods for managing depression symptoms and may help fortify existing efforts to address the current disease burden. The in-person group format of MBCT, however, incurs barriers to care such as expenses, childcare needs, and transportation issues. Alternate delivery modalities such as MBCT delivered via the web can be investigated for their capacity to overcome these barriers and still reduce symptoms of depression with adequate feasibility and efficacy. Objective: This study protocol aims to examine the feasibility and efficacy of MBCT delivered via the web for the treatment of depression. Methods: To attain study aims, 2 phases will be implemented using a waitlist control design. A total of 128 eligible participants will be randomized into either an 8-week MBCT intervention group plus treatment as usual (MBCT + TAU; group 1) or an 8-week waitlist control group (group 2). In phase I (8 weeks), group 1 will complete the intervention and group 2 will proceed with TAU. In phase II (8 weeks), group 2 will complete the intervention and group 1 will continue with TAU until reaching an 8-week follow-up. TAU may consist of receiving psychotherapy, pharmacotherapy, or combined treatment. Data collection will be completed at baseline, 8 weeks (postintervention for group 1 and preintervention for group 2), and 16 weeks (follow-up for group 1, postintervention for group 2). The primary outcomes will include (1) current, residual, or chronic depression symptoms and (2) psychiatric distress. Secondary outcomes will include perceived stress and facets of mindfulness. The feasibility will be measured by assessing protocol adherence, retention, attendance, and engagement. Finally, the extent of mindfulness self-practice and executive functioning skills will be assessed as mediators of intervention outcomes. Results: This study began screening and recruitment in December 2022. Data collection from the first cohort occurred in January 2023. By November 2023, a total of 30 participants were enrolled out of 224 who received screening. Data analysis began in February 2024, with an approximate publication of results by August 2024. Institutional review board approval took place on September 11, 2019. Conclusions: This trial will contribute to examining mindfulness-based interventions, delivered via the web, for improving current, residual, or chronic depression symptoms. It will (1) address the feasibility of MBCT delivered via the web; (2) contribute evidence regarding MBCT’s efficacy in reducing depression symptoms and psychiatric distress; and (3) assess the impact of MBCT on several important secondary outcomes. Findings from this study will develop the understanding of the causal pathways between MBCT delivered via the web and depression symptoms further, elucidating the potential for future larger-scale designs. Trial Registration: ClinicalTrials.gov NCT05347719; https://www.clinicaltrials.gov/ct2/show/NCT05347719 International Registered Report Identifier (IRRID): DERR1-10.2196/53966 %M 38888958 %R 10.2196/53966 %U https://www.researchprotocols.org/2024/1/e53966 %U https://doi.org/10.2196/53966 %U http://www.ncbi.nlm.nih.gov/pubmed/38888958 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e55842 %T Digital Phenotyping of Geriatric Depression Using a Community-Based Digital Mental Health Monitoring Platform for Socially Vulnerable Older Adults and Their Community Caregivers: 6-Week Living Lab Single-Arm Pilot Study %A Song,Sunmi %A Seo,YoungBin %A Hwang,SeoYeon %A Kim,Hae-Young %A Kim,Junesun %+ Department of Health and Environmental Science, Undergraduate School, Korea University, 661 B-Hana Science Building, Seongbuk-gu, Seoul, 02841, Republic of Korea, 82 2 3290 5689, junokim@korea.ac.kr %K depression %K monitoring system %K IoT %K AI %K wearable device %K digital mental health phenotyping %K living lab %K senior care %K Internet of Things %K artificial intelligence %D 2024 %7 17.6.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Despite the increasing need for digital services to support geriatric mental health, the development and implementation of digital mental health care systems for older adults have been hindered by a lack of studies involving socially vulnerable older adult users and their caregivers in natural living environments. Objective: This study aims to determine whether digital sensing data on heart rate variability, sleep quality, and physical activity can predict same-day or next-day depressive symptoms among socially vulnerable older adults in their everyday living environments. In addition, this study tested the feasibility of a digital mental health monitoring platform designed to inform older adult users and their community caregivers about day-to-day changes in the health status of older adults. Methods: A single-arm, nonrandomized living lab pilot study was conducted with socially vulnerable older adults (n=25), their community caregivers (n=16), and a managerial social worker over a 6-week period during and after the COVID-19 pandemic. Depressive symptoms were assessed daily using the 9-item Patient Health Questionnaire via scripted verbal conversations with a mobile chatbot. Digital biomarkers for depression, including heart rate variability, sleep, and physical activity, were measured using a wearable sensor (Fitbit Sense) that was worn continuously, except during charging times. Daily individualized feedback, using traffic signal signs, on the health status of older adult users regarding stress, sleep, physical activity, and health emergency status was displayed on a mobile app for the users and on a web application for their community caregivers. Multilevel modeling was used to examine whether the digital biomarkers predicted same-day or next-day depressive symptoms. Study staff conducted pre- and postsurveys in person at the homes of older adult users to monitor changes in depressive symptoms, sleep quality, and system usability. Results: Among the 31 older adult participants, 25 provided data for the living lab and 24 provided data for the pre-post test analysis. The multilevel modeling results showed that increases in daily sleep fragmentation (P=.003) and sleep efficiency (P=.001) compared with one’s average were associated with an increased risk of daily depressive symptoms in older adults. The pre-post test results indicated improvements in depressive symptoms (P=.048) and sleep quality (P=.02), but not in the system usability (P=.18). Conclusions: The findings suggest that wearable sensors assessing sleep quality may be utilized to predict daily fluctuations in depressive symptoms among socially vulnerable older adults. The results also imply that receiving individualized health feedback and sharing it with community caregivers may help improve the mental health of older adults. However, additional in-person training may be necessary to enhance usability. Trial Registration: ClinicalTrials.gov NCT06270121; https://clinicaltrials.gov/study/NCT06270121 %M 38885033 %R 10.2196/55842 %U https://mhealth.jmir.org/2024/1/e55842 %U https://doi.org/10.2196/55842 %U http://www.ncbi.nlm.nih.gov/pubmed/38885033 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e55578 %T Effectiveness of Mobile-Based Progressive and Fixed Physical Activity on Depression, Stress, Anxiety, and Quality of Life Outcomes Among Adults in South Korea: Randomized Controlled Trial %A Lee,Ye Hoon %A Kim,Hyungsook %A Hwang,Juhee %A Noh,Sihyeon %+ Department of Data Science, Hanyang University, 222, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea, 82 222204751, khsook12@hanyang.ac.kr %K depressive symptoms %K mental health %K mobile-based exercise %K non–face-to-face physical activity %K progressive exercise %K mobile phone %D 2024 %7 12.6.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depression acts as a significant obstacle to the overall well-being of individuals. Given the significant consequences, timely recognition and proactive steps to manage symptoms of depression become essential. Such actions not only reduce personal distress but also play a crucial role in reducing its far-reaching impact on society as a whole. Objective: In response to this concern, the objective of this study was to explore the use of mobile-based interventions as a possible remedy. More specifically, this study aimed to investigate the effectiveness of 2 types of physical activity (PA), progressive and fixed, within a mobile-based app on depression, perceived stress, anxiety, physical health, and psychological health, aiming to contribute to the optimization of mental health benefits. Methods: Participants (N=60; mean age 25.29, SD 6.10 years) were recruited using a combination of web-based and offline methods, and the study lasted for 8 weeks. The baseline and posttest questionnaires were administered to all participants. The participants were randomly assigned to 1 of the 3 groups: progressive group (n=20; performing mobile-based progressive PA), fixed group (n=20; performing mobile-based fixed intensity PA), and control group C (n=20). Data analysis involved comparing scores between the experimental and control groups using a one-way ANOVA, paired sample t tests (2-tailed), and repeated measures ANOVA with a 3 (group)×2 (time) design. Results: The findings revealed significant improvements in mental health indicators among participants engaged in both fixed and progressive PA groups compared with the control group. However, the fixed PA group demonstrated more significant reductions in symptoms. Specifically, the progressive PA group showed significant reductions in depression (F1,36=6.941; P=.01; ηp2=0.16) and perceived stress (F1,36=5.47; P=.03; ηp2=0.13), while the fixed PA group exhibited significant reductions in depression (F1,37=5.36; P=.03; ηp2=0.12), perceived stress (F1,37=7.81; P=.008; ηp2=0.17), and general anxiety disorder (F1,37=5.45; P=.03; ηp2=0.13) compared with the control group. Conclusions: This study underscores the potential of mobile-based PA in improving mental health outcomes. The findings offer significant insights for mental health professionals and researchers aiming to optimize mental well-being through innovative mobile therapies. Trial Registration: Clinical Research Information Service KCT0009100; https://tinyurl.com/mr33fmur %M 38865705 %R 10.2196/55578 %U https://mhealth.jmir.org/2024/1/e55578 %U https://doi.org/10.2196/55578 %U http://www.ncbi.nlm.nih.gov/pubmed/38865705 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e52341 %T The Effects of mHealth Interventions on Quality of Life, Anxiety, and Depression in Patients With Coronary Heart Disease: Meta-Analysis of Randomized Controlled Trials %A Hou,Qiao Ling %A Liu,Le Yang %A Wu,Ying %+ School of Nursing, Capital Medical University, 10 You-an-men Wai Xi-tou-tiao, Feng-tai District, Beijing, 100069, China, 86 10 8391 1766, helenywu@vip.163.com %K mobile health %K coronary heart disease %K quality of life %K anxiety %K depression %K meta-analysis %K mobile phone %D 2024 %7 11.6.2024 %9 Review %J J Med Internet Res %G English %X Background: Coronary heart disease (CHD) is the leading cause of death globally. In addition, 20% to 40% of the patients with CHD have comorbid mental health issues such as anxiety or depression, affecting the prognosis and quality of life (QoL). Mobile health (mHealth) interventions have been developed and are widely used; however, the evidence for the effects of mHealth interventions on QoL, anxiety, and depression in patients with CHD is currently ambiguous. Objective: In this study, we aimed to assess the effects of mHealth interventions on QoL, anxiety, and depression in patients with CHD. Methods: We searched the Cochrane Library, PubMed, Embase, CINAHL, Web of Science, China National Knowledge Infrastructure, and Wanfang databases from inception to August 12, 2023. Eligible studies were randomized controlled trials that involved patients with CHD who received mHealth interventions and that reported on QoL, anxiety, or depression outcomes. We used the Cochrane risk-of-bias tool for randomized trials to evaluate the risk of bias in the studies, ensuring a rigorous and methodologically sound analysis. Review Manager (desktop version 5.4; The Cochrane Collaboration) and Stata MP (version 17.0; StataCorp LLC) were used to conduct the meta-analysis. The effect size was calculated using the standardized mean difference (SMD) and its 95% CI. Results: The meta-analysis included 23 studies (5406 participants in total) and showed that mHealth interventions significantly improved QoL in patients with CHD (SMD 0.49, 95% CI 0.25-0.72; Z=4.07; P<.001) as well as relieved their anxiety (SMD −0.46, 95% CI −0.83 to −0.08; Z=2.38; P=.02) and depression (SMD −0.34, 95% CI −0.56 to −0.12; Z=3.00; P=.003) compared to usual care. The subgroup analyses indicated a significant effect favoring the mHealth intervention on reducing anxiety and depressive symptoms compared to usual care, especially when (1) the intervention duration was ≥6 months (P=.04 and P=.001), (2) the mHealth intervention was a simple one (only 1 mHealth intervention was used) (P=.01 and P<.001), (3) it was implemented during the COVID-19 pandemic (P=.04 and P=.01), (4) it was implemented in low- or middle-income countries (P=.01 and P=.02), (5) the intervention focused on mental health (P=.01 and P=.007), and (6) adherence rates were high (≥90%; P=.03 and P=.002). In addition, comparing mHealth interventions to usual care, there was an improvement in QoL when (1) the mHealth intervention was a simple one (P<.001), (2) it was implemented in low- or middle-income countries (P<.001), and (3) the intervention focused on mental health (P<.001). Conclusions: On the basis of the existing evidence, mHealth interventions might be effective in improving QoL and reducing anxiety and depression in patients with CHD. However, large sample, high-quality, and rigorously designed randomized controlled trials are needed to provide further evidence. Trial Registration: PROSPERO CRD42022383858; https://tinyurl.com/3ea2npxf %M 38861710 %R 10.2196/52341 %U https://www.jmir.org/2024/1/e52341 %U https://doi.org/10.2196/52341 %U http://www.ncbi.nlm.nih.gov/pubmed/38861710 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e48076 %T Association Between Discrimination and Depressive Symptoms Among Hispanic or Latino Adults During the COVID-19 Pandemic: Cross-Sectional Study %A Ormiston,Cameron K %A Villalobos,Kevin %A Montiel Ishino,Francisco Alejandro %A Williams,Faustine %+ National Institute on Minority Health and Health Disparities, National Institutes of Health, 11545 Rockville Pike, Rockville, MD, 20852, United States, 1 301 827 2727, cameron.ormiston@icahn.mssm.edu %K depressive symptoms %K everyday discrimination %K COVID-19 pandemic %K Hispanic and Latino %K immigrant health %D 2024 %7 6.6.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Discrimination and xenophobia toward Hispanic and Latino communities increased during the COVID-19 pandemic, likely inflicting significant harm on the mental health of Hispanic and Latino individuals. Pandemic-related financial and social instability has disproportionately affected Hispanic and Latino communities, potentially compounding existing disparities and worsening mental health. Objective: This study aims to examine the association between discrimination and depressive symptoms during the COVID-19 pandemic among a national sample of Hispanic and Latino adults. Methods: Data from a 116-item web-based nationally distributed survey from May 2021 to January 2022 were analyzed. The sample (N=1181) was restricted to Hispanic or Latino (Mexican or Mexican American, Puerto Rican; Cuban or Cuban American, Central or South American, and Dominican or another Hispanic or Latino ethnicity) adults. Depression symptoms were assessed using the 2-item Patient Health Questionnaire. Discrimination was assessed using the 5-item Everyday Discrimination Scale. A multinomial logistic regression with a block entry model was used to assess the relationship between discrimination and the likelihood of depressive symptoms, as well as examine how controls and covariates affected the relationship of interest. Results: Mexican or Mexican American adults comprised the largest proportion of the sample (533/1181, 45.13%), followed by Central or South American (204/1181, 17.3%), Puerto Rican (189/1181, 16%), Dominican or another Hispanic or Latino ethnicity (172/1181, 14.6%), and Cuban or Cuban American (83/1181, 7.03%). Approximately 31.26% (367/1181) of the sample had depressive symptoms. Regarding discrimination, 54.56% (634/1181) reported experiencing some form of discrimination. Compared with those who did not experience discrimination, those who experienced discrimination had almost 230% higher odds of depressive symptoms (adjusted odds ratio [AOR] 3.31, 95% CI 2.42-4.54). Also, we observed that sociodemographic factors such as age and gender were significant. Compared with participants aged 56 years and older, participants aged 18-35 years and those aged 36-55 years had increased odds of having depressive symptoms (AOR 3.83, 95% CI 2.13-6.90 and AOR 3.10, 95% CI 1.74-5.51, respectively). Women had higher odds of having depressive symptoms (AOR 1.67, 95% CI 1.23-2.30) than men. Respondents with an annual income of less than US $25,000 (AOR 2.14, 95% CI 1.34-3.41) and US $25,000 to less than US $35,000 (AOR 1.89, 95% CI 1.17-3.06) had higher odds of depressive symptoms than those with an annual income of US $50,000 to less than US $75,000. Conclusions: Our findings provide significant importance especially when considering the compounding, numerous socioeconomic challenges stemming from the pandemic that disproportionately impact the Hispanic and Latino communities. These challenges include rising xenophobia and tensions against immigrants, inadequate access to mental health resources for Hispanic and Latino individuals, and existing hesitations toward seeking mental health services among this population. Ultimately, these findings can serve as a foundation for promoting health equity. %M 38843512 %R 10.2196/48076 %U https://formative.jmir.org/2024/1/e48076 %U https://doi.org/10.2196/48076 %U http://www.ncbi.nlm.nih.gov/pubmed/38843512 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e50024 %T A Web-Based Training Program for School Staff to Respond to Self-Harm: Design and Development of the Supportive Response to Self-Harm Program %A Burn,Anne-Marie %A Hall,Poppy %A Anderson,Joanna %+ Department of Psychiatry, University of Cambridge, Herchel Smith Building for Brain and Mind Sciences, Forvie Site, Robinson Way, Cambridge, CB2 0SZ, United Kingdom, 44 1223336961, amb278@cam.ac.uk %K self-harm %K schools %K young people %K youth %K school staff %K training %K coproduction %K qualitative %D 2024 %7 4.6.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Self-harm is common among adolescents and is a major public health concern. School staff may be the first adults to notice a young person’s self-harm and are well placed to provide support or signpost students to help. However, school staff often report that they do not feel equipped or confident to support students. Despite the need, there is a lack of evidence-based training about self-harm for school staff. A web-based training program would provide schools with a flexible and cost-effective method of increasing staff knowledge, skills, and confidence in how to respond to students who self-harm. Objective: The main objective of this study was to coproduce an evidence-based training program for school staff to improve their skills and confidence in responding to students who self-harm (Supportive Response to Self-Harm [SORTS]). This paper describes the design and development process of an initial prototype coproduced with stakeholders to ensure that the intervention meets their requirements. Methods: Using a user-centered design and person-based approach, the SORTS prototype was informed by (1) a review of research literature, existing guidelines, and policies; (2) coproduction discussions with the technical provider and subject matter experts (mental health, education, and self-harm); (3) findings from focus groups with young people; and (4) coproduction workshops with school staff. Thematic analysis using the framework method was applied. Results: Coproduction sessions with experts and the technical provider enabled us to produce a draft of the training content, a wireframe, and example high-fidelity user interface designs. Analysis of focus groups and workshops generated four key themes: (1) need for a training program; (2) acceptability, practicality, and implementation; (3) design, content, and navigation; and (4) adaptations and improvements. The findings showed that there is a clear need for a web-based training program about self-harm in schools, and the proposed program content and design were useful, practical, and acceptable. Consultations with stakeholders informed the iterative development of the prototype. Conclusions: SORTS is a web-based training program for school staff to appropriately respond to students who self-harm that is based on research evidence and developed in collaboration with stakeholders. The SORTS program will equip school staff with the skills and strategies to respond in a supportive way to students who self-harm and encourage schools to adopt a whole-school approach to self-harm. Further research is needed to complete the intervention development based on the feedback from this study and evaluate the program’s effectiveness. If found to be effective, the SORTS program could be implemented in schools and other youth organizations. %M 38833286 %R 10.2196/50024 %U https://formative.jmir.org/2024/1/e50024 %U https://doi.org/10.2196/50024 %U http://www.ncbi.nlm.nih.gov/pubmed/38833286 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e40275 %T The Use of Text Messaging as an Adjunct to Internet-Based Cognitive Behavioral Therapy for Major Depressive Disorder in Youth: Secondary Analysis %A Walters,Clarice %A Gratzer,David %A Dang,Kevin %A Laposa,Judith %A Knyahnytska,Yuliya %A Ortiz,Abigail %A Gonzalez-Torres,Christina %A Moore,Lindsay P %A Chen,Sheng %A Ma,Clement %A Daskalakis,Zafiris %A Ritvo,Paul %+ School of Kinesiology and Health Sciences, York University, 4700 Keele St, Toronto, ON, M3J1P3, Canada, 1 4165808021, paul.ritvo@gmail.com %K online intervention %K randomized controlled trial %K major depressive disorder %K text message %K online %K cognitive %K behavior therapy %K treatment %K depression %K disorder %K symptoms %K young adults %K wellness %K procedure %K anxiety %K model %D 2024 %7 31.5.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: As an established treatment for major depressive disorder (MDD), cognitive behavioral therapy (CBT) is now implemented and assessed in internet-based formats that, when combined with smartphone apps, enable secure text messaging. As an adjunct to such internet-based CBT (ICBT) approaches, text messaging has been associated with increased adherence and therapeutic alliance. Objective: This study analyzed data from the intervention arm of a randomized control trial evaluating 24-week ICBT for MDD (intervention arm) against standard-care psychiatry (waitlist control). The aim of this secondary analysis was to assess MDD symptom improvement in relation to the frequency and content of text messages sent by ICBT participants to Navigator-Coaches during randomized control trial participation. Higher text frequency in general and in 3 conceptual categories (appreciating alliance, alliance building disclosures, and agreement confirmation) was hypothesized to predict larger MDD symptom improvement. Methods: Participants were young adults (18-30 years) from the Centre for Addiction and Mental Health. The frequencies of categorized texts from 20 ICBT completers were analyzed with respect to MDD symptom improvement using linear regression models. Texts were coded by 2 independent coders and categorized using content analysis. MDD symptoms were measured using the Beck Depression Inventory-II (BDI-II). Results: Participants sent an average of 136 text messages. Analyses indicated that BDI-II improvement was negatively associated with text messaging frequency in general (β=–0.029, 95% CI –0.11 to 0.048) and in each of the 3 categories: appreciating alliance (β=–0.096, 95% CI –0.80 to 0.61), alliance building disclosures (β=–0.098, 95% CI –0.28 to 0.084), and agreement confirmation (β=–0.076, 95% CI –0.40 to 0.25). Altogether, the effect of text messaging on BDI-II improvement was uniformly negative across statistical models. More text messaging appeared associated with less MDD symptom improvement. Conclusions: The hypothesized positive associations between conceptually categorized text messages and MDD symptom improvement were not supported in this study. Instead, more text messaging appeared to indicate less treatment benefit. Future studies with larger samples are needed to discern the optimal use of text messaging in ICBT approaches using adjunctive modes of communication. Trial Registration: Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052 %M 38820586 %R 10.2196/40275 %U https://formative.jmir.org/2024/1/e40275 %U https://doi.org/10.2196/40275 %U http://www.ncbi.nlm.nih.gov/pubmed/38820586 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e46895 %T Characterizing Longitudinal Patterns in Cognition, Mood, And Activity in Depression With 6-Week High-Frequency Wearable Assessment: Observational Study %A Cormack,Francesca %A McCue,Maggie %A Skirrow,Caroline %A Cashdollar,Nathan %A Taptiklis,Nick %A van Schaik,Tempest %A Fehnert,Ben %A King,James %A Chrones,Lambros %A Sarkey,Sara %A Kroll,Jasmin %A Barnett,Jennifer H %+ Cambridge Cognition, Tunbridge Court, Bottisham, Cambridge, CB25 9TU, United Kingdom, 44 7961910560, jasmin.kroll@camcog.com %K cognition %K depression %K digital biomarkers %K ecological momentary assessment %K mobile health %K remote testing %D 2024 %7 31.5.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Cognitive symptoms are an underrecognized aspect of depression that are often untreated. High-frequency cognitive assessment holds promise for improving disease and treatment monitoring. Although we have previously found it feasible to remotely assess cognition and mood in this capacity, further work is needed to ascertain the optimal methodology to implement and synthesize these techniques. Objective: The objective of this study was to examine (1) longitudinal changes in mood, cognition, activity levels, and heart rate over 6 weeks; (2) diurnal and weekday-related changes; and (3) co-occurrence of fluctuations between mood, cognitive function, and activity. Methods: A total of 30 adults with current mild-moderate depression stabilized on antidepressant monotherapy responded to testing delivered through an Apple Watch (Apple Inc) for 6 weeks. Outcome measures included cognitive function, assessed with 3 brief n-back tasks daily; self-reported depressed mood, assessed once daily; daily total step count; and average heart rate. Change over a 6-week duration, diurnal and day-of-week variations, and covariation between outcome measures were examined using nonlinear and multilevel models. Results: Participants showed initial improvement in the Cognition Kit N-Back performance, followed by a learning plateau. Performance reached 90% of individual learning levels on average 10 days after study onset. N-back performance was typically better earlier and later in the day, and step counts were lower at the beginning and end of each week. Higher step counts overall were associated with faster n-back learning, and an increased daily step count was associated with better mood on the same (P<.001) and following day (P=.02). Daily n-back performance covaried with self-reported mood after participants reached their learning plateau (P=.01). Conclusions: The current results support the feasibility and sensitivity of high-frequency cognitive assessments for disease and treatment monitoring in patients with depression. Methods to model the individual plateau in task learning can be used as a sensitive approach to better characterize changes in behavior and improve the clinical relevance of cognitive data. Wearable technology allows assessment of activity levels, which may influence both cognition and mood. %M 38819909 %R 10.2196/46895 %U https://mental.jmir.org/2024/1/e46895 %U https://doi.org/10.2196/46895 %U http://www.ncbi.nlm.nih.gov/pubmed/38819909 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e50976 %T Tracking and Profiling Repeated Users Over Time in Text-Based Counseling: Longitudinal Observational Study With Hierarchical Clustering %A Xu,Yucan %A Chan,Christian Shaunlyn %A Chan,Evangeline %A Chen,Junyou %A Cheung,Florence %A Xu,Zhongzhi %A Liu,Joyce %A Yip,Paul Siu Fai %+ Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam, Hong Kong, China (Hong Kong), 852 91401568, sfpyip@hku.hk %K web-based counseling %K text-based counseling %K repeated users %K frequent users %K hierarchical clustering %K service effectiveness %K risk profiling %K psychological profiles %K psycholinguistic analysis %D 2024 %7 30.5.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Due to their accessibility and anonymity, web-based counseling services are expanding at an unprecedented rate. One of the most prominent challenges such services face is repeated users, who represent a small fraction of total users but consume significant resources by continually returning to the system and reiterating the same narrative and issues. A deeper understanding of repeated users and tailoring interventions may help improve service efficiency and effectiveness. Previous studies on repeated users were mainly on telephone counseling, and the classification of repeated users tended to be arbitrary and failed to capture the heterogeneity in this group of users. Objective: In this study, we aimed to develop a systematic method to profile repeated users and to understand what drives their use of the service. By doing so, we aimed to provide insight and practical implications that can inform the provision of service catering to different types of users and improve service effectiveness. Methods: We extracted session data from 29,400 users from a free 24/7 web-based counseling service from 2018 to 2021. To systematically investigate the heterogeneity of repeated users, hierarchical clustering was used to classify the users based on 3 indicators of service use behaviors, including the duration of their user journey, use frequency, and intensity. We then compared the psychological profile of the identified subgroups including their suicide risks and primary concerns to gain insights into the factors driving their patterns of service use. Results: Three clusters of repeated users with clear psychological profiles were detected: episodic, intermittent, and persistent-intensive users. Generally, compared with one-time users, repeated users showed higher suicide risks and more complicated backgrounds, including more severe presenting issues such as suicide or self-harm, bullying, and addictive behaviors. Higher frequency and intensity of service use were also associated with elevated suicide risk levels and a higher proportion of users citing mental disorders as their primary concerns. Conclusions: This study presents a systematic method of identifying and classifying repeated users in web-based counseling services. The proposed bottom-up clustering method identified 3 subgroups of repeated users with distinct service behaviors and psychological profiles. The findings can facilitate frontline personnel in delivering more efficient interventions and the proposed method can also be meaningful to a wider range of services in improving service provision, resource allocation, and service effectiveness. %M 38815258 %R 10.2196/50976 %U https://www.jmir.org/2024/1/e50976 %U https://doi.org/10.2196/50976 %U http://www.ncbi.nlm.nih.gov/pubmed/38815258 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e50025 %T Effectiveness of a Mental Health Chatbot for People With Chronic Diseases: Randomized Controlled Trial %A MacNeill,A Luke %A Doucet,Shelley %A Luke,Alison %+ Centre for Research in Integrated Care, University of New Brunswick, 355 Campus Ring Road, Saint John, NB, E2L 4L5, Canada, 1 506 648 5777, luke.macneill@unb.ca %K chatbot %K chronic disease %K arthritis %K diabetes %K mental health %K depression %K anxiety %K stress %K effectiveness %K application %D 2024 %7 30.5.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: People with chronic diseases tend to experience more mental health issues than their peers without these health conditions. Mental health chatbots offer a potential source of mental health support for people with chronic diseases. Objective: The aim of this study was to determine whether a mental health chatbot can improve mental health in people with chronic diseases. We focused on 2 chronic diseases in particular: arthritis and diabetes. Methods: Individuals with arthritis or diabetes were recruited using various web-based methods. Participants were randomly assigned to 1 of 2 groups. Those in the treatment group used a mental health chatbot app (Wysa [Wysa Inc]) over a period of 4 weeks. Those in the control group received no intervention. Participants completed measures of depression (Patient Health Questionnaire–9), anxiety (Generalized Anxiety Disorder Scale–7), and stress (Perceived Stress Scale–10) at baseline, with follow-up testing 2 and 4 weeks later. Participants in the treatment group completed feedback questions on their experiences with the app at the final assessment point. Results: A total of 68 participants (n=47, 69% women; mean age 42.87, SD 11.27 years) were included in the analysis. Participants were divided evenly between the treatment and control groups. Those in the treatment group reported decreases in depression (P<.001) and anxiety (P<.001) severity over the study period. No such changes were found among participants in the control group. No changes in stress were reported by participants in either group. Participants with arthritis reported higher levels of depression (P=.004) and anxiety (P=.004) severity than participants with diabetes over the course of the study, as well as higher levels of stress (P=.01); otherwise, patterns of results were similar across these health conditions. In response to the feedback questions, participants in the treatment group said that they liked many of the functions and features of the app, the general design of the app, and the user experience. They also disliked some aspects of the app, with most of these reports focusing on the chatbot’s conversational abilities. Conclusions: The results of this study suggest that mental health chatbots can be an effective source of mental health support for people with chronic diseases such as arthritis and diabetes. Although cost-effective and accessible, these programs have limitations and may not be well suited for all individuals. Trial Registration: ClinicalTrials.gov NCT04620668; https://www.clinicaltrials.gov/study/NCT04620668 %M 38814681 %R 10.2196/50025 %U https://formative.jmir.org/2024/1/e50025 %U https://doi.org/10.2196/50025 %U http://www.ncbi.nlm.nih.gov/pubmed/38814681 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e55544 %T Cost-Effectiveness of Digital Mental Health Versus Usual Care During Humanitarian Crises in Lebanon: Pragmatic Randomized Trial %A Abi Hana,Racha %A Abi Ramia,Jinane %A Burchert,Sebastian %A Carswell,Kenneth %A Cuijpers,Pim %A Heim,Eva %A Knaevelsrud,Christine %A Noun,Philip %A Sijbrandij,Marit %A van Ommeren,Mark %A van’t Hof,Edith %A Wijnen,Ben %A Zoghbi,Edwina %A El Chammay,Rabih %A Smit,Filip %+ Clinical, Neuro- and Developmental Psychology Department, Vrije Universiteit Amsterdam, De Boelelaan 1105, Amsterdam, 1105 1081 HV, Netherlands, 31 3978968, rasha_abihana@hotmail.com %K depression %K internet-based intervention %K economic evaluation %K Lebanese %K Syrian %K digital mental health %K digital health %K mental health %K usual care %K Lebanon %K anxiety %K stress-related disorders %K treatment %K symptoms %K large randomized controlled trial %K effectiveness %D 2024 %7 29.5.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is evidence from meta-analyses and systematic reviews that digital mental health interventions for depression, anxiety, and stress-related disorders tend to be cost-effective. However, no such evidence exists for guided digital mental health care in low and middle-income countries (LMICs) facing humanitarian crises, where the needs are highest. Step-by-Step (SbS), a digital mental health intervention for depression, anxiety, and stress-related disorders, proved to be effective for Lebanese citizens and war-affected Syrians residing in Lebanon. Assessing the cost-effectiveness of SbS is crucial because Lebanon’s overstretched health care system must prioritize cost-effective treatment options in the face of continuing humanitarian and economic crises. Objective: This study aims to assess the cost-effectiveness of SbS in a randomized comparison with enhanced usual care (EUC). Methods: The cost-effectiveness analysis was conducted alongside a pragmatic randomized controlled trial in 2 parallel groups comparing SbS (n=614) with EUC (n=635). The primary outcome was cost (in US $ for the reference year 2019) per treatment response of depressive symptoms, defined as >50% reduction of depressive symptoms measured using the Patient Health Questionnaire (PHQ). The secondary outcome was cost per remission of depressive symptoms, defined as a PHQ score <5 at last follow-up (5 months post baseline). The evaluation was conducted first from the health care perspective then from the societal perspective. Results: Taking the health care perspective, SbS had an 80% probability to be regarded as cost-effective compared with EUC when there is a willingness to pay US $220 per additional treatment response or US $840 per additional remission. Taking the wider societal perspective, SbS had a >75% probability to be cost-saving while gaining response or remission. Conclusions: To our knowledge, this study is the first cost-effectiveness analysis based on a large randomized controlled trial (n=1249) of a guided digital mental health intervention in an LMIC. From the principal findings, 2 implications flowed, from the (1) health care perspective and (2) wider societal perspective. First, our findings suggest that SbS is associated with greater health benefits, albeit for higher costs than EUC. It is up to decision makers in health care to decide if they find the balance between additional health gains and additional health care costs acceptable. Second, as seen from the wider societal perspective, there is a substantial likelihood that SbS is not costing more than EUC but is associated with cost-savings as SBS participants become more productive, thus offsetting their health care costs. This finding may suggest to policy makers that it is in the interest of both population health and the wider Lebanese economy to implement SbS on a wide scale. In brief, SbS may offer a scalable, potentially cost-saving response to humanitarian emergencies in an LMIC. Trial Registration: ClinicalTrials.gov NCT03720769; https://clinicaltrials.gov/ct2/show/NCT03720769 International Registered Report Identifier (IRRID): RR2-10.2196/21585 %M 38810255 %R 10.2196/55544 %U https://mental.jmir.org/2024/1/e55544 %U https://doi.org/10.2196/55544 %U http://www.ncbi.nlm.nih.gov/pubmed/38810255 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e40689 %T Digital Phenotyping for Stress, Anxiety, and Mild Depression: Systematic Literature Review %A Choi,Adrien %A Ooi,Aysel %A Lottridge,Danielle %+ School of Computer Science, Faculty of Science, University of Auckland, 38 Princes Street, Auckland, 1010, New Zealand, 64 9 373 7599 ext 82930, d.lottridge@auckland.ac.nz %K digital phenotyping %K passive sensing %K stress %K anxiety %K depression %K PRISMA %K Preferred Reporting Items for Systematic Reviews and Meta-Analyses %K mobile phone %D 2024 %7 23.5.2024 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Unaddressed early-stage mental health issues, including stress, anxiety, and mild depression, can become a burden for individuals in the long term. Digital phenotyping involves capturing continuous behavioral data via digital smartphone devices to monitor human behavior and can potentially identify milder symptoms before they become serious. Objective: This systematic literature review aimed to answer the following questions: (1) what is the evidence of the effectiveness of digital phenotyping using smartphones in identifying behavioral patterns related to stress, anxiety, and mild depression? and (2) in particular, which smartphone sensors are found to be effective, and what are the associated challenges? Methods: We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) process to identify 36 papers (reporting on 40 studies) to assess the key smartphone sensors related to stress, anxiety, and mild depression. We excluded studies conducted with nonadult participants (eg, teenagers and children) and clinical populations, as well as personality measurement and phobia studies. As we focused on the effectiveness of digital phenotyping using smartphones, results related to wearable devices were excluded. Results: We categorized the studies into 3 major groups based on the recruited participants: studies with students enrolled in universities, studies with adults who were unaffiliated to any particular organization, and studies with employees employed in an organization. The study length varied from 10 days to 3 years. A range of passive sensors were used in the studies, including GPS, Bluetooth, accelerometer, microphone, illuminance, gyroscope, and Wi-Fi. These were used to assess locations visited; mobility; speech patterns; phone use, such as screen checking; time spent in bed; physical activity; sleep; and aspects of social interactions, such as the number of interactions and response time. Of the 40 included studies, 31 (78%) used machine learning models for prediction; most others (n=8, 20%) used descriptive statistics. Students and adults who experienced stress, anxiety, or depression visited fewer locations, were more sedentary, had irregular sleep, and accrued increased phone use. In contrast to students and adults, less mobility was seen as positive for employees because less mobility in workplaces was associated with higher performance. Overall, travel, physical activity, sleep, social interaction, and phone use were related to stress, anxiety, and mild depression. Conclusions: This study focused on understanding whether smartphone sensors can be effectively used to detect behavioral patterns associated with stress, anxiety, and mild depression in nonclinical participants. The reviewed studies provided evidence that smartphone sensors are effective in identifying behavioral patterns associated with stress, anxiety, and mild depression. %M 38780995 %R 10.2196/40689 %U https://mhealth.jmir.org/2024/1/e40689 %U https://doi.org/10.2196/40689 %U http://www.ncbi.nlm.nih.gov/pubmed/38780995 %0 Journal Article %@ 2152-7202 %I JMIR Publications %V 16 %N %P e56204 %T Suicide Prevention by Peers Offering Recovery Tactics (SUPPORT) for US Veterans With Serious Mental Illness: Community Engagement Approach %A Chalker,Samantha A %A Serafez,Jesus %A Imai,Yuki %A Stinchcomb,Jeffrey %A Mendez,Estefany %A Depp,Colin A %A Twamley,Elizabeth W %A Fortuna,Karen L %A Goodman,Marianne %A Chinman,Matthew %+ Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA, 92161, United States, 1 6199338749, schalker@health.ucsd.edu %K suicide prevention %K advisor %K veterans %K recovery %K community %K peer specialist %K peer support %K serious mental illness %K participatory design %K community engagement %K lived experience %D 2024 %7 23.5.2024 %9 Original Paper %J J Particip Med %G English %X Background: Peer specialists are hired, trained, and accredited to share their lived experience of psychiatric illness to support other similar individuals through the recovery process. There are limited data on the role of peer specialists in suicide prevention, including their role in intervention development. Objective: To better understand peer specialists within the Veterans Health Administration (VHA), we followed partnership community engagement and a formative research approach to intervention development to (1) identify barriers, facilitators, and perceptions of VHA peer specialists delivering a suicide prevention service and (2) develop and refine an intervention curriculum based on an evidence-informed preliminary intervention framework for veterans with serious mental illness (SMI). Methods: Following the community engagement approach, VHA local and national peer support and mental health leaders, veterans with SMI, and veteran peer specialists met to develop a preliminary intervention framework. Next, VHA peer specialist advisors (n=5) and scientific advisors (n=6) participated in respective advisory boards and met every 2-4 months for more than 18 months via videoconferencing to address study objectives. The process used was a reflexive thematic analysis after each advisory board meeting. Results: The themes discussed included (1) the desire for suicide prevention training for peer specialists, (2) determining the role of VHA peer specialists in suicide prevention, (3) integration of recovery themes in suicide prevention, and (4) difficulties using safety plans during a crisis. There were no discrepancies in thematic content between advisory boards. Advisor input led to the development of Suicide Prevention by Peers Offering Recovery Tactics (SUPPORT). SUPPORT includes training in general suicide prevention and a peer specialist–delivered intervention for veterans with SMI at an increased suicide risk. This training aims to increase the competence and confidence of peer specialists in suicide prevention and the intervention supports veterans with SMI at an increased suicide risk through their recovery process. Conclusions: This paper intends to document the procedures taken in suicide prevention intervention development, specifically those led by peer specialists, and to be a source for future research developing and evaluating similar interventions. Trial Registration: ClinicalTrials.gov NCT05537376; https://classic.clinicaltrials.gov/ct2/show/NCT05537376 %M 38781010 %R 10.2196/56204 %U https://jopm.jmir.org/2024/1/e56204 %U https://doi.org/10.2196/56204 %U http://www.ncbi.nlm.nih.gov/pubmed/38781010 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e53968 %T User Dynamics and Thematic Exploration in r/Depression During the COVID-19 Pandemic: Insights From Overlapping r/SuicideWatch Users %A Zhu,Jianfeng %A Jin,Ruoming %A Kenne,Deric R %A Phan,NhatHai %A Ku,Wei-Shinn %+ Department of Computer Science, Kent State University, 800 E. Summit St., Kent, OH, 44242, United States, 1 3306729980, jzhu10@kent.edu %K reddit %K natural language processing %K NLP %K suicidal ideation %K SI %K online communities %K depression symptoms %K COVID-19 pandemic %K bidirectional encoder representations from transformers %K BERT %K r/SuicideWatch %K r/Depression %D 2024 %7 20.5.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: In 2023, the United States experienced its highest- recorded number of suicides, exceeding 50,000 deaths. In the realm of psychiatric disorders, major depressive disorder stands out as the most common issue, affecting 15% to 17% of the population and carrying a notable suicide risk of approximately 15%. However, not everyone with depression has suicidal thoughts. While “suicidal depression” is not a clinical diagnosis, it may be observed in daily life, emphasizing the need for awareness. Objective: This study aims to examine the dynamics, emotional tones, and topics discussed in posts within the r/Depression subreddit, with a specific focus on users who had also engaged in the r/SuicideWatch community. The objective was to use natural language processing techniques and models to better understand the complexities of depression among users with potential suicide ideation, with the goal of improving intervention and prevention strategies for suicide. Methods: Archived posts were extracted from the r/Depression and r/SuicideWatch Reddit communities in English spanning from 2019 to 2022, resulting in a final data set of over 150,000 posts contributed by approximately 25,000 unique overlapping users. A broad and comprehensive mix of methods was conducted on these posts, including trend and survival analysis, to explore the dynamic of users in the 2 subreddits. The BERT family of models extracted features from data for sentiment and thematic analysis. Results: On August 16, 2020, the post count in r/SuicideWatch surpassed that of r/Depression. The transition from r/Depression to r/SuicideWatch in 2020 was the shortest, lasting only 26 days. Sadness emerged as the most prevalent emotion among overlapping users in the r/Depression community. In addition, physical activity changes, negative self-view, and suicidal thoughts were identified as the most common depression symptoms, all showing strong positive correlations with the emotion tone of disappointment. Furthermore, the topic “struggles with depression and motivation in school and work” (12%) emerged as the most discussed topic aside from suicidal thoughts, categorizing users based on their inclination toward suicide ideation. Conclusions: Our study underscores the effectiveness of using natural language processing techniques to explore language markers and patterns associated with mental health challenges in online communities like r/Depression and r/SuicideWatch. These insights offer novel perspectives distinct from previous research. In the future, there will be potential for further refinement and optimization of machine classifications using these techniques, which could lead to more effective intervention and prevention strategies. %M 38767953 %R 10.2196/53968 %U https://www.jmir.org/2024/1/e53968 %U https://doi.org/10.2196/53968 %U http://www.ncbi.nlm.nih.gov/pubmed/38767953 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e53204 %T Prospective Acceptability of Digital Therapy for Major Depressive Disorder in France: Multicentric Real-Life Study %A Amiot,Odile %A Sauvaget,Anne %A Alamome,Isabelle %A Bulteau,Samuel %A Charpeaud,Thomas %A Clair,Anne-Hélène %A Courtet,Philippe %A Drapier,Dominique %A Haffen,Emmanuel %A Fakra,Eric %A Gaudeau-Bosma,Christian %A Gaillard,Adeline %A Mouchabac,Stéphane %A Pineau,Fanny %A Narboni,Véronique %A Duburcq,Anne %A Lecardeur,Laurent %+ DueL, 8 Quai des Docks, Nice, 06300, France, 33 635568024, laurentlecardeur@gmail.com %K prospective acceptability %K digital health %K depression %K e-mental health %K deprexis %K psychotherapy %D 2024 %7 20.5.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Major depressive disorder is one of the leading causes of disability worldwide. Although most international guidelines recommend psychological and psychosocial interventions as first-line treatment for mild to moderate depression, access remains limited in France due to the limited availability of trained clinicians, high costs for patients in the context of nonreimbursement, and the fear of stigmatization. Therefore, online blended psychological treatment such as Deprexis could improve access to care for people with depression. It has several advantages, such as easy accessibility and scalability, and it is supported by evidence. Objective: This study aims to evaluate the real-life acceptability of Deprexis for people with depression in France outside of a reimbursement pathway. Methods: Deprexis Acceptability Study Measure in Real Life (DARE) was designed as a multicenter cross-sectional study in which Deprexis was offered to any patient meeting the inclusion criteria during the fixed inclusion period (June 2022-March 2023). Inclusion criteria were (1) depression, (2) age between 18 and 65 years, (3) sufficient French language skills, and (4) access to the internet with a device to connect to the Deprexis platform. Exclusion criteria were previous or current diagnoses of bipolar disorder, psychotic symptoms, and suicidal thoughts during the current episode. The primary objective was to measure the prospective acceptability of Deprexis, a new digital therapy. Secondary objectives were to examine differences in acceptability according to patient and clinician characteristics and to identify reasons for refusal. All investigators received video-based training on Deprexis before enrollment to ensure that they all had the same level of information and understanding of the program. Results: A total of 245 patients were eligible (n=159, 64.9% were women and n=138, 56.3% were single). The mean age was 40.7 (SD 14.1) years. A total of 78% (n=191) of the patients had moderate to severe depression (according to the Patient Health Questionnaire-9 [PHQ-9]). More than half of the population had another psychiatric comorbidity (excluding bipolar disorder, psychotic disorders, and suicidal ideation). A total of 33.9% (n=83) of patients accepted the idea of using Deprexis; the main reason for refusal was financial at 83.3% (n=135). Multivariate logistic regression identified factors that might favor the acceptability of Deprexis. Among these, being a couple, being treated with an antidepressant, or having a low severity level favored the acceptance of Deprexis. Conclusions: DARE is the first French study aiming at evaluating the prospective acceptability of digital therapy in the treatment of depression. The main reason for the refusal of Deprexis was financial. DARE will allow better identification of factors influencing acceptability in a natural setting. This study highlights the importance of investigating factors that may be associated with the acceptability of digital interventions, such as marital status, medication use, and severity of depression. %M 38568139 %R 10.2196/53204 %U https://formative.jmir.org/2024/1/e53204 %U https://doi.org/10.2196/53204 %U http://www.ncbi.nlm.nih.gov/pubmed/38568139 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e55913 %T Machine Learning–Based Prediction of Suicidal Thinking in Adolescents by Derivation and Validation in 3 Independent Worldwide Cohorts: Algorithm Development and Validation Study %A Kim,Hyejun %A Son,Yejun %A Lee,Hojae %A Kang,Jiseung %A Hammoodi,Ahmed %A Choi,Yujin %A Kim,Hyeon Jin %A Lee,Hayeon %A Fond,Guillaume %A Boyer,Laurent %A Kwon,Rosie %A Woo,Selin %A Yon,Dong Keon %+ Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, 23 Kyungheedae–ro, Dongdaemun–gu, Seoul, 02447, Republic of Korea, 82 2 6935 2476, yonkkang@gmail.com %K adolescent %K machine learning %K Shapley additive explanations %K SHAP value %K suicidal thinking %K XGBoost %K mental health %K predictive model %K risk behavior %D 2024 %7 17.5.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is the second-leading cause of death among adolescents and is associated with clusters of suicides. Despite numerous studies on this preventable cause of death, the focus has primarily been on single nations and traditional statistical methods. Objective: This study aims to develop a predictive model for adolescent suicidal thinking using multinational data sets and machine learning (ML). Methods: We used data from the Korea Youth Risk Behavior Web-based Survey with 566,875 adolescents aged between 13 and 18 years and conducted external validation using the Youth Risk Behavior Survey with 103,874 adolescents and Norway’s University National General Survey with 19,574 adolescents. Several tree-based ML models were developed, and feature importance and Shapley additive explanations values were analyzed to identify risk factors for adolescent suicidal thinking. Results: When trained on the Korea Youth Risk Behavior Web-based Survey data from South Korea with a 95% CI, the XGBoost model reported an area under the receiver operating characteristic (AUROC) curve of 90.06% (95% CI 89.97-90.16), displaying superior performance compared to other models. For external validation using the Youth Risk Behavior Survey data from the United States and the University National General Survey from Norway, the XGBoost model achieved AUROCs of 83.09% and 81.27%, respectively. Across all data sets, XGBoost consistently outperformed the other models with the highest AUROC score, and was selected as the optimal model. In terms of predictors of suicidal thinking, feelings of sadness and despair were the most influential, accounting for 57.4% of the impact, followed by stress status at 19.8%. This was followed by age (5.7%), household income (4%), academic achievement (3.4%), sex (2.1%), and others, which contributed less than 2% each. Conclusions: This study used ML by integrating diverse data sets from 3 countries to address adolescent suicide. The findings highlight the important role of emotional health indicators in predicting suicidal thinking among adolescents. Specifically, sadness and despair were identified as the most significant predictors, followed by stressful conditions and age. These findings emphasize the critical need for early diagnosis and prevention of mental health issues during adolescence. %M 38758578 %R 10.2196/55913 %U https://www.jmir.org/2024/1/e55913 %U https://doi.org/10.2196/55913 %U http://www.ncbi.nlm.nih.gov/pubmed/38758578 %0 Journal Article %@ 2368-7959 %I %V 11 %N %P e57234 %T Using Large Language Models to Understand Suicidality in a Social Media–Based Taxonomy of Mental Health Disorders: Linguistic Analysis of Reddit Posts %A Bauer,Brian %A Norel,Raquel %A Leow,Alex %A Rached,Zad Abi %A Wen,Bo %A Cecchi,Guillermo %K natural language processing %K explainable AI %K suicide %K mental health disorders %K mental health disorder %K mental health %K social media %K online discussions %K online %K large language model %K LLM %K downstream analyses %K trauma %K stress %K depression %K anxiety %K AI %K artificial intelligence %K explainable artificial intelligence %K web-based discussions %D 2024 %7 16.5.2024 %9 %J JMIR Ment Health %G English %X Background: Rates of suicide have increased by over 35% since 1999. Despite concerted efforts, our ability to predict, explain, or treat suicide risk has not significantly improved over the past 50 years. Objective: The aim of this study was to use large language models to understand natural language use during public web-based discussions (on Reddit) around topics related to suicidality. Methods: We used large language model–based sentence embedding to extract the latent linguistic dimensions of user postings derived from several mental health–related subreddits, with a focus on suicidality. We then applied dimensionality reduction to these sentence embeddings, allowing them to be summarized and visualized in a lower-dimensional Euclidean space for further downstream analyses. We analyzed 2.9 million posts extracted from 30 subreddits, including r/SuicideWatch, between October 1 and December 31, 2022, and the same period in 2010. Results: Our results showed that, in line with existing theories of suicide, posters in the suicidality community (r/SuicideWatch) predominantly wrote about feelings of disconnection, burdensomeness, hopeless, desperation, resignation, and trauma. Further, we identified distinct latent linguistic dimensions (well-being, seeking support, and severity of distress) among all mental health subreddits, and many of the resulting subreddit clusters were in line with a statistically driven diagnostic classification system—namely, the Hierarchical Taxonomy of Psychopathology (HiTOP)—by mapping onto the proposed superspectra. Conclusions: Overall, our findings provide data-driven support for several language-based theories of suicide, as well as dimensional classification systems for mental health disorders. Ultimately, this novel combination of natural language processing techniques can assist researchers in gaining deeper insights about emotions and experiences shared on the web and may aid in the validation and refutation of different mental health theories. %R 10.2196/57234 %U https://mental.jmir.org/2024/1/e57234 %U https://doi.org/10.2196/57234 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e55483 %T Economic Evaluation of a Web Application Implemented in Primary Care for the Treatment of Depression in Patients With Type 2 Diabetes Mellitus: Multicenter Randomized Controlled Trial %A Varela-Moreno,Esperanza %A Anarte-Ortiz,Maria Teresa %A Jodar-Sanchez,Francisco %A Garcia-Palacios,Azucena %A Monreal-Bartolomé,Alicia %A Gili,Margalida %A García-Campayo,Javier %A Mayoral-Cleries,Fermin %+ Department of Applied Economics, Faculty of Economics and Business Administration, University of Malaga, C. El Ejido, 6, Malaga, 29071, Spain, 34 951976620, fjodar@uma.es %K depression %K depressive %K type 2 %K diabetes %K diabetic %K type 2 diabetes mellitus %K eHealth %K web-based intervention %K efficacy %K economic evaluation %K cost-effectiveness %K cost-utility %K randomized controlled trial %K RCT %K randomized %K controlled trial %K controlled trials %K cost %K costs %K economic %K economics %K web based %K internet based %K CBT %K psychotherapy %K cognitive behavioral therapy %K cognitive behavioral therapy %K mental health %D 2024 %7 16.5.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depressive disorder and type 2 diabetes mellitus (T2DM) are prevalent in primary care (PC). Pharmacological treatment, despite controversy, is commonly chosen due to resource limitations and difficulties in accessing face-to-face interventions. Depression significantly impacts various aspects of a person’s life, affecting adherence to medical prescriptions and glycemic control and leading to future complications and increased health care costs. To address these challenges, information and communication technologies (eg, eHealth) have been introduced, showing promise in improving treatment continuity and accessibility. However, while eHealth programs have demonstrated effectiveness in alleviating depressive symptoms, evidence regarding glycemic control remains inconclusive. This randomized controlled trial aimed to test the efficacy of a low-intensity psychological intervention via a web app for mild-moderate depressive symptoms in individuals with T2DM compared with treatment as usual (TAU) in PC. Objective: This study aimed to analyze the cost-effectiveness and cost-utility of a web-based psychological intervention to treat depressive symptomatology in people with T2DM compared with TAU in a PC setting. Methods: A multicenter randomized controlled trial was conducted with 49 patients with T2DM, depressive symptoms of moderate severity, and glycosylated hemoglobin (HbA1c) of 7.47% in PC settings. Patients were randomized to TAU (n=27) or a web-based psychological treatment group (n=22). This web-based treatment consisted of cognitive behavioral therapy, improvement of diabetes self-care behaviors, and mindfulness. Cost-effectiveness analysis for the improvement of depressive symptomatology was conducted based on reductions in 3, 5, or 50 points on the Patient Health Questionnaire–9 (PHQ-9). The efficacy of diabetes control was estimated based on a 0.5% reduction in HbA1c levels. Follow-up was performed at 3 and 6 months. The cost-utility analysis was performed based on quality-adjusted life years. Results: Efficacy analysis showed that the web-based treatment program was more effective in improving depressive symptoms than TAU but showed only a slight improvement in HbA1c. Incremental cost-effectiveness ratios of 186.76 for a 3-point reduction in PHQ-9 and 206.31 for reductions of 5 and 50 percentage points were obtained. In contrast, the incremental cost-effectiveness ratio for improving HbA1c levels amounted to €1510.90 (€1=US $1.18 in 2018) per participant. The incremental cost-utility ratio resulted in €4119.33 per quality-adjusted life year gained. Conclusions: The intervention, using web-based modules incorporating cognitive behavioral therapy tools, diabetes self-care promotion, and mindfulness, effectively reduced depressive symptoms and enhanced glycemic control in patients with T2DM. Notably, it demonstrated clinical efficacy and economic efficiency. This supports the idea that eHealth interventions not only benefit patients clinically but also offer cost-effectiveness for health care systems. The study emphasizes the importance of including specific modules to enhance diabetes self-care behaviors in future web-based psychological interventions, emphasizing personalization and adaptation for this population. Trial Registration: ClinicalTrials.gov NCT03426709; https://clinicaltrials.gov/study/NCT03426709 International Registered Report Identifier (IRRID): RR2-10.1186/S12888-019-2037-3 %M 38754101 %R 10.2196/55483 %U https://mhealth.jmir.org/2024/1/e55483 %U https://doi.org/10.2196/55483 %U http://www.ncbi.nlm.nih.gov/pubmed/38754101 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 11 %N %P e50098 %T A Digital Behavioral Activation Intervention (JuNEX) for Pregnant Women With Subclinical Depression Symptoms: Explorative Co-Design Study %A Mancinelli,Elisa %A Gabrielli,Silvia %A Salcuni,Silvia %+ Department of Developmental and Socialization Psychology, University of Padova, Via Venezia 8, Padova, 35131, Italy, 39 3342799698, elisa.mancinelli@phd.unipd.it %K digital intervention %K behavioral activation %K feasibility %K pregnancy %K subclinical depression symptoms %D 2024 %7 16.5.2024 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Digital interventions are gaining increasing interest due to their structured nature, ready availability, and self-administered capabilities. Perinatal women have expressed a desire for such interventions. In this regard, behavioral activation interventions may be particularly suitable for digital administration. Objective: This study aims to exploratorily investigate and compare the feasibility of the internet-based self-help guided versus unguided version of the Brief Behavioral Activation Treatment for Depression-Revised, an empirically supported in-person behavioral activation protocol, targeting pregnant women with subclinical depression symptoms. A user-centered design is used, whereby data are collected with the intent of evaluating how to adjust the intervention in line with pregnant women’s needs. Usability and user engagement were evaluated. Methods: A total of 11 Italian pregnant women with subclinical depressive symptoms based on the Patient Health Questionnaire-9 (scoring<15) participated in this study; of them, 6 (55%) women were randomly assigned to the guided group (age: mean 32.17, SD 4.36 years) and 5 (45%) to the unguided group (age: mean 31, SD 4.95 years). The Moodle platform was used to deliver the interventions in an e-learning format. It consisted of 6 core modules and 3 optional modules; the latter aimed at revising the content of the former. In the guided group, each woman had weekly chats with their assigned human guide to support them in the homework revisions. The intervention content included text, pictures, and videos. Semistructured interviews were conducted, and descriptive statistics were analyzed. Results: Collectively, the data suggest that the guided intervention was better accepted than the unguided one. However, the high rates of dropout (at T6: guided group: 3/6, 50%; unguided: 4/5, 80%) suggest that a digital replica of Behavioral Activation Treatment for Depression-Revised may not be feasible in an e-learning format. The reduced usability of the platform used was reported, and homework was perceived as too time-consuming and effort-intensive. Moreover, the 6 core modules were deemed sufficient for the intervention’s goals, suggesting that the 3 optional modules could be eliminated. Nevertheless, participants from both groups expressed satisfaction with the content and found it relevant to their pregnancy experiences. Conclusions: Overall, the findings have emphasized both the intervention’s merits and shortcomings. Results highlight the unsuitability of replicating an in-person protocol digitally as well as of the use of nonprofessional tools for the implementation of self-help interventions, ultimately making the intervention not feasible. Pregnant women have nonetheless expressed a desire to receive psychological support and commented on the possibilities of digital psychosocial supports, particularly those that are app-based. The information collected and the issues identified here are important to guide the development and co-design of a more refined platform for the intervention deployment and to tailor the intervention’s content to pregnant women’s needs. %M 38753421 %R 10.2196/50098 %U https://humanfactors.jmir.org/2024/1/e50098 %U https://doi.org/10.2196/50098 %U http://www.ncbi.nlm.nih.gov/pubmed/38753421 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e56198 %T An Internet-Based Intervention to Increase the Ability of Lesbian, Gay, and Bisexual People to Cope With Adverse Events: Single-Group Feasibility Study %A Isbășoiu,Andreea Bogdana %A Sava,Florin Alin %A Larsen,Torill M B %A Anderssen,Norman %A Rotaru,Tudor-Stefan %A Rusu,Andrei %A Sălăgean,Nastasia %A Tulbure,Bogdan Tudor %+ Department of Psychology, West University of Timisoara, 4 Vasile Parvan Bvd., Timisoara, 300223, Romania, 40 256592270, florin.sava@e-uvt.ro %K acceptance and commitment therapy %K anxiety %K depression %K PTSD %K LGBTQ+ %K online interventions %K transdiagnostic %K prevention %D 2024 %7 15.5.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people are at higher risk of mental health problems due to widespread hetero- and cisnormativity, including negative public attitudes toward the LGBTQ+ community. In addition to combating social exclusion at the societal level, strengthening the coping abilities of young LGBTQ+ people is an important goal. Objective: In this transdiagnostic feasibility study, we tested a 6-week internet intervention program designed to increase the ability of nonclinical LGBTQ+ participants to cope with adverse events in their daily lives. The program was based on acceptance and commitment therapy principles. Methods: The program consists of 6 web-based modules and low-intensity assistance for homework provided by a single care provider asynchronously. The design was a single-group assignment of 15 self-identified LGB community members who agreed to participate in an open trial with a single group (pre- and postintervention design). Results: Before starting the program, participants found the intervention credible and expressed high satisfaction at the end of the intervention. Treatment adherence, operationalized by the percentage of completed homework assignments (32/36, 88%) was also high. When we compared participants’ pre- and postintervention scores, we found a significant decrease in clinical symptoms of depression (Cohen d=0.44, 90% CI 0.09-0.80), social phobia (d=0.39, 90% CI 0.07-0.72), and posttraumatic stress disorder (d=0.30, 90% CI 0.04-0.55). There was also a significant improvement in the level of self-acceptance and behavioral effectiveness (d=0.64, 90% CI 0.28-0.99) and a significant decrease in the tendency to avoid negative internal experiences (d=0.38, 90% CI 0.09-0.66). The level of general anxiety disorder (P=.11; d=0.29, 90% CI –0.10 to 0.68) and alcohol consumption (P=.35; d=–0.06, 90% CI –0.31 to 0.19) were the only 2 outcomes for which the results were not statistically significant. Conclusions: The proposed web-based acceptance and commitment therapy program, designed to help LGBTQ+ participants better manage emotional difficulties and become more resilient, represents a promising therapeutic tool. The program could be further tested with more participants to ensure its efficacy and effectiveness. Trial Registration: ClinicalTrials.gov NCT05514964; https://clinicaltrials.gov/study/NCT05514964 %M 38749024 %R 10.2196/56198 %U https://formative.jmir.org/2024/1/e56198 %U https://doi.org/10.2196/56198 %U http://www.ncbi.nlm.nih.gov/pubmed/38749024 %0 Journal Article %@ 2368-7959 %I %V 11 %N %P e56812 %T Coding of Childhood Psychiatric and Neurodevelopmental Disorders in Electronic Health Records of a Large Integrated Health Care System: Validation Study %A Shi,Jiaxiao M %A Chiu,Vicki Y %A Avila,Chantal C %A Lewis,Sierra %A Park,Daniella %A Peltier,Morgan R %A Getahun,Darios %K autism %K autism spectrum disorder %K ASD %K attention deficit hyperactivity disorder %K ADHD %K disruptive behavioral disorders %K DBD %K anxiety disorders %K AD %K major depression disorder %K MDD %K autistic %K coding %K neurodevelopmental %K psychiatric %K electronic health record %K electronic health records %K validation %K accuracy %K mental health %K emotional %K behavior %K behaviors %K behavioral %K disorder %K disorders %K pediatric %K pediatrics %K paediatric %K infant %K paediatrics %K infants %K infancy %K baby %K babies %K neonate %K neotnates %K neonatal %K toddler %K toddlers %K child %K children %K hospital %K hospitals %D 2024 %7 14.5.2024 %9 %J JMIR Ment Health %G English %X Background: Mental, emotional, and behavioral disorders are chronic pediatric conditions, and their prevalence has been on the rise over recent decades. Affected children have long-term health sequelae and a decline in health-related quality of life. Due to the lack of a validated database for pharmacoepidemiological research on selected mental, emotional, and behavioral disorders, there is uncertainty in their reported prevalence in the literature. Objectives: We aimed to evaluate the accuracy of coding related to pediatric mental, emotional, and behavioral disorders in a large integrated health care system’s electronic health records (EHRs) and compare the coding quality before and after the implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding as well as before and after the COVID-19 pandemic. Methods: Medical records of 1200 member children aged 2-17 years with at least 1 clinical visit before the COVID-19 pandemic (January 1, 2012, to December 31, 2014, the ICD-9-CM coding period; and January 1, 2017, to December 31, 2019, the ICD-10-CM coding period) and after the COVID-19 pandemic (January 1, 2021, to December 31, 2022) were selected with stratified random sampling from EHRs for chart review. Two trained research associates reviewed the EHRs for all potential cases of autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD), major depression disorder (MDD), anxiety disorder (AD), and disruptive behavior disorders (DBD) in children during the study period. Children were considered cases only if there was a mention of any one of the conditions (yes for diagnosis) in the electronic chart during the corresponding time period. The validity of diagnosis codes was evaluated by directly comparing them with the gold standard of chart abstraction using sensitivity, specificity, positive predictive value, negative predictive value, the summary statistics of the F-score, and Youden J statistic. κ statistic for interrater reliability among the 2 abstractors was calculated. Results: The overall agreement between the identification of mental, behavioral, and emotional conditions using diagnosis codes compared to medical record abstraction was strong and similar across the ICD-9-CM and ICD-10-CM coding periods as well as during the prepandemic and pandemic time periods. The performance of AD coding, while strong, was relatively lower compared to the other conditions. The weighted sensitivity, specificity, positive predictive value, and negative predictive value for each of the 5 conditions were as follows: 100%, 100%, 99.2%, and 100%, respectively, for ASD; 100%, 99.9%, 99.2%, and 100%, respectively, for ADHD; 100%, 100%, 100%, and 100%, respectively for DBD; 87.7%, 100%, 100%, and 99.2%, respectively, for AD; and 100%, 100%, 99.2%, and 100%, respectively, for MDD. The F-score and Youden J statistic ranged between 87.7% and 100%. The overall agreement between abstractors was almost perfect (κ=95%). Conclusions: Diagnostic codes are quite reliable for identifying selected childhood mental, behavioral, and emotional conditions. The findings remained similar during the pandemic and after the implementation of the ICD-10-CM coding in the EHR system. %R 10.2196/56812 %U https://mental.jmir.org/2024/1/e56812 %U https://doi.org/10.2196/56812 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 13 %N %P e50982 %T Predicting the Effectiveness of a Mindfulness Virtual Community Intervention for University Students: Machine Learning Model %A El Morr,Christo %A Tavangar,Farideh %A Ahmad,Farah %A Ritvo,Paul %A , %+ School of Health Policy and Management, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada, 1 426 736 2100 ext 22053, elmorr@yorku.ca %K machine learning %K virtual community %K virtual care %K mindfulness %K depression %K anxiety %K stress %K students %K online %K randomized controlled trial %K Canada %K virtual %K artificial intelligence %K symptoms %K behavioral therapy %K sociodemographic %K mindfulness video %K online video %D 2024 %7 13.5.2024 %9 Original Paper %J Interact J Med Res %G English %X Background: Students’ mental health crisis was recognized before the COVID-19 pandemic. Mindfulness virtual community (MVC), an 8-week web-based mindfulness and cognitive behavioral therapy program, has proven to be an effective web-based program to reduce symptoms of depression, anxiety, and stress. Predicting the success of MVC before a student enrolls in the program is essential to advise students accordingly. Objective: The objectives of this study were to investigate (1) whether we can predict MVC’s effectiveness using sociodemographic and self-reported features and (2) whether exposure to mindfulness videos is highly predictive of the intervention’s success. Methods: Machine learning models were developed to predict MVC’s effectiveness, defined as success in reducing symptoms of depression, anxiety, and stress as measured using the Patient Health Questionnaire-9 (PHQ-9), the Beck Anxiety Inventory (BAI), and the Perceived Stress Scale (PSS), to at least the minimal clinically important difference. A data set representing a sample of undergraduate students (N=209) who took the MVC intervention between fall 2017 and fall 2018 was used for this secondary analysis. Random forest was used to measure the features’ importance. Results: Gradient boosting achieved the best performance both in terms of area under the curve (AUC) and accuracy for predicting PHQ-9 (AUC=0.85 and accuracy=0.83) and PSS (AUC=1 and accuracy=1), and random forest had the best performance for predicting BAI (AUC=0.93 and accuracy=0.93). Exposure to online mindfulness videos was the most important predictor for the intervention’s effectiveness for PHQ-9, BAI, and PSS, followed by the number of working hours per week. Conclusions: The performance of the models to predict MVC intervention effectiveness for depression, anxiety, and stress is high. These models might be helpful for professionals to advise students early enough on taking the intervention or choosing other alternatives. The students’ exposure to online mindfulness videos is the most important predictor for the effectiveness of the MVC intervention. Trial Registration: ISRCTN Registry ISRCTN12249616; https://www.isrctn.com/ISRCTN12249616 %M 38578872 %R 10.2196/50982 %U https://www.i-jmr.org/2024/1/e50982 %U https://doi.org/10.2196/50982 %U http://www.ncbi.nlm.nih.gov/pubmed/38578872 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e52369 %T Feasibility and Acceptability of a Mobile App–Based TEAM-CBT (Testing Empathy Assessment Methods–Cognitive Behavioral Therapy) Intervention (Feeling Good) for Depression: Secondary Data Analysis %A Bisconti,Nicholas %A Odier,Mackenzie %A Becker,Matthew %A Bullock,Kim %+ PGSP-Stanford PsyD. Consortium, 401 Quarry Rd, Palo Alto, CA, 94304, United States, 1 6506449946, nbisco@stanford.edu %K depression %K mobile health %K mHealth %K cognitive behavioral therapy %K mobile phone %D 2024 %7 10.5.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: The Feeling Good App is an automated stand-alone digital mobile mental health tool currently undergoing beta testing with the goal of providing evidence-informed self-help lessons and exercises to help individuals reduce depressive symptoms without guidance from a mental health provider. Users work through intensive basic training (IBT) and ongoing training models that provide education regarding cognitive behavioral therapy principles from a smartphone. Objective: The key objective of this study was to perform a nonsponsored third-party academic assessment of an industry-generated data set; this data set focused on the safety, feasibility, and accessibility of a commercial automated digital mobile mental health app that was developed to reduce feelings associated with depression. Methods: The Feeling Good App development team created a waitlist cohort crossover design and measured symptoms of depression and anxiety using the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and an app-specific measure of negative feelings called the 7 Dimension Emotion Slider (7-DES). The waitlist cohort crossover design divided the participants into 2 groups, where 48.6% (141/290) of the participants were given immediate access to the apps, while 51.4% (149/290) were placed on a 2-week waitlist before being given access to the app. Data collected by the Feeling Good App development team were deidentified and provided to the authors of this paper for analysis through a nonsponsored university data use agreement. All quantitative data were analyzed using SPSS Statistics (version 28.0; IBM Corp). Descriptive statistics were calculated for demographic variables. Feasibility and acceptability were descriptively assessed. All participants included in the quantitative data were given access to the Feeling Good App; this study did not include a control group. Results: In terms of safety, there was no statistically significant change in suicidality from preintervention to postintervention time points (t288=0.0; P>.99), and there was a statistically significant decrease in hopelessness from preintervention to postintervention time points (F289=30.16; P<.01). In terms of acceptability, 72.2% (166/230) of the users who started the initial 2-day IBT went on to complete it, while 34.8% (80/230) of the users who started IBT completed the entirety of the apps’ 4-week protocol (150/230, 65.22% dropout rate over 4 weeks). Conclusions: This study is the first reported proof-of-concept evaluation of the Feeling Good App in terms of safety, feasibility, and statistical trends within the data set. It demonstrates a feasible and novel approach to industry and academic collaboration in the process of developing a digital mental health technology translated from an existing evidence-informed treatment. The results support the prototype app as safe for a select nonclinical population. The app had acceptable levels of engagement and dropouts throughout the intervention. Those who stay engaged showed reductions in symptom severity of depression warranting further investigation of the app’s efficacy. %M 38728080 %R 10.2196/52369 %U https://mental.jmir.org/2024/1/e52369 %U https://doi.org/10.2196/52369 %U http://www.ncbi.nlm.nih.gov/pubmed/38728080 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e46036 %T Effectiveness of an Artificial Intelligence-Assisted App for Improving Eating Behaviors: Mixed Methods Evaluation %A Chew,Han Shi Jocelyn %A Chew,Nicholas WS %A Loong,Shaun Seh Ern %A Lim,Su Lin %A Tam,Wai San Wilson %A Chin,Yip Han %A Chao,Ariana M %A Dimitriadis,Georgios K %A Gao,Yujia %A So,Jimmy Bok Yan %A Shabbir,Asim %A Ngiam,Kee Yuan %+ Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 3, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore, 117597, Singapore, 65 65168687, jocelyn.chew.hs@nus.edu.sg %K artificial intelligence %K chatbot %K chatbots %K weight %K overweight %K eating %K food %K weight loss %K mHealth %K mobile health %K app %K apps %K applications %K self-regulation %K self-monitoring %K anxiety %K depression %K consideration of future consequences %K mental health %K conversational agent %K conversational agents %K eating behavior %K healthy eating %K food consumption %K obese %K obesity %K diet %K dietary %D 2024 %7 7.5.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: A plethora of weight management apps are available, but many individuals, especially those living with overweight and obesity, still struggle to achieve adequate weight loss. An emerging area in weight management is the support for one’s self-regulation over momentary eating impulses. Objective: This study aims to examine the feasibility and effectiveness of a novel artificial intelligence–assisted weight management app in improving eating behaviors in a Southeast Asian cohort. Methods: A single-group pretest-posttest study was conducted. Participants completed the 1-week run-in period of a 12-week app-based weight management program called the Eating Trigger-Response Inhibition Program (eTRIP). This self-monitoring system was built upon 3 main components, namely, (1) chatbot-based check-ins on eating lapse triggers, (2) food-based computer vision image recognition (system built based on local food items), and (3) automated time-based nudges and meal stopwatch. At every mealtime, participants were prompted to take a picture of their food items, which were identified by a computer vision image recognition technology, thereby triggering a set of chatbot-initiated questions on eating triggers such as who the users were eating with. Paired 2-sided t tests were used to compare the differences in the psychobehavioral constructs before and after the 7-day program, including overeating habits, snacking habits, consideration of future consequences, self-regulation of eating behaviors, anxiety, depression, and physical activity. Qualitative feedback were analyzed by content analysis according to 4 steps, namely, decontextualization, recontextualization, categorization, and compilation. Results: The mean age, self-reported BMI, and waist circumference of the participants were 31.25 (SD 9.98) years, 28.86 (SD 7.02) kg/m2, and 92.60 (SD 18.24) cm, respectively. There were significant improvements in all the 7 psychobehavioral constructs, except for anxiety. After adjusting for multiple comparisons, statistically significant improvements were found for overeating habits (mean –0.32, SD 1.16; P<.001), snacking habits (mean –0.22, SD 1.12; P<.002), self-regulation of eating behavior (mean 0.08, SD 0.49; P=.007), depression (mean –0.12, SD 0.74; P=.007), and physical activity (mean 1288.60, SD 3055.20 metabolic equivalent task-min/day; P<.001). Forty-one participants reported skipping at least 1 meal (ie, breakfast, lunch, or dinner), summing to 578 (67.1%) of the 862 meals skipped. Of the 230 participants, 80 (34.8%) provided textual feedback that indicated satisfactory user experience with eTRIP. Four themes emerged, namely, (1) becoming more mindful of self-monitoring, (2) personalized reminders with prompts and chatbot, (3) food logging with image recognition, and (4) engaging with a simple, easy, and appealing user interface. The attrition rate was 8.4% (21/251). Conclusions: eTRIP is a feasible and effective weight management program to be tested in a larger population for its effectiveness and sustainability as a personalized weight management program for people with overweight and obesity. Trial Registration: ClinicalTrials.gov NCT04833803; https://classic.clinicaltrials.gov/ct2/show/NCT04833803 %M 38713909 %R 10.2196/46036 %U https://www.jmir.org/2024/1/e46036 %U https://doi.org/10.2196/46036 %U http://www.ncbi.nlm.nih.gov/pubmed/38713909 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e55559 %T Development and Pilot-Testing of an Optimized Conversational Agent or “Chatbot” for Peruvian Adolescents Living With HIV to Facilitate Mental Health Screening, Education, Self-Help, and Linkage to Care: Protocol for a Mixed Methods, Community-Engaged Study %A Galea,Jerome T %A Vasquez,Diego H %A Rupani,Neil %A Gordon,Moya B %A Tapia,Milagros %A Greene,Karah Y %A Kolevic,Lenka %A Franke,Molly F %A Contreras,Carmen %+ School of Social Work, College of Behavioral and Community Sciences, University of South Florida, 13301 Bruce B Downs Boulevard, MHC 1400, Tampa, FL, 33612-3807, United States, 1 813 974 2310, jeromegalea@usf.edu %K chatbot %K digital assistant %K depression %K HIV %K adolescents %D 2024 %7 7.5.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Adolescents living with HIV are disproportionally affected by depression, which worsens antiretroviral therapy adherence, increases viral load, and doubles the risk of mortality. Because most adolescents living with HIV live in low- and middle-income countries, few receive depression treatment due to a lack of mental health services and specialists in low-resource settings. Chatbot technology, used increasingly in health service delivery, is a promising approach for delivering low-intensity depression care to adolescents living with HIV in resource-constrained settings. Objective: The goal of this study is to develop and pilot-test for the feasibility and acceptability of a prototype, optimized conversational agent (chatbot) to provide mental health education, self-help skills, and care linkage for adolescents living with HIV. Methods: Chatbot development comprises 3 phases conducted over 2 years. In the first phase (year 1), formative research will be conducted to understand the views, opinions, and preferences of up to 48 youths aged 10-19 years (6 focus groups of up to 8 adolescents living with HIV per group), their caregivers (5 in-depth interviews), and HIV program personnel (5 in-depth interviews) regarding depression among adolescents living with HIV. We will also investigate the perceived acceptability of a mental health chatbot, including barriers and facilitators to accessing and using a chatbot for depression care by adolescents living with HIV. In the second phase (year 1), we will iteratively program a chatbot using the SmartBot360 software with successive versions (0.1, 0.2, and 0.3), meeting regularly with a Youth Advisory Board comprised of adolescents living with HIV who will guide and inform the chatbot development and content to arrive at a prototype version (version 1.0) for pilot-testing. In the third phase (year 2), we will pilot-test the prototype chatbot among 50 adolescents living with HIV naïve to its development. Participants will interact with the chatbot for up to 2 weeks, and data will be collected on the acceptability of the chatbot-delivered depression education and self-help strategies, depression knowledge changes, and intention to seek care linkage. Results: The study was awarded in April 2022, received institutional review board approval in November 2022, received funding in December 2022, and commenced recruitment in March 2023. By the completion of study phases 1 and 2, we expect our chatbot to incorporate key needs and preferences gathered from focus groups and interviews to develop the chatbot. By the completion of study phase 3, we will have assessed the feasibility and acceptability of the prototype chatbot. Study phase 3 began in April 2024. Final results are expected by January 2025 and published thereafter. Conclusions: The study will produce a prototype mental health chatbot developed with and for adolescents living with HIV that will be ready for efficacy testing in a subsequent, larger study. International Registered Report Identifier (IRRID): DERR1-10.2196/55559 %M 38713501 %R 10.2196/55559 %U https://www.researchprotocols.org/2024/1/e55559 %U https://doi.org/10.2196/55559 %U http://www.ncbi.nlm.nih.gov/pubmed/38713501 %0 Journal Article %@ 2368-7959 %I %V 11 %N %P e53730 %T Emerging Trends of Self-Harm Using Sodium Nitrite in an Online Suicide Community: Observational Study Using Natural Language Processing Analysis %A Das,Sudeshna %A Walker,Drew %A Rajwal,Swati %A Lakamana,Sahithi %A Sumner,Steven A %A Mack,Karin A %A Kaczkowski,Wojciech %A Sarker,Abeed %K online suicide community %K suicide %K sodium nitrite %K sodium nitrite sources %K mental health %K adolescent %K juvenile %K self harm %K Sanctioned Suicide %K online forum %K US %K public health %K surveillance %K data mining %K natural language processing %K machine learning %K usage %K suicidal %K accuracy %K consumption %K information %K United States %D 2024 %7 2.5.2024 %9 %J JMIR Ment Health %G English %X Background: There is growing concern around the use of sodium nitrite (SN) as an emerging means of suicide, particularly among younger people. Given the limited information on the topic from traditional public health surveillance sources, we studied posts made to an online suicide discussion forum, “Sanctioned Suicide,” which is a primary source of information on the use and procurement of SN. Objective: This study aims to determine the trends in SN purchase and use, as obtained via data mining from subscriber posts on the forum. We also aim to determine the substances and topics commonly co-occurring with SN, as well as the geographical distribution of users and sources of SN. Methods: We collected all publicly available from the site’s inception in March 2018 to October 2022. Using data-driven methods, including natural language processing and machine learning, we analyzed the trends in SN mentions over time, including the locations of SN consumers and the sources from which SN is procured. We developed a transformer-based source and location classifier to determine the geographical distribution of the sources of SN. Results: Posts pertaining to SN show a rise in popularity, and there were statistically significant correlations between real-life use of SN and suicidal intent when compared to data from the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (⍴=0.727; P<.001) and the National Poison Data System (⍴=0.866; P=.001). We observed frequent co-mentions of antiemetics, benzodiazepines, and acid regulators with SN. Our proposed machine learning–based source and location classifier can detect potential sources of SN with an accuracy of 72.92% and showed consumption in the United States and elsewhere. Conclusions: Vital information about SN and other emerging mechanisms of suicide can be obtained from online forums. %R 10.2196/53730 %U https://mental.jmir.org/2024/1/e53730 %U https://doi.org/10.2196/53730 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e49129 %T Association of the Type of Public Pension With Mental Health Among South Korean Older Adults: Longitudinal Observational Study %A Kim,Seung Hoon %A Kim,Hyunkyu %A Jeong,Sung Hoon %A Park,Eun-Cheol %+ Department of Ophthalmology, Soonchunhyang University Hospital Cheonan, Soonchunhyang University College of Medicine, 31 Sooncheonhyang 6-gil, Dongnam-gu, Chenonan, 31151, Republic of Korea, 82 425702114, immergru@gmail.com %K depression %K retirement %K contributory public pension %K low-income household %K public health %K mental health %K data %K big data %K retirement %K longitudinal data %K low income %D 2024 %7 2.5.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: As income and health are closely related, retirement is considered undesirable for health. Many studies have shown the association between pension and health, but no research has considered the association between contribution-based public pensions or their types and health. Objective: This study investigates the association between the type of contributory public pension and depressive symptoms among older adults. Methods: We analyzed the data of 4541 older adults who participated in the South Korea Welfare Panel Study (2014-2020). Depressive symptoms were measured using the 11-item Center for Epidemiologic Studies Depression scale. Public pensions in South Korea are classified into specific corporate pensions and national pensions. For subgroup analyses, pensioners were categorized according to the amount of pension received and the proportion of public pension over gross income. Analyses using generalized estimating equations were conducted for longitudinal data. Results: Individuals receiving public pension, regardless of the pension type, demonstrated significantly decreased depressive symptoms (national pension: β=–.734; P<.001; specific corporate pension: β=–.775; P=.02). For both pension types, the higher the amount of benefits, the lower were the depression scores. However, this association was absent for those who received the smaller amount among the specific corporate pensioners. In low-income households, the decrease in the depressive symptoms based on the amount of public pension benefits was greater (fourth quartile of national pension: β=–1.472; P<.001; second and third quartiles of specific corporate pension: β=–3.646; P<.001). Conclusions: Our study shows that contributory public pension is significantly associated with lower depressive symptoms, and this association is prominent in low-income households. Thus, contributory public pensions may be good income sources for improving the mental health of older adults after retirement. %M 38696246 %R 10.2196/49129 %U https://publichealth.jmir.org/2024/1/e49129 %U https://doi.org/10.2196/49129 %U http://www.ncbi.nlm.nih.gov/pubmed/38696246 %0 Journal Article %@ 2368-7959 %I %V 11 %N %P e50192 %T Asynchronous Versus Synchronous Screening for Depression and Suicidality in a Primary Health Care System: Quality Improvement Study %A Sattler,Amelia %A Dunn,Julia %A Albarran,Marleni %A Berger,Charlotte %A Calugar,Ana %A Carper,John %A Chirravuri,Lalitha %A Jawad,Nadine %A Zein,Mira %A McGovern,Mark %K depression diagnosis %K primary health care methods %K electronic health records utilization %K quality improvement %K web-based universal screening methods %K suicide prevention and control %K screening %K depression %K asynchronous %K synchronous %K primary care %K suicide %K intervention %K prevention %D 2024 %7 1.5.2024 %9 %J JMIR Ment Health %G English %X Background: Despite being a debilitating, costly, and potentially life-threatening condition, depression is often underdiagnosed and undertreated. Previsit Patient Health Questionnaire-9 (PHQ-9) may help primary care health systems identify symptoms of severe depression and prevent suicide through early intervention. Little is known about the impact of previsit web-based PHQ-9 on patient care and safety. Objective: We aimed to investigate differences among patient characteristics and provider clinical responses for patients who complete a web-based (asynchronous) versus in-clinic (synchronous) PHQ-9. Methods: This quality improvement study was conducted at 33 clinic sites across 2 health systems in Northern California from November 1, 2020, to May 31, 2021, and evaluated 1683 (0.9% of total PHQs completed) records of patients endorsing thoughts that they would be better off dead or of self-harm (question 9 in the PHQ-9) following the implementation of a depression screening program that included automated electronic previsit PHQ-9 distribution. Patient demographics and providers’ clinical response (suicide risk assessment, triage nurse connection, medication management, electronic consultation with psychiatrist, and referral to social worker or psychiatrist) were compared for patients with asynchronous versus synchronous PHQ-9 completion. Results: Of the 1683 patients (female: n=1071, 63.7%; non-Hispanic: n=1293, 76.8%; White: n=831, 49.4%), Hispanic and Latino patients were 40% less likely to complete a PHQ-9 asynchronously (odds ratio [OR] 0.6, 95% CI 0.45-0.8; P<.001). Patients with Medicare insurance were 36% (OR 0.64, 95% CI 0.51-0.79) less likely to complete a PHQ-9 asynchronously than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI 1.21-2.15; P=.001) to complete a PHQ-9 asynchronously than those with no or mild symptoms. Patients who completed a PHQ-9 asynchronously were twice as likely to complete a Columbia-Suicide Severity Rating Scale (OR 2.41, 95% CI 1.89-3.06; P<.001) and 77% less likely to receive a referral to psychiatry (OR 0.23, 95% CI 0.16-0.34; P<.001). Those who endorsed question 9 “more than half the days” (OR 1.62, 95% CI 1.06-2.48) and “nearly every day” (OR 2.38, 95% CI 1.38-4.12) were more likely to receive a referral to psychiatry than those who endorsed question 9 “several days” (P=.002). Conclusions: Shifting depression screening from in-clinic to previsit led to a dramatic increase in PHQ-9 completion without sacrificing patient safety. Asynchronous PHQ-9 can decrease workload on frontline clinical team members, increase patient self-reporting, and elicit more intentional clinical responses from providers. Observed disparities will inform future improvement efforts. %R 10.2196/50192 %U https://mental.jmir.org/2024/1/e50192 %U https://doi.org/10.2196/50192 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e56056 %T Immersive Technologies for Depression Care: Scoping Review %A Reategui-Rivera,C Mahony %A Villarreal-Zegarra,David %A De La Cruz-Torralva,Kelly %A Díaz-Sánchez,Paquita %A Finkelstein,Joseph %+ Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT, 84108, United States, 1 801 581 4080, mahony.reategui@utah.edu %K depression %K immersive technologies %K virtual reality %K augmented reality %K mobile phone %D 2024 %7 25.4.2024 %9 Review %J JMIR Ment Health %G English %X Background: Depression significantly impacts quality of life, affecting approximately 280 million people worldwide. However, only 16.5% of those affected receive treatment, indicating a substantial treatment gap. Immersive technologies (IMTs) such as virtual reality (VR) and augmented reality offer new avenues for treating depression by creating immersive environments for therapeutic interventions. Despite their potential, significant gaps exist in the current evidence regarding the design, implementation, and use of IMTs for depression care. Objective: We aim to map the available evidence on IMT interventions targeting depression treatment. Methods: This scoping review followed a methodological framework, and we systematically searched databases for studies on IMTs and depression. The focus was on randomized clinical trials involving adults and using IMTs. The selection and charting process involved multiple reviewers to minimize bias. Results: The search identified 16 peer-reviewed articles, predominantly from Europe (n=10, 63%), with a notable emphasis on Poland (n=9, 56%), which contributed to more than half of the articles. Most of the studies (9/16, 56%) were conducted between 2020 and 2021. Regarding participant demographics, of the 16 articles, 5 (31%) exclusively involved female participants, and 7 (44%) featured participants whose mean or median age was >60 years. Regarding technical aspects, all studies focused on VR, with most using stand-alone VR headsets (14/16, 88%), and interventions typically ranging from 2 to 8 weeks, predominantly in hospital settings (11/16, 69%). Only 2 (13%) of the 16 studies mentioned using a specific VR design framework in planning their interventions. The most frequently used therapeutic approach was Ericksonian psychotherapy, used in 56% (9/16) of the studies. Notably, none of the articles reported using an implementation framework or identified barriers and enablers to implementation. Conclusions: This scoping review highlights the growing interest in using IMTs, particularly VR, for depression treatment but emphasizes the need for more inclusive and comprehensive research. Future studies should explore varied therapeutic approaches and cost-effectiveness as well as the inclusion of augmented reality to fully realize the potential of IMTs in mental health care. %M 38663004 %R 10.2196/56056 %U https://mental.jmir.org/2024/1/e56056 %U https://doi.org/10.2196/56056 %U http://www.ncbi.nlm.nih.gov/pubmed/38663004 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51949 %T Digital Therapeutic (Mika) Targeting Distress in Patients With Cancer: Results From a Nationwide Waitlist Randomized Controlled Trial %A Springer,Franziska %A Maier,Ayline %A Friedrich,Michael %A Raue,Jan Simon %A Finke,Gandolf %A Lordick,Florian %A Montgomery,Guy %A Esser,Peter %A Brock,Hannah %A Mehnert-Theuerkauf,Anja %+ Department of Medical Psychology and Medical Sociology, Comprehensive Cancer Center Central Germany, University Medical Center Leipzig, Philipp-Rosenthal-Str. 55, Haus W, Leipzig, 04103, Germany, 49 341 97 18800, Anja.Mehnert@medizin.uni-leipzig.de %K digital therapeutic %K digital health %K mobile health %K app %K cancer %K randomized controlled trial %K supportive care %K oncology %K access to care %K distress %K depression %K anxiety %K fatigue %K mobile phone %D 2024 %7 25.4.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Distress is highly prevalent among patients with cancer, but supportive care needs often go unmet. Digital therapeutics hold the potential to overcome barriers in cancer care and improve health outcomes. Objective: This study conducted a randomized controlled trial to investigate the efficacy of Mika, an app-based digital therapeutic designed to reduce distress across the cancer trajectory. Methods: This nationwide waitlist randomized controlled trial in Germany enrolled patients with cancer across all tumor entities diagnosed within the last 5 years. Participants were randomized into the intervention (Mika plus usual care) and control (usual care alone) groups. The participants completed web-based assessments at baseline and at 2, 6, and 12 weeks. The primary outcome was the change in distress from baseline to week 12, as measured by the National Comprehensive Cancer Network Distress Thermometer. Secondary outcomes included depression, anxiety (Hospital Anxiety and Depression Scale), fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue), and quality of life (Clinical Global Impression-Improvement Scale). Intention-to-treat and per-protocol analyses were performed. Analyses of covariance were used to test for outcome changes over time between the groups, controlling for baseline. Results: A total of 218 patients (intervention: n=99 and control: n=119) were included in the intention-to-treat analysis. Compared with the control group, the intervention group reported greater reductions in distress (P=.03; ηp²=0.02), depression (P<.001; ηp²=0.07), anxiety (P=.03; ηp²=0.02), and fatigue (P=.04; ηp²=0.02). Per-protocol analyses revealed more pronounced treatment effects, with the exception of fatigue. No group difference was found for quality of life. Conclusions: Mika effectively diminished distress in patients with cancer. As a digital therapeutic solution, Mika offers accessible, tailored psychosocial and self-management support to address the unmet needs in cancer care. Trial Registration: German Clinical Trials Register (DRKS) DRKS00026038; https://drks.de/search/en/trial/DRKS00026038 %M 38663007 %R 10.2196/51949 %U https://www.jmir.org/2024/1/e51949 %U https://doi.org/10.2196/51949 %U http://www.ncbi.nlm.nih.gov/pubmed/38663007 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e51540 %T Investigating Rhythmicity in App Usage to Predict Depressive Symptoms: Protocol for Personalized Framework Development and Validation Through a Countrywide Study %A Ahmed,Md Sabbir %A Hasan,Tanvir %A Islam,Salekul %A Ahmed,Nova %+ Design Inclusion and Access Lab, North South University, Plot # 15, Block B, Bashundhara R/A, Dhaka, 1229, Bangladesh, 880 1781920068, msg2sabbir@gmail.com %K depressive symptoms %K app usage rhythm %K behavioral markers %K personalization %K multitask learning framework %D 2024 %7 24.4.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Understanding a student’s depressive symptoms could facilitate significantly more precise diagnosis and treatment. However, few studies have focused on depressive symptom prediction through unobtrusive systems, and these studies are limited by small sample sizes, low performance, and the requirement for higher resources. In addition, research has not explored whether statistically significant rhythms based on different app usage behavioral markers (eg, app usage sessions) exist that could be useful in finding subtle differences to predict with higher accuracy like the models based on rhythms of physiological data. Objective: The main objective of this study is to explore whether there exist statistically significant rhythms in resource-insensitive app usage behavioral markers and predict depressive symptoms through these marker-based rhythmic features. Another objective of this study is to understand whether there is a potential link between rhythmic features and depressive symptoms. Methods: Through a countrywide study, we collected 2952 students’ raw app usage behavioral data and responses to the 9 depressive symptoms in the 9-item Patient Health Questionnaire (PHQ-9). The behavioral data were retrieved through our developed app, which was previously used in our pilot studies in Bangladesh on different research problems. To explore whether there is a rhythm based on app usage data, we will conduct a zero-amplitude test. In addition, we will develop a cosinor model for each participant to extract rhythmic parameters (eg, acrophase). In addition, to obtain a comprehensive picture of the rhythms, we will explore nonparametric rhythmic features (eg, interdaily stability). Furthermore, we will conduct regression analysis to understand the association of rhythmic features with depressive symptoms. Finally, we will develop a personalized multitask learning (MTL) framework to predict symptoms through rhythmic features. Results: After applying inclusion criteria (eg, having app usage data of at least 2 days to explore rhythmicity), we kept the data of 2902 (98.31%) students for analysis, with 24.48 million app usage events, and 7 days’ app usage of 2849 (98.17%) students. The students are from all 8 divisions of Bangladesh, both public and private universities (19 different universities and 52 different departments). We are analyzing the data and will publish the findings in a peer-reviewed publication. Conclusions: Having an in-depth understanding of app usage rhythms and their connection with depressive symptoms through a countrywide study can significantly help health care professionals and researchers better understand depressed students and may create possibilities for using app usage–based rhythms for intervention. In addition, the MTL framework based on app usage rhythmic features may more accurately predict depressive symptoms due to the rhythms’ capability to find subtle differences. International Registered Report Identifier (IRRID): DERR1-10.2196/51540 %M 38657238 %R 10.2196/51540 %U https://www.researchprotocols.org/2024/1/e51540 %U https://doi.org/10.2196/51540 %U http://www.ncbi.nlm.nih.gov/pubmed/38657238 %0 Journal Article %@ 2291-9694 %I %V 12 %N %P e48007 %T Reducing Firearm Access for Suicide Prevention: Implementation Evaluation of the Web-Based “Lock to Live” Decision Aid in Routine Health Care Encounters %A Richards,Julie Angerhofer %A Kuo,Elena %A Stewart,Christine %A Shulman,Lisa %A Parrish,Rebecca %A Whiteside,Ursula %A Boggs,Jennifer M %A Simon,Gregory E %A Rowhani-Rahbar,Ali %A Betz,Marian E %K suicide prevention %K firearm %K internet %K implementation %K suicide %K prevention %K decision aid %K risk %K feasible %K support %K evaluation %K mental health %K electronic health record %K tool %D 2024 %7 22.4.2024 %9 %J JMIR Med Inform %G English %X Background: “Lock to Live” (L2L) is a novel web-based decision aid for helping people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during web-based mental health care and in-person contact with clinicians. Objective: The goal of this project was to support the implementation and evaluation of L2L during routine primary care and mental health specialty web-based and in-person encounters. Methods: The L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA)—a large, regional, nonprofit health care system. Three dimensions from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model—Reach, Adoption, and Implementation—were selected to inform and evaluate the implementation of L2L at KPWA (January 1, 2020, to December 31, 2021). Electronic health record (EHR) data were used to purposefully recruit adult patients, including firearm owners and patients reporting suicidality, to participate in semistructured interviews. Interview themes were used to facilitate L2L implementation and inform subsequent semistructured interviews with clinicians responsible for suicide risk mitigation. Audio-recorded interviews were conducted via the web, transcribed, and coded, using a rapid qualitative inquiry approach. A descriptive analysis of EHR data was performed to summarize L2L reach and adoption among patients identified at high risk of suicide. Results: The initial implementation consisted of updates for clinicians to add a URL and QR code referencing L2L to the safety planning EHR templates. Recommendations about introducing L2L were subsequently derived from the thematic analysis of semistructured interviews with patients (n=36), which included (1) “have an open conversation,” (2) “validate their situation,” (3) “share what to expect,” (4) “make it accessible and memorable,” and (5) “walk through the tool.” Clinicians’ interviews (n=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the 2-year observation period, 2739 patients reported prior-month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27.2%) who also received L2L. Over four 6-month subperiods of the observation period, L2L adoption rates increased substantially from 2% to 29% among primary care clinicians and from <1% to 48% among mental health clinicians. Conclusions: Understanding the value of L2L from users’ perspectives was essential for facilitating implementation and increasing patient reach and clinician adoption. Incorporating L2L into the existing system-level, EHR-based safety plan template reduced the effort to use L2L and was likely the most impactful implementation strategy. As rising suicide rates galvanize the urgency of prevention, the findings from this project, including L2L implementation tools and strategies, will support efforts to promote safety for suicide prevention in health care nationwide. %R 10.2196/48007 %U https://medinform.jmir.org/2024/1/e48007 %U https://doi.org/10.2196/48007 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e47428 %T Digital Dietary Behaviors in Individuals With Depression: Real-World Behavioral Observation %A Zhu,Yue %A Zhang,Ran %A Yin,Shuluo %A Sun,Yihui %A Womer,Fay %A Liu,Rongxun %A Zeng,Sheng %A Zhang,Xizhe %A Wang,Fei %+ Early Intervention Unit, Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, 264 Guangzhou Road, Gulou District, Nanjing City, China, Nanjing, 210000, China, 1 86 02583295953, zhangxizhe@njmu.edu.cn %K dietary behaviors %K digital marker %K depression %K mental health %K appetite disturbance %K behavioral monitoring %K eating pattern %K electronic record %K digital health %K behavioral %K surveillance %D 2024 %7 22.4.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Depression is often accompanied by changes in behavior, including dietary behaviors. The relationship between dietary behaviors and depression has been widely studied, yet previous research has relied on self-reported data which is subject to recall bias. Electronic device–based behavioral monitoring offers the potential for objective, real-time data collection of a large amount of continuous, long-term behavior data in naturalistic settings. Objective: The study aims to characterize digital dietary behaviors in depression, and to determine whether these behaviors could be used to detect depression. Methods: A total of 3310 students (2222 healthy controls [HCs], 916 with mild depression, and 172 with moderate-severe depression) were recruited for the study of their dietary behaviors via electronic records over a 1-month period, and depression severity was assessed in the middle of the month. The differences in dietary behaviors across the HCs, mild depression, and moderate-severe depression were determined by ANCOVA (analyses of covariance) with age, gender, BMI, and educational level as covariates. Multivariate logistic regression analyses were used to examine the association between dietary behaviors and depression severity. Support vector machine analysis was used to determine whether changes in dietary behaviors could detect mild and moderate-severe depression. Results: The study found that individuals with moderate-severe depression had more irregular eating patterns, more fluctuated feeding times, spent more money on dinner, less diverse food choices, as well as eating breakfast less frequently, and preferred to eat only lunch and dinner, compared with HCs. Moderate-severe depression was found to be negatively associated with the daily 3 regular meals pattern (breakfast-lunch-dinner pattern; OR 0.467, 95% CI 0.239-0.912), and mild depression was positively associated with daily lunch and dinner pattern (OR 1.460, 95% CI 1.016-2.100). These changes in digital dietary behaviors were able to detect mild and moderate-severe depression (accuracy=0.53, precision=0.60), with better accuracy for detecting moderate-severe depression (accuracy=0.67, precision=0.64). Conclusions: This is the first study to develop a profile of changes in digital dietary behaviors in individuals with depression using real-world behavioral monitoring. The results suggest that digital markers may be a promising approach for detecting depression. %M 38648087 %R 10.2196/47428 %U https://publichealth.jmir.org/2024/1/e47428 %U https://doi.org/10.2196/47428 %U http://www.ncbi.nlm.nih.gov/pubmed/38648087 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e50136 %T Time-Varying Network Models for the Temporal Dynamics of Depressive Symptomatology in Patients With Depressive Disorders: Secondary Analysis of Longitudinal Observational Data %A Siepe,Björn Sebastian %A Sander,Christian %A Schultze,Martin %A Kliem,Andreas %A Ludwig,Sascha %A Hegerl,Ulrich %A Reich,Hanna %+ Psychological Methods Lab, Department of Psychology, University of Marburg, Gutenbergstraße 18, Marburg, 35032, Germany, 49 6421 28 23616, bjoern.siepe@uni-marburg.de %K depression %K time series analysis %K network analysis %K experience sampling %K idiography %K time varying %K mobile phone %D 2024 %7 18.4.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: As depression is highly heterogenous, an increasing number of studies investigate person-specific associations of depressive symptoms in longitudinal data. However, most studies in this area of research conceptualize symptom interrelations to be static and time invariant, which may lead to important temporal features of the disorder being missed. Objective: To reveal the dynamic nature of depression, we aimed to use a recently developed technique to investigate whether and how associations among depressive symptoms change over time. Methods: Using daily data (mean length 274, SD 82 d) of 20 participants with depression, we modeled idiographic associations among depressive symptoms, rumination, sleep, and quantity and quality of social contacts as dynamic networks using time-varying vector autoregressive models. Results: The resulting models showed marked interindividual and intraindividual differences. For some participants, associations among variables changed in the span of some weeks, whereas they stayed stable over months for others. Our results further indicated nonstationarity in all participants. Conclusions: Idiographic symptom networks can provide insights into the temporal course of mental disorders and open new avenues of research for the study of the development and stability of psychopathological processes. %M 38635978 %R 10.2196/50136 %U https://mental.jmir.org/2024/1/e50136 %U https://doi.org/10.2196/50136 %U http://www.ncbi.nlm.nih.gov/pubmed/38635978 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e50996 %T Association Between Frequency of Muscle-Strengthening Exercise and Depression Symptoms Among Middle and High School Students: Cross-Sectional Survey Study %A Wang,Hao %A Du,Huaidong %A Guan,Yunqi %A Zhong,Jieming %A Li,Na %A Pan,Jin %A Yu,Min %+ Department of Noncommunicable Disease Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, 3399 Binsheng Road, Binjiang Distric, Hangzhou, 310051, China, 86 571 87115005, zjcdcmyu@163.com %K depression symptoms %K muscle-strengthening exercise %K adolescents %K cross-sectional study %D 2024 %7 17.4.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Existing literature on the association between the frequency of muscle-strengthening exercise (MSE) and depression among adolescents is limited and contradictory. Objective: This study aimed to elucidate the association of MSE frequency with depression symptoms among middle and high school students in China. Methods: A total of 27,070 students in grades 7-12 from 376 middle and high schools were surveyed using an anonymous self-administered questionnaire between April and June 2022. Information on engaging in MSE was self-reported, and depression symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9). Poisson regression was used to examine the association between MSE frequency and depression symptoms. Results: Among the 27,006 eligible students, 51.6% (n=13,933) were boys, and the mean age was 15.6 (SD 1.7) years. The overall prevalence of meeting MSE recommendations (ie, engaging in MSE ≥3 days/week) was 34.6% (95% CI 32.6%-36.6%; n=9145); the prevalence was higher in boys (43.8%, 95% CI 41.8%-45.8%; 6067/13,933) than in girls (24.3%, 95% CI 22%-26.6%; 3078/13,073; P<.001). A total of 5882 (21.8%) students reported having depression symptoms. After adjustment for sociodemographic status, lifestyle factors, academic performance, and experience of physical fighting, compared to students who did not engage in MSE, the prevalence ratios (PRs) for depression symptoms were 0.98 (95% CI 0.97-0.99) for those engaging in MSE once a week, 0.95 (95% CI 0.93-0.97) for 2 days/week, 0.93 (95% CI 0.90-0.96) for 3 days/week, 0.90 (95% CI 0.87-0.94) for 4 days/week, 0.88 (95% CI 0.84-0.93) for 5 days/week, 0.86 (95% CI 0.81-0.92) for 6 days/week, and 0.84 (95% CI 0.78-0.90) for 7 days/week, respectively. Conclusions: The overall prevalence of meeting MSE recommendations among Chinese adolescents is low. The frequency of MSE was inversely associated with depression symptoms. %M 38630529 %R 10.2196/50996 %U https://publichealth.jmir.org/2024/1/e50996 %U https://doi.org/10.2196/50996 %U http://www.ncbi.nlm.nih.gov/pubmed/38630529 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e52326 %T Examining the Efficacy of Extended Reality–Enhanced Behavioral Activation for Adults With Major Depressive Disorder: Randomized Controlled Trial %A Paul,Margot %A Bullock,Kim %A Bailenson,Jeremy %A Burns,David %+ Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd, Stanford, CA, 94305, United States, 1 781 572 4136, mdpaul@stanford.edu %K virtual reality %K extended reality %K major depressive disorder %K behavioral activation %K depression %K Meta Quest 2 %D 2024 %7 15.4.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Major depressive disorder (MDD) is a global concern with increasing prevalence. While many evidence-based psychotherapies (EBPs) have been identified to treat MDD, there are numerous barriers to patients accessing them. Virtual reality (VR) has been used as a treatment enhancement for a variety of mental health disorders, but few studies have examined its clinical use in treating MDD. Behavioral activation (BA) is a simple yet effective and established first-line EBP for MDD that has the potential to be easily enhanced and adapted with VR technology. A previous report by our group explored the feasibility and acceptability of VR-enhanced BA in a small clinical proof-of-concept pilot. This study examines the clinical efficacy of a more immersive extended reality (XR)–enhanced BA (XR-BA) prototype. This is the first clinical efficacy test of an XR-BA protocol. Objective: This study examined whether XR-BA was feasible and efficacious in treating MDD in an ambulatory telemedicine clinic. Methods: A nonblinded between-subject randomized controlled trial compared XR-BA to traditional BA delivered via telehealth. The study used a previously established, brief 3-week, 4-session BA EBP intervention. The experimental XR-BA participants were directed to use a Meta Quest 2 (Reality Labs) VR headset to engage in simulated pleasant or mastery activities and were compared to a control arm, which used only real-life mastery or pleasant activities as between-session homework. The Patient Health Questionnaire (PHQ)–9 was the primary outcome measure. Independent-sample and paired-sample t tests (2-tailed) were used to determine statistical significance and confirmed using structural equation modeling. Results: Overall, 26 participants with MDD were randomized to receive either XR-BA (n=13, 50%) or traditional BA (n=13, 50%). The mean age of the 26 participants (n=6, 23% male; n=19, 73% female; n=1, 4% nonbinary or third gender) was 50.3 (SD 17.3) years. No adverse events were reported in either group, and no substantial differences in dropout rates or homework completion were observed. XR-BA was found to be statistically noninferior to traditional BA (t18.6=−0.28; P=.78). Both the XR-BA (t9=2.5; P=.04) and traditional BA (t10=2.3; P=.04) arms showed a statistically significant decrease in PHQ-9 and clinical severity from the beginning of session 1 to the beginning of session 4. There was a significant decrease in PHQ-8 to PHQ-9 scores between the phone intake and the beginning of session 1 for the XR-BA group (t11=2.6; P=.03) but not the traditional BA group (t11=1.4; P=.20). Conclusions: This study confirmed previous findings that XR-BA may be a feasible, non-inferior, and acceptable enhancement to traditional BA. Additionally, there was evidence that supports the potential of XR to enhance expectation or placebo effects. Further research is needed to examine the potential of XR to improve access, outcomes, and barriers to MDD care. Trial Registration: ClinicalTrials.gov NCT05525390; https://clinicaltrials.gov/study/NCT05525390 %M 38437873 %R 10.2196/52326 %U https://mental.jmir.org/2024/1/e52326 %U https://doi.org/10.2196/52326 %U http://www.ncbi.nlm.nih.gov/pubmed/38437873 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 9 %N %P e55165 %T Moderating Effect of Depression on Glycemic Control in an eHealth Intervention Among Black Youth With Type 1 Diabetes: Findings From a Multicenter Randomized Controlled Trial %A Ellis,Deborah %A Carcone,April Idalski %A Templin,Thomas %A Evans,Meredyth %A Weissberg-Benchell,Jill %A Buggs-Saxton,Colleen %A Boucher-Berry,Claudia %A Miller,Jennifer L %A Drossos,Tina %A Dekelbab,M Bassem %+ Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, IBio Behavioral Health, 6135 Woodward Avenue, Detroit, MI, 48202, United States, 1 3135771055, dellis@med.wayne.edu %K adolescents %K black %K depression %K eHealth %K family intervention %K randomized clinical trial %K randomized controlled trial %K T1D %K type 1 diabetes %D 2024 %7 9.4.2024 %9 Original Paper %J JMIR Diabetes %G English %X Background: Black adolescents with type 1 diabetes (T1D) are at increased risk for suboptimal diabetes health outcomes; however, evidence-based interventions for this population are lacking. Depression affects a high percentage of youth with T1D and increases the likelihood of health problems associated with diabetes. Objective: Our aim was to test whether baseline levels of depression moderate the effects of a brief eHealth parenting intervention delivered to caregivers of young Black adolescents with T1D on youths’ glycemic control. Methods: We conducted a multicenter randomized controlled trial at 7 pediatric diabetes clinics located in 2 large US cities. Participants (N=149) were allocated to either the intervention group or a standard medical care control group. Up to 3 intervention sessions were delivered on a tablet computer during diabetes clinic visits over a 12-month period. Results: In a linear mixed effects regression model, planned contrasts did not show significant reductions in hemoglobin A1c (HbA1c) for intervention adolescents compared to controls. However, adolescents with higher baseline levels of depressive symptoms who received the intervention had significantly greater improvements in HbA1c levels at 6-month follow-up (0.94%; P=.01) and 18-month follow-up (1.42%; P=.002) than those with lower levels of depression. Within the intervention group, adolescents had a statistically significant reduction in HbA1c levels from baseline at 6-month and 18-month follow-up. Conclusions: A brief, culturally tailored eHealth parenting intervention improved health outcomes among Black adolescents with T1D and depressive symptoms. Trial Registration: ClinicalTrials.gov NCT03168867; https://clinicaltrials.gov/study/NCT03168867 %M 38593428 %R 10.2196/55165 %U https://diabetes.jmir.org/2024/1/e55165 %U https://doi.org/10.2196/55165 %U http://www.ncbi.nlm.nih.gov/pubmed/38593428 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e52558 %T Nudges and Prompts Increase Engagement in Self-Guided Digital Health Treatment for Depression and Anxiety: Results From a 3-Arm Randomized Controlled Trial %A van Mierlo,Trevor %A Rondina,Renante %A Fournier,Rachel %+ Evolution Health, 206-90 Eglinton Avenue East, Toronto, ON, M4P 2Y3, Canada, 1 4166448476, tvanmierlo@evolutionhealth.care %K behavioral economics %K digital health %K attrition %K engagement %K nudges %K depression %K anxiety %K mood disorders %D 2024 %7 9.4.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Accessible and effective approaches to mental health treatment are important because of common barriers such as cost, stigma, and provider shortage. The effectiveness of self-guided treatment is well established, and its use has intensified because of the COVID-19 pandemic. Engagement remains important as dose-response relationships have been observed. Platforms such as Facebook (Meta Platform, Inc), LinkedIn (Microsoft Corp), and X Corp (formerly known as Twitter, Inc) use principles of behavioral economics to increase engagement. We hypothesized that similar concepts would increase engagement in self-guided digital health. Objective: This 3-arm randomized controlled trial aimed to test whether members of 2 digital self-health courses for anxiety and depression would engage with behavioral nudges and prompts. Our primary hypothesis was that members would click on 2 features: tips and a to-do checklist. Our secondary hypothesis was that members would prefer to engage with directive tips in arm 2 versus social proof and present bias tips in arm 3. Our tertiary hypothesis was that rotating tips and a to-do checklist would increase completion rates. The results of this study will form a baseline for future artificial intelligence–directed research. Methods: Overall, 13,224 new members registered between November 2021 and May 2022 for Evolution Health’s self-guided treatment courses for anxiety and depression. The control arm featured a member home page without nudges or prompts. Arm 2 featured a home page with a tip-of-the-day section. Arm 3 featured a home page with a tip-of-the-day section and a to-do checklist. The research protocol for this study was published in JMIR Research Protocols on August 15, 2022. Results: Arm 3 had significantly younger members (F2,4564=40.97; P<.001) and significantly more female members (χ24=92.2; P<.001) than the other 2 arms. Control arm members (1788/13,224, 13.52%) completed an average of 1.5 course components. Arm 2 members (865/13,224, 6.54%) clicked on 5% of tips and completed an average of 1.8 course components. Arm 3 members (1914/13,224, 14.47%) clicked on 5% of tips, completed 2.7 of 8 to-do checklist items, and completed an average of 2.11 course components. Completion rates in arm 2 were greater than those in arm 1 (z score=3.37; P<.001), and completion rates in arm 3 were greater than those in arm 1 (z score=12.23; P<.001). Engagement in all 8 components in arm 3 was higher than that in arm 2 (z score=1.31; P<.001). Conclusions: Members engaged with behavioral nudges and prompts. The results of this study may be important because efficacy is related to increased engagement. Due to its novel approach, the outcomes of this study should be interpreted with caution and used as a guideline for future research in this nascent field. International Registered Report Identifier (IRRID): RR2-10.2196/37231 %M 38592752 %R 10.2196/52558 %U https://formative.jmir.org/2024/1/e52558 %U https://doi.org/10.2196/52558 %U http://www.ncbi.nlm.nih.gov/pubmed/38592752 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e53998 %T Feasibility, Acceptability, and Preliminary Efficacy of a Smartphone App–Led Cognitive Behavioral Therapy for Depression Under Therapist Supervision: Open Trial %A Wilhelm,Sabine %A Bernstein,Emily E %A Bentley,Kate H %A Snorrason,Ivar %A Hoeppner,Susanne S %A Klare,Dalton %A Greenberg,Jennifer L %A Weingarden,Hilary %A McCoy,Thomas H %A Harrison,Oliver %+ Massachusetts General Hospital, Harvard Medical School, 185 Cambridge Street, Suite 2000, Boston, MA, 02114, United States, 1 617 724 6146, swilhelm@mgh.harvard.edu %K depressive disorder %K depressive %K depression %K open trial %K open trials %K single arm %K smartphone %K cognitive behavioral therapy %K cognitive behavioural therapy %K CBT %K psychotherapy %K psychoeducation %K digital health %K mobile applications %K mHealth %K mobile health %K app %K apps %K application %K applications %K psychiatry %K psychiatric %K feasibility %K acceptability %K usability %K satisfaction %K user experience %K mental %D 2024 %7 9.4.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Major depressive disorder affects approximately 1 in 5 adults during their lifetime and is the leading cause of disability worldwide. Yet, a minority receive adequate treatment due to person-level (eg, geographical distance to providers) and systems-level (eg, shortage of trained providers) barriers. Digital tools could improve this treatment gap by reducing the time and frequency of therapy sessions needed for effective treatment through the provision of flexible, automated support. Objective: This study aimed to examine the feasibility, acceptability, and preliminary clinical effect of Mindset for Depression, a deployment-ready 8-week smartphone-based cognitive behavioral therapy (CBT) supported by brief teletherapy appointments with a therapist. Methods: This 8-week, single-arm open trial tested the Mindset for Depression app when combined with 8 brief (16-25 minutes) video conferencing visits with a licensed doctoral-level CBT therapist (n=28 participants). The app offers flexible, accessible psychoeducation, CBT skills practice, and support to patients as well as clinician guidance to promote sustained engagement, monitor safety, and tailor treatment to individual patient needs. To increase accessibility and thus generalizability, all study procedures were conducted remotely. Feasibility and acceptability were assessed via attrition, patient expectations and feedback, and treatment utilization. The primary clinical outcome measure was the clinician-rated Hamilton Depression Rating Scale, administered at pretreatment, midpoint, and posttreatment. Secondary measures of functional impairment and quality of life as well as maintenance of gains (3-month follow-up) were also collected. Results: Treatment credibility (week 4), expectancy (week 4), and satisfaction (week 8) were moderate to high, and attrition was low (n=2, 7%). Participants self-reported using the app or practicing (either on or off the app) the CBT skills taught in the app for a median of 50 (IQR 30-60; week 4) or 60 (IQR 30-90; week 8) minutes per week; participants accessed the app on an average 36.8 (SD 10.0) days and completed a median of 7 of 8 (IQR 6-8) steps by the week 8 assessment. The app was rated positively across domains of engagement, functionality, aesthetics, and information. Participants’ depression severity scores decreased from an average Hamilton Depression Rating Scale score indicating moderate depression (mean 19.1, SD 5.0) at baseline to a week 8 mean score indicating mild depression (mean 10.8, SD 6.1; d=1.47; P<.001). Improvement was also observed for functional impairment and quality of life. Gains were maintained at 3-month follow-up. Conclusions: The results show that Mindset for Depression is a feasible and acceptable treatment option for individuals with major depressive disorder. This smartphone-led treatment holds promise to be an efficacious, scalable, and cost-effective treatment option. The next steps include testing Mindset for Depression in a fully powered randomized controlled trial and real-world clinical settings. Trial Registration: ClinicalTrials.gov NCT05386329; https://clinicaltrials.gov/study/NCT05386329?term=NCT05386329 %M 38592771 %R 10.2196/53998 %U https://mental.jmir.org/2024/1/e53998 %U https://doi.org/10.2196/53998 %U http://www.ncbi.nlm.nih.gov/pubmed/38592771 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e50018 %T The Role of Mental Health Stigma in University Students’ Satisfaction With Web-Based Stress Management Resources: Intervention Study %A Cho,Sohyun %A Bastien,Laurianne %A Petrovic,Julia %A Böke,Bilun Naz %A Heath,Nancy L %+ Department of Educational and Counselling Psychology, McGill University, 3700 McTavish Street, Montreal, QC, H3A 1Y2, Canada, 1 514 398 4242, sohyun.cho@mail.mcgill.ca %K help-seeking behavior %K help-seeking %K mental health services %K mental health stigma %K mental health %K university students %K web-based workshop %D 2024 %7 4.4.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: University students frequently report elevated levels of stress and mental health difficulties. Thus, the need to build coping capacity on university campuses has been highlighted as critical to mitigating the negative effects of prolonged stress and distress among students. Since the COVID-19 pandemic, web-based stress management resources such as infographics and web-based workshops have been central to supporting university students’ mental health and well-being. However, there is a lack of research on students’ satisfaction with and uptake of these approaches. Furthermore, mental health stigma has been suggested to have not only fueled the emergence of these web-based approaches to stress management but may also influence students’ help-seeking behaviors and their satisfaction with and uptake of these resources. Objective: This study explored potential differences in students’ satisfaction and strategy use in response to an interactive infographic (an emerging resource delivery modality) presenting stress management strategies and a web-based workshop (a more common modality) presenting identical strategies. This study also examined the relative contribution of students’ strategy use and family-based mental health stigma in predicting their sustained satisfaction with the 2 web-based stress management approaches. Methods: University students (N=113; mean age 20.93, SD 1.53 years; 100/113, 88.5% women) completed our web-based self-report measure of family-based mental health stigma at baseline and were randomly assigned to either independently review an interactive infographic (n=60) or attend a synchronous web-based workshop (n=53). All participants reported their satisfaction with their assigned modality at postintervention (T1) and follow-up (T2) and their strategy use at T2. Results: Interestingly, a 2-way mixed ANOVA revealed no significant group × time interaction or main effect of group on satisfaction. However, there was a significant decrease in satisfaction from T1 to T2, despite relatively high levels of satisfaction being reported at both time points. In addition, a 1-way ANOVA revealed no significant difference in strategy use between groups. Results from a hierarchical multiple regression revealed that students’ strategy use positively predicted T2 satisfaction in both groups. However, only in the web-based workshop group did family-based mental health stigma predict T2 satisfaction over and above strategy use. Conclusions: While both approaches were highly satisfactory over time, findings highlight the potential utility of interactive infographics since they are less resource-intensive than web-based workshops and students’ satisfaction with them is not impacted by family-based mental health stigma. Moreover, although numerous intervention studies measure satisfaction at a single time point, this study highlights the need for tracking satisfaction over time following intervention delivery. These findings have implications for student service units in the higher education context, emphasizing the need to consider student perceptions of family-based mental health stigma and preferences regarding delivery format when designing programming aimed at bolstering students’ coping capacity. %M 38573758 %R 10.2196/50018 %U https://formative.jmir.org/2024/1/e50018 %U https://doi.org/10.2196/50018 %U http://www.ncbi.nlm.nih.gov/pubmed/38573758 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e54282 %T Effects of a Digital Mental Health Intervention on Perceived Stress and Rumination in Adolescents Aged 13 to 17 Years: Randomized Controlled Trial %A Boucher,Eliane M %A Ward,Haley %A Miles,Cynthia J %A Henry,Robert D %A Stoeckl,Sarah Elizabeth %+ Twill, 114 Fifth Avenue, 10th Floor, New York, NY, 10011, United States, 1 432 258 5233, eliane@twill.health %K digital intervention %K adolescents %K adolescent %K stress management %K mental health %K mobile phone %K mobile health %K mHealth %K teen %K teens %K teenager %K teenagers %K stress %K mental health %K rumination %K brooding %K randomized controlled trial %K RCT %K randomized %K controlled trial %K controlled trials %K digital mental health intervention %K DMHI %K digital health %D 2024 %7 29.3.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Although adolescents report high levels of stress, they report engaging in few stress management techniques. Consequently, developing effective and targeted programs to help address this transdiagnostic risk factor in adolescence is particularly important. Most stress management programs for adolescents are delivered within schools, and the evidence for these programs is mixed, suggesting a need for alternative options for stress management among adolescents. Objective: The aim of the study is to test the short-term effects of a self-guided digital mental health intervention (DMHI) designed for adolescents on perceived stress and rumination (ie, brooding). Methods: This was a 12-week, 2-arm decentralized randomized controlled trial of adolescents aged 13 to 17 years who presented with elevated levels of perceived stress and brooding. Participants were randomly assigned to engage with a self-guided DMHI (Happify for Teens) or to a waitlist control. Participants assigned to the intervention group were given access to the program for 12 weeks. Happify for Teens consists of various evidence-based activities drawn from therapeutic modalities such as cognitive behavioral therapy, positive psychology, and mindfulness, which are then organized into several programs targeting specific areas of concern (eg, Stress Buster 101). Participants in the waitlist control received access to this product for 12 weeks upon completing the study. Participants in both groups completed measures of perceived stress, brooding, optimism, sleep disturbance, and loneliness at baseline, 4 weeks, 8 weeks, and 12 weeks. Changes in outcomes between the intervention and waitlist control groups were assessed using repeated-measures multilevel models. Results: Of the 303 participants included in data analyses, 132 were assigned to the intervention and 171 to the waitlist. There were significantly greater improvements in the intervention condition for perceived stress (intervention: B=–1.50; 95% CI –1.82 to –1.19; P<.001 and control: B=–0.09; 95% CI –0.44 to 0.26; P=.61), brooding (intervention: B=–0.84; 95% CI –1.00 to –0.68; P<.001 and control: B=–0.30; 95% CI –0.47 to –0.12; P=.001), and loneliness (intervention: B=–0.96; 95% CI –1.2 to –0.73; P<.001 and control: B=–0.38; 95% CI: –0.64 to –0.12; P=.005) over the 12-week study period. Changes in optimism and sleep disturbance were not significantly different across groups (Ps≥.096). Conclusions: Happify for Teens was effective at reducing perceived stress, rumination, and loneliness among adolescents over 12 weeks when compared to a waitlist control group. Our data reveal the potential benefits of DMHIs for adolescents, which may present a more scalable, destigmatized, and cost-effective alternative to school-based programs. Trial Registration: ClinicalTrials.gov NCT04567888; https://clinicaltrials.gov/ct2/show/NCT04567888 International Registered Report Identifier (IRRID): RR2-10.2196/25545 %M 38551617 %R 10.2196/54282 %U https://www.jmir.org/2024/1/e54282 %U https://doi.org/10.2196/54282 %U http://www.ncbi.nlm.nih.gov/pubmed/38551617 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e52763 %T Translating Suicide Safety Planning Components Into the Design of mHealth App Features: Systematic Review %A Gryglewicz,Kim %A Orr,Victoria L %A McNeil,Marissa J %A Taliaferro,Lindsay A %A Hines,Serenea %A Duffy,Taylor L %A Wisniewski,Pamela J %+ School of Social Work, University of Central Florida, 12805 Pegasus Drive HS I, Orlando, FL, 32816, United States, 1 14078232954, kgryglew@ucf.edu %K suicide prevention %K suicide safety planning %K mobile health %K mHealth apps %K eHealth %K digital health %K systematic review %K Preferred Reporting Items for Systematic Reviews and Meta-Analyses %K PRISMA %D 2024 %7 28.3.2024 %9 Review %J JMIR Ment Health %G English %X Background: Suicide safety planning is an evidence-based approach used to help individuals identify strategies to keep themselves safe during a mental health crisis. This study systematically reviewed the literature focused on mobile health (mHealth) suicide safety planning apps. Objective: This study aims to evaluate the extent to which apps integrated components of the safety planning intervention (SPI), and if so, how these safety planning components were integrated into the design-based features of the apps. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we systematically analyzed 14 peer-reviewed studies specific to mHealth apps for suicide safety planning. We conducted an analysis of the literature to evaluate how the apps incorporated SPI components and examined similarities and differences among the apps by conducting a comparative analysis of app features. An independent review of SPI components and app features was conducted by downloading the available apps. Results: Most of the mHealth apps (5/7, 71%) integrated SPI components and provided customizable features that expanded upon traditional paper-based safety planning processes. App design features were categorized into 5 themes, including interactive features, individualized user experiences, interface design, guidance and training, and privacy and sharing. All apps included access to community supports and revisable safety plans. Fewer mHealth apps (3/7, 43%) included interactive features, such as associating coping strategies with specific stressors. Most studies (10/14, 71%) examined the usability, feasibility, and acceptability of the safety planning mHealth apps. Usability findings were generally positive, as users often found these apps easy to use and visually appealing. In terms of feasibility, users preferred using mHealth apps during times of crisis, but the continuous use of the apps outside of crisis situations received less support. Few studies (4/14, 29%) examined the effectiveness of mHealth apps for suicide-related outcomes. Positive shifts in attitudes and desire to live, improved coping strategies, enhanced emotional stability, and a decrease in suicidal thoughts or self-harm behaviors were examined in these studies. Conclusions: Our study highlights the need for researchers, clinicians, and app designers to continue to work together to align evidence-based research on mHealth suicide safety planning apps with lessons learned for how to best deliver these technologies to end users. Our review brings to light mHealth suicide safety planning strategies needing further development and testing, such as lethal means guidance, collaborative safety planning, and the opportunity to embed more interactive features that leverage the advanced capabilities of technology to improve client outcomes as well as foster sustained user engagement beyond a crisis. Although preliminary evidence shows that these apps may help to mitigate suicide risk, clinical trials with larger sample sizes and more robust research designs are needed to validate their efficacy before the widespread adoption and use. %M 38546711 %R 10.2196/52763 %U https://mental.jmir.org/2024/1/e52763 %U https://doi.org/10.2196/52763 %U http://www.ncbi.nlm.nih.gov/pubmed/38546711 %0 Journal Article %@ 2564-1891 %I JMIR Publications %V 4 %N %P e47699 %T The Journey of Engaging With Web-Based Self-Harm and Suicide Content: Longitudinal Qualitative Study %A Haime,Zoë %A Kennedy,Laura %A Grace,Lydia %A Cohen,Rachel %A Derges,Jane %A Biddle,Lucy %+ Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, United Kingdom, 44 01179289000, zoe.haime@bristol.ac.uk %K suicide %K self-harm %K online %K longitudinal %K qualitative %D 2024 %7 28.3.2024 %9 Original Paper %J JMIR Infodemiology %G English %X Background: Self-harm and suicide are major public health concerns worldwide, with attention focused on the web environment as a helpful or harmful influence. Longitudinal research on self-harm and suicide–related internet use is limited, highlighting a paucity of evidence on long-term patterns and effects of engaging with such content. Objective: This study explores the experiences of people engaging with self-harm or suicide content over a 6-month period. Methods: This study used qualitative and digital ethnographic methods longitudinally, including one-to-one interviews at 3 time points to explore individual narratives. A trajectory analysis approach involving 4 steps was used to interpret the data. Results: The findings from 14 participants established the web-based journey of people who engage with self-harm or suicide content. In total, 5 themes were identified: initial interactions with self-harm or suicide content, changes in what self-harm or suicide content people engage with and where, changes in experiences of self-harm or suicide behaviors associated with web-based self-harm or suicide content engagement, the disengagement-reengagement cycle, and future perspectives on web-based self-harm or suicide content engagement. Initial engagements were driven by participants seeking help, often when offline support had been unavailable. Some participants’ exposure to self-harm and suicide content led to their own self-harm and suicide behaviors, with varying patterns of change over time. Notably, disengagement from web-based self-harm and suicide spaces served as a protective measure for all participants, but the pull of familiar content resulted in only brief periods of disconnection. Participants also expressed future intentions to continue returning to these self-harm and suicide web-based spaces, acknowledging the nonlinear nature of their own recovery journey and aiming to support others in the community. Within the themes identified in this study, narratives revealed that participants’ behavior was shaped by cognitive flexibility and rigidity, metacognitive abilities, and digital expertise. Opportunities for behavior change arose during periods of cognitive flexibility prompted by life events, stressors, and shifts in mental health. Participants sought diverse and potentially harmful content during challenging times but moved toward recovery-oriented engagements in positive circumstances. Metacognitive and digital efficacy skills also played a pivotal role in participants’ control of web-based interactions, enabling more effective management of content or platforms or sites that posed potential harms. Conclusions: This study demonstrated the complexity of web-based interactions, with beneficial and harmful content intertwined. Participants who demonstrated metacognition and digital efficacy had better control over web-based engagements. Some attributed these skills to study processes, including taking part in reflective diaries, showing the potential of upskilling users. This study also highlighted how participants remained vulnerable by engaging with familiar web-based spaces, emphasizing the responsibility of web-based industry leaders to develop tools that empower users to enhance their web-based safety. %M 38546718 %R 10.2196/47699 %U https://infodemiology.jmir.org/2024/1/e47699 %U https://doi.org/10.2196/47699 %U http://www.ncbi.nlm.nih.gov/pubmed/38546718 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e53160 %T Investigating Father or Partner Involvement in Family Integrated Care in Neonatal Units: Protocol for a Prospective, Multicenter, Multiphase Study %A Rubinstein,Rupa %A Gallagher,Katie %A Ho,John %A Bose,Julian %A Khashu,Minesh %A Aladangady,Narendra %+ Neonatal Unit, Homerton Healthcare NHS Foundation Trust, Homerton Row, London, E9 6SR, United Kingdom, 44 2085105555, n.aladangady@nhs.net %K family integrated care %K FICare %K neonatal intensive care unit %K NICU %K fathers %K premature infants, mental health %K pediatric %K pediatrics %K infant %K infants %K infancy %K baby %K babies %K neonate %K neonates %K neonatal %K premature %K partner %K couple %K family care %K NU admission %K NICU admission %K engagement %D 2024 %7 25.3.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Neonatal unit (NU) admissions for premature babies can last for months, which can significantly impact parental mental health (MH) with symptoms of depression, stress, and anxiety. Literature suggests fathers experience comparable MH symptoms to mothers. Family integrated care (FICare) is a culture where parents are collaborators and partners in caring for their hospitalized newborns. FICare improves infant outcomes and maternal MH. Similar reports on fathers are limited. Objective: The primary aim of this study is to investigate the impact of supporting father or partner engagement in FICare of preterm infants on their MH up to 6 weeks postdischarge. The secondary aim is to investigate the impact on maternal MH. Methods: This is a 2-phase study: phase 1 to gather baseline information and phase 2 to assess the impact of enhanced father or partner engagement in FICare on their MH, involving 2 NUs (tertiary and level 2). Enhanced FICare will be developed and introduced (eg, information booklet, workbook, classes, and a father peer-support group) alongside standard FICare practices. Father or partner MH will be assessed with semistructured qualitative interviews and validated questionnaires: Generalized Anxiety Disorder Assessment, Patient Health Questionnaire, and Parental Stressor Scale: Neonatal Intensive Care Unit from NU admission to 6 weeks postdischarge. Mothers will be assessed by focus groups and the same questionnaires. Descriptive statistics and appropriate comparative tests, such as the 2-tailed t test, will be used to analyze and compare phase 1 and 2 data. Qualitative data will be coded line by line with the use of NVivo (Lumivero) and thematically analyzed. Simultaneously, systematic reviews (SRs) of fathers’ experiences of FICare and their MH outcomes will be conducted. The study was approved by the National Research Ethics Committee (22/EM/0140) in August 2022. A parent advisory group was formed to advise on the study methodology, materials, involvement of participant parents, and dissemination of study findings. Results: A recent SR demonstrated that data saturation is likely to be achieved by interviewing 9 to 17 participants. We will study a maximum of 20 parents of infants born at less than 33 weeks’ gestation in each phase. As of October 2023, the study was ongoing. The SR studies are registered with the PROSPERO database (324275 and 306760). The projected end date for data collection is July 2024; data analysis will be conducted in November 2024 and publication will occur in 2025. Conclusions: The study aims to demonstrate the feasibility of using a father or partner-sensitive FICare model for parents of premature babies with a positive impact on their MH. It will demonstrate the feasibility of providing FICare to extremely premature babies receiving intensive care. This study may support the development of inclusive FICare guidelines for nonbirthing parents and their extremely premature infants. Trial Registration: ClinicalTrials.gov: NCT06022991; https://classic.clinicaltrials.gov/ct2/show/NCT06022991 International Registered Report Identifier (IRRID): DERR1-10.2196/53160 %M 38526549 %R 10.2196/53160 %U https://www.researchprotocols.org/2024/1/e53160 %U https://doi.org/10.2196/53160 %U http://www.ncbi.nlm.nih.gov/pubmed/38526549 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e47960 %T Effectiveness of a Web-based and Mobile Therapy Chatbot on Anxiety and Depressive Symptoms in Subclinical Young Adults: Randomized Controlled Trial %A Karkosz,Stanisław %A Szymański,Robert %A Sanna,Katarzyna %A Michałowski,Jarosław %+ Laboratory of Affective Neuroscience in Poznan, SWPS University, Chodakowska 19/31, Warsaw, 03-815, Poland, 48 22 517 96 00, skarkosz@swps.edu.pl %K chatbots %K conversational agents %K chatbot %K conversational agent %K artificial intelligence %K mental health %K depression %K anxiety %K depressive %K cognitive distortions %K young adults %K randomized control trial %K RCT %K user experience %K CBT %K psychotherapy %K cognitive behavioral therapy %D 2024 %7 20.3.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: There has been an increased need to provide specialized help for people with depressive and anxiety symptoms, particularly teenagers and young adults. There is evidence from a 2-week intervention that chatbots (eg, Woebot) are effective in reducing depression and anxiety, an effect that was not detected in the control group that was provided self-help materials. Although chatbots are a promising solution, there is limited scientific evidence for the efficacy of agent-guided cognitive behavioral therapy (CBT) outside the English language, especially for highly inflected languages. Objective: This study aimed to measure the efficacy of Fido, a therapy chatbot that uses the Polish language. It targets depressive and anxiety symptoms using CBT techniques. We hypothesized that participants using Fido would show a greater reduction in anxiety and depressive symptoms than the control group. Methods: We conducted a 2-arm, open-label, randomized controlled trial with 81 participants with subclinical depression or anxiety who were recruited via social media. Participants were divided into experimental (interacted with a fully automated Fido chatbot) and control (received a self-help book) groups. Both intervention methods addressed topics such as general psychoeducation and cognitive distortion identification and modification via Socratic questioning. The chatbot also featured suicidal ideation identification and redirection to suicide hotlines. We used self-assessment scales to measure primary outcomes, including the levels of depression, anxiety, worry tendencies, satisfaction with life, and loneliness at baseline, after the 2-week intervention and at the 1-month follow-up. We also controlled for secondary outcomes, including engagement and frequency of use. Results: There were no differences in anxiety and depressive symptoms between the groups at enrollment and baseline. After the intervention, depressive and anxiety symptoms were reduced in both groups (chatbot: n=36; control: n=38), which remained stable at the 1-month follow-up. Loneliness was not significantly different between the groups after the intervention, but an exploratory analysis showed a decline in loneliness among participants who used Fido more frequently. Both groups used their intervention technique with similar frequency; however, the control group spent more time (mean 117.57, SD 72.40 minutes) on the intervention than the Fido group (mean 79.44, SD 42.96 minutes). Conclusions: We did not replicate the findings from previous (eg, Woebot) studies, as both arms yielded therapeutic effects. However, such results are in line with other research of Internet interventions. Nevertheless, Fido provided sufficient help to reduce anxiety and depressive symptoms and decreased perceived loneliness among high-frequency users, which is one of the first pieces of evidence of chatbot efficacy with agents that use a highly inflected language. Further research is needed to determine the long-term, real-world effectiveness of Fido and its efficacy in a clinical sample. Trial Registration: ClinicalTrials.gov NCT05762939; https://clinicaltrials.gov/study/NCT05762939; Open Science Foundation Registry 2cqt3; https://osf.io/2cqt3 %M 38506892 %R 10.2196/47960 %U https://formative.jmir.org/2024/1/e47960 %U https://doi.org/10.2196/47960 %U http://www.ncbi.nlm.nih.gov/pubmed/38506892 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e55999 %T Examining Passively Collected Smartphone-Based Data in the Days Prior to Psychiatric Hospitalization for a Suicidal Crisis: Comparative Case Analysis %A Jacobucci,Ross %A Ammerman,Brooke %A Ram,Nilam %+ Department of Psychology, University of Notre Dame, 390 Corbett Family Hall, Notre Dame, IN, 46556, United States, 1 574 631 6650, rjacobuc@nd.edu %K screenomics %K digital phenotyping %K passive assessment %K intensive time sampling %K suicide risk %K suicidal behaviors %K risk detection %K Comparative Analysis %K suicide %K suicidal %K risk %K risks %K behavior %K behaviors %K detection %K prediction %K Smartphone-Based %K screenomic %K case review %K participant %K participants %K smartphone %K smartphones %K suicidal ideation %D 2024 %7 20.3.2024 %9 Case Report %J JMIR Form Res %G English %X Background: Digital phenotyping has seen a broad increase in application across clinical research; however, little research has implemented passive assessment approaches for suicide risk detection. There is a significant potential for a novel form of digital phenotyping, termed screenomics, which captures smartphone activity via screenshots. Objective: This paper focuses on a comprehensive case review of 2 participants who reported past 1-month active suicidal ideation, detailing their passive (ie, obtained via screenomics screenshot capture) and active (ie, obtained via ecological momentary assessment [EMA]) risk profiles that culminated in suicidal crises and subsequent psychiatric hospitalizations. Through this analysis, we shed light on the timescale of risk processes as they unfold before hospitalization, as well as introduce the novel application of screenomics within the field of suicide research. Methods: To underscore the potential benefits of screenomics in comprehending suicide risk, the analysis concentrates on a specific type of data gleaned from screenshots—text—captured prior to hospitalization, alongside self-reported EMA responses. Following a comprehensive baseline assessment, participants completed an intensive time sampling period. During this period, screenshots were collected every 5 seconds while one’s phone was in use for 35 days, and EMA data were collected 6 times a day for 28 days. In our analysis, we focus on the following: suicide-related content (obtained via screenshots and EMA), risk factors theoretically and empirically relevant to suicide risk (obtained via screenshots and EMA), and social content (obtained via screenshots). Results: Our analysis revealed several key findings. First, there was a notable decrease in EMA compliance during suicidal crises, with both participants completing fewer EMAs in the days prior to hospitalization. This contrasted with an overall increase in phone usage leading up to hospitalization, which was particularly marked by heightened social use. Screenomics also captured prominent precipitating factors in each instance of suicidal crisis that were not well detected via self-report, specifically physical pain and loneliness. Conclusions: Our preliminary findings underscore the potential of passively collected data in understanding and predicting suicidal crises. The vast number of screenshots from each participant offers a granular look into their daily digital interactions, shedding light on novel risks not captured via self-report alone. When combined with EMA assessments, screenomics provides a more comprehensive view of an individual’s psychological processes in the time leading up to a suicidal crisis. %M 38506916 %R 10.2196/55999 %U https://formative.jmir.org/2024/1/e55999 %U https://doi.org/10.2196/55999 %U http://www.ncbi.nlm.nih.gov/pubmed/38506916 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e50283 %T The Effect of Explicit Suicide Language in Engagement With a Suicide Prevention Search Page Help-Seeking Prompt: Nonrandomized Trial %A Onie,Sandersan %A Armstrong,Susanne Oliver %A Josifovski,Natasha %A Berlinquette,Patrick %A Livingstone,Nicola %A Holland,Sarah %A Finemore,Coco %A Gale,Nyree %A Elder,Emma %A Laggis,George %A Heffernan,Cassandra %A Theobald,Adam %A Torok,Michelle %A Shand,Fiona %A Larsen,Mark %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney, 2031, Australia, 61 432359134, s.onie@blackdog.org.au %K suicide %K suicide prevention %K Google %K Google Ads %K internet search %K explicit wording %K mental health %K suicidal %K advertisement %K advertisements %K messaging %K prevention signage %K campaign %K campaigns %K distress %K engagement %K prompt %K prompts %K information seeking %K help seeking %K searching %K search %D 2024 %7 19.3.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Given that signage, messaging, and advertisements (ads) are the gateway to many interventions in suicide prevention, it is important that we understand what type of messaging works best for whom. Objective: We investigated whether explicitly mentioning suicide increases engagement using internet ads by investigating engagement with campaigns with different categories of keywords searched, which may reflect different cognitive states. Methods: We ran a 2-arm study Australia-wide, with or without ads featuring explicit suicide wording. We analyzed whether there were differences in engagement for campaigns with explicit and nonexplicit ads for low-risk (distressed but not explicitly suicidal), high-risk (explicitly suicidal), and help-seeking for suicide keywords. Results: Our analyses revealed that having explicit wording has opposite effects, depending on the search terms used: explicit wording reduced the engagement rate for individuals searching for low-risk keywords but increased engagement for those using high-risk keywords. Conclusions: The findings suggest that individuals who are aware of their suicidality respond better to campaigns that explicitly use the word “suicide.” We found that individuals who search for low-risk keywords also respond to explicit ads, suggesting that some individuals who are experiencing suicidality search for low-risk keywords. %M 38502162 %R 10.2196/50283 %U https://mental.jmir.org/2024/1/e50283 %U https://doi.org/10.2196/50283 %U http://www.ncbi.nlm.nih.gov/pubmed/38502162 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e55210 %T Providing Lesbian, Gay, Bisexual, Transgender, Nonbinary, and Queer Adolescents With Nurturance, Trustworthiness, and Safety: Protocol for Pilot Cluster Randomized Controlled Trial Design %A Coulter,Robert WS %A Mahal,Isabella Kaur %A Lin,Clarisse A %A Schneider,Shari Kessel %A Mathias,Aaryn S %A Baral,Karuna %A Miller,Elizabeth %A Abebe,Kaleab Z %+ Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, 130 De Soto Street, Pittsburgh, PA, 15261, United States, 1 412 624 3001, robert.ws.coulter@pitt.edu %K sexual minority youths %K gender minority youths %K cluster randomized controlled trial %K web-based behavior change intervention %K high school staff %D 2024 %7 19.3.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Sexual and gender minority youths (lesbian, gay, bisexual, transgender, nonbinary, and queer individuals) face elevated risks of substance use (eg, alcohol and tobacco) and mental health issues (eg, depressive symptoms and suicidality) compared to their cisgender heterosexual peers. These inequities are hypothesized to be reduced by building supportive high school environments via the training of school staff. An intervention that trains school staff to better understand and support sexual and gender minority youths and engage in positive bystander behaviors that protect them from bullying exposure may reduce disparities in drug and alcohol use among them. Experts, school staff, and sexual and gender minority youths developed Providing LGBTQ+ Adolescents with Nurturance, Trustworthiness, and Safety (PLANTS), a web-based intervention to train school staff on how to support, affirm, and protect sexual and gender minority youths. Objective: This paper describes the design of the PLANTS pilot trial primarily aimed at assessing its acceptability, usability, appropriateness, and feasibility. We hypothesize PLANTS will have high acceptability, usability, appropriateness, and feasibility as rated by the school staff. Secondary objectives focus on implementation, safety, and pre-post changes in high school staff outcomes, including self-efficacy and skills (eg, active-empathic listening and bullying intervention). Exploratory objectives focus on the impact of PLANTS on student health outcomes. Methods: In a 2-arm cluster randomized controlled trial, high schools in Massachusetts are allocated to PLANTS or an active comparator group (publicly available sexual and gender minority youths resources or training). High school staff complete pretest and posttest surveys containing validated scales. Primary outcomes are validated measures of acceptability, usability, appropriateness, and feasibility of the intervention completed by staff during posttest surveys. To test our primary hypotheses for each outcome, we will calculate means and 95% CIs and P values using 1-sample 2-sided t tests against a priori thresholds or benchmarks of success. Secondary outcomes include staff’s active-empathetic listening skills, self-efficacy for working with sexual and gender minority youths, bystander intervention behaviors for bullying and cyberbullying, and self-efficacy for PLANTS’ change objectives completed during pretest and posttest staff surveys. Staff can also complete a posttest interview guided by the Information-Motivation-Behavior model and Consolidated Framework for Implementation Research. Exploratory outcomes include student-level data collected via the 2021 and 2023 MetroWest Adolescent Health Surveys, a health behavior surveillance system in 30 Massachusetts schools. Results: School enrollment began in May 2023 and participant enrollment began in June 2023. Data collection is expected to be completed by February 2024. Conclusions: This pilot trial will yield important information about the PLANTS intervention and provide necessary information to conduct a fully powered trial of the efficacy of PLANTS for reducing the deleterious health inequities experienced by sexual and gender minority youths. Trial Registration: ClinicalTrials.gov NCT05897827; https://clinicaltrials.gov/study/NCT05897827 International Registered Report Identifier (IRRID): DERR1-10.2196/55210 %M 38502156 %R 10.2196/55210 %U https://www.researchprotocols.org/2024/1/e55210 %U https://doi.org/10.2196/55210 %U http://www.ncbi.nlm.nih.gov/pubmed/38502156 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e52809 %T A Closed-Loop Digital Health Tool to Improve Depression Care in Multiple Sclerosis: Iterative Design and Cross-Sectional Pilot Randomized Controlled Trial and its Impact on Depression Care %A Henderson,Kyra %A Reihm,Jennifer %A Koshal,Kanishka %A Wijangco,Jaeleene %A Sara,Narender %A Miller,Nicolette %A Doyle,Marianne %A Mallory,Alicia %A Sheridan,Judith %A Guo,Chu-Yueh %A Oommen,Lauren %A Rankin,Katherine P %A Sanders,Stephan %A Feinstein,Anthony %A Mangurian,Christina %A Bove,Riley %+ Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, 1651 4th Street, San Francisco, CA, 94158, United States, 1 4155027209, riley.bove@ucsf.edu %K depression %K quality of life %K bring your own device %K mHealth %K closed-loop %K clinical trial %K multiple sclerosis %D 2024 %7 15.3.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: People living with multiple sclerosis (MS) face a higher likelihood of being diagnosed with a depressive disorder than the general population. Although many low-cost screening tools and evidence-based interventions exist, depression in people living with MS is underreported, underascertained by clinicians, and undertreated. Objective: This study aims to design a closed-loop tool to improve depression care for these patients. It would support regular depression screening, tie into the point of care, and support shared decision-making and comprehensive follow-up. After an initial development phase, this study involved a proof-of-concept pilot randomized controlled trial (RCT) validation phase and a detailed human-centered design (HCD) phase. Methods: During the initial development phase, the technological infrastructure of a clinician-facing point-of-care clinical dashboard for MS management (BRIDGE) was leveraged to incorporate features that would support depression screening and comprehensive care (Care Technology to Ascertain, Treat, and Engage the Community to Heal Depression in people living with MS [MS CATCH]). This linked a patient survey, in-basket messages, and a clinician dashboard. During the pilot RCT phase, a convenience sample of 50 adults with MS was recruited from a single MS center with 9-item Patient Health Questionnaire scores of 5-19 (mild to moderately severe depression). During the routine MS visit, their clinicians were either asked or not to use MS CATCH to review their scores and care outcomes were collected. During the HCD phase, the MS CATCH components were iteratively modified based on feedback from stakeholders: people living with MS, MS clinicians, and interprofessional experts. Results: MS CATCH links 3 features designed to support mood reporting and ascertainment, comprehensive evidence-based management, and clinician and patient self-management behaviors likely to lead to sustained depression relief. In the pilot RCT (n=50 visits), visits in which the clinician was randomized to use MS CATCH had more notes documenting a discussion of depressive symptoms than those in which MS CATCH was not used (75% vs 34.6%; χ21=8.2; P=.004). During the HCD phase, 45 people living with MS, clinicians, and other experts participated in the design and refinement. The final testing round included 20 people living with MS and 10 clinicians including 5 not affiliated with our health system. Most scoring targets for likeability and usability, including perceived ease of use and perceived effectiveness, were met. Net Promoter Scale was 50 for patients and 40 for clinicians. Conclusions: Created with extensive stakeholder feedback, MS CATCH is a closed-loop system aimed to increase communication about depression between people living with MS and their clinicians, and ultimately improve depression care. The pilot findings showed evidence of enhanced communication. Stakeholders also advised on trial design features of a full year long Department of Defense–funded feasibility and efficacy trial, which is now underway. Trial Registration: ClinicalTrials.gov NCT05865405; http://tinyurl.com/4zkvru9x %M 38488827 %R 10.2196/52809 %U https://formative.jmir.org/2024/1/e52809 %U https://doi.org/10.2196/52809 %U http://www.ncbi.nlm.nih.gov/pubmed/38488827 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e52324 %T Development of a Multiplatform Tool for the Prevention of Prevalent Mental Health Pathologies in Adults: Protocol for a Randomized Control Trial %A Ramos,Nadia %A Besoain,Felipe %A Cancino,Natalia %A Gallardo,Ismael %A Albornoz,Paula %A Fresno,Andres %A Spencer,Rosario %A Schott,Soledad %A Núñez,Daniel %A Salgado,Carolina %A Campos,Susana %+ Center of Applied Psychology, Faculty of Psychology, University of Talca, 1 Poniente 1141, Talca, 3460000, Chile, 56 71 2 201783, susana.campos@utalca.cl %K adults %K anxiety %K depression %K eHealth %K mental health %K mobile app %K RCT %D 2024 %7 11.3.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: The prevalence of depression and anxiety has increased in recent years, with many individuals having trouble accessing mental health support. Smartphones have become an integral part of modern life, with apps offering new ways to deliver evidence-based self-help strategies to cope with common mental health symptoms. However, most of them do not have empirical evidence of their overall effectiveness or the effectiveness of their components, which could pose a risk for users. Objective: The aim of this study is to evaluate the effectiveness of the modules of evaluation, psychoeducation, and emotional regulation strategies in a multiplatform self-help mental health mobile app in the Maule region of Chile. Methods: A sample of 196 adults will be selected, who will be randomly assigned to different components of the app for a fixed period to assess its ability to reduce symptomatology. Results: The trial is not yet recruiting and is expected to end in October 2024. The first results are expected in April 2024. Conclusions: This is the first study in Chile to develop and test the effectiveness of a mobile app to manage anxiety and depression symptoms in adults. The intervention proposed is based on evidence suggesting that the internet or remote intervention tools and self-management of prevalent symptomatology could be the future of mental health care systems in the digital era. If the effects of the intervention are positive, wide implementation in Chile and other Spanish-speaking countries could be possible in the future. International Registered Report Identifier (IRRID): PRR1-10.2196/52324 %M 38466982 %R 10.2196/52324 %U https://www.researchprotocols.org/2024/1/e52324 %U https://doi.org/10.2196/52324 %U http://www.ncbi.nlm.nih.gov/pubmed/38466982 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e54635 %T An mHealth Intervention to Address Depression and Improve Antiretroviral Therapy Adherence Among Youths Living With HIV in Uganda: Protocol for a Pilot Randomized Controlled Trial %A Nabunya,Proscovia %A Cavazos-Rehg,Patricia %A Mugisha,James %A Kasson,Erin %A Namuyaba,Olive Imelda %A Najjuuko,Claire %A Nsubuga,Edward %A Filiatreau,Lindsey M %A Mwebembezi,Abel %A Ssewamala,Fred M %+ International Center for Child Health and Development, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130, United States, 1 3149359087, nabunyap@wustl.edu %K depression %K adherence %K mHealth %K cognitive behavioral therapy %K antiretroviral therapy %K youth living with HIV %K Uganda %D 2024 %7 8.3.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: People living with HIV often struggle with mental health comorbidities that lower their antiretroviral therapy (ART) adherence. There is growing evidence that depression treatment may improve ART adherence and result in improved HIV outcomes. Given that mental health services are severely underequipped in low-resource settings, including in Uganda, new solutions to increase access to mental health care and close the treatment gap are urgently needed. This protocol paper presents the Suubi-Mhealth study, which proposed to develop a mobile health (mHealth) intervention for use among Ugandan youths (14-17 years) with comorbid HIV and depression, taking into account their unique contextual, cultural, and developmental needs. Objective: The proposed study is guided by the following objectives: (1) to develop and iteratively refine an intervention protocol for Suubi-Mhealth based on formative work to understand the needs of youths living with HIV; (2) to explore the feasibility and acceptability of Suubi-Mhealth on a small scale to inform subsequent refinement; (3) to test the preliminary impact of Suubi-Mhealth versus a waitlist control group on youths’ outcomes, including depression and treatment adherence; and (4) to examine barriers and facilitators for integrating Suubi-Mhealth into health care settings. Methods: Youths will be eligible to participate in the study if they are (1) 14-17 years of age, (2) HIV-positive and aware of their status, (3) receiving care and ART from one of the participating clinics, and (4) living within a family. The study will be conducted in 2 phases. In phase 1, we will conduct focus group discussions with youths and health care providers, for feedback on the proposed intervention content and methods, and explore the feasibility and acceptability of the intervention. In phase II, we will pilot-test the preliminary impact of the intervention on reducing depression and improving ART adherence. Assessments will be conducted at baseline, 1-, 2-, and 6-months post intervention completion. Results: Participant recruitment for phase 1 is completed. Youths and health care providers participated in focus group discussions to share their feedback on the proposed Suubi-Mhealth intervention content, methods, design, and format. Transcription and translation of focus group discussions have been completed. The team is currently developing Suubi-Mhealth content based on participants’ feedback. Conclusions: This study will lay important groundwork for several initiatives at the intersection of digital therapeutics, HIV treatment, and mental health, especially among sub-Saharan African youths, as they transition through adolescence and into adult HIV care settings. Trial Registration: ClinicalTrials.gov NCT05965245; https://clinicaltrials.gov/study/NCT05965245 International Registered Report Identifier (IRRID): DERR1-10.2196/54635 %M 38457202 %R 10.2196/54635 %U https://www.researchprotocols.org/2024/1/e54635 %U https://doi.org/10.2196/54635 %U http://www.ncbi.nlm.nih.gov/pubmed/38457202 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e46195 %T Evaluation of the Effectiveness of Suicide.ca, Quebec’s Digital Suicide Prevention Strategy Platform: Cross-Sectional Descriptive Study %A Côté,Louis-Philippe %A Lane,Julie %+ Centre for Research and Intervention on Suicide, Ethical Issues and End-of-life practices, Université du Québec à Montréal, 100 rue Sherbrooke Ouest, Montreal, QC, H2X 3P2, Canada, 1 (514) 987 4832, cote.louis-philippe.3@courrier.uqam.ca %K suicide prevention %K public health %K information and communication technology %K digital mental health %K helpline %K digital strategy %K communication technology %K information technology %K suicide %K psychoeducation %K mobile app %K suicide risk %K risk factor %K users %K mental health %K text %K website %K prevention strategy %K prevention %K Google Analytics %K Canada %K Quebec %K questionnaire %K mobile phone %D 2024 %7 6.3.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: In 2017, the Quebec government assigned the Association québécoise de prévention du suicide (AQPS) to develop a digital suicide prevention strategy (DSPS). The AQPS responded by creating a centralized website that provides information on suicide and mental health, identifies at-risk individuals on the internet, and offers direct crisis intervention support via chat and text. Objective: This study aims to evaluate the effectiveness of suicide.ca, Quebec’s DSPS platform. Methods: This study used a cross-sectional descriptive design. The study population comprised internet users from Quebec, Canada, who visited the suicide.ca platform between October 2020 and October 2021. Various data sources, such as Google Analytics, Firebase Console, and Customer Relation Management data, were analyzed to document the use of the platform. To understand the profile of suicide.ca users, frequency analyses were conducted using data from the self-assessment module questionnaires, the intervention service’s triage questionnaire, and the counselors’ intervention reports. The effectiveness of the platform’s promotional activities on social media was assessed by examining traffic peaks. Google Analytics was used to evaluate the effectiveness of AQPS’ strategy for identifying at-risk internet users. The impact of the intervention service was evaluated through an analysis of counselors’ intervention reports and postintervention survey results. Results: The platform received traffic from a diverse range of sources, with promotional efforts on social media directly contributing to the increased traffic. The requirement of a user account posed a barrier to the use of the mobile app, and a triage question that involved personal information led to a substantial number of dropouts during the intervention service triage. AdWords campaigns and fact sheets addressing suicide risk factors played a crucial role in driving traffic to the platform. With regard to the profile of suicide.ca users, the findings revealed that the platform engaged individuals with diverse levels of suicidal risk. Notably, users of the chat service displayed a higher suicide risk than those who used the self-assessment module. Crisis chat counselors reported a positive impact on approximately half of the contacts, and overall, intervention service users expressed satisfaction with the support they received. Conclusions: A centralized digital platform can be used to implement a DSPS, effectively reaching the general population, individuals with risk factors for suicide, and those facing suicidal issues. %M 38446536 %R 10.2196/46195 %U https://formative.jmir.org/2024/1/e46195 %U https://doi.org/10.2196/46195 %U http://www.ncbi.nlm.nih.gov/pubmed/38446536 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e53353 %T Factors Associated With Perception of Stigma Among Parents of Children With Cleft Lip and Palate: Cross-Sectional Study %A Zhang,Yanan %A Zhang,Xinwen %A Jiang,Jinzhuo %A Xie,Wanhua %A Xiang,Daoman %+ Outpatient Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, 9 Jinsui Road, Guangzhou, 510623, China, 1 13725370379, xiewanhua1@126.com %K stigma %K social anxiety %K depression %K parents of children with cleft lip and palate %K cleft lip %K cleft palate %K cross-sectional study %D 2024 %7 4.3.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Parents of children with cleft lip with or without cleft palate (CL/P) often face stigmatization, which has a significant impact on their quality of life and mental health. However, to date, there is a lack of comprehensive, multicenter empirical research on parents of children with CL/P in China, particularly those with large-scale samples. Objective: This study aimed to identify major factors that contribute to the perception of stigma experienced by parents of children with CL/P. Methods: A cross-sectional survey was conducted. A total of 104 parents of children diagnosed with CL/P in 2 hospitals were selected by convenience sampling. Demographics and disease information, the Chinese Perception of Stigma Questionnaire, the Center for Epidemiological Studies Depression Scale, and the Social Anxiety Scale were used in this study. Descriptive statistics, t tests, and one-way ANOVA were used to compare the differences between participants’ demographic information and perception of stigma. Multivariable linear regression was performed to assess associations between demographic factors, social anxiety, depression, and perception of stigma. Results: The mean scores for the dimensions of perception of stigma, depression, and social anxiety were 22.97 (SD 9.21), 38.34 (SD 8.25), and 22.86 (SD 6.69), respectively. Depression and social anxiety were positively associated with discrimination, while surgery status was a negatively associated variable. Parents with a college education or higher had significantly lower levels of perceived stigma compared to parents with a junior high school education (all P values <.05). These 4 factors explained 40.4% of the total model variance (F8=9.726; P<.001; R2=0.450; adjusted R2=0.404). Conclusions: Our findings highlight a concerning trend of diminished quality of life among parents of children with CL/P. Factors such as parents’ education level, surgery status, depression, and social anxiety are shown to influence the level of stigma experienced. Implementing comprehensive nursing care and providing presurgical support are effective strategies for alleviating parents’ social anxiety, reducing perceived stigma, and preventing depression. %M 38437002 %R 10.2196/53353 %U https://formative.jmir.org/2024/1/e53353 %U https://doi.org/10.2196/53353 %U http://www.ncbi.nlm.nih.gov/pubmed/38437002 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e53001 %T Layperson-Supported, Web-Delivered Cognitive Behavioral Therapy for Depression in Older Adults: Randomized Controlled Trial %A Xiang,Xiaoling %A Kayser,Jay %A Turner,Skyla %A Ash,Samson %A Himle,Joseph A %+ School of Social Work, University of Michigan, 1080 S University Ave, Ann Arbor, MI, 48109, United States, 1 (734) 763 6581, xiangxi@umich.edu %K internet-based cognitive behavioral therapy %K iCBT %K digital mental health interventions %K older adults %K depression %D 2024 %7 4.3.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is the most prevalent mental health condition in older adults. However, not all evidence-based treatments are easily accessible. Web-delivered cognitive behavioral therapy (wCBT) facilitated by laypersons is a viable treatment alternative. Objective: This randomized controlled trial aims to evaluate the efficacy of a novel wCBT program, Empower@Home, supported by trained lay coaches, against a waitlist attention control. Empower@Home is among the very few existing wCBT programs specifically designed for older adults. The primary objective was to assess the efficacy of the intervention compared with attention control. The secondary objective was to evaluate the program’s impact on secondary psychosocial outcomes and explore potential change mechanisms. Methods: Older adults (N=70) were recruited via web-based research registries, social media advertisements, and community agency referrals and randomly assigned to either the intervention or control group in a 1:1 allocation ratio. The intervention group received access to Empower@Home, which included 9 web-delivered self-help lessons and weekly telephone coaching sessions by a trained layperson over 10 weeks. The control group received weekly friendly phone calls and depressive symptom monitoring. The primary clinical outcome was the severity of depressive symptoms assessed using the Patient Health Questionnaire-9. The secondary clinical outcomes included anxiety, anger, social isolation, insomnia, pain intensity, and quality of life. Linear mixed modeling was used to determine the treatment effects on depression, and 2-tailed t tests were used to assess within-group changes and between-group differences. Results: Most participants in the intervention group completed all 9 sessions (31/35, 89%). The usability and acceptability ratings were excellent. The intervention group had a large within-group change in depressive symptoms (Cohen d=1.22; P<.001), whereas the attention control group experienced a medium change (Cohen d=0.57; P<.001). The between-group effect size was significant, favoring the intervention group over the control group (Cohen d=0.72; P<.001). In the linear mixed model, the group-by-time interaction was statistically significant (b=–0.68, 95% CI –1.00 to –0.35; P<.001). The treatment effects were mediated by improvements in cognitive behavioral therapy skills acquisition; behavioral activation; and satisfaction with the basic psychological needs of autonomy, competence, and relatedness. Furthermore, the intervention group showed significant within-group improvements in secondary psychosocial outcomes, including anxiety (P=.001), anger (P<.001), social isolation (P=.02), insomnia (P=.007), and pain (P=.03). By contrast, the control group did not experience significant changes in these outcome domains. However, the between-group differences in secondary outcomes were not statistically significant, owing to the small sample size. Conclusions: Empower@Home, a wCBT program supported by lay coaches, was more efficacious in reducing depressive symptoms than friendly telephone calls and depression symptom monitoring. Future studies should examine the effectiveness of the intervention in community and practice settings using nonclinician staff already present in these real-world settings as coaches. Trial Registration: ClinicalTrials.gov NCT05593276; https://clinicaltrials.gov/ct2/show/NCT05593276 International Registered Report Identifier (IRRID): RR2-10.2196/44210 %M 38437013 %R 10.2196/53001 %U https://www.jmir.org/2024/1/e53001 %U https://doi.org/10.2196/53001 %U http://www.ncbi.nlm.nih.gov/pubmed/38437013 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e40187 %T Efficacy of Internet-Based Cognitive Behavioral Therapy for Subthreshold Depression Among Older Adults in Institutional Long-Term Care Settings: Pragmatic Randomized Controlled Trial %A Kong,Fanqian %A Yu,Libo %A Hou,Yanbin %A Zhu,Lijie %A Zhou,Jing %A Huang,Lingjie %A Lv,Yueer %A Wang,Li %A Zhang,Li %A Yang,Yiling %A Ying,Yuchen %+ Ningbo College of Health Sciences, 51 Xuefu Street, Yinzhou District, Ningbo, Zhejiang, 315100, China, 86 13685733802, 1246401741@qq.com %K internet-based cognitive behavioral therapy %K subthreshold depression %K randomized controlled trial %K older adults %K LTC setting %D 2024 %7 1.3.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Subthreshold depression (sD) is prevalent in older populations in long-term care (LTC) settings, but psychological therapy in LTC settings in China is not readily available. Thus, internet-based cognitive behavioral therapy (ICBT) may be suitable for this population, but research on the efficacy of ICBT for older adults with sD, especially those living in LTC settings, is limited. Objective: This study aimed to evaluate the efficacy and acceptability of ICBT treatment for sD among LTC residents in China. We also examined whether ICBT is as effective as group-based cognitive behavioral therapy (CBT) for treating sD in this population. Methods: We conducted a pragmatic randomized controlled trial, which included 18 LTC institutions. A total of 354 participants were randomized to ICBT, group-based CBT, or a waiting list and were followed up for 12 months. The primary outcome was self-reported depressive symptoms on the Center for Epidemiological Studies Depression Scale (CES-D). Secondary outcomes were the scores of the Patient Health Questionnaire–9 (PHQ-9), Generalized Anxiety Disorder 7-Item (GAD-7), and Geriatric Depression Scale (GDS). A mixed-effects model was used to assess the efficacy of ICBT. Results: The ICBT group showed a significant improvement in self-reported depressive symptoms, which was maintained at the 12-month follow-up (all P<.001). The ICBT group exhibited a significantly larger reduction in the scores of the CES-D (Cohen d=0.07, 95% CI 0.04-0.09; P=.01), PHQ-9 (d=0.30, 95% CI 0.28-0.33; P<.001), GDS (d=0.10, 95% CI 0.08-0.13; P<.001), and GAD-7 (d=0.19, 95% CI 0.17-0.22; P<.001) compared with a waiting list at postintervention. ICBT had significantly stronger effects than CBT on the PHQ-9 and GAD-7 at postintervention (d=0.15, 95% CI 0.13-0.17; P<.001 and d=0.21, 95% CI 0.19-0.23; P<.001, respectively), 6-month follow-up (d=0.18, 95% CI 0.16-0.21; P<.001 and d=0.18, 95% CI 0.15-0.21; P<.001, respectively), and 12-month follow-up (d=0.15, 95% CI 0.11-0.19; P<.001 and d=0.18, 95% CI 0.14-0.21; P<.001, respectively). Conclusions: ICBT is a relatively effective and acceptable intervention for reducing depressive symptoms among Chinese LTC residents with sD. These findings indicate the usefulness of ICBT application for sD in LTC settings. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000030697; https://www.chictr.org.cn/showproj.aspx?proj=50781 %M 38427424 %R 10.2196/40187 %U https://www.jmir.org/2024/1/e40187 %U https://doi.org/10.2196/40187 %U http://www.ncbi.nlm.nih.gov/pubmed/38427424 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e48894 %T Identifying Unmet Needs in Major Depressive Disorder Using a Computer-Assisted Alternative to Conventional Thematic Analysis: Qualitative Interview Study With Psychiatrists %A Worthington,Michelle A %A Christie,Richard H %A Masino,Aaron J %A Kark,Sarah M %+ AiCure, 214 Sullivan Street 6C, New York, NY, 10012, United States, 1 (800) 570 0448, sarah.kark@aicure.com %K consumer health informatics %K interview %K major depressive disorder %K medical informatics applications %K needs assessment %K psychiatry and psychology %D 2024 %7 1.3.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: The development of digital health tools that are clinically relevant requires a deep understanding of the unmet needs of stakeholders, such as clinicians and patients. One way to reveal unforeseen stakeholder needs is through qualitative research, including stakeholder interviews. However, conventional qualitative data analytical approaches are time-consuming and resource-intensive, rendering them untenable in many industry settings where digital tools are conceived of and developed. Thus, a more time-efficient process for identifying clinically relevant target needs for digital tool development is needed. Objective: The objective of this study was to address the need for an accessible, simple, and time-efficient alternative to conventional thematic analysis of qualitative research data through text analysis of semistructured interview transcripts. In addition, we sought to identify important themes across expert psychiatrist advisor interview transcripts to efficiently reveal areas for the development of digital tools that target unmet clinical needs. Methods: We conducted 10 (1-hour-long) semistructured interviews with US-based psychiatrists treating major depressive disorder. The interviews were conducted using an interview guide that comprised open-ended questions predesigned to (1) understand the clinicians’ experience of the care management process and (2) understand the clinicians’ perceptions of the patients’ experience of the care management process. We then implemented a hybrid analytical approach that combines computer-assisted text analyses with deductive analyses as an alternative to conventional qualitative thematic analysis to identify word combination frequencies, content categories, and broad themes characterizing unmet needs in the care management process. Results: Using this hybrid computer-assisted analytical approach, we were able to identify several key areas that are of interest to clinicians in the context of major depressive disorder and would be appropriate targets for digital tool development. Conclusions: A hybrid approach to qualitative research combining computer-assisted techniques with deductive techniques provides a time-efficient approach to identifying unmet needs, targets, and relevant themes to inform digital tool development. This can increase the likelihood that useful and practical tools are built and implemented to ultimately improve health outcomes for patients. %M 38427407 %R 10.2196/48894 %U https://formative.jmir.org/2024/1/e48894 %U https://doi.org/10.2196/48894 %U http://www.ncbi.nlm.nih.gov/pubmed/38427407 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e48557 %T A Social Media–Based Mindfulness Psycho-Behavioral Intervention (MCARE) for Patients With Acute Coronary Syndrome: Randomized Controlled Trial %A Zou,Huijing %A Chair,Sek Ying %A Feng,Bilong %A Liu,Qian %A Liu,Yu Jia %A Cheng,Yu Xin %A Luo,Dan %A Wang,Xiao Qin %A Chen,Wei %A Huang,Leiqing %A Xianyu,Yunyan %A Yang,Bing Xiang %+ School of Nursing, Wuhan University, No. 115 Donghu Road, Wuchang District, Wuhan, 430071, China, 86 02768788685, yangbx@whu.edu.cn %K acute coronary syndrome %K psychological distress %K depression %K anxiety %K mindfulness %K mindfulness-based intervention %K quality of life %K risk factors %K cardiac rehabilitation %K social media %D 2024 %7 20.2.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Psychological distress is common among patients with acute coronary syndrome (ACS) and has considerable adverse impacts on disease progression and health outcomes. Mindfulness-based intervention is a promising complementary approach to address patients’ psychological needs and promote holistic well-being. Objective: This study aims to examine the effects of a social media–based mindfulness psycho-behavioral intervention (MCARE) on psychological distress, psychological stress, health-related quality of life (HRQoL), and cardiovascular risk factors among patients with ACS. Methods: This study was a 2-arm, parallel-group randomized controlled trial. We recruited 178 patients (mean age 58.7, SD 8.9 years; 122/178, 68.5% male) with ACS at 2 tertiary hospitals in Jinan, China. Participants were randomly assigned to the MCARE group (n=89) or control group (n=89). The 6-week intervention consisted of 1 face-to-face session (phase I) and 5 weekly WeChat (Tencent Holdings Ltd)–delivered sessions (phase II) on mindfulness training and health education and lifestyle modification. The primary outcomes were depression and anxiety. Secondary outcomes included psychological stress, HRQoL, and cardiovascular risk factors (ie, smoking status, physical activity, dietary behavior, BMI, blood pressure, blood lipids, and blood glucose). Outcomes were measured at baseline (T0), immediately after the intervention (T1), and 12 weeks after the commencement of the intervention (T2). Results: The MCARE group showed significantly greater reductions in depression (T1: β=–2.016, 95% CI –2.584 to –1.449, Cohen d=–1.28, P<.001; T2: β=–2.089, 95% CI –2.777 to –1.402, Cohen d=–1.12, P<.001) and anxiety (T1: β=–1.024, 95% CI –1.551 to –0.497, Cohen d=–0.83, P<.001; T2: β=–0.932, 95% CI –1.519 to –0.346, Cohen d=–0.70, P=.002). Significantly greater improvements were also observed in psychological stress (β=–1.186, 95% CI –1.678 to –0.694, Cohen d=–1.41, P<.001), physical HRQoL (β=0.088, 95% CI 0.008-0.167, Cohen d=0.72, P=.03), emotional HRQoL (β=0.294, 95% CI 0.169-0.419, Cohen d=0.81, P<.001), and general HRQoL (β=0.147, 95% CI 0.070-0.224, Cohen d=1.07) at T1, as well as dietary behavior (β=0.069, 95% CI 0.003-0.136, Cohen d=0.75, P=.04), physical activity level (β=177.542, 95% CI –39.073 to 316.011, Cohen d=0.51, P=.01), and systolic blood pressure (β=–3.326, 95% CI –5.928 to –0.725, Cohen d=–1.32, P=.01) at T2. The overall completion rate of the intervention (completing ≥5 sessions) was 76% (68/89). Positive responses to the questions of the acceptability questionnaire ranged from 93% (76/82) to 100% (82/82). Conclusions: The MCARE program generated favorable effects on psychological distress, psychological stress, HRQoL, and several aspects of cardiovascular risk factors in patients with ACS. This study provides clues for guiding clinical practice in the recognition and management of psychological distress and integrating the intervention into routine rehabilitation practice. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000033526; https://www.chictr.org.cn/showprojEN.html?proj=54693 %M 38376899 %R 10.2196/48557 %U https://www.jmir.org/2024/1/e48557 %U https://doi.org/10.2196/48557 %U http://www.ncbi.nlm.nih.gov/pubmed/38376899 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e49317 %T HealthySMS Text Messaging System Adjunct to Adolescent Group Cognitive Behavioral Therapy in the Context of COVID-19 (Let’s Text!): Pilot Feasibility and Acceptability Study %A Haack,Lauren M %A Armstrong,Courtney C %A Travis,Kate %A Aguilera,Adrian %A Darrow,Sabrina M %+ Department of Psychiatry and Behavioral Sciences, University of California San Francisco, 675 18th Street, San Francisco, CA, 94107, United States, 1 415 502 8060, lauren.haack@ucsf.edu %K depression %K adolescents %K evidence-based intervention %K texting %K SMS text message %K cognitive behavioral therapy %K CBT %K group CBT %K shelter-in-place %K COVID-19 %K mobile health %K mHealth %K therapy %K cognitive %K behavior %K web-based therapy %K e-therapy %K youth %K young adults %K mobile phone %D 2024 %7 19.2.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: The widespread occurrence and devastating impact of adolescent depression warrant health service research focused on feasible and acceptable digital health tools to supplement evidence-based intervention (EBI) efforts, particularly in the context of shelter-in-place guidelines disrupting youth socialization and service use in the wake of the COVID-19 pandemic. Given the promise of SMS text message interventions to enhance EBI engagement, our team developed the HealthySMS system as an adjunct to one of the most empirically supported interventions for adolescent depression: cognitive behavioral therapy (CBT) group services. The system sends daily SMS text messages requesting responses assessing mood, thoughts, and activities; weekly attendance reminder messages; daily tips about adherence (eg, a prompt for activity completion); and personalized responses based on participants’ texts. Objective: This study aims to evaluate the feasibility and acceptability of HealthySMS in a real-world setting and explore potential mechanisms of change in EBI engagement, before evaluating the system’s impact on adolescents’ group CBT engagement and, ultimately, depression outcomes. Methods: Over the course of 2020, we invited all 20 adolescents receiving CBT group services for depression at an outpatient psychiatry clinic to enroll in our HealthySMS study; ultimately, 17 (85%) adolescents agreed to participate. We tracked participant initiation and engagement with the HealthySMS system as well as the content of SMS text message responses to HealthySMS. We also invited each participant to engage in a semistructured interview to gather additional qualitative inputs on the system. Results: All (n=17, 100%) research participants invited agreed to receive HealthySMS messages, and 94% (16/17) of the participants maintained use during the first month without opting out. We uncovered meaningful qualitative themes regarding the feasibility and acceptability of HealthySMS, as well as its potential impact on EBI engagement. Conclusions: Taken together, the results of this pilot study suggest that HealthySMS adjunct to adolescent CBT group depression services is feasible and acceptable, as evidenced by high rates of HealthySMS initiation and low rates of dropout, as well as meaningful themes uncovered from participants’ qualitative feedback. In addition, the findings provide evidence regarding iterative improvements to the HealthySMS system and research protocol, as well as potential mechanisms of change for enhanced EBI engagement and, ultimately, adolescent depression outcomes, which can be used in future effectiveness research. %M 38373030 %R 10.2196/49317 %U https://mental.jmir.org/2024/1/e49317 %U https://doi.org/10.2196/49317 %U http://www.ncbi.nlm.nih.gov/pubmed/38373030 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e50113 %T Patient and Therapist Perceptions of a Publicly Funded Internet-Based Cognitive Behavioral Therapy (iCBT) Program for Ontario Adults During the COVID-19 Pandemic: Qualitative Study %A Thapar,Serena %A Nguyen,Megan %A Khan,Bilal Noreen %A Fanaieyan,Roz %A Kishimoto,Vanessa %A Liu,Rebecca %A Bolea-Alamañac,Blanca %A Leon-Carlyle,Marisa %A O’Riordan,Anne %A Keresteci,Maggie %A Bhattacharyya,Onil %+ Institute for Health System Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada, 1 6474580101, serena.thapar@mail.mcgill.ca %K depression %K anxiety %K cognitive behavioral therapy %K digital health %K internet-delivered cognitive behavioral therapy %K iCBT %K CBT %K implementation %K facilitators %K barriers %K interviews %K qualitative %D 2024 %7 19.2.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: To address the anticipated rise in mental health symptoms experienced at the population level during the COVID-19 pandemic, the Ontario government provided 2 therapist-assisted internet-delivered cognitive behavioral therapy (iCBT) programs to adults free of charge at the point of service. Objective: The study aims to explore the facilitators of and barriers to implementing iCBT at the population level in Ontario, Canada, from the perspective of patients and therapists to better understand how therapist-assisted iCBT programs can be effectively implemented at the population level and inform strategies for enhancing service delivery and integration into the health care system. Methods: Using a convenience sampling methodology, semistructured interviews were conducted with 10 therapists who delivered iCBT and 20 patients who received iCBT through either of the publicly funded programs to explore their perspectives of the program. Interview data were analyzed using inductive thematic analysis to generate themes. Results: Six salient themes were identified. Facilitators included the therapist-assisted nature of the program; the ease of registration and the lack of cost; and the feasibility of completing the psychoeducational modules given the online and self-paced nature of the program. Barriers included challenges with the online remote modality for developing the therapeutic alliance; the program’s generalized nature, which limited customization to individual needs; and a lack of formal integration between the iCBT program and the health care system. Conclusions: Although the program was generally well-received by patients and therapists due to its accessibility and feasibility, the digital format of the program presented both benefits and unique challenges. Strategies for improving the quality of service delivery include opportunities for synchronous communication between therapists and patients, options for increased customization, and the formal integration of iCBT into a broader stepped-care model that centralizes patient referrals between care providers and promotes continuity of care. %M 38373027 %R 10.2196/50113 %U https://formative.jmir.org/2024/1/e50113 %U https://doi.org/10.2196/50113 %U http://www.ncbi.nlm.nih.gov/pubmed/38373027 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51473 %T Machine Learning–Based Prediction of Suicidality in Adolescents With Allergic Rhinitis: Derivation and Validation in 2 Independent Nationwide Cohorts %A Lee,Hojae %A Cho,Joong Ki %A Park,Jaeyu %A Lee,Hyeri %A Fond,Guillaume %A Boyer,Laurent %A Kim,Hyeon Jin %A Park,Seoyoung %A Cho,Wonyoung %A Lee,Hayeon %A Lee,Jinseok %A Yon,Dong Keon %+ Department of Regulatory Science, Kyung Hee University, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea, 82 2 6935 2476, yonkkang@gmail.com %K machine learning %K allergic rhinitis %K prediction %K random forest %K suicidality %D 2024 %7 14.2.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Given the additional risk of suicide-related behaviors in adolescents with allergic rhinitis (AR), it is important to use the growing field of machine learning (ML) to evaluate this risk. Objective: This study aims to evaluate the validity and usefulness of an ML model for predicting suicide risk in patients with AR. Methods: We used data from 2 independent survey studies, Korea Youth Risk Behavior Web-based Survey (KYRBS; n=299,468) for the original data set and Korea National Health and Nutrition Examination Survey (KNHANES; n=833) for the external validation data set, to predict suicide risks of AR in adolescents aged 13 to 18 years, with 3.45% (10,341/299,468) and 1.4% (12/833) of the patients attempting suicide in the KYRBS and KNHANES studies, respectively. The outcome of interest was the suicide attempt risks. We selected various ML-based models with hyperparameter tuning in the discovery and performed an area under the receiver operating characteristic curve (AUROC) analysis in the train, test, and external validation data. Results: The study data set included 299,468 (KYRBS; original data set) and 833 (KNHANES; external validation data set) patients with AR recruited between 2005 and 2022. The best-performing ML model was the random forest model with a mean AUROC of 84.12% (95% CI 83.98%-84.27%) in the original data set. Applying this result to the external validation data set revealed the best performance among the models, with an AUROC of 89.87% (sensitivity 83.33%, specificity 82.58%, accuracy 82.59%, and balanced accuracy 82.96%). While looking at feature importance, the 5 most important features in predicting suicide attempts in adolescent patients with AR are depression, stress status, academic achievement, age, and alcohol consumption. Conclusions: This study emphasizes the potential of ML models in predicting suicide risks in patients with AR, encouraging further application of these models in other conditions to enhance adolescent health and decrease suicide rates. %M 38354043 %R 10.2196/51473 %U https://www.jmir.org/2024/1/e51473 %U https://doi.org/10.2196/51473 %U http://www.ncbi.nlm.nih.gov/pubmed/38354043 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e51704 %T Incorporating a Stepped Care Approach Into Internet-Based Cognitive Behavioral Therapy for Depression: Randomized Controlled Trial %A Jagayat,Jasleen Kaur %A Kumar,Anchan %A Shao,Yijia %A Pannu,Amrita %A Patel,Charmy %A Shirazi,Amirhossein %A Omrani,Mohsen %A Alavi,Nazanin %+ Centre for Neuroscience Studies, Queen's University, 18 Stuart Street, Kingston, ON, K7L 3N6, Canada, 1 613 533 2600, jasleenjagayat@gmail.com %K internet-based cognitive behavioral therapy %K i-CBT %K major depressive disorder %K MDD %K stepped care %K digital mental health care %K mobile phone %D 2024 %7 9.2.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is a hidden burden, yet it is a leading cause of disability worldwide. Despite the adverse effects of depression, fewer than one-third of patients receive care. Internet-based cognitive behavioral therapy (i-CBT) is an effective treatment for depression, and combining i-CBT with supervised care could make the therapy scalable and effective. A stepped care model is a framework for beginning treatment with an effective and low-intensity intervention while adapting care based on the patient’s needs. Objective: This study investigated the efficacy of a stepped care i-CBT model for depression based on changes in self-reported depressive symptoms. Methods: In this single-blinded, randomized controlled trial, participants were allocated to either the i-CBT–only group (28/56, 50%) or the i-CBT with stepped care group (28/56, 50%). Both groups received a 13-week i-CBT program tailored for depression. The i-CBT program was provided through a secure, online mental health clinic called the Online Psychotherapy Tool. Participants read through the sessions and completed the assignments related to each session. Participants in the stepped care group received additional interventions from their care provider based on standard questionnaire scores (ie, Patient Health Questionnaire–9 [PHQ-9], Quick Inventory of Depressive Symptomatology [QIDS], and Quality of Life Enjoyment and Satisfaction Questionnaire–Short Form) and their assignment responses. From lowest to highest intensity, the additional interventions included SMS text messages, phone calls, video calls, or a video call with a psychiatrist. Results: For this study, 56 participants were recruited to complete an i-CBT program (n=28, 50%; mean age 37.9; SD 13.08 y; 7/28, 27% were men) or an i-CBT with stepped care program (n=28, 50%; mean age 40.6; SD 14.28 y; 11/28, 42% were men). The results of this study indicate that the i-CBT program was effective in significantly reducing depressive symptoms, as measured by the PHQ-9 (F4,80=9.95; P<.001) and QIDS (F2,28=5.73; P=.008); however, there were no significant differences in the reduction of depressive symptoms between the 2 groups (PHQ-9: F4,80=0.43; P=.78; QIDS: F2,28=3.05; P=.06). The stepped care group was not significantly better in reducing depressive symptoms than the i-CBT group (PHQ-9, P=.79; QIDS, P=.06). Although there were no significant differences observed between the number of participants who completed the program between the groups (χ21=2.6; P=.10), participants in the stepped care group, on average, participated in more sessions than those who prematurely terminated participation in the i-CBT group (t55=−2; P=.03; 95% CI –4.83 to –0.002). Conclusions: Implementing a stepped care approach in i-CBT is an effective treatment for depression, and the stepped care model can assist patients to complete more sessions in their treatment. Trial Registration: Clinicaltrials.gov NCT04747873; https://clinicaltrials.gov/study/NCT04747873 %M 38173167 %R 10.2196/51704 %U https://mental.jmir.org/2024/1/e51704 %U https://doi.org/10.2196/51704 %U http://www.ncbi.nlm.nih.gov/pubmed/38173167 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e48467 %T Preliminary Efficacy of a Digital Intervention for Adolescent Depression: Randomized Controlled Trial %A Peake,Emily %A Miller,Ian %A Flannery,Jessica %A Chen,Lang %A Lake,Jessica %A Padmanabhan,Aarthi %+ Limbix Health Inc, 548 Market St, PMB 91609, San Francisco, CA, 94104, United States, 1 888 546 2495, aarthi.padmanabhan@bighealth.com %K adolescent %K depression %K randomized controlled trial %K mobile phone %K digital therapeutics %K mobile app %K cognitive behavioral therapy %K behavioral activation %K mobile health %D 2024 %7 7.2.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Adolescent depression is a significant public health concern; however, access to effective mental health care is limited. Digital therapeutics (DTx) can improve access to evidence-based interventions; however, their efficacy in adolescents is sparsely documented. Objective: This study aims to examine the efficacy of a mobile app DTx versus an active control as an adjunct treatment for adolescent depression symptoms. Methods: An internet-based open-label randomized control trial was conducted nationwide with a partial crossover design, and 168 adolescents aged 13 to 21 years with symptoms of depression were recruited between November 2020 and September 2021. Participants were randomized (1:1) to the cognitive behavioral therapy–based treatment app (Spark) or to a psychoeducational control app (control), which they would use for a duration of 5 weeks. The primary outcome was a between-group (Spark vs control) difference in the change in depression symptoms from baseline to postintervention, as measured by the Patient Health Questionnaire-8 (PHQ-8) using a linear mixed-effects analysis. The PHQ-8 ranges from 0 to 24, with scores of 5 to 9 indicating mild depression symptoms, scores of 10 to 14 indicating moderate symptoms, scores of 15 to 19 indicating moderately severe symptoms, and scores of 20 to 24 indicating severe symptoms. A minimal clinically important difference (5-point reduction between baseline and postintervention) in the Spark arm and group differences in remission and treatment response rates based on the PHQ-8 at postintervention were also investigated. Results: A total of 160 participants were randomized, 80 in the Spark arm (mean age 16.89, SD 2.5 y) and 80 in the control arm (mean age 16.79, SD 2.59 y). Data from 121 participants (Spark: n=63; control: n=58) with moderate to severe (PHQ-8≥10) symptoms at baseline were included in the primary analyses following a modified intention-to-treat principle. A linear mixed-effect analysis revealed a nonsignificant difference between the study arms in depression symptom change over the intervention period. The Spark arm met a minimal clinically important difference threshold (mean −5.08, 95% CI −6.72 to −3.42). The remission rate in the Spark arm was significantly higher than that in the control arm (11/63, 17% vs 2/58, 3%; χ21=6.2; P=.01; false discovery rate–adjusted P=.03). The treatment response rates were not significantly different between the study arms (P=.07; false discovery rate–adjusted P=.16). Post hoc analyses including participants with mild to severe (PHQ-8 score ≥5) symptoms at baseline revealed promising evidence that Spark is effective in those with mild to severe symptoms. Conclusions: There is initial evidence that a self-guided, cognitive behavioral therapy–based DTx intervention may effectively treat mild to severe depression symptoms in adolescents. DTx may improve access to mental health care for adolescents or serve as an important adjunct to the standard of care. Trial Registration: ClinicalTrials.gov NCT04524598; https://clinicaltrials.gov/study/NCT04524598 %M 38324367 %R 10.2196/48467 %U https://www.jmir.org/2024/1/e48467 %U https://doi.org/10.2196/48467 %U http://www.ncbi.nlm.nih.gov/pubmed/38324367 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e46637 %T Effectiveness of Online and Remote Interventions for Mental Health in Children, Adolescents, and Young Adults After the Onset of the COVID-19 Pandemic: Systematic Review and Meta-Analysis %A Fischer-Grote,Linda %A Fössing,Vera %A Aigner,Martin %A Fehrmann,Elisabeth %A Boeckle,Markus %+ Department of Psychology and Psychodynamics, Karl Landsteiner University of Health Sciences, Dr.-Karl-Dorrek-Straße 30, Krems, 3500, Austria, 43 6503032923, elisabeth.fehrmann@kl.ac.at %K COVID-19 pandemic %K online/digital mental health intervention %K e-mental health %K anxiety %K social functioning %K depression %K well-being %K psychological distress %K eating disorder %K COVID-19 symptoms %D 2024 %7 5.2.2024 %9 Review %J JMIR Ment Health %G English %X Background: The prevalence of mental illness increased in children, adolescents, and young adults during the COVID-19 pandemic, while at the same time, access to treatment facilities has been restricted, resulting in a need for the quick implementation of remote or online interventions. Objective: This study aimed to give an overview of randomized controlled studies examining remote or online interventions for mental health in children, adolescents, and young adults and to explore the overall effectiveness of these interventions regarding different symptoms. Methods: A systematic literature search was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines using PubMed, PsycInfo, Psyndex, Embase, and Google Scholar. A meta-analysis was conducted using a random effects model to calculate overall effect sizes for interventions using standardized mean differences (SMDs) for postintervention scores. Results: We identified 17 articles with 8732 participants in the final sample, and 13 were included in the quantitative analysis. The studies examined different digital interventions for several outcomes, showing better outcomes than the control in some studies. Meta-analyses revealed significant medium overall effects for anxiety (SMD=0.44, 95% CI 0.20 to 0.67) and social functioning (SMD=0.42, 95% CI –0.68 to –0.17) and a large significant effect for depression (SMD=1.31, 95% CI 0.34 to 2.95). In contrast, no significant overall treatment effects for well-being, psychological distress, disordered eating, and COVID-19–related symptoms were found. Conclusions: The qualitative and quantitative analyses of the included studies show promising results regarding the effectiveness of online interventions, especially for symptoms of anxiety and depression and for training of social functioning. However, the effectiveness needs to be further investigated for other groups of symptoms in the future. All in all, more research with high-quality studies is required. %M 38315524 %R 10.2196/46637 %U https://mental.jmir.org/2024/1/e46637 %U https://doi.org/10.2196/46637 %U http://www.ncbi.nlm.nih.gov/pubmed/38315524 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e50780 %T Race, Ethnicity, and Other Cultural Background Factors in Trials of Internet-Based Cognitive Behavioral Therapy for Depression: Systematic Review %A De Jesús-Romero,Robinson %A Holder-Dixon,Amani R %A Buss,John F %A Lorenzo-Luaces,Lorenzo %+ Department of Psychological and Brain Sciences, Indiana University - Bloomington, 1101 East 10th Street, Bloomington, IN, 47405, United States, 1 7872409456, robdejes@iu.edu %K diversity %K cognitive behavioral therapy %K internet-based %K depression %K race %K racial %K ethnicity %K culture %K depressive %K diverse %K inclusive %K inclusivity %K DEI %K diversity, equity, and inclusion %K internet-based cognitive behavioral therapy %K mental health %K ethnic %K cultures %K culturally %K review methods %K review methodology %K systematic %K clinical trial %K clinical trials %K randomized controlled trial %K randomized controlled trials %K controlled trial %K controlled trials %K reporting %K immigrant %K migrant %K migrants %K immigrants %K psychotherapy %K underrepresented %K underrepresentation %K representation %K mobile phone %D 2024 %7 1.2.2024 %9 Review %J J Med Internet Res %G English %X Background: There is a growing interest in developing scalable interventions, including internet-based cognitive behavioral therapy (iCBT), to meet the increasing demand for mental health services. Given the growth in diversity worldwide, it is essential that the clinical trials of iCBT for depression include diverse samples or, at least, report information on the race, ethnicity, or other background indicators of their samples. Unfortunately, the field lacks data on how well diversity is currently reported and represented in the iCBT literature. Objective: Thus, the main objective of this systematic review was to examine the overall reporting of racial and ethnic identities in published clinical trials of iCBT for depression. We also aimed to review the representation of specific racial and ethnic minoritized groups and the inclusion of alternative background indicators such as migration status or country of residence. Methods: Studies were included if they were randomized controlled trials in which iCBT was compared to a waiting list, care-as-usual, active control, or another iCBT. The included papers also had to have a focus on acute treatment (eg, 4 weeks to 6 months) of depression, be delivered via the internet on a website or a smartphone app and use guided or unguided self-help. Studies were initially identified from the METAPSY database (n=59) and then extended to include papers up to 2022, with papers retrieved from Embase, PubMed, PsycINFO, and Cochrane (n=3). Risk of bias assessment suggested that reported studies had at least some risk of bias due to use of self-report outcome measures. Results: A total of 62 iCBT randomized controlled trials representing 17,210 participants are summarized in this study. Out of those 62 papers, only 17 (27%) of the trials reported race, and only 12 (19%) reported ethnicity. Reporting outside of the United States was very poor, with the United States accounting for 15 (88%) out of 17 of studies that reported race and 9 (75%) out of 12 for ethnicity. Out of 3,623 participants whose race was reported in the systematic review, the racial category reported the most was White (n=2716, 74.9%), followed by Asian (n=209, 5.8%) and Black (n=274, 7.6%). Furthermore, only 25 (54%) out of the 46 papers conducted outside of the United States reported other background demographics. Conclusions: It is important to note that the underreporting observed in this study does not necessarily indicate an underrepresentation in the actual study population. However, these findings highlight the poor reporting of race and ethnicity in iCBT trials for depression found in the literature. This lack of diversity reporting may have significant implications for the scalability of these interventions. %M 38300699 %R 10.2196/50780 %U https://www.jmir.org/2024/1/e50780 %U https://doi.org/10.2196/50780 %U http://www.ncbi.nlm.nih.gov/pubmed/38300699 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e42976 %T The Evaluation of the GET.ON Nationwide Web-Only Treatment Service for Depression- and Stress-Related Symptoms: Naturalistic Trial %A Etzelmueller,Anne %A Heber,Elena %A Horvath,Hanne %A Radkovsky,Anna %A Lehr,Dirk %A Ebert,David Daniel %+ Department of Sports and Health Sciences, Professorship Psychology and Digital Mental Health Care, Technical University of Munich, Georg-Brauchle-Ring 60, Munich, 80992, Germany, 49 621345167, anneetzelmueller@gmail.com %K depression %K stress %K digital %K internet %K effectiveness %K routine care %D 2024 %7 1.2.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: GET.ON (HelloBetter) treatment interventions have been shown to be efficacious in multiple randomized controlled trials. Objective: This study evaluated the effectiveness of 2 GET.ON interventions, GET.ON Mood Enhancer and GET.ON Stress, in a national digital mental health service implemented across Germany. Methods: Following an initial web-based questionnaire, participants were allocated to either intervention based on their baseline symptom severity and personal choice and received a semistandardized guided, feedback-on-demand guided, or self-guided version of the treatment. Uncontrolled routine care data from 851 participants were analyzed using a pretest-posttest design. Half of the participants (461/851, 54.2%) were allocated to the stress intervention (189/461, 41% semistandardized; 240/461, 52% feedback on demand; and 32/461, 6.9% self-guided), and almost all participants in the mood intervention (349/352, 99.2%) received semistandardized guidance. Results: Results on depression-related symptom severity indicated a reduction in reported symptoms, with a large effect size of d=−0.92 (95% CI −1.21 to −0.63). Results on perceived stress and insomnia indicated a reduction in symptom severity, with large effect sizes of d=1.02 (95% CI −1.46 to −0.58) and d=−0.75 (95% CI −1.10 to −0.40), respectively. A small percentage of participants experienced deterioration in depression-related symptoms (11/289, 3.8%), perceived stress (6/296, 2%), and insomnia (5/252, 2%). After completing treatment, 51.9% (150/289) of participants showed a clinically reliable change in depression-related symptoms, whereas 20.4% (59/289) achieved a close to symptom-free status. Similar improvements were observed in perceived stress and insomnia severity. Guidance moderated the effectiveness of and adherence to the interventions in reducing depressive symptom severity. Effect sizes on depression-related symptom severity were d=−1.20 (95% CI −1.45 to −0.93) for the semistandardized group, d=−0.36 (95% CI −0.68 to −0.04) for the feedback-on-demand group, and d=−0.83 (95% CI −1.03 to −0.63) for the self-guided group. Furthermore, 47.6% (405/851) of the participants completed all modules of the intervention. Participant satisfaction was high across all patient groups and both interventions; 89.3% (242/271) of participants would recommend it to a friend in need of similar help. Limitations include the assignment to treatments and guidance formats based on symptom severity. Furthermore, part of the differences in symptom change between groups must be assumed to be due to this baseline difference in the measures. Conclusions: Future digital health implementation and routine care research should focus on monitoring symptom deterioration and other negative effects, as well as possible predictors of deterioration and the investigation of individual patient trajectories. In conclusion, this study supports the effectiveness of tailored digital mental health services in routine care for depression- and stress-related symptoms in Germany. The results highlight the importance of guidance in delivering internet-based cognitive behavioral therapy interventions and provide further evidence for its potential delivered as web-only solutions for increasing access to and use of psychological treatments. %M 38300701 %R 10.2196/42976 %U https://www.jmir.org/2024/1/e42976 %U https://doi.org/10.2196/42976 %U http://www.ncbi.nlm.nih.gov/pubmed/38300701 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e43286 %T Formative Evaluation of a Comprehensive Self-Management Intervention for Irritable Bowel Syndrome, Comorbid Anxiety, and Depression: Mixed Methods Study %A Kamp,Kendra %A Yang,Pei-Lin %A Friedman,Emily %A Lopez,Alejandra %A Iribarren,Sarah %A Barney,Pamela %A Munson,Sean %A Heitkemper,Margaret %A Levy,Rona %+ Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, 1410 NE Campus Parkway, Seattle, WA, 98195, United States, 1 206 221 4617, kamp@uw.edu %K acceptability %K anxiety %K depression %K design %K effectiveness %K feasibility %K implementation %K intervention %K irritable bowel syndrome %K management %K mixed methods %K patient %K self-management %K support %K usability %D 2024 %7 31.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Irritable bowel syndrome (IBS) is a disorder of the gut-brain interaction that is associated with abdominal pain, altered bowel patterns, and reduced quality of life. Up to 50% of patients with IBS also report anxiety or depressive symptoms. Although effective self-management interventions exist for individuals with IBS, few have been effectively implemented, and most do not consider the unique needs of patients with comorbid IBS and anxiety or depression. Objective: This study aimed to determine the anticipated acceptability, appropriateness, feasibility, and usability of a comprehensive self-management intervention using an implementation science and human-centered design approach among individuals with comorbid IBS and anxiety or depression and health care providers. Methods: A convergent mixed methods design was used to elicit feedback on the comprehensive self-management intervention outline and content to identify refinement needs before testing. Patients with IBS and moderate to severe anxiety or depression and health care providers were purposefully sampled from primary care and gastroenterology settings. Participants completed semistructured interviews and surveys on anticipated acceptability, appropriateness, feasibility, and usability. Results: Patient participants (n=12) were on average 36.8 (SD 12.2) years of age, and 42% (5/12) were currently receiving psychological therapy. Health care providers (n=14) were from primary care (n=7) and gastroenterology (n=7) settings. The mean usability scores (out of 100) were 52.5 (SD 14.5) for patients and 45.6 (SD 11.6) for providers. For patients and providers, qualitative data expanded the quantitative findings for acceptability and appropriateness. Acceptability findings were the comprehensive nature of the intervention and discussion of the gut-brain interaction. For appropriateness, participants reported that the intervention provided structure, accountability, and support. Feasibility was confirmed for patients, but there was a divergence of findings between quantitative and qualitative measures for providers. Patients focused on intervention feasibility, while providers focused on implementation feasibility in the clinic. Identified usability issues to address before implementation included the intervention delivery format, length, and lack of integration into health care settings that, if not addressed, may limit the reach of the intervention. Conclusions: Patients and health care providers found the intervention acceptable and appropriate. Several feasibility and usability issues were identified, including intervention delivery methods, length of intervention, and the best methods to implement in the clinic setting. The next steps are to refine the intervention to address the identified issues and test in a pilot study whether addressing usability issues leads to the anticipated improvements in implementation and uptake. %M 38294871 %R 10.2196/43286 %U https://formative.jmir.org/2024/1/e43286 %U https://doi.org/10.2196/43286 %U http://www.ncbi.nlm.nih.gov/pubmed/38294871 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e49755 %T Assessing the Labeling Information on Drugs Associated With Suicide Risk: Systematic Review %A Jeon,Soo Min %A Lim,HyunJoo %A Cheon,Hyo-bin %A Ryu,Juhee %A Kwon,Jin-Won %+ BK21 FOUR Community-Based Intelligent Novel Drug Discovery Education Unit, College of Pharmacy and Research Institute of Pharmaceutical Sciences, 80 Daehak-ro, Daegu, 41566, Republic of Korea, 82 539508580, jwkwon@knu.ac.kr %K suicide %K adverse drug events %K review %K drug %K mental health %K systematic review %K drug induced suicide %K drug reaction %K substance use %K suicidal %K medication %K suicide symptoms %K suicidal risk %K drugs %K adverse drug event %D 2024 %7 30.1.2024 %9 Review %J JMIR Public Health Surveill %G English %X Background: Drug-induced suicide (DIS) is a severe adverse drug reaction (ADR). Although clinical trials have provided evidence on DIS, limited investigations have been performed on rare ADRs, such as suicide. Objective: We aimed to systematically review case reports on DIS to provide evidence-based drug information. Methods: We searched PubMed to obtain case reports regarding DIS published until July 2021. Cases resulting from drugs that are no longer used or are nonapproved, substance use, and suicidal intentions were excluded. The quality of each case report was assessed using the CASE (Case Reports) checklist. We extracted data regarding demographics, medication history, suicide symptoms, and symptom improvement and evaluated the causality of DIS using the Naranjo score. Furthermore, to identify the potential suicidal risk of the unknown drugs, we compared the results of the causality assessment with those of the approved drug labels. Results: In 83 articles, we identified 152 cases involving 61 drugs. Antidepressants were reported as the most frequent causative drugs of DIS followed by immunostimulants. The causality assessment revealed 61 cases having possible, 89 cases having probable, and 2 cases having definite relationships with DIS. For approximately 85% of suspected drugs, the risk of suicidal ADRs was indicated on the approved label; however, the approved labels for 9 drugs, including lumacaftor/ivacaftor, doxycycline, clozapine, dextromethorphan, adalimumab, infliximab, piroxicam, paclitaxel, and formoterol, did not provide information about these risks. Conclusions: We found several case reports involving drugs without suicide risk information on the drug label. Our findings might provide valuable insights into drugs that may cause suicidal ADRs. %M 38289650 %R 10.2196/49755 %U https://publichealth.jmir.org/2024/1/e49755 %U https://doi.org/10.2196/49755 %U http://www.ncbi.nlm.nih.gov/pubmed/38289650 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e47048 %T Depression and Anxiety Symptoms Among Cisgender Gay and Bisexual Men During the Onset of the COVID-19 Pandemic: Time Series Analysis of a US National Cohort Study %A Mirzayi,Chloe %A Westmoreland,Drew %A Stief,Matthew %A Grov,Christian %+ CUNY Graduate School of Public Health and Health Policy, 55 W 125 Street, New York, NY, 10027, United States, 1 6463640254, cgrov@sph.cuny.edu %K COVID-19 pandemic %K lesbian, gay, bisexual, transgender, and queer %K LGBTQ %K mental health %K depression %K anxiety %K time series %K gay and bisexual men %K cisgender gay %K pandemic %K gay %D 2024 %7 26.1.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The onset of the COVID-19 pandemic in the United States in March 2020 caused a dramatic change in the way many people lived. Few aspects of daily life were left undisrupted by the pandemic’s onset as well as the accompanying policies to control the spread of the disease. Previous research has found that the pandemic may have significantly impacted the mental health of lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals—potentially more so than other individuals. However, the pandemic did not affect all areas of the United States at the same time, and there may be regional variation in the impact of the onset of the pandemic on depressive symptoms among LGBTQ individuals. Objective: To assess regional variation of the impact of the pandemic, we conducted a time series analysis stratified by US geographic region to examine symptoms of depression and anxiety among a sample of primarily cisgender gay and bisexual men before and after the onset of the COVID-19 pandemic in the United States. Methods: In total, 5007 participants completed assessments as part of the Together 5000 study, an ongoing prospective cohort study. Depressive and anxiety symptoms were measured using the Patient Health Questionnaire-4. Patient Health Questionnaire-4 scores were graphed as a function of days from March 15, 2020. Locally estimated scatterplot smoothing trend lines were applied. A sieve-bootstrap Mann-Kendall test for monotonic trend was conducted to assess the presence and direction of trends in the scatterplots. We then compared the observed trends to those observed for 1 year prior (2018-2019) to the pandemic onset using data collected from the same sample. Results: Significant positive trends were detected for the Northeast (P=.03) and Midwest (P=.01) regions of the United States in the 2020 assessment, indicating that symptoms of anxiety and depression were increasing in the sample in these regions immediately prior to and during the onset of the pandemic. In contrast, these trends were not present in data from the 2018 to 2019 assessment window. Conclusions: Symptoms of anxiety and depression increased among the study population in the Northeast and Midwest during the beginning months of the COVID-19 pandemic, but similar increase was not observed in the South and West regions. These trends were also not found for any region in the 2018 to 2019 assessment window. This may indicate region-specific trends in anxiety and depression, potentially driven by the burden of the pandemic and policies that varied from region to region. Future studies should consider geographic variation in COVID-19 spread and policies as well as explore potential mechanisms by which this could influence the mental health of LGBTQ individuals. %M 38277213 %R 10.2196/47048 %U https://publichealth.jmir.org/2024/1/e47048 %U https://doi.org/10.2196/47048 %U http://www.ncbi.nlm.nih.gov/pubmed/38277213 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e48992 %T Acceptability and Feasibility of a Smartphone-Based Real-Time Assessment of Suicide Among Black Men: Mixed Methods Pilot Study %A Adams,Leslie B %A Watts,Thomasina %A DeVinney,Aubrey %A Haroz,Emily E %A Thrul,Johannes %A Stephens,Jasmin Brooks %A Campbell,Mia N %A Antoine,Denis %A Lê Cook,Benjamin %A Joe,Sean %A Thorpe Jr,Roland J %+ Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, United States, 1 410 955 1906, ladams36@jhu.edu %K Black men %K suicide %K ecological momentary assessment %K feasibility %K acceptability %K mixed methods %K smartphone %K real-time assessment %K suicide prevention %K user experience %K behavior %K implementation %K intervention %K mobile phone %D 2024 %7 22.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Suicide rates in the United States have increased recently among Black men. To address this public health crisis, smartphone-based ecological momentary assessment (EMA) platforms are a promising way to collect dynamic, real-time data that can help improve suicide prevention efforts. Despite the promise of this methodology, little is known about its suitability in detecting experiences related to suicidal thoughts and behavior (STB) among Black men. Objective: This study aims to clarify the acceptability and feasibility of using smartphone-based EMA through a pilot study that assesses the user experience among Black men. Methods: We recruited Black men aged 18 years and older using the MyChart patient portal messaging (the patient-facing side of the Epic electronic medical record system) or outpatient provider referrals. Eligible participants self-identified as Black men with a previous history of STB and ownership of an Android or iOS smartphone. Eligible participants completed a 7-day smartphone-based EMA study. They received a prompt 4 times per day to complete a brief survey detailing their STB, as well as proximal risk factors, such as depression, social isolation, and feeling like a burden to others. At the conclusion of each day, participants also received a daily diary survey detailing their sleep quality and their daily experiences of everyday discrimination. Participants completed a semistructured exit interview of 60-90 minutes at the study’s conclusion. Results: In total, 10 participants completed 166 EMA surveys and 39 daily diary entries. A total of 4 of the 10 participants completed 75% (21/28) or more of the EMA surveys, while 9 (90%) out of 10 completed 25% (7/28) or more. The average completion rate of all surveys was 58% (20.3/35), with a minimum of 17% (6/35) and maximum of 100% (35/35). A total of 4 (40%) out of 10 participants completed daily diary entries for the full pilot study. No safety-related incidents were reported. On average, participants took 2.08 minutes to complete EMA prompts and 2.72 minutes for daily diary surveys. Our qualitative results generally affirm the acceptability and feasibility of the study procedures, but the participants noted difficulties with the technology and the redundancy of the survey questions. Emerging themes also addressed issues such as reduced EMA survey compliance and diminished mood related to deficit-framed questions related to suicide. Conclusions: Findings from this study will be used to clarify the suitability of EMA for Black men. Overall, our EMA pilot study demonstrated mixed feasibility and acceptability when delivered through smartphone-based apps to Black men. Specific recommendations are provided for managing safety within these study designs and for refinements in future intervention and implementation science research. International Registered Report Identifier (IRRID): RR2-10.2196/31241 %M 38252475 %R 10.2196/48992 %U https://formative.jmir.org/2024/1/e48992 %U https://doi.org/10.2196/48992 %U http://www.ncbi.nlm.nih.gov/pubmed/38252475 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e44214 %T Engagement With a Remote Symptom-Tracking Platform Among Participants With Major Depressive Disorder: Randomized Controlled Trial %A White,Katie M %A Carr,Ewan %A Leightley,Daniel %A Matcham,Faith %A Conde,Pauline %A Ranjan,Yatharth %A Simblett,Sara %A Dawe-Lane,Erin %A Williams,Laura %A Henderson,Claire %A Hotopf,Matthew %+ Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, United Kingdom, 44 020 7848 0002, katie.white@kcl.ac.uk %K remote measurement %K technology %K engagement %K app %K depression %K smartphones %K wearable devices %K engagement %K symptom tracking %K self-awareness %K community %K mobile phone %D 2024 %7 19.1.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Multiparametric remote measurement technologies (RMTs), which comprise smartphones and wearable devices, have the potential to revolutionize understanding of the etiology and trajectory of major depressive disorder (MDD). Engagement with RMTs in MDD research is of the utmost importance for the validity of predictive analytical methods and long-term use and can be conceptualized as both objective engagement (data availability) and subjective engagement (system usability and experiential factors). Positioning the design of user interfaces within the theoretical framework of the Behavior Change Wheel can help maximize effectiveness. In-app components containing information from credible sources, visual feedback, and access to support provide an opportunity to promote engagement with RMTs while minimizing team resources. Randomized controlled trials are the gold standard in quantifying the effects of in-app components on engagement with RMTs in patients with MDD. Objective: This study aims to evaluate whether a multiparametric RMT system with theoretically informed notifications, visual progress tracking, and access to research team contact details could promote engagement with remote symptom tracking over and above the system as usual. We hypothesized that participants using the adapted app (intervention group) would have higher engagement in symptom monitoring, as measured by objective and subjective engagement. Methods: A 2-arm, parallel-group randomized controlled trial (participant-blinded) with 1:1 randomization was conducted with 100 participants with MDD over 12 weeks. Participants in both arms used the RADAR-base system, comprising a smartphone app for weekly symptom assessments and a wearable Fitbit device for continuous passive tracking. Participants in the intervention arm (n=50, 50%) also had access to additional in-app components. The primary outcome was objective engagement, measured as the percentage of weekly questionnaires completed during follow-up. The secondary outcomes measured subjective engagement (system engagement, system usability, and emotional self-awareness). Results: The levels of completion of the Patient Health Questionnaire-8 (PHQ-8) were similar between the control (67/97, 69%) and intervention (66/97, 68%) arms (P value for the difference between the arms=.83, 95% CI −9.32 to 11.65). The intervention group participants reported slightly higher user engagement (1.93, 95% CI −1.91 to 5.78), emotional self-awareness (1.13, 95% CI −2.93 to 5.19), and system usability (2.29, 95% CI −5.93 to 10.52) scores than the control group participants at follow-up; however, all CIs were wide and included 0. Process evaluation suggested that participants saw the in-app components as helpful in increasing task completion. Conclusions: The adapted system did not increase objective or subjective engagement in remote symptom tracking in our research cohort. This study provides an important foundation for understanding engagement with RMTs for research and the methodologies by which this work can be replicated in both community and clinical settings. Trial Registration: ClinicalTrials.gov NCT04972474; https://clinicaltrials.gov/ct2/show/NCT04972474 International Registered Report Identifier (IRRID): RR2-10.2196/32653 %M 38241070 %R 10.2196/44214 %U https://mhealth.jmir.org/2024/1/e44214 %U https://doi.org/10.2196/44214 %U http://www.ncbi.nlm.nih.gov/pubmed/38241070 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e52816 %T eHealth in the Management of Depressive Episodes in Catalonia’s Primary Care From 2017 to 2022: Retrospective Observational Study %A Fuster-Casanovas,Aïna %A Miró Catalina,Queralt %A Vidal-Alaball,Josep %A Escalé-Besa,Anna %A Carrión,Carme %+ Unitat de Suport a la Recerca de la Catalunya Central, Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Carrer Pica d'Estats, 13-15, Sant Fruitós de Bages, 08272, Spain, 34 936 93 00 40, jvidal.cc.ics@gencat.cat %K eHealth %K depression %K depressive disorder %K primary health care %K mental health patient %K patient %K patients %K healthcare system %K digital transformation %K mental disorder %K mental disorders %K diagnostic %K clinical practice %K clinical practices %K retrospective %K observational %K regression %K digital tool %K digital tools %D 2024 %7 18.1.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: The reasons for mental health consultations are becoming increasingly relevant in primary care. The Catalan health care system is undergoing a process of digital transformation, where eHealth is becoming increasingly relevant in routine clinical practice. Objective: This study aimed to analyze the approach to depressive episodes and the role of eHealth in the Catalan health care system from 2017 to 2022. Methods: A retrospective observational study was conducted on diagnostic codes related to depressive episodes and mood disorders between 2017 and 2022 using data from the Catalan Institute of Health. The sociodemographic evolution and prevalence of depression and mood disorders in Catalonia were analyzed between 2017 and 2022. Sociodemographic variables were analyzed using absolute frequency and percentage. The prevalence of depressive episodes was calculated, highlighting the year-to-year changes. The use of eHealth for related consultations was assessed by comparing the percentages of eHealth and face-to-face consultations. A comparison of sociodemographic variables based on attendance type was conducted. Additionally, a logistic regression model was used to explore factors influencing face-to-face attendance. The analysis used R software (version 4.2.1), with all differences examined using 95% CIs. Results: From 2017 to 2022, there was an 86.6% increase in the prevalence of depression and mood disorders, with women consistently more affected (20,950/31,197, 67.2% in 2017 and 22,078/33,169, 66.6% in 2022). In 2022, a significant rise in depression diagnoses was observed in rural areas (difference 0.71%, 95% CI 0.04%-1.43%), contrasting with a significant decrease in urban settings (difference –0.7%, 95% CI –1.35% to –0.05%). There was a significant increase in antidepressant use in 2022 compared to 2017 (difference 2.4%, 95% CI 1.87%-3.06%) and the proportion of eHealth visits rose from 4.34% (1240/28,561) in 2017 to 26.3% (8501/32,267) in 2022. Logistic regression analysis indicated that men (odds ratio [OR] 1.06, 95% CI 1.04-1.09) and younger individuals had a higher likelihood of eHealth consultations in 2022. Furthermore, individuals using eHealth consultations were more likely to use antidepressants (OR 1.54, 95% CI 1.50-1.57) and anxiolytics (OR 1.06, 95% CI 1.03-1.09). Conclusions: The prevalence of depression in Catalonia has significantly increased in the last 6 years, likely influenced by the COVID-19 pandemic. Despite ongoing digital transformation since 2011, eHealth usage remained limited as of 2017. During the lockdown period, eHealth accounted for nearly half of all health care consultations, representing a quarter of consultations by 2022. In the immediate aftermath of the COVID-19 pandemic, emerging evidence suggests a significant role of eHealth in managing depression-related consultations, along with an apparent likelihood of patients being prescribed antidepressants and anxiolytics. Further research is needed to understand the long-term impact of eHealth on diagnostic practices and medication use. %M 38236631 %R 10.2196/52816 %U https://mental.jmir.org/2024/1/e52816 %U https://doi.org/10.2196/52816 %U http://www.ncbi.nlm.nih.gov/pubmed/38236631 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e49222 %T Speech Features as Predictors of Momentary Depression Severity in Patients With Depressive Disorder Undergoing Sleep Deprivation Therapy: Ambulatory Assessment Pilot Study %A Wadle,Lisa-Marie %A Ebner-Priemer,Ulrich W %A Foo,Jerome C %A Yamamoto,Yoshiharu %A Streit,Fabian %A Witt,Stephanie H %A Frank,Josef %A Zillich,Lea %A Limberger,Matthias F %A Ablimit,Ayimnisagul %A Schultz,Tanja %A Gilles,Maria %A Rietschel,Marcella %A Sirignano,Lea %+ Mental mHealth Lab, Institute of Sports and Sports Science, Karlsruhe Institute of Technology, Hertzstrasse 16, Bldg 06.31, Karlsruhe, 76187, Germany, 49 72160847543, lisa.wadle@kit.edu %K ambulatory assessment %K experience sampling %K ecological momentary assessment %K speech features %K speech pattern %K depression %K sleep deprivation therapy %K mobile phone %D 2024 %7 18.1.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: The use of mobile devices to continuously monitor objectively extracted parameters of depressive symptomatology is seen as an important step in the understanding and prevention of upcoming depressive episodes. Speech features such as pitch variability, speech pauses, and speech rate are promising indicators, but empirical evidence is limited, given the variability of study designs. Objective: Previous research studies have found different speech patterns when comparing single speech recordings between patients and healthy controls, but only a few studies have used repeated assessments to compare depressive and nondepressive episodes within the same patient. To our knowledge, no study has used a series of measurements within patients with depression (eg, intensive longitudinal data) to model the dynamic ebb and flow of subjectively reported depression and concomitant speech samples. However, such data are indispensable for detecting and ultimately preventing upcoming episodes. Methods: In this study, we captured voice samples and momentary affect ratings over the course of 3 weeks in a sample of patients (N=30) with an acute depressive episode receiving stationary care. Patients underwent sleep deprivation therapy, a chronotherapeutic intervention that can rapidly improve depression symptomatology. We hypothesized that within-person variability in depressive and affective momentary states would be reflected in the following 3 speech features: pitch variability, speech pauses, and speech rate. We parametrized them using the extended Geneva Minimalistic Acoustic Parameter Set (eGeMAPS) from open-source Speech and Music Interpretation by Large-Space Extraction (openSMILE; audEERING GmbH) and extracted them from a transcript. We analyzed the speech features along with self-reported momentary affect ratings, using multilevel linear regression analysis. We analyzed an average of 32 (SD 19.83) assessments per patient. Results: Analyses revealed that pitch variability, speech pauses, and speech rate were associated with depression severity, positive affect, valence, and energetic arousal; furthermore, speech pauses and speech rate were associated with negative affect, and speech pauses were additionally associated with calmness. Specifically, pitch variability was negatively associated with improved momentary states (ie, lower pitch variability was linked to lower depression severity as well as higher positive affect, valence, and energetic arousal). Speech pauses were negatively associated with improved momentary states, whereas speech rate was positively associated with improved momentary states. Conclusions: Pitch variability, speech pauses, and speech rate are promising features for the development of clinical prediction technologies to improve patient care as well as timely diagnosis and monitoring of treatment response. Our research is a step forward on the path to developing an automated depression monitoring system, facilitating individually tailored treatments and increased patient empowerment. %M 38236637 %R 10.2196/49222 %U https://mental.jmir.org/2024/1/e49222 %U https://doi.org/10.2196/49222 %U http://www.ncbi.nlm.nih.gov/pubmed/38236637 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e50787 %T Effectiveness of Telecare Interventions on Depression Symptoms Among Older Adults: Systematic Review and Meta-Analysis %A Wu,Man %A Li,Chaoyang %A Hu,Ting %A Zhao,Xueyang %A Qiao,Guiyuan %A Gao,Xiaolian %A Zhu,Xinhong %A Yang,Fen %+ School of Nursing, Hubei University of Chinese Medicine, North District, No 16, Huangjiahu West Road, Hongshan District, Wuhan, 430065, China, 86 18062003261, fenyang@hbtcm.edu.cn %K telecare %K depression %K anxiety %K quality of life %K older adults %K meta-analysis %D 2024 %7 17.1.2024 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Depression is the most common psychiatric disorder among older adults. Despite the effectiveness of pharmacological and psychological therapies, many patients with late-life depression (LLD) are unable to access timely treatment. Telecare has been shown to be effective in addressing patients' psychosocial issues, while its effectiveness in serving patients with LLD remains unclear. Objective: This study aimed to evaluate the effectiveness of telecare in reducing depression and anxiety symptoms and improving quality of life (QoL) in patients with LLD. Methods: Databases including the Cochrane Library, Web of Science, PubMed, Embase, and EBSCO were searched for randomized controlled trials (RCTs) evaluating the effectiveness of telecare for LLD from database establishment to December 28, 2022. Results: A total of 12 RCTs involving 1663 participants were identified in this study. The meta-analysis showed that (1) telecare significantly reduced depressive symptoms in patients with LLD compared to those in usual care (UC; standardized mean difference [SMD]=–0.46, 95% CI –0.53 to –0.38; P<.001), with the best improvement observed within 3 months of intervention (SMD=–0.72, 95% CI –1.16 to –0.28; P<.001); (2) other scales appeared more effective than the Patient Health Questionnaire-9 for LLD in telecare interventions (SMD=–0.65, 95% CI –0.96 to –0.35; P<.001); (3) telecare was more effective than telephone-based interventions for remote monitoring of LLD (SMD=–1.13, 95% CI –1.51 to –0.76; P<.001); (4) the reduction of depressive symptoms was more pronounced in patients with LLD with chronic conditions (SMD=–0.67, 95% CI –0.89 to –0.44; P<.001); (5) telecare was more effective for LLD in Europe and the Americas than in other regions (SMD=–0.73, 95% CI –0.99 to –0.47; P<.001); (6) telecare significantly reduced anxiety symptoms in patients with LLD (SMD=–0.53, 95% CI –0.73 to –0.33; P=.02); and (7) there was no significant improvement in the psychological components of QoL in patients with LLD compared to those receiving UC (SMD=0.30, 95% CI 0.18-0.43; P=.80). Conclusions: Telecare is a promising modality of care for treatment, which can alleviate depression and anxiety symptoms in patients with LLD. Continued in-depth research into the effectiveness of telecare in treating depression could better identify where older patients would benefit from this intervention. %M 38231546 %R 10.2196/50787 %U https://mhealth.jmir.org/2024/1/e50787 %U https://doi.org/10.2196/50787 %U http://www.ncbi.nlm.nih.gov/pubmed/38231546 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e52197 %T Predictors of Use and Drop Out From a Web-Based Cognitive Behavioral Therapy Program and Health Community for Depression and Anxiety in Primary Care Patients: Secondary Analysis of a Randomized Controlled Trial %A Rotondi,Armando J %A Belnap,Bea Herbeck %A Rothenberger,Scott %A Feldman,Robert %A Hanusa,Barbara %A Rollman,Bruce L %+ Mental Illness Research Education and Clinical Center, VA Pittsburgh Healthcare System, Veterans Administration, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240, United States, 1 412 360 2494, armandorotondi1@gmail.com %K e-mental health %K user engagement %K initiation %K discontinue %K depression %K anxiety %K cognitive behavioral therapy %K computerized CBT %K online health community %K collaborative care %K internet support group %D 2024 %7 17.1.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: A previously reported study examined the treatment of primary care patients with at least moderate severity depressive or anxiety symptoms via an evidence-based computerized cognitive behavioral therapy (CCBT) program (Beating the Blues) and an online health community (OHC) that included a moderated internet support group. The 2 treatment arms proved to be equally successful at 6-month follow-up. Objective: Although highly promising, e-mental health treatment programs have encountered high rates of noninitiation, poor adherence, and discontinuation. Identifying ways to counter these tendencies is critical for their success. To further explore these issues, this study identified the primary care patient characteristics that increased the chances patients would not initiate the use of an intervention, (ie, not try it even once), initiate use, and go on to discontinue or continue to use an intervention. Methods: The study had 3 arms: one received access to CCBT (n=301); another received CCBT plus OHC (n=302), which included a moderated internet support group; and the third received usual care (n=101). Participants in the 2 active intervention arms of the study were grouped together for analyses of CCBT use (n=603) because both arms had access to CCBT, and there were no differences in outcomes between the 2 arms. Analyses of OHC use were based on 302 participants who were randomized to that arm. Results: Several baseline patient characteristics were associated with failure to initiate the use of CCBT, including having worse physical health (measured by the Short Form Health Survey Physical Components Score, P=.01), more interference from pain (by the Patient-Reported Outcomes Measurement Information System Pain Interference score, P=.048), less formal education (P=.02), and being African American or another US minority group (P=.006). Characteristics associated with failure to initiate use of the OHC were better mental health (by the Short Form Health Survey Mental Components Score, P=.04), lower use of the internet (P=.005), and less formal education (P=.001). Those who initiated the use of the CCBT program but went on to complete less of the program had less formal education (P=.01) and lower severity of anxiety symptoms (P=.03). Conclusions: This study found that several patient characteristics predicted whether a patient was likely to not initiate use or discontinue the use of CCBT or OHC. These findings have clear implications for actionable areas that can be targeted during initial and ongoing engagement activities designed to increase patient buy-in, as well as increase subsequent use and the resulting success of eHealth programs. Trial Registration: ClinicalTrials.gov NCT01482806; https://clinicaltrials.gov/study/NCT01482806 %M 38231552 %R 10.2196/52197 %U https://mental.jmir.org/2024/1/e52197 %U https://doi.org/10.2196/52197 %U http://www.ncbi.nlm.nih.gov/pubmed/38231552 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e50738 %T Identification of Predictors of Mood Disorder Misdiagnosis and Subsequent Help-Seeking Behavior in Individuals With Depressive Symptoms: Gradient-Boosted Tree Machine Learning Approach %A Benacek,Jiri %A Lawal,Nimotalai %A Ong,Tommy %A Tomasik,Jakub %A Martin-Key,Nayra A %A Funnell,Erin L %A Barton-Owen,Giles %A Olmert,Tony %A Cowell,Dan %A Bahn,Sabine %+ Department of Chemical Engineering and Biotechnology, Cambridge Centre for Neuropsychiatric Research, University of Cambridge, Philippa Fawcett Drive, Cambridge, CB3 0AS, United Kingdom, 44 1223334151, sb209@cam.ac.uk %K misdiagnosis %K help-seeking %K gradient-boosted trees %K machine learning %K depression %K bipolar disorder %K diagnose %K diagnosis %K mood %K mental health %K mental disorder %K mental disorders %K depression %K depressive %K predict %K predictive %K prediction %K depressed %K algorithm %K algorithms %D 2024 %7 11.1.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Misdiagnosis and delayed help-seeking cause significant burden for individuals with mood disorders such as major depressive disorder and bipolar disorder. Misdiagnosis can lead to inappropriate treatment, while delayed help-seeking can result in more severe symptoms, functional impairment, and poor treatment response. Such challenges are common in individuals with major depressive disorder and bipolar disorder due to the overlap of symptoms with other mental and physical health conditions, as well as, stigma and insufficient understanding of these disorders. Objective: In this study, we aimed to identify factors that may contribute to mood disorder misdiagnosis and delayed help-seeking. Methods: Participants with current depressive symptoms were recruited online and data were collected using an extensive digital mental health questionnaire, with the World Health Organization World Mental Health Composite International Diagnostic Interview delivered via telephone. A series of predictive gradient-boosted tree algorithms were trained and validated to identify the most important predictors of misdiagnosis and subsequent help-seeking in misdiagnosed individuals. Results: The analysis included data from 924 symptomatic individuals for predicting misdiagnosis and from a subset of 379 misdiagnosed participants who provided follow-up information when predicting help-seeking. Models achieved good predictive power, with area under the receiver operating characteristic curve of 0.75 and 0.71 for misdiagnosis and help-seeking, respectively. The most predictive features with respect to misdiagnosis were high severity of depressed mood, instability of self-image, the involvement of a psychiatrist in diagnosing depression, higher age at depression diagnosis, and reckless spending. Regarding help-seeking behavior, the strongest predictors included shorter time elapsed since last speaking to a general practitioner about mental health, sleep problems disrupting daily tasks, taking antidepressant medication, and being diagnosed with depression at younger ages. Conclusions: This study provides a novel, machine learning–based approach to understand the interplay of factors that may contribute to the misdiagnosis and subsequent help-seeking in patients experiencing low mood. The present findings can inform the development of targeted interventions to improve early detection and appropriate treatment of individuals with mood disorders. %M 38206660 %R 10.2196/50738 %U https://mental.jmir.org/2024/1/e50738 %U https://doi.org/10.2196/50738 %U http://www.ncbi.nlm.nih.gov/pubmed/38206660 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e48935 %T Population-Level Portal-Based Anxiety and Depression Screening Perspectives in HIV Care Clinicians: Qualitative Study Using the Consolidated Framework for Implementation Research %A Zimmer,Daniela %A Staab,Erin M %A Ridgway,Jessica P %A Schmitt,Jessica %A Franco,Melissa %A Hunter,Scott J %A Motley,Darnell %A Laiteerapong,Neda %+ Section of General Internal Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, United States, 1 312 702 8847, dazimmer@bsd.uchicago.edu %K HIV %K patient portal %K clinic staff perspectives %K depression and anxiety screening %K implementation %D 2024 %7 11.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression and anxiety are common among people with HIV and are associated with inadequate viral suppression, disease progression, and increased mortality. However, depression and anxiety are underdiagnosed and undertreated in people with HIV owing to inadequate visit time and personnel availability. Conducting population-level depression and anxiety screening via the patient portal is a promising intervention that has not been studied in HIV care settings. Objective: We aimed to explore facilitators of and barriers to implementing population-level portal-based depression and anxiety screening for people with HIV. Methods: We conducted semistructured hour-long qualitative interviews based on the Consolidated Framework for Implementation Research with clinicians at an HIV clinic. Results: A total of 10 clinicians participated in interviews. In total, 10 facilitators and 7 barriers were identified across 5 Consolidated Framework for Implementation Research domains. Facilitators included advantages of systematic screening outside clinic visits; the expectation that assessment frequency could be tailored to patient needs; evidence from the literature and previous experience in other settings; respect for patient privacy; empowering patients and facilitating communication about mental health; compatibility with clinic culture, workflows, and systems; staff beliefs about the importance of mental health screening and benefits for HIV care; engaging all clinic staff and leveraging their strengths; and clear planning and communication with staff. Barriers included difficulty in ensuring prompt response to suicidal ideation; patient access, experience, and comfort using the portal; limited availability of mental health services; variations in how providers use the electronic health record and communicate with patients; limited capacity to address mental health concerns during HIV visits; staff knowledge and self-efficacy regarding the management of mental health conditions; and the impersonal approach to a sensitive topic. Conclusions: We proposed 13 strategies for implementing population-level portal-based screening for people with HIV. Before implementation, clinics can conduct local assessments of clinicians and clinic staff; engage clinicians and clinic staff with various roles and expertise to support the implementation; highlight advantages, relevance, and evidence for population-level portal-based mental health screening; make screening frequency adaptable based on patient history and symptoms; use user-centered design methods to refine results that are displayed and communicated in the electronic health record; make screening tools available for patients to use on demand in the portal; and create protocols for positive depression and anxiety screeners, including those indicating imminent risk. During implementation, clinics should communicate with clinicians and clinic staff and provide training on protocols; provide technical support and demonstrations for patients on how to use the portal; use multiple screening methods for broad reach; use patient-centered communication in portal messages; provide clinical decision support tools, training, and mentorship to help clinicians manage mental health concerns; and implement integrated behavioral health and increase mental health referral partnerships. %M 38206651 %R 10.2196/48935 %U https://formative.jmir.org/2024/1/e48935 %U https://doi.org/10.2196/48935 %U http://www.ncbi.nlm.nih.gov/pubmed/38206651 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e52969 %T Remote Delivery of the Cuidándome Telehealth Intervention for Self-Management of Depression and Anxiety Among Latina Immigrant Women: Randomized Controlled Trial %A Alvarez,Carmen %A Aryal,Subhash %A Vrany,Elizabeth %A Sanchez R,Maria Jose %A Quiles,Rosalphie %A Escobar-Acosta,Lia %A Hill-Briggs,Felicia %+ School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA, 19104, United States, 1 2158980715, alcarmen@nursing.upenn.edu %K Latina immigrant %K mental health %K depression %K anxiety %K problem-solving %K intervention study %K trauma-informed %K depressive %K Latinx %K Latin %K Latino %K Latina %K Hispanic %K Spanish %K immigrant %K immigrants %K survivor %K child %K children %K childhood %K trauma %K traumatic %K adverse %K telehealth %K telemedicine %K eHealth %K digital health %K feasibility %K acceptability %K randomized %K controlled trial %K controlled trials %K mobile phone %D 2024 %7 8.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Growing evidence suggests that Latina immigrant survivors of adverse childhood experiences (ACEs) are at increased risk for developing and remaining with either depression or anxiety or both symptoms. This study examined the feasibility and acceptability of a telehealth intervention—Cuidándome (quee-DAN-doh-meh, “taking care of myself”). Cuidándome is a 10-week, patient-centered, trauma-informed intervention delivered by a trained facilitator that promotes self-management of depression and anxiety symptoms through improved problem-solving skills and strategies. Objective: The aim of this study was to examine the feasibility and acceptability of Cuidándome delivered remotely (via Zoom) with Latina immigrant ACE survivors with either depression or anxiety or both symptoms. We also estimated the effect sizes associated with the intervention on decreasing depression and anxiety symptoms and improving social problem–solving styles. Methods: We evaluated Cuidándome using a randomized controlled trial design. Latina immigrants (N=47) who had experienced at least 1 ACE and had at least mild depression or anxiety symptoms were randomized to Cuidándome or a comparison group delivered by trained facilitators. We assessed for changes in depression and anxiety symptoms as well as social problem–solving styles at baseline, post intervention, and 3- and 6-month follow-up. Results: Analyses indicated significant decreases over time within both Cuidándome and comparison groups for depression and anxiety symptoms and maladaptive problem-solving. The intervention effect was largest for anxiety; at 6-month follow-up, Cuidándome participants had significantly lower anxiety scores than the comparison group. In addition, we observed a greater average point reduction in depression symptoms at 6 months among Cuidándome participants (5.7 points) than in the comparison group (3.7 points). Conclusions: A mental health program delivered via Zoom by a trained facilitator was feasible and acceptable to Latina immigrant women and can be beneficial for reducing anxiety and depression symptoms. More research is needed to assess the effectiveness of Cuidándome among a powered sample size of Latina immigrants. Trial Registration: ISRCTN Registry ISRCTN16668518; https://www.isrctn.com/ISRCTN16668518 %M 38190239 %R 10.2196/52969 %U https://formative.jmir.org/2024/1/e52969 %U https://doi.org/10.2196/52969 %U http://www.ncbi.nlm.nih.gov/pubmed/38190239 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e46364 %T Determining Distinct Suicide Attempts From Recurrent Electronic Health Record Codes: Classification Study %A Bentley,Kate H %A Madsen,Emily M %A Song,Eugene %A Zhou,Yu %A Castro,Victor %A Lee,Hyunjoon %A Lee,Younga H %A Smoller,Jordan W %+ Center for Precision Psychiatry, Department of Psychiatry, Massachusetts General Hospital, 185 Cambridge Street, 2nd Floor, Boston, MA, 02114, United States, 1 6177247741, kbentley@mgh.harvard.edu %K suicide %K suicide attempt %K self-injury %K electronic health record %K EHR %K prediction %K predictive model %K predict %K model %K suicidal %K informatics %K automated rule %K psychiatry %K machine learning %D 2024 %7 8.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Prior suicide attempts are a relatively strong risk factor for future suicide attempts. There is growing interest in using longitudinal electronic health record (EHR) data to derive statistical risk prediction models for future suicide attempts and other suicidal behavior outcomes. However, model performance may be inflated by a largely unrecognized form of “data leakage” during model training: diagnostic codes for suicide attempt outcomes may refer to prior attempts that are also included in the model as predictors. Objective: We aimed to develop an automated rule for determining when documented suicide attempt diagnostic codes identify distinct suicide attempt events. Methods: From a large health care system’s EHR, we randomly sampled suicide attempt codes for 300 patients with at least one pair of suicide attempt codes documented at least one but no more than 90 days apart. Supervised chart reviewers assigned the clinical settings (ie, emergency department [ED] versus non-ED), methods of suicide attempt, and intercode interval (number of days). The probability (or positive predictive value) that the second suicide attempt code in a given pair of codes referred to a distinct suicide attempt event from its preceding suicide attempt code was calculated by clinical setting, method, and intercode interval. Results: Of 1015 code pairs reviewed, 835 (82.3%) were nonindependent (ie, the 2 codes referred to the same suicide attempt event). When the second code in a pair was documented in a clinical setting other than the ED, it represented a distinct suicide attempt 3.3% of the time. The more time elapsed between codes, the more likely the second code in a pair referred to a distinct suicide attempt event from its preceding code. Code pairs in which the second suicide attempt code was assigned in an ED at least 5 days after its preceding suicide attempt code had a positive predictive value of 0.90. Conclusions: EHR-based suicide risk prediction models that include International Classification of Diseases codes for prior suicide attempts as a predictor may be highly susceptible to bias due to data leakage in model training. We derived a simple rule to distinguish codes that reflect new, independent suicide attempts: suicide attempt codes documented in an ED setting at least 5 days after a preceding suicide attempt code can be confidently treated as new events in EHR-based suicide risk prediction models. This rule has the potential to minimize upward bias in model performance when prior suicide attempts are included as predictors in EHR-based suicide risk prediction models. %M 38190236 %R 10.2196/46364 %U https://formative.jmir.org/2024/1/e46364 %U https://doi.org/10.2196/46364 %U http://www.ncbi.nlm.nih.gov/pubmed/38190236 %0 Journal Article %I JMIR Publications %V 5 %N %P e53365 %T Development of Depression Data Sets and a Language Model for Depression Detection: Mixed Methods Study %A Tumaliuan,Faye Beatriz %A Grepo,Lorelie %A Jalao,Eugene Rex %+ Department of Industrial Engineering and Operations Research, University of the Philippines Diliman, Melchor Hall, Magsaysay Avenue, Quezon City, 1101, Philippines, 63 9176593613, fayetumaliuan@gmail.com %K depression data set %K depression detection %K social media %K natural language processing %K Filipino %D 2024 %7 4.9.2024 %9 Original Paper %J JMIR Data %G English %X Background: Depression detection in social media has gained attention in recent years with the help of natural language processing (NLP) techniques. Because of the low-resource standing of Filipino depression data, valid data sets need to be created to aid various machine learning techniques in depression detection classification tasks. Objective: The primary objective is to build a depression corpus of Philippine Twitter users who were clinically diagnosed with depression by mental health professionals and develop from this a corpus of depression symptoms that can later serve as a baseline for predicting depression symptoms in the Filipino and English languages. Methods: The proposed process included the implementation of clinical screening methods with the help of clinical psychologists in the recruitment of study participants who were young adults aged 18 to 30 years. A total of 72 participants were assessed by clinical psychologists and provided their Twitter data: 60 with depression and 12 with no depression. Six participants provided 2 Twitter accounts each, making 78 Twitter accounts. A data set was developed consisting of depression symptom–annotated tweets with 13 depression categories. These were created through manual annotation in a process constructed, guided, and validated by clinical psychologists. Results: Three annotators completed the process for approximately 79,614 tweets, resulting in a substantial interannotator agreement score of 0.735 using Fleiss κ and a 95.59% psychologist validation score. A word2vec language model was developed using Filipino and English data sets to create a 300-feature word embedding that can be used in various machine learning techniques for NLP. Conclusions: This study contributes to depression research by constructing depression data sets from social media to aid NLP in the Philippine setting. These 2 validated data sets can be significant in user detection or tweet-level detection of depression in young adults in further studies. %R 10.2196/53365 %U https://data.jmir.org/2024/1/e53365 %U https://doi.org/10.2196/53365 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 12 %P e36806 %T Patient and Therapist Expectations for a Blended Cognitive Behavioral Therapy Program for Depression: Qualitative Exploratory Study %A Atik,Ece %A Schückes,Magnus %A Apolinário-Hagen,Jennifer %+ Institute for SME Research and Entrepreneurship, University of Mannheim, L 9, 1–2, Mannheim, 68161, Germany, 49 621 181 2273, schueckes@bwl.uni-mannheim.de %K blended cognitive behavioral therapy %K bCBT %K cognitive behavioral therapy %K digital health %K mental health %K internet %K mobile app %K blended psychotherapy %K depression %K user perspectives %K mobile phone %D 2022 %7 30.12.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Blended cognitive behavioral therapy (bCBT)—the combination of digital elements and face-to-face psychotherapy—has been proposed to alleviate challenges that patients and therapists face in conventional cognitive behavioral therapy. There is growing evidence that adding digital elements to face-to-face psychotherapy can contribute to better treatment outcomes. However, bCBT programs still show considerable shortcomings, and knowledge on how to improve digital apps using a bCBT protocol is limited. Objective: This study aimed to inductively identify functions and qualities that are expected from a bCBT treatment for depression in the eyes of patients and psychotherapists who were not currently receiving or practicing bCBT treatment. Methods: We used a qualitative exploratory study design and conducted 3 focus group interviews (n=6 in each) and 5 semistructured in-depth interviews with therapists as well as 11 individual interviews with patients with a primary diagnosis of depression and currently undergoing cognitive behavioral therapy treatment in Germany. Themes and categories were established inductively from transcribed interview records based on a rigorous coding method. Results: Both therapists and patients expected a digital app to provide patients with the opportunity to track their mood, work on therapeutic homework activities, easily access an intervention set for harder moments, and efficiently facilitate administrative tasks. The desire to be able to customize bCBT protocols to individual patient circumstances was evident in both patient and therapist interviews. Patients differed with respect to what content and the amount of material the app should focus on as well as the method of recording experiences. Therapists viewed digital apps as potentially aiding in their documentation work outside of sessions. Different attitudes surfaced on the topic of data security, with patients not as concerned as therapists. Conclusions: Both patients and therapists had substantially positive attitudes toward the option of an integrated bCBT treatment. Our study presents novel findings on the expectations and attitudes of patients and therapists. %M 36583934 %R 10.2196/36806 %U https://mental.jmir.org/2022/12/e36806 %U https://doi.org/10.2196/36806 %U http://www.ncbi.nlm.nih.gov/pubmed/36583934 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 12 %P e42526 %T General Practice Patients’ Experiences and Perceptions of the WiserAD Structured Web-Based Support Tool for Antidepressant Deprescribing: Protocol for a Mixed Methods Case Study With Realist Evaluation %A Coe,Amy %A Gunn,Jane %A Kaylor-Hughes,Catherine %+ Department of General Practice, University of Melbourne, Level 2, 780 Elizabeth St, Melbourne, 3004, Australia, 61 90356335, amy.coe@unimelb.edu.au %K antidepressants %K primary care %K depression %K deprescribing %K realist evaluation %K online support tool %K case study %K general practice %K online %K tool %K data %K evaluation %K intervention %K clinical %D 2022 %7 29.12.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Research suggests that the rapid increase in worldwide antidepressant use is mainly due to a rise in long-term and potentially inappropriate use. It has been suggested that 1 in 3 antidepressant users among general practice patients are no longer experiencing clinical benefits from their medication and should commence deprescribing. However there are many barriers to antidepressant deprescribing for both patients and clinicians, which adds to the complex nature of reducing or ceasing the medication. As such, antidepressant deprescribing does not routinely occur in clinical practice. Evidence-based supports and interventions for safe and successful antidepressant deprescribing are needed to assist patients and their doctors. Interventions should also include an understanding of how an intervention works, why it works, and whom it is for. Objective: This study aims to evaluate how the WiserAD approach to antidepressant deprescribing works, whom it is for, and the underlying circumstances by (1) examining the experiences and perceptions of WiserAD among antidepressant users, (2) identifying the underlying mechanisms of the WiserAD approach to antidepressant deprescribing, and (3) describing in what contexts and to what extent the underlying mechanisms of WiserAD are suited for antidepressant users. Methods: A mixed methods case study with realist evaluation will be conducted among participants in the WiserAD randomized controlled trial for antidepressant deprescribing. Quantitative data will be obtained from up to 12 participants from the intervention and control arms at baseline and 3-month follow-up. Baseline data will be used to characterize the sample using descriptive statistics. Paired samples t tests will also be performed to compare responses between baseline and 3-month follow-up for participant self-management, skills, confidence and knowledge, beliefs about medicines, current emotional health, and well-being symptoms. Qualitative data from the same participants will be collected via narrative interview at 3-month follow-up. Quantitative and qualitative data will be converged to form a “case,” and analysis will be conducted within each case with comparisons made across multiple cases. Results: Recruitment of participants commenced in October 2022 and will be completed by March 2023. Analysis will be completed by June 2023. Conclusions: To our knowledge, this will be the first realist evaluation of an antidepressant deprescribing intervention in general practice. Findings from this evaluation may assist in the implementation of the WiserAD approach to antidepressant deprescribing in routine clinical practice. International Registered Report Identifier (IRRID): PRR1-10.2196/42526 %M 36580362 %R 10.2196/42526 %U https://www.researchprotocols.org/2022/12/e42526 %U https://doi.org/10.2196/42526 %U http://www.ncbi.nlm.nih.gov/pubmed/36580362 %0 Journal Article %@ 2561-3278 %I JMIR Publications %V 7 %N 2 %P e42386 %T Detection of Suicide Risk Using Vocal Characteristics: Systematic Review %A Iyer,Ravi %A Meyer,Denny %+ Centre for Mental Health, Swinburne University of Technology, 34 Wakefield Street, Hawthorn, 3122, Australia, 61 456565575, raviiyer@swin.edu.au %K voice %K suicide %K suicidal %K biological signal processing %K machine learning %K systematic review %K review methodology %K risk %K speech %K mental health %D 2022 %7 22.12.2022 %9 Review %J JMIR Biomed Eng %G English %X Background: In an age when telehealth services are increasingly being used for forward triage, there is a need for accurate suicide risk detection. Vocal characteristics analyzed using artificial intelligence are now proving capable of detecting suicide risk with accuracies superior to traditional survey-based approaches, suggesting an efficient and economical approach to ensuring ongoing patient safety. Objective: This systematic review aimed to identify which vocal characteristics perform best at differentiating between patients with an elevated risk of suicide in comparison with other cohorts and identify the methodological specifications of the systems used to derive each feature and the accuracies of classification that result. Methods: A search of MEDLINE via Ovid, Scopus, Computers and Applied Science Complete, CADTH, Web of Science, ProQuest Dissertations and Theses A&I, Australian Policy Online, and Mednar was conducted between 1995 and 2020 and updated in 2021. The inclusion criteria were human participants with no language, age, or setting restrictions applied; randomized controlled studies, observational cohort studies, and theses; studies that used some measure of vocal quality; and individuals assessed as being at high risk of suicide compared with other individuals at lower risk using a validated measure of suicide risk. Risk of bias was assessed using the Risk of Bias in Non-randomized Studies tool. A random-effects model meta-analysis was used wherever mean measures of vocal quality were reported. Results: The search yielded 1074 unique citations, of which 30 (2.79%) were screened via full text. A total of 21 studies involving 1734 participants met all inclusion criteria. Most studies (15/21, 71%) sourced participants via either the Vanderbilt II database of recordings (8/21, 38%) or the Silverman and Silverman perceptual study recording database (7/21, 33%). Candidate vocal characteristics that performed best at differentiating between high risk of suicide and comparison cohorts included timing patterns of speech (median accuracy 95%), power spectral density sub-bands (median accuracy 90.3%), and mel-frequency cepstral coefficients (median accuracy 80%). A random-effects meta-analysis was used to compare 22 characteristics nested within 14% (3/21) of the studies, which demonstrated significant standardized mean differences for frequencies within the first and second formants (standardized mean difference ranged between −1.07 and −2.56) and jitter values (standardized mean difference=1.47). In 43% (9/21) of the studies, risk of bias was assessed as moderate, whereas in the remaining studies (12/21, 57%), the risk of bias was assessed as high. Conclusions: Although several key methodological issues prevailed among the studies reviewed, there is promise in the use of vocal characteristics to detect elevations in suicide risk, particularly in novel settings such as telehealth or conversational agents. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD420200167413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020167413 %M 38875684 %R 10.2196/42386 %U https://biomedeng.jmir.org/2022/2/e42386 %U https://doi.org/10.2196/42386 %U http://www.ncbi.nlm.nih.gov/pubmed/38875684 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e38133 %T Applying Gamification Principles and Therapeutic Movement Sequences to Design an Interactive Physical Activity Game: Development Study %A Kim,Hyungsook %A O'Sullivan,David Michael %A Chung,Seong Hee %+ Division of Sport Science, Pusan National University, 2, Busandaehak-ro 63beon-gil, Geumjeong-gu, Pusan, 46241, Republic of Korea, 82 1076845811, davidosullivan@pusan.ac.kr %K home workout %K mobile assistant %K movement %K physical activity %K depression %D 2022 %7 16.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a severe illness that has accelerated with the spread of COVID-19 and associated lockdowns. As a result, reported physical activity has substantially decreased, further increasing depressive symptoms. Objective: This study aims to explain the use of gamification principles to develop content for an interactive physical activity game for depression based on clinically proven depression diagnostic criteria. Methods: We discuss related work in this field, the game design framework, the users’ depression severity, how we customize the contents accordingly, the gradual progression of the game to match exercise principles, and user flow optimization. Results: We provide a brief description of each of the games developed, including instructions on how to play and design aspects for flow, audio, and visual feedback methods. Exergames (interactive physical activity–based games) stimulate certain physical fitness factors such as improving reaction time, endurance, cardiovascular fitness, and flexibility. In addition, the game difficulty progresses based on various factors, such as the user’s performance for successful completion, reaction time, movement speed, and stimulated larger joint range of motions. Cognitive aspects are included, as the user has to memorize particular movement sequences. Conclusions: Mental health issues are linked to behavior and movement; therefore, future physical activity–based interactive games may provide excellent stimulation for inducing user flow, while physical activity can help train various physical fitness factors linked to depression. %M 36525298 %R 10.2196/38133 %U https://games.jmir.org/2022/4/e38133 %U https://doi.org/10.2196/38133 %U http://www.ncbi.nlm.nih.gov/pubmed/36525298 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 12 %P e40892 %T Challenges in Recruiting University Students for Web-Based Indicated Prevention of Depression and Anxiety: Results From a Randomized Controlled Trial (ICare Prevent) %A Bolinski,Felix %A Kleiboer,Annet %A Neijenhuijs,Koen %A Karyotaki,Eirini %A Wiers,Reinout %A de Koning,Lisa %A Jacobi,Corinna %A Zarski,Anna-Carlotta %A Weisel,Kiona K %A Cuijpers,Pim %A Riper,Heleen %+ Department of Clinical, Neuro, and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, De Boelelaan 1105, Amsterdam, 1081HV, Netherlands, 31 0205985204, f.bolinski@vu.nl %K digital mental health %K students %K indicated prevention %K recruitment %K randomized trial %K mobile phone %D 2022 %7 14.12.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression and anxiety are common mental health conditions in college and university student populations. Offering transdiagnostic, web-based prevention programs such as ICare Prevent to those with subclinical complaints has the potential to reduce some barriers to receiving help (eg, availability of services, privacy considerations, and students’ desire for autonomy). However, uptake of these interventions is often low, and accounts of recruitment challenges are needed to complement available effectiveness research in student populations. Objective: The aims of this study were to describe recruitment challenges together with effective recruitment strategies for ICare Prevent and provide basic information on the intervention’s effectiveness. Methods: A 3-arm randomized controlled trial was conducted in a student sample with subclinical symptoms of depression and anxiety on the effectiveness of an individually guided (human support and feedback on exercises provided after each session, tailored to each participant) and automatically guided (computer-generated messages provided after each session, geared toward motivation) version of ICare Prevent, a web-based intervention with transdiagnostic components for the indicated prevention of depression and anxiety. The intervention was compared with care as usual. Descriptive statistics were used to outline recruitment challenges and effective web-based and offline strategies as well as students’ use of the intervention. A basic analysis of intervention effects was conducted using a Bayesian linear mixed model, with Bayes factors reported as the effect size. Results: Direct recruitment through students’ email addresses via the central student administration was the most effective strategy. Data from 35 participants were analyzed (individually guided: n=14, 40%; automatically guided: n=8, 23%; care as usual: n=13, 37%). Use of the intervention was low, with an average of 3 out of 7 sessions (SD 2.9) completed. The analyses did not suggest any intervention effects other than anecdotal evidence (all Bayes factors10≤2.7). Conclusions: This report adds to the existing literature on recruitment challenges specific to the student population. Testing the feasibility of recruitment measures and the greater involvement of the target population in their design, as well as shifting from direct to indirect prevention, can potentially help future studies in the field. In addition, this report demonstrates an alternative basic analytical strategy for underpowered randomized controlled trials. Trial Registration: International Clinical Trials Registry Platform NTR6562; https://tinyurl.com/4rbexzrk International Registered Report Identifier (IRRID): RR2-10.1186/s13063-018-2477-y %M 36515986 %R 10.2196/40892 %U https://www.jmir.org/2022/12/e40892 %U https://doi.org/10.2196/40892 %U http://www.ncbi.nlm.nih.gov/pubmed/36515986 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 12 %P e38785 %T The Use of Passive Smartphone Data to Monitor Anxiety and Depression Among College Students in Real-World Settings: Protocol for a Systematic Review %A Girousse,Eva %A Vuillerme,Nicolas %+ AGEIS, Université Grenoble Alpes, La Tronche, Grenoble, 38706, France, 33 4 7663 7104, nicolas.vuillerme@univ-grenoble-alpes.fr %K smartphones %K anxiety %K depression %K college students %K smartphone %K data %K monitor %K students %K systematic review %K public health %K mental conditions %K disorder %K strength %K limitation %D 2022 %7 14.12.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: College students are particularly at risk of depression and anxiety. These disorders have a serious impact on public health and affect patients’ daily lives. The potential for using smartphones to monitor these mental conditions, providing passively collected physiological and behavioral data, has been reported among the general population. However, research on the use of passive smartphone data to monitor anxiety and depression among specific populations of college students has never been reviewed. Objective: This review’s objectives are (1) to provide an overview of the use of passive smartphone data to monitor depression and anxiety among college students, given their specific type of smartphone use and living setting, and (2) to evaluate the different methods used to assess those smartphone data, including their strengths and limitations. Methods: This review will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two independent investigators will review English-language, full-text, peer-reviewed papers extracted from PubMed and Web of Science that measure passive smartphone data and levels of depression or anxiety among college students. A preliminary search was conducted in February 2022 as a proof of concept. Results: Our preliminary search identified 115 original articles, 8 of which met our eligibility criteria. Our planned full study will include an article selection flowchart, tables, and figures representing the main information extracted on the use of passive smartphone data to monitor anxiety and depression among college students. Conclusions: The planned review will summarize the published research on using passive smartphone data to monitor anxiety and depression among college students. The review aims to better understand whether and how passive smartphone data are associated with indicators of depression and anxiety among college students. This could be valuable in order to provide a digital solution for monitoring mental health issues in this specific population by enabling easier identification and follow-up of the patients. Trial Registration: PROSPERO CRD42022316263; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=316263 International Registered Report Identifier (IRRID): DERR1-10.2196/38785 %M 36515983 %R 10.2196/38785 %U https://www.researchprotocols.org/2022/12/e38785 %U https://doi.org/10.2196/38785 %U http://www.ncbi.nlm.nih.gov/pubmed/36515983 %0 Journal Article %@ 2562-7600 %I JMIR Publications %V 5 %N 1 %P e42731 %T Nurse-Led Virtual Delivery of PIECES in Canadian Long-Term Care Homes to Support the Care of Older Adults Experiencing Responsive Behaviors During COVID-19: Qualitative Descriptive Study %A Garnett,Anna %A Connelly,Denise %A Yous,Marie-Lee %A Hung,Lillian %A Snobelen,Nancy %A Hay,Melissa %A Furlan-Craievich,Cherie %A Snelgrove,Shannon %A Babcock,Melissa %A Ripley,Jacqueline %A Hamilton,Pam %A Sturdy-Smith,Cathy %A O’Connell,Maureen %+ Arthur Labatt Family School of Nursing, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada, 1 519 661 2111, agarnet6@uwo.ca %K long-term care %K older adults %K families %K responsive behaviors %K qualitative %K COVID-19 %K PIECES %K nurse(s) %K care home %K infection %K therapeutic %K anxiety %K depression %K cognitive %K fear %K death %K dementia %K communication %K technology %D 2022 %7 13.12.2022 %9 Original Paper %J JMIR Nursing %G English %X Background: Worldwide, the COVID-19 pandemic has resulted in profound loss of life among older adults living in long-term care (LTC) homes. As a pandemic response, LTC homes enforced infection control processes, including isolating older adults in their rooms, canceling therapeutic programs, and restricting family member visits. Social isolation negatively impacts older adults in LTC, which may result in increased rates of anxiety, depression, physical and cognitive decline, disorientation, fear, apathy, and premature death. Isolation of older adults can also cause an increase in responsive behaviors (eg, yelling, hitting, calling out) to express frustration, fear, restricted movement, and boredom. To respond to the challenges in LTC and support frontline staff, older adults, and family members, a novel registered practical nurse (RPN)-led delivery of the PIECES approach for addressing responsive behaviors among older adults with dementia using virtual training/mentoring was implemented in Canadian LTC homes. PIECES employs a person- and family/care partner–centered collaborative team-based approach to provide education and capacity-building for nurses; engages families as active participants in care; and embeds evidence-informed practices to provide person- and family-centered care to older adults with complex needs, including dementia. Objective: The aim of this study was to describe the experiences of LTC staff, family/care partners, and older adult research partners with implementation of a novel RPN-led virtual adaptation of the PIECES care-planning approach for responsive behaviors in two Canadian LTC homes during the COVID-19 pandemic. Methods: Using a qualitative descriptive design, two focus groups were held with three to four staff members (eg, RPNs, managers) per LTC home in Ontario. A third focus group was held with three PIECES mentors. Individual semistructured interviews were conducted with RPN champions, family/care partners, and older adult research partners. Research team meeting notes provided an additional source of data. Content analysis was performed. Results: A total of 22 participants took part in a focus group (n=11) or an in-depth individual interview (n=11). Participant experiences suggest that implementation of RPN-led virtual PIECES fostered individualized care, included family as partners in care, increased interdisciplinary collaboration, and improved staff practices. However, virtual PIECES, as delivered, lacked opportunities for family member feedback on older adult outcomes. Implementation facilitators included the provision of mentorship and leadership at all levels of implementation and suitable technological infrastructure. Barriers were related to availability and use of virtual communication technology (family members) and older adults became upset due to lack of comprehension during virtual care conferences. Conclusions: These findings offer promising support to adopting virtual PIECES, a team approach to gather valuable family input and engagement to address residents’ unmet needs and responsive behaviors in LTC. Future research should investigate a hybridized communication format to foster sustainable person- and family-centered care-planning practices to include active collaboration of families in individualized care plans. %M 36446050 %R 10.2196/42731 %U https://nursing.jmir.org/2022/1/e42731 %U https://doi.org/10.2196/42731 %U http://www.ncbi.nlm.nih.gov/pubmed/36446050 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 12 %P e40045 %T Development of an mHealth App–Based Intervention for Depressive Rumination (RuminAid): Mixed Methods Focus Group Evaluation %A Rosenfeld,Eve A %A Lyman,Cassondra %A Roberts,John E %+ Dissemination and Training Division, National Center for PTSD, VA Palo Alto Healthcare System, NCPTSD – 334, 795 Willow Road, Menlo Park, CA, 94025, United States, 1 908 907 4135, earosenf@stanford.edu %K depression %K rumination %K mobile health %K mHealth %K evidence-based treatment %K focus group %K mental health %K mobile app %K mobile phone %D 2022 %7 13.12.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression is a common mental health condition that poses a significant public health burden. Effective treatments for depression exist; however, access to evidence-based care remains limited. Mobile health (mHealth) apps offer an avenue for improving access. However, few mHealth apps are informed by evidence-based treatments and even fewer are empirically evaluated before dissemination. To address this gap, we developed RuminAid, an mHealth app that uses evidence-based treatment components to reduce depression by targeting a single key depressogenic process—rumination. Objective: The primary objective of this study was to collect qualitative and quantitative feedback that could be used to improve the design of RuminAid before the software development phase. Methods: We reviewed empirically supported interventions for depression and rumination and used the key aspects of each to create a storyboard version of RuminAid. We distributed an audio-guided presentation of the RuminAid storyboard to 22 individuals for viewing and solicited user feedback on app content, design, and perceived functionality across 7 focus group sessions. Results: The consumer-rated quality of the storyboard version of RuminAid was in the acceptable to good range. Indeed, most participants reported that they thought RuminAid would be an engaging, functional, and informational app. Likewise, they endorsed overwhelming positive beliefs about the perceived impact of RuminAid; specifically, 96% (21/22) believed that RuminAid will help depressed ruminators with depression and rumination. Nevertheless, the results highlighted the need for improved app aesthetics (eg, a more appealing color scheme and modern design). Conclusions: Focus group members reported that the quality of information was quite good and had the potential to help adults who struggle with depression and rumination but expressed concern that poor aesthetics would interfere with users’ desire to continue using the app. To address these comments, we hired a graphic designer and redesigned each screen to improve visual appeal. We also removed time gating from the app based on participant feedback and findings from related research. These changes helped elevate RuminAid and informed its initial software build for a pilot trial that focused on evaluating its feasibility and acceptability. %M 36512400 %R 10.2196/40045 %U https://formative.jmir.org/2022/12/e40045 %U https://doi.org/10.2196/40045 %U http://www.ncbi.nlm.nih.gov/pubmed/36512400 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 12 %P e38049 %T The Effectiveness of Internet-Guided Self-help Interventions to Promote Physical Activity Among Individuals With Depression: Systematic Review %A Tang,Yiling %A Gierc,Madelaine %A Lam,Raymond W %A Liu,Sam %A Faulkner,Guy %+ School of Kinesiology, University of British Columbia, 6081 University Blvd, Vancouver, BC, V6T 1Z1, Canada, 1 6048222211, yilingtt@student.ubc.ca %K physical activity %K eHealth %K mobile health %K mHealth %K depression %K systematic review %K internet %K mobile phone %D 2022 %7 12.12.2022 %9 Review %J JMIR Ment Health %G English %X Background: Depression is a prevalent and debilitating mental disorder and a leading cause of disability worldwide. Physical activity (PA) interventions have been shown to alleviate depressive symptoms. However, not all patients have access to PA programing tailored for depression. Internet-guided self-help (IGSH) interventions may be an effective option for increasing PA among people with depression who cannot or prefer not to access supervised exercise treatment. Objective: We aimed to evaluate the effectiveness of IGSH interventions in increasing PA and alleviating depressive symptoms in people with depression. Methods: A systematic literature search was conducted for randomized controlled trials and quasiexperimental studies using 9 electronic databases. The review was registered in PROSPERO (2020 CRD42020221713). Results: A total of 4 randomized controlled trials (430 participants) met the inclusion criteria. Of these, 3 were web-based and 1 was app-based. Three studies found IGSH interventions to have medium to large effects on decreasing depressive symptoms but not on increasing PA compared with waitlist or usual care. One study showed increased self-reported PA but no significant difference in depressive symptoms in the intervention group compared with the control group. Goal setting was the most common behavior change technique used in the interventions. Dropout rates within the intervention groups were relatively low (0%-19%). Conclusions: Our findings suggested that IGSH PA interventions are feasible and have the potential to reduce depressive symptoms in people with depression. More well-designed and tailored interventions with different combinations of behavior change techniques, particularly those targeting the emotion domain, are needed to assess the overall effectiveness and feasibility of using IGSH interventions to increase PA among people with depression. Trial Registration: PROSPERO CRD42020221713; https://tinyurl.com/ysaua5bu %M 36508243 %R 10.2196/38049 %U https://mental.jmir.org/2022/12/e38049 %U https://doi.org/10.2196/38049 %U http://www.ncbi.nlm.nih.gov/pubmed/36508243 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 12 %P e39727 %T Efficacy of Internet-Based Acceptance and Commitment Therapy for Depressive Symptoms, Anxiety, Stress, Psychological Distress, and Quality of Life: Systematic Review and Meta-analysis %A Han,Areum %A Kim,Tae Hui %+ Department of Psychiatry, Yonsei Wonju Medical College, Ilsan-ro 20, Wonju, 26426, Republic of Korea, 82 337410534, gooddr@yonsei.ac.kr %K acceptance and commitment therapy %K anxiety %K depression %K internet-based intervention %K meta-analysis %K psychological distress %K quality of life %K stress %K systematic review %D 2022 %7 9.12.2022 %9 Review %J J Med Internet Res %G English %X Background: Acceptance and commitment therapy (ACT) is an empirically supported transdiagnostic approach that involves mindfulness processes and behavior change processes for valued living. Objective: This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to assess the efficacy of internet-based ACT (iACT) for depressive symptoms, anxiety, stress, psychological distress, and quality of life (QoL). Methods: PubMed, CINAHL, PsycINFO, and SCOPUS databases were searched to identify relevant RCTs published up to June 5, 2021. The included RCTs were assessed using the Cochrane Collaboration risk-of-bias tool. The use of either a random effects model or fixed effects model was determined using I2 statistic values for heterogeneity. Subgroup analyses were conducted according to the type of control group, the use of therapist guidance, delivery modes, and the use of targeted participants, when applicable. Results: A total of 39 RCTs met the inclusion criteria. Meta-analyses found small effects of iACT on depressive symptoms, anxiety, stress, psychological distress, and QoL at the immediate posttest and follow-up. There was no significant effect of iACT on stress at follow-up. Subgroup analyses showed small to medium effects of iACT on all the outcomes at the immediate posttest and follow-up compared with the passive control groups. In contrast, subgroup analyses that compared iACT with active control groups found no differences between groups on stress, psychological distress, and QoL at the immediate posttest or on depressive symptoms, anxiety, and stress at follow-up. In addition, subgroup analyses conducted according to the use of therapist guidance, delivery modes, and the use of targeted participants found no statistically significant subgroup differences among studies in all the outcomes, except for the subgroup difference among studies according to the use of targeted participants for depressive symptoms at the immediate posttest (ie, a statistically significant, larger effect of iACT when studies targeted people with depressive symptoms). The overall risk of bias across the studies was unclear. Conclusions: The findings of this study contribute to the body of evidence regarding the effects of iACT on depressive symptoms, anxiety, stress, psychological distress, and QoL and may be applicable in any population, as ACT is a transdiagnostic approach. Few studies have compared iACT with active control conditions, especially for stress and psychological distress at the immediate posttest and follow-up. In addition, the active control conditions varied among the included studies. Further high-quality studies are needed to better understand whether iACT is comparable or superior to other evidence-based interventions, such as cognitive behavioral therapy, in decreasing depressive symptoms, anxiety, stress, and psychological distress and improving QoL. %M 36485030 %R 10.2196/39727 %U https://www.jmir.org/2022/12/e39727 %U https://doi.org/10.2196/39727 %U http://www.ncbi.nlm.nih.gov/pubmed/36485030 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 12 %P e42031 %T Engagement, Use, and Impact of Digital Mental Health Resources for Diverse Populations in COVID-19: Community-Partnered Evaluation %A Wells,Kenneth %A Thames,April Denise %A Young,Alexander S %A Zhang,Lily %A Heilemann,MarySue V %A Romero,Daniela Flores %A Oliva,Adrian %A Jones,Felica %A Tang,Lingqi %A Brymer,Melissa %A Elliott,Thomas %A Arevian,Armen %A , %+ Research Center for Health Services and Society, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, 10920 Wilshire Blvd Suite 300, Los Angeles, CA, 90024, United States, 1 310 794 3728, KWells@mednet.ucla.edu %K digital mental health %K prevention %K COVID-19 %K depression %K hotline use %K health disparity %K community health %K public health %K health resource %K mental well-being %K ethnic %K website engagement %K minority population %K digital resource %D 2022 %7 7.12.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The COVID-19 pandemic increased disparities for communities burdened by structural barriers such as reduced affordable housing, with mental health consequences. Limited data are available on digital resources for public mental health prevention during the COVID-19 pandemic. Objective: The study aim was to evaluate engagement in and impact of free digital resources on the Together for Wellness/Juntos por Nuestro Bienestar (T4W/Juntos) website during COVID-19 in California. Methods: A pilot evaluation of T4W/Juntos was performed, with partner agencies inviting providers, clients, and partners to visit the website and complete surveys at baseline (September 20, 2021, to April 4, 2022) and at 4-6–week follow-up (October 22, 2021, to May 17, 2022). Website use was assessed by three engagement items (ease of use, satisfaction, relevance), comfort in use, and use of six resource categories. Primary outcomes at follow-up were depression and anxiety (scores≥3 on Patient Health Questionnaire-2 item [PHQ2] and Generalized Anxiety Disorder-2 item [GAD2] scales). Secondary outcomes were post-pre differences in PHQ2 and GAD2 scores, and use of behavioral health hotlines and services the month before follow-up. Results: Of 366 eligible participants, 315 (86.1%) completed baseline and 193 (61.3%) completed follow-up surveys. Of baseline participants, 72.6% identified as female, and 21.3% identified as lesbian, gay, bisexual, transgender, queer/questioning, and others (LGBTQ+). In terms of ethnicity, 44.0% identified as Hispanic, 17.8% as African American, 26.9% as non-Hispanic white, and 11.4% as other ethnicity. Overall, 32.7% had moderate anxiety or depression (GAD2/PHQ2≥3) at baseline. Predictors of baseline website engagement included being Hispanic versus other race/ethnicity (β=.27, 95% CI .10-.44; P=.002) and number of COVID-19–related behavior changes (β=.09, 95% CI .05-.13; P<.001). Predictors of comfort using the website were preferring English for website use (odds ratio [OR] 5.57, 95% CI 2.22-13.96; P<.001) and COVID-19–related behavior changes (OR 1.37, 95% CI 1.12-1.66; P=.002); receiving overnight behavioral health treatment in the prior 6 months (OR 0.15, 95% CI 0.03-0.69, P=.015) was associated with less comfort in website use. The main predictor of depression at follow-up (PHQ2≥3) was baseline depression (OR 6.24, 95% CI 2.77-14.09; P<.001). Engagement in T4W/Juntos was associated with lower likelihood of depression (OR 0.54, 95% CI 0.34-0.86; P=.01). Website use the month before follow-up was associated with a post-pre reduction in PHQ2 score (β=–.62, 95% CI –1.04 to –0.20; P=.004). The main predictor of GAD2≥3 at follow-up was baseline GAD2≥3 (OR 13.65, 95% CI 6.06-30.72; P<.001). Greater baseline website engagement predicted reduced hotline use (OR 0.36, 95% CI 0.18-0.71; P=.004). Conclusions: Ethnicity/language and COVID-19–related behavior changes were associated with website engagement; engagement and use predicted reduced follow-up depression and behavioral hotline use. Findings are based on participants recommended by community agencies with moderate follow-up rates; however, significance was similar when weighting for nonresponse. This study may inform research and policy on digital mental health prevention resources. %M 36346902 %R 10.2196/42031 %U https://formative.jmir.org/2022/12/e42031 %U https://doi.org/10.2196/42031 %U http://www.ncbi.nlm.nih.gov/pubmed/36346902 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 12 %P e40713 %T A Smartphone-Based Intervention for Anxiety and Depression in Racially and Ethnically Diverse Adults (EASE): Protocol for a Randomized Controlled Trial %A Garey,Lorra %A Zvolensky,Michael J %A Gallagher,Matthew W %A Vujanovic,Anka %A Kendzor,Darla E %A Stephens,Lancer %A Cheney,Marshall K %A Cole,Ashley B %A Kezbers,Krista %A Matoska,Cameron T %A Robison,Jillian %A Montgomery,Audrey %A Zappi,Christopher V %A Businelle,Michael S %+ Department of Psychology, University of Houston, Fred J. Heyne Building, Suite 104, 3695 Cullen Blvd, Houston, TX, 77204, United States, 1 713 743 8056, llgarey@uh.edu %K COVID-19 %K just-in-time adaptive intervention %K anxiety %K depression %K mHealth %K minority populations %K death %K behavioral %K care %K mobile application %K app %K public health %K symptoms %K risk %D 2022 %7 5.12.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Clear health disparities have emerged in the rates of COVID-19 exposure, hospitalization, and death among Black, Hispanic, and American Indian (BHAI) individuals, relative to non-Hispanic White (NHW) individuals. BHAI populations have been disproportionately affected by lower behavioral health access and heightened negative mental health outcomes during the pandemic. Objective: This project directly addresses health disparities in access to behavioral health care during the COVID-19 pandemic among BHAI populations via an adaptation of the established, initially validated, low-cost, mobile app Easing Anxiety Sensitivity for Everyone (EASE) among individuals with symptoms of elevated anxiety or depression or both. Methods: The EASE trial is a 2-arm, prospective, randomized, blinded-assessor study with intention-to-treat analysis. Participants (N=800; n=200, 25%, Black; n=200, 25%, Hispanic; n=200, 25%, American Indian; and n=200, 25%, NHW) are randomized to receive either EASE or an active comparison condition for anxiety and depression. Participants compete an online prescreener, an enrollment call to provide informed consent, a baseline survey, a 6-month intervention period, and 3- and 6-month postbaseline assessments. Select participants also complete a 3- and 6-month postbaseline qualitative interview via phone or an online platform (eg, Zoom). Participants complete 2 scheduled daily ecological momentary assessments (EMAs) during the 6-month study period. These twice-daily EMAs guide a just-in-time approach to immediate, personalized behavioral health care. Results: Outcomes include reductions in anxiety and depressive symptoms and functional impairment at 3 and 6 months postrandomization. We also will examine putative mechanisms (eg, anxiety sensitivity [AS] and COVID-19–specific stress and fear) of the intervention effects. Further, as treatment effects may differ across sociocultural factors, perceived discrimination, social support, and socioeconomic status (SES) will be evaluated as potential moderators of treatment effects on the primary outcomes. Process evaluation using data collected during the study, as well as individual interviews with participants, will complement quantitative data. Conclusions: Data from this efficacy trial will determine whether EASE successfully improves symptoms of anxiety and depression and whether these improvements outperform an active comparison control app. If successful, findings from this study have the potential to decrease anxiety and depression symptoms among vulnerable populations determined to be most at risk of exacerbated, long-lasting negative health sequelae. Data from this study may be used to support an implementation and dissemination trial of EASE within real-world behavioral health and social service settings. Trial Registration: ClinicalTrials.gov NCT05074693; https://clinicaltrials.gov/ct2/show/NCT05074693 International Registered Report Identifier (IRRID): DERR1-10.2196/40713 %M 36409958 %R 10.2196/40713 %U https://www.researchprotocols.org/2022/12/e40713 %U https://doi.org/10.2196/40713 %U http://www.ncbi.nlm.nih.gov/pubmed/36409958 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 11 %P e33952 %T Fitbits for Monitoring Depressive Symptoms in Older Aged Persons: Qualitative Feasibility Study %A Mughal,Fiza %A Raffe,William %A Stubbs,Peter %A Kneebone,Ian %A Garcia,Jaime %+ Faculty of Engineering and IT, University of Technology Sydney, 15 Broadway, Ultimo, Sydney, 2007, Australia, 61 4 5262 7824, fiza.mughal@uts.edu.au %K digital mental health %K Fitbit %K smartwatch %K smart wearable %K geriatric %K aging %K health informatics %K feasibility %K usability %K older aged %D 2022 %7 29.11.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: In 2022, an estimated 1.105 billion people used smart wearables and 31 million used Fitbit devices worldwide. Although there is growing evidence for the use of smart wearables to benefit physical health, more research is required on the feasibility of using these devices for mental health and well-being. In studies focusing on emotion recognition, emotions are often inferred and dependent on external cues, which may not be representative of true emotional states. Objective: The aim of this study was to evaluate the feasibility and acceptability of using consumer-grade activity trackers for apps in the remote mental health monitoring of older aged people. Methods: Older adults were recruited using criterion sampling. Participants were provided an activity tracker (Fitbit Alta HR) and completed weekly online questionnaires, including the Geriatric Depression Scale, for 4 weeks. Before and after the study period, semistructured qualitative interviews were conducted to provide insight into the acceptance and feasibility of performing the protocol over a 4-week period. Interview transcripts were analyzed using a hybrid inductive-deductive thematic analysis. Results: In total, 12 participants enrolled in the study, and 9 returned for interviews after the study period. Participants had positive attitudes toward being remotely monitored, with 78% (7/9) of participants experiencing no inconvenience throughout the study period. Moreover, 67% (6/9) were interested in trialing our prototype when it is implemented. Participants stated they would feel more comfortable if mental well-being was being monitored by carers remotely. Conclusions: Fitbit-like devices were an unobtrusive and convenient tool to collect physiological user data. Future research should integrate physiological user inputs to differentiate and predict depressive tendencies in users. %M 36268552 %R 10.2196/33952 %U https://formative.jmir.org/2022/11/e33952 %U https://doi.org/10.2196/33952 %U http://www.ncbi.nlm.nih.gov/pubmed/36268552 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 11 %P e42146 %T Passive Sensing in the Prediction of Suicidal Thoughts and Behaviors: Protocol for a Systematic Review %A Winkler,Tanita %A Büscher,Rebekka %A Larsen,Mark Erik %A Kwon,Sam %A Torous,John %A Firth,Joseph %A Sander,Lasse B %+ Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Hebelstraße 29, Freiburg, 79104, Germany, 49 7612035519, Lasse.Sander@mps.uni-freiburg.de %K suicide prediction %K passive sensing %K review %K systematic review %K sensors %K suicidal thoughts and behaviors %K digital markers %K behavioral markers %D 2022 %7 29.11.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is a severe public health problem, resulting in a high number of attempts and deaths each year. Early detection of suicidal thoughts and behaviors (STBs) is key to preventing attempts. We discuss passive sensing of digital and behavioral markers to enhance the detection and prediction of STBs. Objective: The paper presents the protocol for a systematic review that aims to summarize existing research on passive sensing of STBs and evaluate whether the STB prediction can be improved using passive sensing compared to prior prediction models. Methods: A systematic search will be conducted in the scientific databases MEDLINE, PubMed, Embase, PsycINFO, and Web of Science. Eligible studies need to investigate any passive sensor data from smartphones or wearables to predict STBs. The predictive value of passive sensing will be the primary outcome. The practical implications and feasibility of the studies will be considered as secondary outcomes. Study quality will be assessed using the Prediction Model Risk of Bias Assessment Tool (PROBAST). If studies are sufficiently homogenous, we will conduct a meta-analysis of the predictive value of passive sensing on STBs. Results: The review process started in July 2022 with data extraction in September 2022. Results are expected in December 2022. Conclusions: Despite intensive research efforts, the ability to predict STBs is little better than chance. This systematic review will contribute to our understanding of the potential of passive sensing to improve STB prediction. Future research will be stimulated since gaps in the current literature will be identified and promising next steps toward clinical implementation will be outlined. Trial Registration: OSF Registries osf-registrations-hzxua-v1; https://osf.io/hzxua International Registered Report Identifier (IRRID): DERR1-10.2196/42146 %M 36445737 %R 10.2196/42146 %U https://www.researchprotocols.org/2022/11/e42146 %U https://doi.org/10.2196/42146 %U http://www.ncbi.nlm.nih.gov/pubmed/36445737 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 11 %P e37954 %T Digital Phenotyping Data to Predict Symptom Improvement and App Personalization: Protocol for a Prospective Study %A Currey,Danielle %A Torous,John %+ School of Medicine, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106, United States, 1 617 667 6700, jtorous@gmail.com %K digital phenotyping %K digital phenotype %K mental health %K depression %K anxiety %K smartphone %K app %K college student %K university student %K young adult %K engagement %K digital health %K mobile health %K mHealth %K health app %K Technology Acceptance Model %K adoption %D 2022 %7 29.11.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Smartphone apps that capture surveys and sensors are increasingly being leveraged to collect data on clinical conditions. In mental health, this data could be used to personalize psychiatric support offered by apps so that they are more effective and engaging. Yet today, few mental health apps offer this type of support, often because of challenges associated with accurately predicting users’ actual future mental health. Objective: In this protocol, we present a study design to explore engagement with mental health apps in college students, using the Technology Acceptance Model as a theoretical framework, and assess the accuracy of predicting mental health changes using digital phenotyping data. Methods: There are two main goals of this study. First, we present a logistic regression model fit on data from a prior study on college students and prospectively test this model on a new student cohort to assess its accuracy. Second, we will provide users with data-driven activity suggestions every 4 days to determine whether this type of personalization will increase engagement or attitudes toward the app compared to those receiving no personalized recommendations. Results: The study was completed in the spring of 2022, and the manuscript is currently in review at JMIR Publications. Conclusions: This is one of the first digital phenotyping algorithms to be prospectively validated. Overall, our results will inform the potential of digital phenotyping data to serve as tailoring data in adaptive interventions and to increase rates of engagement. International Registered Report Identifier (IRRID): PRR1-10.2196/37954 %M 36445745 %R 10.2196/37954 %U https://www.researchprotocols.org/2022/11/e37954 %U https://doi.org/10.2196/37954 %U http://www.ncbi.nlm.nih.gov/pubmed/36445745 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 11 %P e39079 %T Health Needs for Suicide Prevention and Acceptance of e-Mental Health Interventions in Adolescents and Young Adults: Qualitative Study %A Blattert,Lisa %A Armbruster,Christoph %A Buehler,Eva %A Heiberger,Andrea %A Augstein,Patrick %A Kaufmann,Sarina %A Reime,Birgit %A , %+ Scientific Institute of Office-Based Haematologists and Oncologists (WINHO), Vor den Siebenburgen 2, Köln, 50676, Germany, 49 221933191918, blattert@winho.de %K suicide prevention %K e-mental health %K peer support %K adolescents and young adults %K health needs %K acceptance %K qualitative data analysis %K suicide %K mental health %K teens %K adolescent %K young adult %K vulnerable %K behavior %K Germany %K rural %K intervention %K formative %K digital %K online %D 2022 %7 23.11.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Adolescence is a phase of higher vulnerability for suicidal behavior. In Germany, almost 500 adolescents and young adults aged 15-25 years commit suicide each year. Youths in rural areas are characterized by a higher likelihood of poorer mental health. In rural areas, appropriate support for adolescents and young adults in mental health crises is difficult to access. The general acceptability of digital communication in youths can make the provision of an eHealth tool a promising strategy. Objective: The aim of this study was to explore the health needs regarding suicide prevention for adolescents and young adults in rural areas of Germany and Switzerland and to identify characteristics of suitable e-mental health interventions. Methods: This study reports on a qualitative secondary analysis of archived data, which had been collected through formative participatory research. Using 32 semistructured interviews (individually or in groups of 2) with 13 adolescents and young adults (aged 18-25 years) and 23 experts from relevant fields, we applied a deductive-inductive methodological approach and used qualitative content analyses according to Kuckartz (2016). Results: Experts as well as adolescents and young adults have reported health needs in digital suicide prevention. The health needs for rural adolescents and young adults in crises were characterized by several categories. First, the need for suicide prevention in general was highlighted. Additionally, the need for a peer concept and web-based suicide prevention were stressed. The factors influencing the acceptability of a peer-driven, web-based support were related to low-threshold access, lifelike intervention, anonymity, and trustworthiness. Conclusions: The results suggest a need for suicide prevention services for adolescents and young adults in this rural setting. Peer-driven and web-based suicide prevention services may add an important element of support during crises. By establishing such a service, an improvement in mental health support and well-being could be enabled. These services should be developed with the participation of the target group, taking anonymity, trustworthiness, and low-threshold access into account. %M 36416884 %R 10.2196/39079 %U https://mental.jmir.org/2022/11/e39079 %U https://doi.org/10.2196/39079 %U http://www.ncbi.nlm.nih.gov/pubmed/36416884 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 4 %P e40133 %T Health Tracking via Mobile Apps for Depression Self-management: Qualitative Content Analysis of User Reviews %A Polhemus,Ashley %A Simblett,Sara %A Dawe-Lane,Erin %A Gilpin,Gina %A Elliott,Benjamin %A Jilka,Sagar %A Novak,Jan %A Nica,Raluca Ileana %A Temesi,Gergely %A Wykes,Til %+ Merck Research Labs Information Technology, Merck, Sharpe, & Dohme, The Circle 66, Zurich, 8058, Switzerland, 41 762519453, polhemusam@gmail.com %K depression %K mental health %K health tracking %K self-management %K data visualization %K mobile phone %D 2022 %7 23.11.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Tracking and visualizing health data using mobile apps can be an effective self-management strategy for mental health conditions. However, little evidence is available to guide the design of mental health–tracking mechanisms. Objective: The aim of this study was to analyze the content of user reviews of depression self-management apps to guide the design of data tracking and visualization mechanisms for future apps. Methods: We systematically reviewed depression self-management apps on Google Play and iOS App stores. English-language reviews of eligible apps published between January 1, 2018, and December 31, 2021, were extracted from the app stores. Reviews that referenced health tracking and data visualization were included in sentiment and qualitative framework analyses. Results: The search identified 130 unique apps, 26 (20%) of which were eligible for inclusion. We included 783 reviews in the framework analysis, revealing 3 themes. Impact of app-based mental health tracking described how apps increased reviewers’ self-awareness and ultimately enabled condition self-management. The theme designing impactful mental health–tracking apps described reviewers’ feedback and requests for app features during data reporting, review, and visualization. It also described the desire for customization and contexts that moderated reviewer preference. Finally, implementing impactful mental health–tracking apps described considerations for integrating apps into a larger health ecosystem, as well as the influence of paywalls and technical issues on mental health tracking. Conclusions: App-based mental health tracking supports depression self-management when features align with users’ individual needs and goals. Heterogeneous needs and preferences raise the need for flexibility in app design, posing challenges for app developers. Further research should prioritize the features based on their importance and impact on users. %M 36416875 %R 10.2196/40133 %U https://humanfactors.jmir.org/2022/4/e40133 %U https://doi.org/10.2196/40133 %U http://www.ncbi.nlm.nih.gov/pubmed/36416875 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 11 %P e40242 %T Chatbot-Delivered Cognitive Behavioral Therapy in Adolescents With Depression and Anxiety During the COVID-19 Pandemic: Feasibility and Acceptability Study %A Nicol,Ginger %A Wang,Ruoyun %A Graham,Sharon %A Dodd,Sherry %A Garbutt,Jane %+ Division of Child and Adolescent Psychiatry, Department of Psychiatry, Washington University School of Medicine, 600 S Taylor Ave, Suite 121, St Louis, MO, 63110, United States, 1 3143625939, nicolg@wustl.edu %K COVID-19 %K adolescent depression %K mobile health %K cognitive behavioral therapy %K chatbot %K relational conversational agent %K depression %K anxiety %K suicide %K self-harm %K pandemic %K pediatric %K youth %K adolescent %K adolescence %K psychiatry %K conversational agent %K CBT %K clinic %K data %K acceptability %K feasibility %K usability %K primary care %K intervention %K mental health %K digital health %K technology mediated %K computer mediated %D 2022 %7 22.11.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Symptoms of depression and anxiety, suicidal ideation, and self-harm have escalated among adolescents to crisis levels during the COVID-19 pandemic. As a result, primary care providers (PCPs) are often called on to provide first-line care for these youth. Digital health interventions can extend mental health specialty care, but few are evidence based. We evaluated the feasibility of delivering an evidence-based mobile health (mHealth) app with an embedded conversational agent to deliver cognitive behavioral therapy (CBT) to symptomatic adolescents presenting in primary care settings during the pandemic. Objective: In this 12-week pilot study, we evaluated the feasibility of delivering the app-based intervention to adolescents aged 13 to 17 years with moderate depressive symptoms who were treated in a practice-based research network (PBRN) of academically affiliated primary care clinics. We also obtained preliminary estimates of app acceptability, effectiveness, and usability. Methods: This small, pilot randomized controlled trial (RCT) evaluated depressive symptom severity in adolescents randomized to the app or to a wait list control condition. The primary end point was depression severity at 4-weeks, measured by the 9-item Patient Health Questionnaire (PHQ-9). Data on acceptability, feasibility, and usability were collected from adolescents and their parent or legal guardian. Qualitative interviews were conducted with 13 PCPs from 11 PBRN clinics to identify facilitators and barriers to incorporating mental health apps in treatment planning for adolescents with depression and anxiety. Results: The pilot randomized 18 participants to the app (n=10, 56%) or to a wait list control condition (n=8, 44%); 17 participants were included in the analysis, and 1 became ineligible upon chart review due to lack of eligibility based on documented diagnosis. The overall sample was predominantly female (15/17, 88%), White (15/17, 88%), and privately insured (15/17, 88%). Mean PHQ-9 scores at 4 weeks decreased by 3.3 points in the active treatment group (representing a shift in mean depression score from moderate to mild symptom severity categories) and 2 points in the wait list control group (no shift in symptom severity category). Teen- and parent-reported usability, feasibility, and acceptability of the app was high. PCPs reported preference for introducing mHealth interventions like the one in this study early in the course of care for individuals presenting with mild or moderate symptoms. Conclusions: In this small study, we demonstrated the feasibility, acceptability, usability, and safety of using a CBT-based chatbot for adolescents presenting with moderate depressive symptoms in a network of PBRN-based primary care clinics. This pilot study could not establish effectiveness, but our results suggest that further study in a larger pediatric population is warranted. Future study inclusive of rural, socioeconomically disadvantaged, and underrepresented communities is needed to establish generalizability of effectiveness and identify implementation-related adaptations needed to promote broader uptake in pediatric primary care. Trial Registration: ClinicalTrials.gov NCT04603053; https://clinicaltrials.gov/ct2/show/NCT04603053 %M 36413390 %R 10.2196/40242 %U https://formative.jmir.org/2022/11/e40242 %U https://doi.org/10.2196/40242 %U http://www.ncbi.nlm.nih.gov/pubmed/36413390 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 11 %P e40719 %T Mental Health Chatbot for Young Adults With Depressive Symptoms During the COVID-19 Pandemic: Single-Blind, Three-Arm Randomized Controlled Trial %A He,Yuhao %A Yang,Li %A Zhu,Xiaokun %A Wu,Bin %A Zhang,Shuo %A Qian,Chunlian %A Tian,Tian %+ Institute of Applied Psychology, College of Education, Tianjin University, 135 Yaguan Road, Jinnan District, Tianjin, 300354, China, 86 13752183496, yangli@tju.edu.cn %K chatbot %K conversational agent %K depression %K mental health %K mHealth %K digital medicine %K randomized controlled trial %K evaluation %K cognitive behavioral therapy %K young adult %K youth %K health service %K mobile health %K COVID-19 %D 2022 %7 21.11.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression has a high prevalence among young adults, especially during the COVID-19 pandemic. However, mental health services remain scarce and underutilized worldwide. Mental health chatbots are a novel digital technology to provide fully automated interventions for depressive symptoms. Objective: The purpose of this study was to test the clinical effectiveness and nonclinical performance of a cognitive behavioral therapy (CBT)–based mental health chatbot (XiaoE) for young adults with depressive symptoms during the COVID-19 pandemic. Methods: In a single-blind, 3-arm randomized controlled trial, participants manifesting depressive symptoms recruited from a Chinese university were randomly assigned to a mental health chatbot (XiaoE; n=49), an e-book (n=49), or a general chatbot (Xiaoai; n=50) group in a ratio of 1:1:1. Participants received a 1-week intervention. The primary outcome was the reduction of depressive symptoms according to the 9-item Patient Health Questionnaire (PHQ-9) at 1 week later (T1) and 1 month later (T2). Both intention-to-treat and per-protocol analyses were conducted under analysis of covariance models adjusting for baseline data. Controlled multiple imputation and δ-based sensitivity analysis were performed for missing data. The secondary outcomes were the level of working alliance measured using the Working Alliance Questionnaire (WAQ), usability measured using the Usability Metric for User Experience-LITE (UMUX-LITE), and acceptability measured using the Acceptability Scale (AS). Results: Participants were on average 18.78 years old, and 37.2% (55/148) were female. The mean baseline PHQ-9 score was 10.02 (SD 3.18; range 2-19). Intention-to-treat analysis revealed lower PHQ-9 scores among participants in the XiaoE group compared with participants in the e-book group and Xiaoai group at both T1 (F2,136=17.011; P<.001; d=0.51) and T2 (F2,136=5.477; P=.005; d=0.31). Better working alliance (WAQ; F2,145=3.407; P=.04) and acceptability (AS; F2,145=4.322; P=.02) were discovered with XiaoE, while no significant difference among arms was found for usability (UMUX-LITE; F2,145=0.968; P=.38). Conclusions: A CBT-based chatbot is a feasible and engaging digital therapeutic approach that allows easy accessibility and self-guided mental health assistance for young adults with depressive symptoms. A systematic evaluation of nonclinical metrics for a mental health chatbot has been established in this study. In the future, focus on both clinical outcomes and nonclinical metrics is necessary to explore the mechanism by which mental health chatbots work on patients. Further evidence is required to confirm the long-term effectiveness of the mental health chatbot via trails replicated with a longer dose, as well as exploration of its stronger efficacy in comparison with other active controls. Trial Registration: Chinese Clinical Trial Registry ChiCTR2100052532; http://www.chictr.org.cn/showproj.aspx?proj=135744 %M 36355633 %R 10.2196/40719 %U https://www.jmir.org/2022/11/e40719 %U https://doi.org/10.2196/40719 %U http://www.ncbi.nlm.nih.gov/pubmed/36355633 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 11 %P e40261 %T A Conversational, Virtual, Avatar-Led Cognitive Behavioral Therapy App Intervention for Improving the Quality of Life and Mental Health of People With Epilepsy: Protocol for a Randomized Controlled Trial %A Burbach,Frank %A Lecce,Francesca %A Allen,Victoria M E %A Porter,Catherine M %+ Healios Ltd, 4a Tileyard Studios Tileyard Road Kings Cross, London, N7 9AH, United Kingdom, 44 330 124 4222, frank.burbach@healios.org.uk %K epilepsy %K mental health %K anxiety %K depression %K quality of life %K cognitive behavioral therapy %K digital therapy %K smartphone %K mobile phone %K app %D 2022 %7 21.11.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Epilepsy is a common neurological disorder affecting about 1 in 100 people in the United Kingdom. Many individuals experience a lower quality of life as a result of their epilepsy diagnosis and are more likely to develop mental health problems, such as anxiety and depression. Medical interventions for this client group tend to focus on the treatment of seizures, whereas mental health disorders often remain undiagnosed and untreated. Early identification and treatment of mental health difficulties in people with epilepsy are vital to ensure better outcomes and improvements in quality of life. Objective: The aim of this exploratory randomized controlled trial is to evaluate whether an 8-week cognitive behavioral therapy–based intervention delivered through a mobile app—ThinkNinja for Epilepsy—is a clinically effective tool to improve quality of life, mental health, and emotional well-being in a large sample of people with epilepsy and anxiety or comorbid anxiety and depression. Methods: The study aims to recruit 184 individuals, 18 to 65 years of age, with a self-reported diagnosis of epilepsy and anxiety or comorbid anxiety and depression. Participants will be randomly assigned to the ThinkNinja for Epilepsy app condition (arm A) or the waiting-list control group (arm B). Participants in arm A will receive access to the ThinkNinja for Epilepsy app first. After 8 weeks, participants in arm B will receive the same full access to the ThinkNinja for Epilepsy app as the participants in arm A. This design will allow an initial between-subjects analysis between the two conditions as well as a within-subject analysis including all participants. The primary outcome is participants’ quality of life, measured by the 10-item patient-weighted Quality of Life in Epilepsy questionnaire. The secondary outcomes include measures of anxiety, using the 7-item Generalized Anxiety Disorder assessment; depression, using the 9-item Patient Health Questionnaire; medication adherence, using the Medication Adherence Questionnaire; and impression of change, using the Patient Global Impression of Change questionnaire. Results: Recruitment for this study began in March 2022 and was completed in October 2022. We expect data collection to be finalized by May 2023 and study results to be available within 12 months of the final data collection date. Results of the study will be written up as soon as possible thereafter, with the intention of publishing the outcomes in high-quality peer-reviewed journals. Conclusions: This study aims to determine the clinical efficacy and safety of the ThinkNinja for Epilepsy intervention at improving the quality of life, mental health, and emotional well-being of people with epilepsy. The findings from our study will hopefully contribute to addressing the critical gap in universal provision and accessibility of mental health and emotional well-being support for people with epilepsy. Trial Registration: ISRCTN Registry 16270209 (04/03/2022); https://www.isrctn.com/ISRCTN16270209 International Registered Report Identifier (IRRID): DERR1-10.2196/40261 %M 36409536 %R 10.2196/40261 %U https://www.researchprotocols.org/2022/11/e40261 %U https://doi.org/10.2196/40261 %U http://www.ncbi.nlm.nih.gov/pubmed/36409536 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 11 %P e41721 %T Mental Health Outcomes for Youths With Public Versus Private Health Insurance Attending a Telehealth Intensive Outpatient Program: Quality Improvement Analysis %A Gliske,Kate %A Berry,Katie R %A Ballard,Jaime %A Evans-Chase,Michelle %A Solomon,Phyllis L %A Fenkel,Caroline %+ Charlie Health, 233 E Main St., Suite 401, Bozeman, MT, 59715, United States, 1 952 334 1411, kate.gliske@charliehealth.com %K telehealth %K telepsychiatry %K telemedicine %K intensive outpatient %K remote outpatient %K mental health %K quality improvement %K routine outcome monitoring %K mental health treatment %K patient outcome %K outpatient program %K youth %K young adult %K depression %K suicidal ideation %K health outcome %K outcome monitoring %D 2022 %7 10.11.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: COVID-19 exacerbated a growing mental health crisis among youths and young adults, worsened by a lack of existing in-person options for high-acuity care. The emergence and growth of remote intensive outpatient programs (IOPs) is a solution to overcome geographic limitations to care. However, it remains unclear whether remote IOPs engender equivalent clinical outcomes among youths with public insurance (eg, Medicaid) versus private insurance (eg, commercial) given the disparities found in previous research on place-based treatment in both clinical and engagement outcomes. Objective: This analysis sought to establish, as part of ongoing quality improvement efforts, whether engagement and clinical outcomes among adolescents and young adults attending remote IOP treatment differed between youths with public and those with private insurance. The identification of disparities by payer type was used to inform programmatic decisions within the remote IOP system for which this quality improvement analysis was conducted. Methods: Pearson chi-square analyses and independent 2-tailed t tests were used to establish that the 2 groups defined by insurance type were equivalent on clinical outcomes (depression, suicidal ideation, and nonsuicidal self-injury [NSSI]) at intake and compare changes in clinical outcomes. McNemar chi-square analyses and repeated-measure 2-tailed t tests were used to assess changes in clinical outcomes between intake and discharge in the sample overall. In total, 495 clients who attended the remote IOP for youths and young adults in 14 states participated in ≥7 treatment sessions, and completed intake and discharge surveys between July 2021 and April 2022 were included in the analysis. Results: Overall, the youths and young adults in the remote IOP attended a median of 91% of their scheduled group sessions (mean 85.9%, SD 16.48%) and reported significantly fewer depressive symptoms at discharge (t447=12.51; P<.001). McNemar chi-square tests of change indicated significant reductions from intake to discharge in suicidal ideation (N=470, χ21=104.4; P<.001), with nearly three-quarters of youths who reported active suicidal ideation at intake (200/468, 42.7%) no longer reporting it at discharge (142/200, 71%), and in NSSI (N=430, χ21=40.7; P<.001), with more than half of youths who reported NSSI at intake (205/428, 47.9%) reporting lower self-harm at discharge (119/205, 58%). No significant differences emerged by insurance type in attendance (median public 89%, median private 92%; P=.10), length of stay (t416=−0.35; P=.73), or reductions in clinical outcomes (depressive symptom severity: t444=−0.87 and P=.38; active suicidal ideation: N=200, χ21=0.6 and P=.49; NSSI frequency: t426=−0.98 and P=.33). Conclusions: Our findings suggest that youths and young adults who participated in remote IOP had significant reductions in depression, suicidal ideation, and NSSI. Given access to the same remote high-acuity care, youths and young adults on both public and private insurance engaged in programming at comparable rates and achieved similar improvements in clinical outcomes. %M 36355428 %R 10.2196/41721 %U https://formative.jmir.org/2022/11/e41721 %U https://doi.org/10.2196/41721 %U http://www.ncbi.nlm.nih.gov/pubmed/36355428 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 11 %P e37101 %T Psychological Disorders of Patients With Allergic Rhinitis in Chengdu, China: Exploratory Research %A Huang,Heyin %A Wang,Yichen %A Zhang,Lanzhi %A Zhang,Qinxiu %A Wu,Xiaojuan %A He,Hengsheng %+ Department of Otolaryngology, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, No. 39-41, Shierqiao Road, Jinniu District, Chengdu, 610000, China, 86 18980880173, zhqinxiu@163.com %K psychological disorders %K allergic rhinitis %K Chengdu %K China %D 2022 %7 10.11.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The number of patients with allergic rhinitis (AR) has exceeded 500 million worldwide due to the unstable curative effect that can easily produce mental and psychological disorders. However, most of the relevant existing literature is one-on-one retrospective analyses or targeted meta-analyses of AR with psychological disorders like irritability, depression, and anxiety, while “multi-hospital + interdisciplinary” multiple regression analyses are scarce. Objective: This study aims to precisely identify the psychological disorders of patients with AR who were diagnosed and treated in the five most renowned hospitals in Chengdu, China over the past 5 years using 10 classification methods so as to attract attention and care from otolaryngologists. Methods: The Symptom Checklist 90 (SCL-90) was used to group and score the mental state of 827 strictly screened patients with AR according to 9 classification criteria. The scores were then compared within groups. Intergroup comparisons were made between the study group and the Chinese norm, and the positive factors for psychological disorders were extracted. Four symptoms in the study group, that is, nasal itching, sneezing, clear discharge, and nasal congestion, were scored on a visual analog scale. Partial correlation analysis was performed between the extracted positive factors for psychological disorders and the symptom scores by the multiple regression statistical method. Results: Among 827 patients, 124 (15%) had no mental health impairments, 176 (21.3%) had mild impairments, 474 (57.3%) had mild to moderate impairments, 41 (5%) had moderate to severe impairments, and 12 (1.4%) had severe impairments. The average score of the SCL-90 for all 827 patients was 2.64 (SD 0.25), which corresponded to mild to moderate mental health impairments. The 827 patients scored significantly higher for the 4 positive factors: depression, anxiety, psychosis, and other (sleep, diet). Depression was positively correlated with sneezing and clear discharge, anxiety was positively correlated with nasal itching and congestion, psychosis was positively correlated with nasal itching and sneezing, and other (sleep, diet) was positively correlated with clear discharge and nasal congestion. Conclusions: Patients with AR have mild to moderate mental health impairments, with women and those with abnormal BMI, aged ≥45 years, with a monthly salary <¥5110 (US $700), with a disease duration <13 years, residing in urban areas, with a high school or above education, or who are indoor laborers being at high risk and requiring more care, follow-up, and comprehensive therapy from otolaryngologists. %M 36355407 %R 10.2196/37101 %U https://formative.jmir.org/2022/11/e37101 %U https://doi.org/10.2196/37101 %U http://www.ncbi.nlm.nih.gov/pubmed/36355407 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 11 %P e39122 %T Barriers to and Facilitators of Engaging With and Adhering to Guided Internet-Based Interventions for Depression Prevention and Reduction of Pain-Related Disability in Green Professions: Mixed Methods Study %A Braun,Lina %A Freund,Johanna %A Thielecke,Janika %A Baumeister,Harald %A Ebert,David Daniel %A Titzler,Ingrid %+ Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University of Ulm, Lise-Meitner-Str. 16, Ulm, 89081, Germany, 49 731 50 32814, lina.braun@uni-ulm.de %K internet-based intervention %K depression %K chronic pain %K barriers and facilitators %K qualitative research %K uptake %K adherence %K farmers %K gardeners %K foresters %D 2022 %7 9.11.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Internet-based interventions (IBIs) are effective for the prevention and treatment of mental disorders and are valuable additions for improving routine care. However, the uptake of and adherence to IBIs are often limited. To increase the actual use of IBIs, it is important to identify factors for engaging with and adhering to IBIs. Objective: We qualitatively evaluated barriers and facilitators regarding a portfolio of guided IBIs in green professions (farmers, gardeners, and foresters). Methods: Interview participants were selected from 2 randomized controlled trials for either the prevention of depression (Prevention of Depression in Agriculturists [PROD-A]) or the reduction of pain interference (Preventive Acceptance and Commitment Therapy for Chronic Pain in Agriculturists [PACT-A]) in green professions. The intervention group in PROD-A (N=180) participated in an IBI program, receiving access to 1 of 6 symptom-tailored IBIs. The intervention group in PACT-A (N=44) received access to an IBI for chronic pain. Overall, 41 semistructured qualitative interviews were conducted and transcribed verbatim. Barriers and facilitators were identified via inductive qualitative content analysis, with 2 independent coders reaching almost perfect intercoder reliability (Cohen κ=0.92). A quantitative follow-up survey (30/41, 73%) was conducted to validate the results. Subgroup analyses were performed based on intervention characteristics. Results: We identified 42 barriers and 26 facilitators, which we assigned to 4 superordinate categories related to the intervention (20 barriers; 17 facilitators), work (4 barriers; 1 facilitator), individual (13 barriers; 8 facilitators), and technical (5 barriers; 0 facilitators) aspects. Key barriers (identified by at least 50% of the interviewees) were time-consuming work life (29/40, 73%) and time-consuming private life (23/40, 58%). Similarly, the most frequently identified facilitators included presence of motivation, curiosity, interest and perseverance (30/40, 75%), flexible time management at work (25/40, 63%), and support from family and friends (20/40, 50%). Although agreement with barriers in the quantitative follow-up survey was rather low (mean 24%, SD 11%), agreement with facilitators was substantially higher (mean 80%, SD 13%). Differences in agreement rates were found particularly between intervention completers and noncompleters. Completers agreed significantly more often that perceived IBI success; being motivated, curious, interested, and perseverant; and having a persisting level of psychological strain have been facilitating. Noncompleters agreed more often with experiencing the e-coach contact as insufficient and technical problems as hindering for intervention completion. Conclusions: Based on these results, strategies such as customization of modules for more flexible and adaptive use; video chat options with the e-coach; options to facilitate social support by family, friends, or other participants; or using prompts to facilitate training completion can be derived. These approaches could be evaluated in further quantitative research designs in terms of their potential to enhance intervention use in this occupational group. Trial Registration: German Clinical Trials Register DRKS00014000, https://tinyurl.com/3bukfr48; German Clinical Trials Register DRKS0001461, https://tinyurl.com/ebsn4sns %M 36350684 %R 10.2196/39122 %U https://mental.jmir.org/2022/11/e39122 %U https://doi.org/10.2196/39122 %U http://www.ncbi.nlm.nih.gov/pubmed/36350684 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 11 %P e41689 %T Effectiveness of Mental Health Apps for Distress During COVID-19 in US Unemployed and Essential Workers: Remote Pragmatic Randomized Clinical Trial %A Comtois,Katherine Anne %A Mata-Greve,Felicia %A Johnson,Morgan %A Pullmann,Michael D %A Mosser,Brittany %A Arean,Patricia %+ Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 Pacific Stree NE, Seattle, WA, 98195, United States, 1 14152727222, parean@uw.edu %K COVID-19 %K COVID %K coronavirus %K pandemic %K SARS-CoV-2 %K essential worker %K suicide %K suicidal %K commercial app %K mental health apps %K health app %K mental health %K mHealth %K mobile health %K occupational health %K employee %K employment %K unemployed %K worker %K job %K depression %K anxiety %K stress %K distress %K mobile app %K RCT %K pragmatic trial %K randomized %K health care worker %K health care provider %K frontline staff %D 2022 %7 7.11.2022 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: During the COVID-19 pandemic, the general public was concerned about the mental health impacts of unemployment due to COVID-19 and the stress essential workers experienced during this time. Several reports indicated that people in distress were turning to digital technology, but there was little evidence about the impact of these tools on mitigating distress. Objective: This study seeks to determine the acceptability, feasibility, usability, and effectiveness of mobile mental health apps for decreasing mental health symptoms in essential workers and unemployed individuals with suicide risk. Methods: We recruited participants who indicated that they were unemployed because of COVID-19 or were COVID-19–designated essential workers. Participants were randomized to 1 of 4 free commercial mobile apps for managing distress that were (1) highly rated by PsyberGuide and (2) met the criteria for intervention features these participants indicated were desirable in a previous survey. Participants used the apps for 4 weeks and completed baseline and 4-week self-assessments of depression, anxiety emotional regulation, and suicide risk. Results: We found no differences between the apps in any outcome but did find significant changes in depression and anxiety over time (Patient Health Questionnaire [PHQ]-9: estimate=–1.5, SE 0.2, 95% CI –1.1 to –1.8, P<.001; Generalized Anxiety Disorder Scale [GAD]-7: estimate=–1.3, SE 0.2, 95% CI –1.0 to –1.6, P<.001). We found no significant changes in suicidal behavior (Suicide Behaviors Questionnaire-Revised [SBQ-R]) or emotional regulation (Difficulties in Emotion Regulation Scale – Short Form [DERS-SF]) for the 4 weeks. We did find a significant dose-response pattern for changes in depression and anxiety. Using the app at least once a week resulted in greater improvements in treatment conditions over time on depression (estimate=–0.6, SE 0.2, 95% CI 1.0-0.2, P=.003) and anxiety (estimate=0.1, SE 0.2, 95% CI 0.4-0.6, P=.78). There was no association between app frequency and changes in suicidal behavior (SBQ-R) or emotional regulation (DERS-SF). We further found a significant difference between the conditions with regard to app usability, with the control app being the most usable (meanBeautiful Mood 72.9, SD 16.7; meanCOVID Coach 71.2, SD 15.4; meanCalm 66.8, SD 17.3; mean7 Cups 65.2, SD 17.7). We found no significant differences for app acceptability or appropriateness. Conclusions: Few studies have evaluated prospectively the utility and usability of commercial apps for mood. This study found that free, self-guided commercial mobile mental health apps are seen as usable, but no one app is superior to the other. Although we found that regular use is indicated for effects on depression and anxiety to occur in those who are more symptomatic, regression to the mean cannot be ruled out. Trial Registration: ClinicalTrials.gov NCT04536935; https://tinyurl.com/mr36zx3s %M 36191176 %R 10.2196/41689 %U https://mhealth.jmir.org/2022/11/e41689 %U https://doi.org/10.2196/41689 %U http://www.ncbi.nlm.nih.gov/pubmed/36191176 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 11 %P e39912 %T User Engagement Within an Online Peer Support Community (Depression Connect) and Recovery-Related Changes in Empowerment: Longitudinal User Survey %A Smit,Dorien %A Vrijsen,Janna N %A Broekman,Theo %A Groeneweg,Bart %A Spijker,Jan %+ Pro Persona Mental Health Care, Pro Persona Research, Depression Expertise Centre, Nijmeegsebaan 61, Nijmegen, 6525 DX, Netherlands, 31 647074551, d.smit@propersona.nl %K depression %K online peer support community %K internet support group %K experiential knowledge %K self-management %K empowerment %K user engagement %K longitudinal user survey %D 2022 %7 2.11.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The chronic nature of depression and limited availability of evidence-based treatments emphasize the need for complementary recovery-oriented services, such as peer support interventions (PSIs). Peer support is associated with positive effects on clinical and personal recovery from mental illness, but little is known about the processes of engagement that foster change, and studies targeting individuals with depression specifically are limited. Objective: This study aimed to evaluate whether the level of user engagement, assessed on several dimensions, in an online peer support community for individuals with depression promotes empowerment and the use of self-management strategies and reduces symptom severity and disability. Methods: In a longitudinal survey conducted from June 2019 to September 2020, we analyzed the data of the users of Depression Connect (DC), an online peer support community hosted by the Dutch Patient Association for Depression and the Pro Persona Mental Health Care institute, on measures of empowerment, self-management, depression, and disability. Of the 301 respondents, 49 (16.3%) respondents completed the survey again after 3 months and 74 (24.6%) respondents, after 6 months. Analysis of 3 parameters (ie, total time spent on the platform, number of page views, and number of posts) derived from their data logs yielded 4 engagement profiles. Linear mixed models were fitted to determine whether the outcomes had significantly changed over time and differed for the various profiles. Results: Baseline engagement with the online peer support community was “very low” (177/301, 58.8%) or “low” (87/301, 28.9%) for most of the participants, with few showing “medium” (30/301, 9.9%) or “high” engagement patterns (7/301, 2.3%), while user profiles did not differ in demographic and clinical characteristics. Empowerment, self-management, depressive symptoms, and disability improved over time, but none were associated with the intensity or nature of user engagement. Conclusions: With most DC members showing very low to low engagement and only a few being identified as high-engaged users, it is likely that this flexibility in use frequency is what provides value to online PSI users. In other more formal supportive environments for depression, a certain level of engagement is predetermined either by their organizational or by their societal context; at DC, users can adapt the intensity and nature of their engagement to their current needs on their personal road to recovery. This study added to the current knowledge base on user engagement for PSIs because previous studies targeting depression with an online format focused on active users, precluding passive and flexible engagement. Future studies should explore the content and quality of the interactions in online PSIs to identify optimal user engagement as a function of current, self-reported clinical parameters and reasons to engage in the PSI. %M 36322110 %R 10.2196/39912 %U https://formative.jmir.org/2022/11/e39912 %U https://doi.org/10.2196/39912 %U http://www.ncbi.nlm.nih.gov/pubmed/36322110 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 11 %P e36496 %T Cost-Utility and Cost-effectiveness of MoodSwings 2.0, an Internet-Based Self-management Program for Bipolar Disorder: Economic Evaluation Alongside a Randomized Controlled Trial %A Chatterton,Mary Lou %A Lee,Yong Yi %A Berk,Lesley %A Mohebbi,Mohammadreza %A Berk,Michael %A Suppes,Trisha %A Lauder,Sue %A Mihalopoulos,Cathrine %+ Institute for Health Transformation, Deakin University, Locked Bag 20001, Geelong, 3220, Australia, 61 03 52278409, mchatter@deakin.edu.au %K economic evaluation %K cost-effectiveness %K cost-utility %K clinical trial %K bipolar disorder %K psychoeducation %K cognitive behavioral therapy %K internet intervention %K mania %K depression %K psychiatry %K neuroscience %K mental disorders %D 2022 %7 1.11.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Internet-delivered psychosocial interventions can overcome barriers to face-to-face psychosocial care, but limited evidence supports their cost-effectiveness for people with bipolar disorders (BDs). Objective: This study aimed to conduct within-trial cost-effectiveness and cost-utility analyses of an internet-based intervention for people with BD, MoodSwings 2.0, from an Australian health sector perspective. Methods: MoodSwings 2.0 included an economic evaluation alongside an international, parallel, and individually stratified randomized controlled trial comparing an internet-based discussion forum (control; group 1), a discussion forum plus internet-based psychoeducation (group 2), and a discussion forum plus psychoeducation and cognitive behavioral tools (group 3). The trial enrolled adults (aged 21 to 65 years) with a diagnosis of BD assessed by telephone using a structured clinical interview. Health sector costs included intervention delivery and additional health care resources used by participants over the 12-month trial follow-up. Outcomes included depression symptoms measured by the Montgomery-Åsberg Depression Rating Scale (MADRS; the trial primary outcome) and quality-adjusted life years (QALYs) calculated using the short-form 6-dimension instrument derived from the 12-item version of the short-form health survey. Average incremental cost-effectiveness (cost per MADRS score) and cost-utility (cost per QALY) ratios were calculated using estimated mean differences between intervention and control groups from linear mixed effects models in the base case. Results: In total, 304 participants were randomized. Average health sector cost was lowest for group 2 (Aus $9431, SD Aus $8540; Aus $1=US $0.7058) compared with the control group (Aus $15,175, SD Aus $17,206) and group 3 (Aus $15,518, SD Aus $30,523), but none was statistically significantly different. The average QALYs were not significantly different among the groups (group 1: 0.627, SD 0.062; group 2: 0.618, SD 0.094; and group 3: 0.622, SD 0.087). The MADRS scores were previously shown to differ significantly between group 2 and the control group at all follow-up time points (P<.05). Group 2 was dominant (lower costs and greater effects) compared with the control group for average incremental cost per point decrease in MADRS score over 12 months (95% CI dominated to Aus $331). Average cost per point change in MADRS score for group 3 versus the control group was dominant (95% CI dominant to Aus $22,585). Group 2 was dominant (95% CI Aus $43,000 to dominant) over the control group based on lower average health sector cost and average QALY benefit of 0.012 (95% CI –0.009 to 0.033). Group 3, compared with the control group, had an average incremental cost-effectiveness ratio of dominant (95% CI dominated to Aus $19,978). Conclusions: Web-based psychoeducation through MoodSwings 2.0 has the potential to be a cost-effective intervention for people with BD. Additional research is needed to understand the lack of effectiveness for the addition of cognitive behavioral tools with the group 3 intervention. %M 36318243 %R 10.2196/36496 %U https://mental.jmir.org/2022/11/e36496 %U https://doi.org/10.2196/36496 %U http://www.ncbi.nlm.nih.gov/pubmed/36318243 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 10 %P e33871 %T An App-Based Digit Symbol Substitution Test for Assessment of Cognitive Deficits in Adults With Major Depressive Disorder: Evaluation Study %A McIntyre,Roger S %A Lipsitz,Orly %A Rodrigues,Nelson B %A Subramaniapillai,Mehala %A Nasri,Flora %A Lee,Yena %A Fehnert,Ben %A King,James %A Chrones,Lambros %A Kratiuk,Kevin %A Uddin,Sharif %A Rosenblat,Joshua D %A Mansur,Rodrigo B %A McCue,Maggie %+ Brain and Cognition Discovery Foundation, 73 Mathersfield Drive, Toronto, ON, M4W 3W4, Canada, 1 416 603 5279, roger.mcintyre@bcdf.org %K depression %K DSST %K Digit Symbol Substitution Test %K smartphone %K technology %K measurement-based care %K cognition %D 2022 %7 27.10.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Cognitive dysfunction is an impairing core symptom of depression. Among adults with major depressive disorder (MDD) treated with antidepressants, residual cognitive symptoms interfere with patient-reported outcomes. The foregoing characterization of cognitive symptoms provides the rationale for screening and assessing the severity of cognitive symptoms at point of care. However, clinical neurocognitive assessments are time-consuming and difficult, and they require specialist expertise to interpret them. A smartphone-delivered neurocognitive test may offer an effective and accessible tool that can be readily implemented into a measurement-based care framework. Objective: We aimed to evaluate the use of a smartphone-delivered app-based version of the established Cognition Kit Digit Symbol Substitution Test (DSST) neurocognitive assessment compared to a traditional paper-and-pencil version. Methods: Convergent validity and test-retest reliability of the 2 versions were evaluated. Patient satisfaction with the app was also assessed. Results: Assessments made using the app-based Cognition Kit DSST were highly correlated with the standard paper-and-pencil version of the test, both at the baseline visit (r=0.69, df=27; P<.001) and at the end-of-study visit (r=0.82, df=27; P<.001), and they were positively evaluated by 30 patients as being user-friendly, easy to navigate, and preferable over the paper-and-pencil version of the DSST. However, although the app-based Cognition Kit DSST was validated in patients with MDD, it still needs to be evaluated in healthy controls. Conclusions: App-based DSST may facilitate a more personalized, convenient, and cost-effective method of cognitive assessment, helping to guide measurement-based care and psychotherapeutic and pharmacologic treatment options for patients with MDD. Trial Registration: ClinicalTrials.gov NCT03999567; https://tinyurl.com/2p8pnyv7 %M 36301615 %R 10.2196/33871 %U https://mental.jmir.org/2022/10/e33871 %U https://doi.org/10.2196/33871 %U http://www.ncbi.nlm.nih.gov/pubmed/36301615 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 10 %P e34923 %T Mobile App to Enhance Patient Activation and Patient-Provider Communication in Major Depressive Disorder Management: Collaborative, Randomized Controlled Pilot Study %A McCue,Maggie %A Blair,Christopher %A Fehnert,Ben %A King,James %A Cormack,Francesca %A Sarkey,Sara %A Eramo,Anna %A Kabir,Christopher %A Khatib,Rasha %A Kemp,David %+ Takeda Pharmaceuticals USA, Inc, 95 Hayden Ave, Lexington, MA, 02421, United States, 1 224 554 2820, Maggie.McCue@takeda.com %K depression %K major depressive disorder %K depression management %K patient engagement %K patient satisfaction %K mobile app %K patient-reported outcomes %K mobile phone %D 2022 %7 27.10.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Enhanced patient-provider engagement can improve patient health outcomes in chronic conditions, including major depressive disorder (MDD). Objective: We evaluated the impact of a digitally enabled care mobile app, Pathway, designed to improve MDD patient-provider engagement. Patients used a mobile interface to assess treatment progress and share this information with primary care providers (PCPs). Methods: In this 52-week, real-world effectiveness and feasibility study conducted in primary care clinics, 40 patients with MDD who were recently prescribed antidepressant monotherapy were randomized to use a mobile app with usual care (20/40, 50%) or usual care alone (20/40, 50%). Patients in the app arm engaged with the app daily for 18 weeks; a report was generated at 6-week intervals and shared with the PCPs to facilitate shared treatment decision-making discussions. The patients discontinued the app at week 18 and were followed through year 1. Coprimary outcome measures, assessed via research visits, included change from baseline in the 13-item Patient Activation Measure (PAM-13) and 7-item Patient-Provider Engagement Scale scores at week 18. Additional outcome measures included depression severity (9-item Patient Health Questionnaire [PHQ-9]) and cognitive symptoms (5-item Perceived Deficits Questionnaire–Depression). Results: All 37 patients (app arm: n=18, 49%; usual care arm: n=19, 51%) who completed the 18-week follow-up period (n=31, 84% female, mean age 36, SD 11.3 years) had moderate to moderately severe depression. Improvements in PAM-13 and PHQ-9 scores were observed in both arms. Increases in PAM-13 scores from baseline to 18 weeks were numerically greater in the app arm than in the usual care arm (mean 10.5, SD 13.2 vs mean 8.8, SD 9.4; P=.65). At 52 weeks, differences in PAM-13 scores from baseline demonstrated significantly greater improvements in the app arm than in the usual care arm (mean 20.2, SD 17.7 vs mean 1.6, SD 14.2; P=.04). Compared with baseline, PHQ-9 scores decreased in both the app arm and the usual care arm at 18 weeks (mean 7.8, SD 7.2 vs mean 7.0, SD 6.5; P=.73) and 52 weeks (mean 9.5, SD 4.0 vs mean 4.7, SD 6.0; P=.07). Improvements in 7-item Patient-Provider Engagement Scale and WHO-5 scores were observed in both arms at 18 weeks and were sustained through 52 weeks in the app arm. Improvements in WHO-5 scores at 52 weeks were significantly greater in the app arm than in the usual care arm (41.5 vs 20.0; P=.02). Conclusions: Patients with MDD will engage with a mobile app designed to track treatment and disease progression. PCPs will use the data generated as part of their assessment to inform clinical care. The study results suggest that an app-enabled clinical care pathway may enhance patient activation and benefit MDD management. Trial Registration: ClinicalTrials.gov NCT03242213; https://clinicaltrials.gov/ct2/show/NCT03242213 %M 36301599 %R 10.2196/34923 %U https://formative.jmir.org/2022/10/e34923 %U https://doi.org/10.2196/34923 %U http://www.ncbi.nlm.nih.gov/pubmed/36301599 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 10 %P e39233 %T Mindfulness Training for Depressed Older Adults Using Smartphone Technology: Protocol for a Fully Remote Precision Clinical Trial %A Schweiger,Abigail %A Rodebaugh,Thomas L %A Lenze,Eric J %A Keenoy,Katie %A Hassenstab,Jason %A Kloeckner,Jeanne %A Gettinger,Torie R %A Nicol,Ginger E %+ Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine, Campus Box 8134, 660 South Euclid, Saint Louis, MO, 63110, United States, 1 314 747 1862, nicolg@wustl.edu %K mHealth %K mindfulness %K depression %K aging %K precision medicine %K fully remote trial %K technology %K older %K adult %K smartphone %K clinical trial %K intervention %K death %K needs %K preferences %K online %K remote %K treatment %K depressed %K training %K mind %K session %K medicine %D 2022 %7 27.10.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Precision medicine, optimized interventions, and access to care are catchphrases for the future of behavioral treatments. Progress has been slow due to the dearth of clinical trials that optimize interventions’ benefits, individually tailor interventions to meet individual needs and preferences, and lead to rapid implementation after effectiveness is demonstrated. Two innovations have emerged to meet these challenges: fully remote trials and precision clinical trials. Objective: This paper provides a detailed description of Mindful MyWay, a study designed to test online mindfulness training in older adults with depression. Consistent with the concept of fully remote trials using a smartphone app, the study requires no in-person contact and can be conducted with participants anywhere in the United States. Based upon the precision medicine framework, the study assesses participants using high-frequency assessments of symptoms, cognitive performance, and patient preferences to both understand the individualized nature of treatment response and help individually tailor the intervention. Methods: Mindful MyWay is an open-label early-phase clinical trial for individuals 65 years and older with current depression. A smartphone app was developed to help coordinate the study, deliver the intervention, and evaluate the acceptability of the intervention, as well as predictors and outcomes of it. The curriculum for the fully remote intervention parallels the mindfulness-based stress reduction curriculum, a protocolized group-based mindfulness training that is typically provided in person. After consent and screening, participants download The Healthy Mind Lab mobile health smartphone app from the Apple App Store, allowing them to complete brief smartphone-based assessments of depressive symptoms and cognitive performance 4 times each day for 4 weeks prior to and after completing the intervention. The intervention consists of an introduction video and 10 weekly mindfulness training sessions, with the expectation to practice mindfulness at home daily. The app collects participant preference data throughout the 10-week intervention period; these high-frequency assessments identify participants’ individually dynamic preferences toward the goal of optimizing the intervention in future iterations. Results: Participant recruitment and data collection began in March 2019. Final end point assessments will be collected in May 2022. The paper describes lessons learned regarding the critical role of early-phase testing prior to moving to a randomized trial. Conclusions: The Mindful MyWay study is an exemplar of innovative clinical trial designs that use smartphone technology in behavioral and neuropsychiatric conditions. These include fully remote studies that can recruit throughout the United States, including hard-to-access areas, and collect high-frequency data, which is ideal for idiographic assessment and individualized intervention optimization. Our findings will be used to modify our methods and inform future randomized controlled trials within a precision medicine framework. Trial Registration: ClinicalTrials.gov NCT03922217; https://clinicaltrials.gov/ct2/show/NCT03922217 International Registered Report Identifier (IRRID): DERR1-10.2196/39233 %M 36301604 %R 10.2196/39233 %U https://www.researchprotocols.org/2022/10/e39233 %U https://doi.org/10.2196/39233 %U http://www.ncbi.nlm.nih.gov/pubmed/36301604 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 10 %P e31251 %T Factors Influencing Increased Use of Technology to Communicate With Others During the COVID-19 Pandemic: Cross-sectional Web-Based Survey Study %A Dawe-Lane,Erin %A Mutepua,Magano %A Morris,Daniel %A Odoi,Clarissa M %A Wilson,Emma %A Evans,Joanne %A Pinfold,Vanessa %A Wykes,Til %A Jilka,Sagar %A Simblett,Sara %+ Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, Henry Wellcome Building, London, SE5 8AF, United Kingdom, 44 2078480762, sara.simblett@kcl.ac.uk %K COVID-19 %K technology use %K communication %K demographics %K digital health %K mental health %K pandemic %K depression %K health technology %K psychosocial %K lockdown %K United Kingdom %K cross-sectional %K survey %K social interaction %K mental health %K social connection %K social connectivity %D 2022 %7 25.10.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Communication via technology is regarded as an effective way of maintaining social connection and helping individuals to cope with the psychological impact of social distancing measures during a pandemic. However, there is little information about which factors have influenced increased use of technology to communicate with others during lockdowns and whether this has changed over time. Objective: The aim of this study is to explore which psychosocial factors (eg, mental health and employment) and pandemic-related factors (eg, shielding and time) influenced an increase in communication via technology during the first lockdown in the United Kingdom. Methods: A cross-sectional, web-based survey was conducted between April and July 2020, examining thoughts, feelings, and behaviors associated with the pandemic, including communicating more using technology (eg, via messaging, phone, or video). We collected sociodemographic information, employment status, mental health service user status, and depression symptoms. We used hierarchical logistic regression to test which factors were associated with communicating more using technology during the lockdown. Results: Participants (N=1464) were on average 41.07 (SD 14.61) years old, and mostly women (n=1141; 77.9%), White (n=1265; 86.4%), and employed (n=1030; 70.4%). Participants reported a mild level of depression (mean 9.43, SD 7.02), and were communicating more using technology (n=1164; 79.5%). The hierarchical regression indicated that people who were employed and experiencing lower levels of depression were more likely to report increased communication using technology during a lockdown period of the COVID-19 pandemic, and over time, men communicated more using technology. Increased use of technology to communicate was related to greater communication and the inability to see others due to the social distancing measures enacted during the lockdown. It was not related to a general increase in technology use during the lockdown. Conclusions: Although most participants reported increased use of technology to communicate during a lockdown period of the COVID-19 pandemic, this was more apparent in the employed and those experiencing low levels of depression. Moving forward, we should continue to monitor groups who may have been excluded from the benefits of support and communication using technology. %M 35435852 %R 10.2196/31251 %U https://mental.jmir.org/2022/10/e31251 %U https://doi.org/10.2196/31251 %U http://www.ncbi.nlm.nih.gov/pubmed/35435852 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 10 %P e36656 %T Anxiety, Post–COVID-19 Syndrome-Related Depression, and Suicidal Thoughts and Behaviors in COVID-19 Survivors: Cross-sectional Study %A Woodward,Sean F %A Bari,Sumra %A Vike,Nicole %A Lalvani,Shamal %A Stetsiv,Khrystyna %A Kim,Byoung Woo %A Stefanopoulos,Leandros %A Maglaveras,Nicos %A Breiter,Hans %A Katsaggelos,Aggelos K %+ Department of Electrical and Computer Engineering, Northwestern University, 2145 Sheridan Road, Evanston, IL, 60208, United States, 1 847 491 3451, a-katsaggelos@northwestern.edu %K COVID-19 %K post–COVID-19 syndrome %K suicidality %K depression %K Patient Health Questionnaire-9 %K PHQ-9 %K State Trait Anxiety Index %K STAI %D 2022 %7 25.10.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Although the mental health impacts of COVID-19 on the general population have been well studied, studies of the long-term impacts of COVID-19 on infected individuals are relatively new. To date, depression, anxiety, and neurological symptoms associated with post–COVID-19 syndrome (PCS) have been observed in the months following COVID-19 recovery. Suicidal thoughts and behavior (STB) have also been preliminarily proposed as sequelae of COVID-19. Objective: We asked 3 questions. First, do participants reporting a history of COVID-19 diagnosis or a close relative having severe COVID-19 symptoms score higher on depression (Patient Health Questionnaire-9 [PHQ-9]) or state anxiety (State Trait Anxiety Index) screens than those who do not? Second, do participants reporting a COVID-19 diagnosis score higher on PCS-related PHQ-9 items? Third, do participants reporting a COVID-19 diagnosis or a close relative having severe COVID-19 symptoms score higher in STB before, during, or after the first year of the pandemic? Methods: This preliminary study analyzed responses to a COVID-19 and mental health questionnaire obtained from a US population sample, whose data were collected between February 2021 and March 2021. We used the Mann-Whitney U test to detect differences in the medians of the total PHQ-9 scores, PHQ-9 component scores, and several STB scores between participants claiming a past clinician diagnosis of COVID-19 and those denying one, as well as between participants claiming severe COVID-19 symptoms in a close relative and those denying them. Where significant differences existed, we created linear regression models to predict the scores based on COVID-19 response as well as demographics to identify potential confounding factors in the Mann-Whitney relationships. Moreover, for STB scores, which corresponded to 5 questions asking about 3 different time intervals (i.e., past 1 year or more, past 1 month to 1 year, and past 1 month), we developed repeated-measures ANOVAs to determine whether scores tended to vary over time. Results: We found greater total depression (PHQ-9) and state anxiety (State Trait Anxiety Index) scores in those with COVID-19 history than those without (Bonferroni P=.001 and Bonferroni P=.004) despite a similar history of diagnosed depression and anxiety. Greater scores were noted for a subset of depression symptoms (PHQ-9 items) that overlapped with the symptoms of PCS (all Bonferroni Ps<.05). Moreover, we found greater overall STB scores in those with COVID-19 history, equally in time windows preceding, during, and proceeding infection (all Bonferroni Ps<.05). Conclusions: We confirm previous studies linking depression and anxiety diagnoses to COVID-19 recovery. Moreover, our findings suggest that depression diagnoses associated with COVID-19 history relate to PCS symptoms, and that STB associated with COVID-19 in some cases precede infection. %M 35763757 %R 10.2196/36656 %U https://formative.jmir.org/2022/10/e36656 %U https://doi.org/10.2196/36656 %U http://www.ncbi.nlm.nih.gov/pubmed/35763757 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 10 %P e35538 %T User Behavior of a Publicly Available, Free-to-Use, Self-guided mHealth App for Depression: Observational Study in a Global Sample %A Su,Langting %A Anderson,Page Lyn %+ Department of Psychology, Georgia State University, Psychology Department, Urban Life Building, 140 Decatur Street, Atlanta, GA, 30033, United States, 1 404 822 7009, panderson@gsu.edu %K mHealth %K depression %K smartphone %K mobile app %K digital health %K global mental health %K MoodTools %K mobile health %K mental health %K mobile phone %K low- and middle-income countries %D 2022 %7 25.10.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Reducing the burden of depression is a global health concern. Self-guided mobile health (mHealth) apps are one approach to address this problem. However, there is little research on self-guided mHealth apps in a global sample or on how they are used in the real world. These gaps in our knowledge must be addressed to bring the promise of mHealth apps for reducing the global burden of depression closer to reality. Objective: The purpose of this study is to examine the naturalistic user behavior of MoodTools, a publicly available, free-to-use, self-guided mHealth app designed to improve symptoms of depression, in a global community sample. Methods: Mobile analytics data were collected from all unique downloads of the Android version of MoodTools between March 1, 2016, and February 28, 2018. Due to the deidentification and data aggregation process, no demographic or personal identifying information was tied to individual user data. All information was stored in aggregated, anonymized data files on Google Analytics’ storage database. Google’s software development kit was used to securely capture data about the number of downloads, location of downloads, number of app sessions, frequency and duration of app sessions, time between app sessions, and user retention, allowing for examination of which app’s tools were viewed and for how long, including Information (psychoeducation), Test (self-monitoring using the Patient Health Questionnaire [PHQ-9]), Thought Diary (targeting negative cognitions), Activities (behavioral activation), Videos (curated from YouTube), and Safety Plan (safety plan development and links to quickly access crisis management resources). Results: MoodTools was used by 158,930 people from 198 countries, including countries where English was not the primary language and in low- and middle-income countries. After the initial download, 51.14% (n=81,277) of users returned to the app after the initial download, and retention rates decreased with each subsequent app session. The typical person used the app for 3 sessions for a total of 12 minutes over 90 days. The most frequently visited tools were Test and Thought Diary (n=393,549, 24.32%). On average, users completed and reviewed the results of the PHQ-9 for 49 seconds and 53 seconds, respectively, and spent 3 minutes and 5 seconds on Thought Diary. Conclusions: Self-guided mHealth apps could be one approach (among the many needed) to reduce the burden of depression. Observational data collected in this study show a global interest in MoodTools, including in low- and middle-income countries and countries where English is not the primary language. Future research is needed to determine whether people who use self-guided apps experience improvement in depressive symptoms, and if so, what “dosage” provides a meaningful benefit. %M 36282559 %R 10.2196/35538 %U https://formative.jmir.org/2022/10/e35538 %U https://doi.org/10.2196/35538 %U http://www.ncbi.nlm.nih.gov/pubmed/36282559 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 10 %P e41445 %T Feasibility of Digital Cognitive Behavioral Therapy for Depressed Older Adults With the Moodbuster Platform: Protocol for 2 Pilot Feasibility Studies %A Amarti,Khadicha %A Schulte,Mieke H J %A Kleiboer,Annet %A Van Genugten,Claire Rosalie %A Oudega,Mardien %A Sonnenberg,Caroline %A Gonçalves,Gonçalo C %A Rocha,Artur %A Riper,Heleen %+ Clinical Psychology Section, Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit, De Boelelaan 1117, Amsterdam, 1081 HV, Netherlands, 31 020 59 83 348, k.amarti@vu.nl %K iCBT %K study protocol %K feasibility study %K acceptance %K satisfaction %K usability %K engagement %K depression severity %K older adults %D 2022 %7 25.10.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Internet-based interventions can be effective in the treatment of depression. However, internet-based interventions for older adults with depression are scarce, and little is known about their feasibility and effectiveness. Objective: To present the design of 2 studies aiming to assess the feasibility of internet-based cognitive behavioral treatment for older adults with depression. We will assess the feasibility of an online, guided version of the Moodbuster platform among depressed older adults from the general population as well as the feasibility of a blended format (combining integrated face-to-face sessions and internet-based modules) in a specialized mental health care outpatient clinic. Methods: A single-group, pretest-posttest design will be applied in both settings. The primary outcome of the studies will be feasibility in terms of (1) acceptance and satisfaction (measured with the Client Satisfaction Questionnaire-8), (2) usability (measured with the System Usability Scale), and (3) engagement (measured with the Twente Engagement with eHealth Technologies Scale). Secondary outcomes include (1) the severity of depressive symptoms (measured with the 8-item Patient Health Questionnaire depression scale), (2) participant and therapist experience with the digital technology (measured with qualitative interviews), (3) the working alliance between patients and practitioners (from both perspectives; measured with the Working Alliance Inventory–Short Revised questionnaire), (4) the technical alliance between patients and the platform (measured with the Working Alliance Inventory for Online Interventions–Short Form questionnaire), and (5) uptake, in terms of attempted and completed modules. A total of 30 older adults with mild to moderate depressive symptoms (Geriatric Depression Scale 15 score between 5 and 11) will be recruited from the general population. A total of 15 older adults with moderate to severe depressive symptoms (Geriatric Depression Scale 15 score between 8 and 15) will be recruited from a specialized mental health care outpatient clinic. A mixed methods approach combining quantitative and qualitative analyses will be adopted. Both the primary and secondary outcomes will be further explored with individual semistructured interviews and synthesized descriptively. Descriptive statistics (reported as means and SDs) will be used to examine the primary and secondary outcome measures. Within-group depression severity will be analyzed using a 2-tailed, paired-sample t test to investigate differences between time points. The interviews will be recorded and analyzed using thematic analysis. Results: The studies were funded in October 2019. Recruitment started in September 2022. Conclusions: The results of these pilot studies will show whether this platform is feasible for use by the older adult population in a blended, guided format in the 2 settings and will represent the first exploration of the size of the effect of Moodbuster in terms of decreased depressive symptoms. International Registered Report Identifier (IRRID): PRR1-10.2196/41445 %M 36282565 %R 10.2196/41445 %U https://www.researchprotocols.org/2022/10/e41445 %U https://doi.org/10.2196/41445 %U http://www.ncbi.nlm.nih.gov/pubmed/36282565 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 10 %P e39324 %T Sociodemographics and Transdiagnostic Mental Health Symptoms in SOCIAL (Studies of Online Cohorts for Internalizing Symptoms and Language) I and II: Cross-sectional Survey and Botometer Analysis %A Lorenzo-Luaces,Lorenzo %A Howard,Jacqueline %A Edinger,Andy %A Yan,Harry Yaojun %A Rutter,Lauren A %A Valdez,Danny %A Bollen,Johan %+ Department of Psychological and Brain Sciences, Indiana University-Bloomington, 1101 E 10th Street, Bloomington, IN, 47401, United States, 1 812 856 0866, lolorenz@indiana.edu %K depression %K anxiety %K pain %K alcohol %K social media %D 2022 %7 20.10.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Internalizing, externalizing, and somatoform disorders are the most common and disabling forms of psychopathology. Our understanding of these clinical problems is limited by a reliance on self-report along with research using small samples. Social media has emerged as an exciting channel for collecting a large sample of longitudinal data from individuals to study psychopathology. Objective: This study reported the results of 2 large ongoing studies in which we collected data from Twitter and self-reported clinical screening scales, the Studies of Online Cohorts for Internalizing Symptoms and Language (SOCIAL) I and II. Methods: The participants were a sample of Twitter-using adults (SOCIAL I: N=1123) targeted to be nationally representative in terms of age, sex assigned at birth, race, and ethnicity, as well as a sample of college students in the Midwest (SOCIAL II: N=1988), of which 61.78% (1228/1988) were Twitter users. For all participants who were Twitter users, we asked for access to their Twitter handle, which we analyzed using Botometer, which rates the likelihood of an account belonging to a bot. We divided participants into 4 groups: Twitter users who did not give us their handle or gave us invalid handles (invalid), those who denied being Twitter users (no Twitter, only available for SOCIAL II), Twitter users who gave their handles but whose accounts had high bot scores (bot-like), and Twitter users who provided their handles and had low bot scores (valid). We explored whether there were significant differences among these groups in terms of their sociodemographic features, clinical symptoms, and aspects of social media use (ie, platforms used and time). Results: In SOCIAL I, most individuals were classified as valid (580/1123, 51.65%), and a few were deemed bot-like (190/1123, 16.91%). A total of 31.43% (353/1123) gave no handle or gave an invalid handle (eg, entered “N/A”). In SOCIAL II, many individuals were not Twitter users (760/1988, 38.23%). Of the Twitter users in SOCIAL II (1228/1988, 61.78%), most were classified as either invalid (515/1228, 41.94%) or valid (484/1228, 39.41%), with a smaller fraction deemed bot-like (229/1228, 18.65%). Participants reported high rates of mental health diagnoses as well as high levels of symptoms, especially in SOCIAL II. In general, the differences between individuals who provided or did not provide their social media handles were small and not statistically significant. Conclusions: Triangulating passively acquired social media data and self-reported questionnaires offers new possibilities for large-scale assessment and evaluation of vulnerability to mental disorders. The propensity of participants to share social media handles is likely not a source of sample bias in subsequent social media analytics. %M 36264616 %R 10.2196/39324 %U https://formative.jmir.org/2022/10/e39324 %U https://doi.org/10.2196/39324 %U http://www.ncbi.nlm.nih.gov/pubmed/36264616 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 5 %N 4 %P e38879 %T Assessing the Racial and Socioeconomic Disparities in Postpartum Depression Using Population-Level Hospital Discharge Data: Longitudinal Retrospective Study %A Liu,Star %A Ding,Xiyu %A Belouali,Anas %A Bai,Haibin %A Raja,Kanimozhi %A Kharrazi,Hadi %+ Johns Hopkins University School of Medicine, 2024 E Monument St. S 1-200, Baltimore, MD, 21205, United States, 1 470 538 5974, sliu197@jhmi.edu %K health disparity %K hospital discharge summary %K phenotyping %K data quality %K vulnerable population %K postpartum depression %K maternal health %D 2022 %7 17.10.2022 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: In the United States, >3.6 million deliveries occur annually. Among them, up to 20% (approximately 700,000) of women experience postpartum depression (PPD) according to the Centers for Disease Control and Prevention. Absence of accurate reporting and diagnosis has made phenotyping of patients with PPD difficult. Existing literature has shown that factors such as race, socioeconomic status, and history of substance abuse are associated with the differential risks of PPD. However, limited research has considered differential temporal associations with the outcome. Objective: This study aimed to estimate the disparities in the risk of PPD and time to diagnosis for patients of different racial and socioeconomic backgrounds. Methods: This is a longitudinal retrospective study using the statewide hospital discharge data from Maryland. We identified 160,066 individuals who had a hospital delivery from 2017 to 2019. We applied logistic regression and Cox regression to study the risk of PPD across racial and socioeconomic strata. Multinomial regression was used to estimate the risk of PPD at different postpartum stages. Results: The cumulative incidence of PPD diagnosis was highest for White patients (8779/65,028, 13.5%) and lowest for Asian and Pacific Islander patients (248/10,760, 2.3%). Compared with White patients, PPD diagnosis was less likely to occur for Black patients (odds ratio [OR] 0.31, 95% CI 0.30-0.33), Asian or Pacific Islander patients (OR 0.17, 95% CI 0.15-0.19), and Hispanic patients (OR 0.21, 95% CI 0.19-0.22). Similar findings were observed from the Cox regression analysis. Multinomial regression showed that compared with White patients, Black patients (relative risk 2.12, 95% CI 1.73-2.60) and Asian and Pacific Islander patients (relative risk 2.48, 95% CI 1.46-4.21) were more likely to be diagnosed with PPD after 8 weeks of delivery. Conclusions: Compared with White patients, PPD diagnosis is less likely to occur in individuals of other races. We found disparate timing in PPD diagnosis across different racial groups and socioeconomic backgrounds. Our findings serve to enhance intervention strategies and policies for phenotyping patients at the highest risk of PPD and to highlight needs in data quality to support future work on racial disparities in PPD. %M 36103575 %R 10.2196/38879 %U https://pediatrics.jmir.org/2022/4/e38879 %U https://doi.org/10.2196/38879 %U http://www.ncbi.nlm.nih.gov/pubmed/36103575 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 10 %P e39204 %T Digital Mental Health Interventions for Depression: Scoping Review of User Engagement %A Lipschitz,Jessica M %A Van Boxtel,Rachel %A Torous,John %A Firth,Joseph %A Lebovitz,Julia G %A Burdick,Katherine E %A Hogan,Timothy P %+ Department of Psychiatry, Brigham and Women's Hospital, 221 Longwood Ave, Boston, MA, 02115, United States, 1 617 732 6548, jlipschitz@bwh.harvard.edu %K mHealth %K mobile apps %K engagement %K adherence %K randomized controlled trials %K depression %D 2022 %7 14.10.2022 %9 Review %J J Med Internet Res %G English %X Background: While many digital mental health interventions (DMHIs) have been found to be efficacious, patient engagement with DMHIs has increasingly emerged as a concern for implementation in real-world clinical settings. To address engagement, we must first understand what standard engagement levels are in the context of randomized controlled trials (RCTs) and how these compare with other treatments. Objective: This scoping review aims to examine the state of reporting on intervention engagement in RCTs of mobile app–based interventions intended to treat symptoms of depression. We sought to identify what engagement metrics are and are not routinely reported as well as what the metrics that are reported reflect about standard engagement levels. Methods: We conducted a systematic search of 7 databases to identify studies meeting our eligibility criteria, namely, RCTs that evaluated use of a mobile app–based intervention in adults, for which depressive symptoms were a primary outcome of interest. We then extracted 2 kinds of information from each article: intervention details and indices of DMHI engagement. A 5-element framework of minimum necessary DMHI engagement reporting was derived by our team and guided our data extraction. This framework included (1) recommended app use as communicated to participants at enrollment and, when reported, app adherence criteria; (2) rate of intervention uptake among those assigned to the intervention; (3) level of app use metrics reported, specifically number of uses and time spent using the app; (4) duration of app use metrics (ie, weekly use patterns); and (5) number of intervention completers. Results: Database searching yielded 2083 unique records. Of these, 22 studies were eligible for inclusion. Only 64% (14/22) of studies included in this review specified rate of intervention uptake. Level of use metrics was only reported in 59% (13/22) of the studies reviewed. Approximately one-quarter of the studies (5/22, 23%) reported duration of use metrics. Only half (11/22, 50%) of the studies reported the number of participants who completed the app-based components of the intervention as intended or other metrics related to completion. Findings in those studies reporting metrics related to intervention completion indicated that between 14.4% and 93.0% of participants randomized to a DMHI condition completed the intervention as intended or according to a specified adherence criteria. Conclusions: Findings suggest that engagement was underreported and widely varied. It was not uncommon to see completion rates at or below 50% (11/22) of those participants randomized to a treatment condition or to simply see completion rates not reported at all. This variability in reporting suggests a failure to establish sufficient reporting standards and limits the conclusions that can be drawn about level of engagement with DMHIs. Based on these findings, the 5-element framework applied in this review may be useful as a minimum necessary standard for DMHI engagement reporting. %M 36240001 %R 10.2196/39204 %U https://www.jmir.org/2022/10/e39204 %U https://doi.org/10.2196/39204 %U http://www.ncbi.nlm.nih.gov/pubmed/36240001 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 10 %P e37695 %T The Use of Close Friends on Instagram, Help-Seeking Willingness, and Suicidality Among Hong Kong Youth: Exploratory Sequential Mixed Methods Study %A Chen,Sikky Shiqi %A Lam,Tai Pong %A Lam,Kwok Fai %A Lo,Tak Lam %A Chao,David Vai Kiong %A Mak,Ki Yan %A Lam,Edmund Wing Wo %A Tang,Wai Sin %A Chan,Hoi Yan %A Yip,Paul Siu Fai %+ Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China, 852 25185688, tplam@hku.hk %K Close Friends %K private online expression %K help-seeking willingness %K suicide %K youth %D 2022 %7 12.10.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Social networking sites (SNSs) have gained popularity in recent years for help seeking and self-distress expression among adolescents. Although online suicidal expression is believed to have major benefits, various concerns have also been raised, particularly around privacy issues. Understanding youths’ help-seeking behavior on SNSs is critical for effective suicide prevention; however, most research neglects the impacts of the private SNS context. Objective: This study aims to examine youths’ private SNS use via the new Instagram feature, Close Friends, and its association with both online and offline help-seeking willingness as well as youths’ suicidality. Methods: This study employed an exploratory sequential mixed methods approach with a combination of explorative qualitative interviews and a systematic quantitative survey, targeting youth aged 15-19 years in Hong Kong. The motivations for utilizing Close Friends and concerns regarding online expression were addressed in the focus group and individual interviews (n=40). A cross-sectional survey (n=1676) was conducted subsequently with eligible secondary school students to examine the prevalence of Close Friends usage, their online and offline help-seeking willingness, and suicide-related experiences. Results: A total of 3 primary motives for using Close Friends were identified during interviews, including (1) interaction and help seeking, (2) release of negative emotions, and (3) ventilation and self-expression. Most participants also highlighted the privacy concerns associated with public online communication and the importance of contacting close friends for emotional support. Survey results showed that use of Close Friends was quite prevalent among adolescents (1163/1646, 70.66%), with around 46% (754/1646, 45.81%) of respondents being frequent users. Differences by gender and school academic banding were also revealed. Regarding help-seeking intentions, youths were generally positive about seeking help from peers and friends offline (1010/1266, 79.78%) yet negative about seeking assistance from online friends or professionals with whom they had not yet developed a real-world connection (173/1266, 13.67%). Most notably, frequencies of Close Friends usage were differentially associated with online and offline help-seeking willingness and youths’ suicidality. Compared with nonusers, those who had ever used the feature were more likely to seek offline support (adjusted odds ratios [AORs] 1.82-2.36), whereas heavy use of Close Friends was associated with increased odds of online help-seeking willingness (AOR 1.76, 95% CI 1.06-2.93) and a higher risk of suicidality (AOR 1.53, 95% CI 1.01-2.31). Conclusions: The popularity of Close Friends reflects the increasing need for private online expression among youth. This study demonstrates the importance of Close Friends for self-expression and private conversation and inadequacy of peer support for suicidal adolescents. Further research is needed to identify the causal relationship between Close Friends usage and help-seeking willingness to guide the advancement of suicide prevention strategies. Researchers and social media platforms may cooperate to co-design a risk monitoring system tailored to the private SNS context, assisting professionals in identifying youth at risk of suicide. %M 36223182 %R 10.2196/37695 %U https://www.jmir.org/2022/10/e37695 %U https://doi.org/10.2196/37695 %U http://www.ncbi.nlm.nih.gov/pubmed/36223182 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 10 %P e37968 %T A Digital Mental Health Intervention (Inuka) for Common Mental Health Disorders in Zimbabwean Adults in Response to the COVID-19 Pandemic: Feasibility and Acceptability Pilot Study %A Dambi,Jermaine %A Norman,Clara %A Doukani,Asmae %A Potgieter,Stephan %A Turner,Jean %A Musesengwa,Rosemary %A Verhey,Ruth %A Chibanda,Dixon %+ Rehabilitation Sciences Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Mt Pleasant, Harare, Zimbabwe, 263 773444911, jermainedambi@gmail.com %K acceptability %K COVID-19 %K feasibility %K Friendship Bench %K Inuka %K pilot %K task-shifting %K Zimbabwe %D 2022 %7 7.10.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Common mental health disorders (CMDs) are leading causes of disability globally. The ongoing COVID-19 pandemic has further exacerbated the burden of CMDs. COVID-19 containment measures, including lockdowns, have disrupted access to in-person mental health care. It is therefore imperative to explore the utility of digital mental health interventions to bridge the treatment gap. Mobile health technologies are effective tools for increasing access to treatment at a lower cost. This study explores the utility of Inuka, a chat-based app hinged on the Friendship Bench problem-solving therapy intervention. The Inuka app offers double anonymity, and clients can book or cancel a session at their convenience. Inuka services can be accessed either through a mobile app or the web. Objective: We aimed to explore the feasibility of conducting a future clinical trial. Additionally, we evaluated the feasibility, acceptability, appropriateness, scalability, and preliminary effectiveness of Inuka. Methods: Data were collected using concurrent mixed methods. We used a pragmatic quasiexperimental design to compare the feasibility, acceptability, and preliminary clinical effectiveness of Inuka (experimental group) and WhatsApp chat-based counseling (control). Participants received 6 problem-solving therapy sessions delivered by lay counselors. A reduction in CMDs was the primary clinical outcome. The secondary outcomes were health-related quality of life (HRQoL), disability and functioning, and social support. Quantitative outcomes were analyzed using descriptive and bivariate statistics. Finally, we used administrative data and semistructured interviews to gather data on acceptability and feasibility; this was analyzed using thematic analysis. Results: Altogether, 258 participants were screened over 6 months, with 202 assessed for eligibility, and 176 participants were included in the study (recruitment ratio of 29 participants/month). The participants’ mean age was 24.4 (SD 5.3) years, and most participants were female and had tertiary education. The mean daily smartphone usage was 8 (SD 3.5) hours. Eighty-three users signed up and completed at least one session. The average completion rate was 3 out of 4 sessions. Inuka was deemed feasible and acceptable in the local context, with connectivity challenges, app instability, expensive mobile data, and power outages cited as potential barriers to scale up. Generally, there was a decline in CMDs (F2,73=2.63; P=.08), depression (F2,73=7.67; P<.001), and anxiety (F2,73=2.95; P=.06) and a corresponding increase in HRQoL (F2,73=7.287; P<.001) in both groups. Conclusions: Study outcomes showed that it is feasible to run a future large-scale randomized clinical trial (RCT) and lend support to the feasibility and acceptability of Inuka, including evidence of preliminary effectiveness. The app’s double anonymity and structured support were the most salient features. There is a great need for iterative app updates before scaling up. Finally, a large-scale hybrid RCT with a longer follow-up to evaluate the clinical implementation and cost-effectiveness of the app is needed. %M 35960595 %R 10.2196/37968 %U https://mental.jmir.org/2022/10/e37968 %U https://doi.org/10.2196/37968 %U http://www.ncbi.nlm.nih.gov/pubmed/35960595 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 10 %P e35313 %T A Social Media Website (Supporting Our Valued Adolescents) to Support Treatment Uptake for Adolescents With Depression or Anxiety: Pilot Randomized Controlled Trial %A Radovic,Ana %A Li,Yaming %A Landsittel,Doug %A Odenthal,Kayla R %A Stein,Bradley D %A Miller,Elizabeth %+ Division of Adolescent and Young Adult Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 120 Lytton Ave, Suite 302, Pittsburgh, PA, 15213, United States, 1 412 692 7227, ana.radovic@chp.edu %K adolescent %K adolescent health services %K technology %K depression %K anxiety %D 2022 %7 7.10.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Adolescents with depression or anxiety initiate mental health treatment in low numbers. Supporting Our Valued Adolescents (SOVA) is a peer support website intervention for adolescents seen in primary care settings and their parents with the goal of increasing treatment uptake through changing negative health beliefs, enhancing knowledge, offering peer emotional support, and increasing parent-adolescent communication about mental health. Objective: This pilot study aimed to refine recruitment and retention strategies, refine document intervention fidelity, and explore changes in study outcomes (the primary outcome being treatment uptake). Methods: We conducted a 2-group, single-blind, pilot randomized controlled trial in a single adolescent medicine clinic. Participants were aged 12 to 19 years with clinician-identified symptoms of depression or anxiety for which a health care provider recommended treatment. The patient and parent, if interested, were randomized to receive the SOVA websites and enhanced usual care (EUC) compared with EUC alone. Baseline, 6-week, and 3-month measures were collected using a web-based self-report survey and blinded electronic health record review. The main pilot outcomes assessed were the feasibility of recruitment and retention strategies. Implementation outcomes, intervention fidelity, missingness, and adequacy of safety protocols were documented. Descriptive statistics were used to summarize mental health service use and target measures with 2-sample t tests to compare differences between arms. Results: Less than half of the adolescents who were offered patient education material (195/461, 42.2%) were referred by their clinician to the study. Of 146 adolescents meeting the inclusion criteria, 38 completed the baseline survey, qualifying them for randomization, and 25 (66%, 95% CI 51%-81%) completed the 6-week measures. There was limited engagement in the treatment arm, with 45% (5/11) of adolescents who completed 6-week measures reporting accessing SOVA, and most of those who did not access cited forgetting as the reason. Changes were found in target factors at 6 weeks but not in per-protocol analyses. At 12 weeks, 83% (15/18) of adolescents randomized to SOVA received mental health treatment as compared with 50% (10/20) of adolescents randomized to EUC (P=.03). Conclusions: In this pilot trial of a peer support website intervention for adolescents with depression or anxiety, we found lower-than-expected study enrollment after recruitment. Although generalizability may be enhanced by not requiring parental permission for adolescent participation in the trials of mental health interventions, this may limit study recruitment and retention. We found that implementing education introducing the study into provider workflow was feasible and acceptable, resulting in almost 500 study referrals. Finally, although not the primary outcome, we found a signal for greater uptake of mental health treatment in the arm using the SOVA intervention than in the usual care arm. Trial Registration: ClinicalTrials.gov NCT03318666; https://clinicaltrials.gov/ct2/show/NCT03318666 International Registered Report Identifier (IRRID): RR2-10.2196/12117 %M 36206044 %R 10.2196/35313 %U https://mental.jmir.org/2022/10/e35313 %U https://doi.org/10.2196/35313 %U http://www.ncbi.nlm.nih.gov/pubmed/36206044 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 10 %P e37342 %T Guided Internet-Delivered Treatment for Depression: Scoping Review %A Børtveit,Line %A Dechsling,Anders %A Sütterlin,Stefan %A Nordgreen,Tine %A Nordahl-Hansen,Anders %+ Faculty of Health, Welfare and Organisation, Østfold University College, Høgskolen i Østfold, Postboks 700, Halden, 1757, Norway, 47 93203985, linebortveit@gmail.com %K web-based therapy %K computer-assisted therapy %K internet %K digital interventions %K major depression %K mental health %K mobile phone %D 2022 %7 4.10.2022 %9 Review %J JMIR Ment Health %G English %X Background: Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder. Objective: The aim of this study was to provide an overview of this research area and identify potential gaps in the research. Methods: In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition. Results: A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion. Conclusions: This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies. %M 36194467 %R 10.2196/37342 %U https://mental.jmir.org/2022/10/e37342 %U https://doi.org/10.2196/37342 %U http://www.ncbi.nlm.nih.gov/pubmed/36194467 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 10 %P e41697 %T A Video-Delivered Family Therapeutic Intervention for Perinatal Women With Clinically Significant Depressive Symptoms and Family Conflict: Indicators of Feasibility and Acceptability %A Cluxton-Keller,Fallon %A Hegel,Mark T %+ Department of Psychiatry, Geisel School of Medicine, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, United States, 1 603 650 4724, Fallon.P.Cluxton-Keller@dartmouth.edu %K family intervention %K perinatal %K postnatal %K depression %K conflict %K telehealth %K family conflict %K family therapy %K family therapist %K video conferencing %K teleconference %K teleconferencing %K telemedicine %K virtual care %K mental health %K psychological health %K digital health intervention %K parenting %D 2022 %7 4.10.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Variation in family therapeutic intervention fidelity has an impact on outcomes. The use of video conferencing technology can strengthen therapist fidelity to family therapeutic interventions. Objective: This article explores indicators of feasibility and acceptability for a video-delivered family therapeutic intervention for perinatal women with depressive symptoms and family conflict. The objectives of this article are to describe indicators of feasibility, including therapist fidelity to the intervention and technological factors that relate to implementation of the intervention, as well as indicators of acceptability for participants of the intervention. Methods: The data included in this article are from an ongoing randomized trial of the Resilience Enhancement Skills Training (REST) video-delivered family therapeutic intervention. Participant recruitment and data collection are still underway for this clinical trial. Of the 106 participants who are currently enrolled in this study, 54 (51%) have been randomized to receive REST from May 2021 through July 2022. Currently, 2 therapists are delivering the intervention, and the training procedures for therapists are summarized herein. Therapist fidelity to the family therapeutic intervention was assessed in 67 audio recorded sessions. The training procedures were summarized for use of video conferencing technology by therapists and the 54 study participants. Knowledge of the video conferencing technology features was assessed in therapists and study participants by the number of attempts required to use the features. Participant responsiveness to the intervention was assessed by the percentage of attended sessions and percentage of complete homework assignments. Results: To date, both therapists have demonstrated high fidelity to the family therapeutic intervention and used all video conferencing technology features on their first attempt. The current participants required 1 to 3 attempts to use 1 or more of the video conferencing technology features. About 59% (n=32) of the current participants immediately accessed the features on the first attempt. Our results show that perinatal women attended all sessions, and their family members attended 80% of the sessions. To date, participants have completed 80% of the homework assignments. Conclusions: These early findings describe indicators of the feasibility and acceptability of the video-delivered family therapeutic intervention for use with this high priority population. Upon completion of recruitment and data collection, a subsequent article will include a mixed methods process evaluation of the feasibility and acceptability of the video-delivered family therapeutic intervention. Trial Registration: ClinicalTrials.gov NCT04741776; https://clinicaltrials.gov/ct2/show/NCT04741776 %M 36194458 %R 10.2196/41697 %U https://formative.jmir.org/2022/10/e41697 %U https://doi.org/10.2196/41697 %U http://www.ncbi.nlm.nih.gov/pubmed/36194458 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 9 %P e37746 %T Telehealth-Supported Decision-making Psychiatric Care for Suicidal Ideation: Longitudinal Observational Study %A O'Callaghan,Erin %A Mahrer,Nicole %A Belanger,Heather G %A Sullivan,Scott %A Lee,Christine %A Gupta,Carina T %A Winsberg,Mirène %+ Brightside Health Inc, 2471 Peralta St, Unit A, Oakland, CA, 94607, United States, 1 813 786 7685, heather.belanger@brightside.com %K telemedicine %K telehealth %K psychiatry %K mental health %K suicidal ideation %K depression %K anxiety %K suicide %K depressive disorder %K digital health %K eHealth %K psychiatric medication %K demographic %K psychiatric care %K decision-making %K decision support %D 2022 %7 30.9.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Suicide is a leading cause of death in the United States, and suicidal ideation (SI) is a significant precursor and risk factor for suicide. Objective: This study aimed to examine the impact of a telepsychiatric care platform on changes in SI over time and remission, as well as to investigate the relationship between various demographic and medical factors on SI and SI remission. Methods: Participants included 8581 US-based adults (8366 in the treatment group and 215 in the control group) seeking treatment for depression, anxiety, or both. The treatment group included patients who had completed at least 12 weeks of treatment and had received a prescription for at least one psychiatric medication during the study period. Providers prescribed psychiatric medications for each patient during their first session and received regular data on participants. They also received decision support at treatment onset via the digital platform, which leveraged an empirically derived proprietary precision-prescribing algorithm to give providers real-time care guidelines. Participants in the control group consisted of individuals who completed the initial enrollment data and completed surveys at baseline and 12 weeks but did not receive care. Results: Greater feelings of hopelessness, anhedonia, and feeling bad about oneself were most significantly correlated (r=0.24-0.37) with SI at baseline. Sleep issues and feeling tired or having low energy, although significant, had lower correlations with SI (r=0.13-0.14). In terms of demographic variables, advancing age and education were associated with less SI at baseline (r=−0.16) and 12 weeks (r=−0.10) but less improvement over time (r=−0.12 and −0.11, respectively). Although not different at baseline, the SI expression was evident in 34.4% (74/215) of the participants in the control group and 12.32% (1031/8366) of the participants in the treatment group at 12 weeks. Although the participants in the treatment group improved over time regardless of various demographic variables, participants in the control group with less education worsened over time, after controlling for age and depression severity. A model incorporating the treatment group, age, sex, and 8-item Patient Health Questionnaire scores was 77% accurate in its classification of complete remission. Those in the treatment group were 4.3 times more likely (odds ratio 4.31, 95% CI 2.88-6.44) to have complete SI remission than those in the control group. Female participants and those with advanced education beyond high school were approximately 1.4 times more likely (odds ratio 1.38, 95% CI 1.18-1.62) to remit than their counterparts. Conclusions: The results highlight the efficacy of an antidepressant intervention in reducing SI, in this case administered via a telehealth platform and with decision support, as well as the importance of considering covariates, or subpopulations, when considering SI. Further research and refinement, ideally via randomized controlled trials, are needed. %M 36178727 %R 10.2196/37746 %U https://formative.jmir.org/2022/9/e37746 %U https://doi.org/10.2196/37746 %U http://www.ncbi.nlm.nih.gov/pubmed/36178727 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 9 %P e36118 %T Detection of Depression Severity Using Bengali Social Media Posts on Mental Health: Study Using Natural Language Processing Techniques %A Kabir,Muhammad Khubayeeb %A Islam,Maisha %A Kabir,Anika Nahian Binte %A Haque,Adiba %A Rhaman,Md Khalilur %+ Department of Computer Science, Brac University, 66 Mohakhali, Dhaka, 1212, Bangladesh, 880 1708812609, muhammad.khubayeeb.kabir@g.bracu.ac.bd %K mental health forums %K natural language processing %K severity %K major depressive disorder %K deep learning %K machine learning %K multiclass text classification %D 2022 %7 28.9.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: There are a myriad of language cues that indicate depression in written texts, and natural language processing (NLP) researchers have proven the ability of machine learning and deep learning approaches to detect these cues. However, to date, these approaches bridging NLP and the domain of mental health for Bengali literature are not comprehensive. The Bengali-speaking population can express emotions in their native language in greater detail. Objective: Our goal is to detect the severity of depression using Bengali texts by generating a novel Bengali corpus of depressive posts. We collaborated with mental health experts to generate a clinically sound labeling scheme and an annotated corpus to train machine learning and deep learning models. Methods: We conducted a study using Bengali text-based data from blogs and open source platforms. We constructed a procedure for annotated corpus generation and extraction of textual information from Bengali literature for predictive analysis. We developed our own structured data set and designed a clinically sound labeling scheme with the help of mental health professionals, adhering to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) during the process. We used 5 machine learning models for detecting the severity of depression: kernel support vector machine (SVM), random forest, logistic regression K-nearest neighbor (KNN), and complement naive Bayes (NB). For the deep learning approach, we used long short-term memory (LSTM) units and gated recurrent units (GRUs) coupled with convolutional blocks or self-attention layers. Finally, we aimed for enhanced outcomes by using state-of-the-art pretrained language models. Results: The independent recurrent neural network (RNN) models yielded the highest accuracies and weighted F1 scores. GRUs, in particular, produced 81% accuracy. The hybrid architectures could not surpass the RNNs in terms of performance. Kernel SVM with term frequency–inverse document frequency (TF-IDF) embeddings generated 78% accuracy on test data. We used validation and training loss curves to observe and report the performance of our architectures. Overall, the number of available data remained the limitation of our experiment. Conclusions: The findings from our experimental setup indicate that machine learning and deep learning models are fairly capable of assessing the severity of mental health issues from texts. For the future, we suggest more research endeavors to increase the volume of Bengali text data, in particular, so that modern architectures reach improved generalization capability. %M 36169989 %R 10.2196/36118 %U https://formative.jmir.org/2022/9/e36118 %U https://doi.org/10.2196/36118 %U http://www.ncbi.nlm.nih.gov/pubmed/36169989 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 9 %P e38030 %T Digital Health Interventions for Depression and Anxiety Among People With Chronic Conditions: Scoping Review %A Shah,Amika %A Hussain-Shamsy,Neesha %A Strudwick,Gillian %A Sockalingam,Sanjeev %A Nolan,Robert P %A Seto,Emily %+ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada, 1 416 978 4326, amika.shah@mail.utoronto.ca %K depression %K anxiety %K multiple chronic conditions %K chronic disease %K mental health %K psychiatry %K digital health %K eHealth %K telehealth %K mobile health %K mHealth %K telemedicine %D 2022 %7 26.9.2022 %9 Review %J J Med Internet Res %G English %X Background: Chronic conditions are characterized by their long duration (≥1 year), need for ongoing medical attention, and limitations in activities of daily living. These can often co-occur with depression and anxiety as common and detrimental comorbidities among the growing population living with chronic conditions. Digital health interventions (DHIs) hold promise in overcoming barriers to accessing mental health support for these individuals; however, the design and implementation of DHIs for depression and anxiety in people with chronic conditions are yet to be explored. Objective: This study aimed to explore what is known in the literature regarding DHIs for the prevention, detection, or treatment of depression and anxiety among people with chronic conditions. Methods: A scoping review of the literature was conducted using the Arksey and O’Malley framework. Searches of the literature published in 5 databases between 1990 and 2019 were conducted in April 2019 and updated in March 2021. To be included, studies must have described a DHI tested with, or designed for, the prevention, detection, or treatment of depression or anxiety in people with common chronic conditions (arthritis, asthma, diabetes mellitus, heart disease, chronic obstructive pulmonary disease, cancer, stroke, and Alzheimer disease or dementia). Studies were independently screened by 2 reviewers against the inclusion and exclusion criteria. Both quantitative and qualitative data were extracted, charted, and synthesized to provide a descriptive summary of the trends and considerations for future research. Results: Database searches yielded 11,422 articles across the initial and updated searches, 53 (0.46%) of which were included in this review. DHIs predominantly sought to provide treatment (44/53, 83%), followed by detection (5/53, 9%) and prevention (4/53, 8%). Most DHIs were focused on depression (36/53, 68%), guided (32/53, 60%), tailored to chronic physical conditions (19/53, 36%), and delivered through web-based platforms (20/53, 38%). Only 2 studies described the implementation of a DHI. Conclusions: As a growing research area, DHIs offer the potential to address the gap in care for depression and anxiety among people with chronic conditions; however, their implementation in standard care is scarce. Although stepped care has been identified as a promising model to implement efficacious DHIs, few studies have investigated the use of DHIs for depression and anxiety among chronic conditions using such models. In developing stepped care, we outlined DHI tailoring, guidance, and intensity as key considerations that require further research. %M 36155409 %R 10.2196/38030 %U https://www.jmir.org/2022/9/e38030 %U https://doi.org/10.2196/38030 %U http://www.ncbi.nlm.nih.gov/pubmed/36155409 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 9 %P e38067 %T Assessing the Impact of Conversational Artificial Intelligence in the Treatment of Stress and Anxiety in Aging Adults: Randomized Controlled Trial %A Danieli,Morena %A Ciulli,Tommaso %A Mousavi,Seyed Mahed %A Silvestri,Giorgia %A Barbato,Simone %A Di Natale,Lorenzo %A Riccardi,Giuseppe %+ Signal & Interactive Systems Lab, Dipartimento di Ingegneria e Scienze dell'Informazione, Università degli Studi di Trento, via Sommarive 9, Povo di Trento - Trento, 38123, Italy, 39 5381237 ext 686, morena.danieli@unitn.it %K mental health care %K conversational artificial intelligence %K mobile health %K mHealth %K personal health care agent %D 2022 %7 23.9.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: While mental health applications are increasingly becoming available for large populations of users, there is a lack of controlled trials on the impacts of such applications. Artificial intelligence (AI)-empowered agents have been evaluated when assisting adults with cognitive impairments; however, few applications are available for aging adults who are still actively working. These adults often have high stress levels related to changes in their work places, and related symptoms eventually affect their quality of life. Objective: We aimed to evaluate the contribution of TEO (Therapy Empowerment Opportunity), a mobile personal health care agent with conversational AI. TEO promotes mental health and well-being by engaging patients in conversations to recollect the details of events that increased their anxiety and by providing therapeutic exercises and suggestions. Methods: The study was based on a protocolized intervention for stress and anxiety management. Participants with stress symptoms and mild-to-moderate anxiety received an 8-week cognitive behavioral therapy (CBT) intervention delivered remotely. A group of participants also interacted with the agent TEO. The participants were active workers aged over 55 years. The experimental groups were as follows: group 1, traditional therapy; group 2, traditional therapy and mobile health (mHealth) agent; group 3, mHealth agent; and group 4, no treatment (assigned to a waiting list). Symptoms related to stress (anxiety, physical disease, and depression) were assessed prior to treatment (T1), at the end (T2), and 3 months after treatment (T3), using standardized psychological questionnaires. Moreover, the Patient Health Questionnaire-8 and General Anxiety Disorders-7 scales were administered before the intervention (T1), at mid-term (T2), at the end of the intervention (T3), and after 3 months (T4). At the end of the intervention, participants in groups 1, 2, and 3 filled in a satisfaction questionnaire. Results: Despite randomization, statistically significant differences between groups were present at T1. Group 4 showed lower levels of anxiety and depression compared with group 1, and lower levels of stress compared with group 2. Comparisons between groups at T2 and T3 did not show significant differences in outcomes. Analyses conducted within groups showed significant differences between times in group 2, with greater improvements in the levels of stress and scores related to overall well-being. A general worsening trend between T2 and T3 was detected in all groups, with a significant increase in stress levels in group 2. Group 2 reported higher levels of perceived usefulness and satisfaction. Conclusions: No statistically significant differences could be observed between participants who used the mHealth app alone or within the traditional CBT setting. However, the results indicated significant differences within the groups that received treatment and a stable tendency toward improvement, which was limited to individual perceptions of stress-related symptoms. Trial Registration: ClinicalTrials.gov NCT04809090; https://clinicaltrials.gov/ct2/show/NCT04809090 %M 36149730 %R 10.2196/38067 %U https://mental.jmir.org/2022/9/e38067 %U https://doi.org/10.2196/38067 %U http://www.ncbi.nlm.nih.gov/pubmed/36149730 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 9 %P e37854 %T Psychometric Properties of the Hospital Anxiety and Depression Scale in Individuals With Chronic Obstructive Pulmonary Disease: Protocol for a Systematic Review %A Nikolovski,Aleksandra %A Gamgoum,Lara %A Deol,Arshpreet %A Quilichini,Shea %A Kazemir,Ethan %A Rhodenizer,Jonathan %A Oliveira,Ana %A Brooks,Dina %A Alsubheen,Sanaa %+ School of Rehabilitation Science, McMaster University, 1280 Main St W,, Hamilton, ON, L8S 4L8, Canada, 1 519 878 9647, alsubhes@mcmaster.ca %K COPD %K HADS %K reliability %K responsiveness %K validity %K anxiety %K depression %K mental health %K pulmonary %K systematic review %K protocol %K mortality %K functioning %K quality of life %K tool %K symptoms %K database %D 2022 %7 22.9.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: In individuals with chronic obstructive pulmonary disease (COPD), anxiety and depression contribute to increased mortality and exacerbations, decreased physical functioning, and deteriorated health-related quality of life. The Hospital Anxiety and Depression Scale (HADS) is a patient-reported tool developed to measure symptoms of anxiety and depression in clinical settings. The HADS has been frequently used with individuals with COPD; however, its measurement properties lack critical appraisal in this population. Objective: This review aims to summarize and critically appraise the validity, reliability, and responsiveness of the HADS in individuals with COPD. Methods: Five electronic databases (MEDLINE, Embase, Scopus, PsychINFO, and Web of Science) will be systematically searched. Articles will be included if they assessed the measurement properties of the HADS in COPD; were published in a peer-reviewed journal; and were written in English. The COSMIN (Consensus-based Standards for the Selection of Health Measurement Instruments) guidelines will be used to assess the methodological quality and level of evidence in the selected studies. Results: To date, 12 articles met the inclusion criteria and will be included in the systematic review. The results of the psychometric properties of HADS will be qualitatively summarized and compared against the criteria for good measurement properties. The overall quality of evidence will be graded using the modified Grading of Recommendations, Assessment, Development and Evaluation approach. We expect to complete the systematic review by December 2022. Conclusions: This systematic review will be the first to evaluate the psychometric properties of the HADS in individuals with COPD. Given the negative impact of anxiety and depression on physical functioning and health-related quality of life, this systematic review provides an opportunity to use the HADS as a validated measurement tool for the assessment and treatment of anxiety and depression in individuals with COPD. Trial Registration: PROSPERO CRD42022302064; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=302064 International Registered Report Identifier (IRRID): PRR1-10.2196/37854 %M 36136379 %R 10.2196/37854 %U https://www.researchprotocols.org/2022/9/e37854 %U https://doi.org/10.2196/37854 %U http://www.ncbi.nlm.nih.gov/pubmed/36136379 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 9 %P e38497 %T Preliminary Investigation of Shift, a Novel Smartphone App to Support Junior Doctors’ Mental Health and Well-being: Examination of Symptom Progression, Usability, and Acceptability After 1 Month of Use %A Sanatkar,Samineh %A Counson,Isabelle %A Mackinnon,Andrew %A Bartholomew,Alexandra %A Glozier,Nick %A Harvey,Samuel %+ Black Dog Institute, Hospital Road, Randwick, 2031, Australia, 61 02 9065 9179, s.sanatkar@unsw.edu.au %K digital mental health %K mobile health apps %K mHealth apps %K help seeking %K junior doctors %K depression %K mobile phone %D 2022 %7 21.9.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Shift is a novel smartphone app for providing a digital-first mental health resource to junior doctors. It contains psychoeducational material, cognitive behavioral modules, guided mediations, information on common work stressors, and a section on help-seeking options for psychological problems through workplace and private avenues. Objective: This study aimed to conduct a preliminary investigation of the use and potential effectiveness of Shift on depressive and anxiety symptoms (primary outcomes) and work and social functioning, COVID-19 safety concerns, and help seeking (secondary outcomes). This study also sought feedback on whether Shift was seen as an acceptable tool. Methods: Junior doctors in New South Wales, Australia, were approached through promotional activities from the Ministry of Health, specialist medical colleges, and social media advertisements between June and August 2020. Consenting participants provided web-based baseline data, used the Shift app for 30 days, and were asked to complete a poststudy web-based questionnaire. Outcomes were analyzed under the intention-to-treat principle. Results: A total of 222 (n=156 female, 70.3%; mean age 29.2, SD 4.61 years) junior doctors provided full baseline data. Of these, 89.2% (198/222) downloaded the app, logged into the app approximately 6 times (mean 5.68, SD 7.51), completed 4 in-app activities (mean 3.77, SD 4.36), and spent a total of 1 hour on in-app activities (mean 52:23, SD 6:00:18) over 30 days. Postintervention and app use data were provided by 24.3% (54/222) of participants. Depressive and anxiety symptoms significantly decreased between the pre- and postassessment points as expected; however, physicians’ COVID-19 safety concerns significantly increased. Work and social functioning, COVID-19 concerns for family and friends, and help seeking did not change significantly. There was no significant relationship between symptom changes and app use (number of log-ins, days between first and last log-in, and total activity time). Most poststudy completers (31/54, 57%) rated Shift highly or very highly. Conclusions: Despite high levels of nonresponse to the poststudy assessment and increases in COVID-19 safety concerns, junior doctors who used the app reported some improvements in depression and anxiety, which warrant further exploration in a robust manner. %M 36129745 %R 10.2196/38497 %U https://www.jmir.org/2022/9/e38497 %U https://doi.org/10.2196/38497 %U http://www.ncbi.nlm.nih.gov/pubmed/36129745 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 9 %P e39787 %T Waiting Lists for Psychotherapy and Provider Attitudes Toward Low-Intensity Treatments as Potential Interventions: Survey Study %A Peipert,Allison %A Krendl,Anne C %A Lorenzo-Luaces,Lorenzo %+ Department of Psychological and Brain Sciences, Indiana University Bloomington, 1101 E 10th St, Bloomington, IN, 47405, United States, 1 812 855 2012, lolorenz@indiana.edu %K psychotherapy %K CBT %K cognitive behavioral therapy %K behavior therapy %K digital mental health %K self-help %K support group %K mental health %K digital health %K eHealth %K low-intensity intervention %K survey %K waiting list %K health system %K health care delivery %K health care professional %K care provider %K bibliotherapy %K attitude %K perception %K digital intervention %K web-based intervention %K depression %K anxiety %K mental disorder %D 2022 %7 16.9.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Common mental disorders, including depression and anxiety, are leading causes of disability worldwide. Digital mental health interventions, such as web-based self-help and other low-intensity treatments (LITs) that are not digital (eg, bibliotherapy), have the potential to reach many individuals by circumventing common barriers present in traditional mental health care. It is unclear how often LITs are used in clinical practice, or whether providers would be interested in their use for treatment waiting lists. Objective: The aims of this study were to (1) describe current practices for treatment waiting lists, (2) describe providers’ attitudes toward digital and nondigital LITs for patients on a waiting list, and (3) explore providers’ willingness to use digital and nondigital LITs and their decisions to learn about them. Methods: We surveyed 141 practicing mental health care providers (eg, therapists and psychologists) and provided an opportunity for them to learn about LITs. Results: Most participants reported keeping a waiting list. Few participants reported currently recommending digital or nondigital LITs, though most were willing to use at least one for patients on their waiting list. Attitudes toward digital and nondigital LITs were neutral to positive. Guided digital and nondigital LITs were generally perceived to be more effective but less accessible, and unguided interventions were perceived to be less effective but more accessible. Most participants selected to access additional information on LITs, with the most popular being web-based self-help. Conclusions: Results suggest providers are currently not recommending LITs for patients on treatment waiting lists but would be willing to recommend them. Future work should explore barriers and facilitators to implementing digital and nondigital LITs for patients on treatment waiting lists. %M 36112400 %R 10.2196/39787 %U https://formative.jmir.org/2022/9/e39787 %U https://doi.org/10.2196/39787 %U http://www.ncbi.nlm.nih.gov/pubmed/36112400 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 3 %P e35486 %T Participants’ and Nurses’ Experiences With a Digital Intervention for Patients With Depressive Symptoms and Comorbid Hypertension or Diabetes in Peru: Qualitative Post–Randomized Controlled Trial Study %A Toyama,Mauricio %A Cavero,Victoria %A Araya,Ricardo %A Menezes,Paulo Rossi %A Mohr,David C %A Miranda,J Jaime %A Diez-Canseco,Francisco %+ CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 445, Miraflores, Lima, 15074, Peru, 51 958549065, m.toyama.g@gmail.com %K mobile intervention %K depression %K diabetes %K hypertension %K comorbidity %K qualitative research %K mobile phone %D 2022 %7 15.9.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Depression is one of the most prevalent mental disorders and a leading cause of disability, disproportionately affecting specific groups, such as patients with noncommunicable diseases. Over the past decade, digital interventions have been developed to provide treatment for these patients. CONEMO (Emotional Control in Spanish) is an 18-session psychoeducational digital intervention delivered through a smartphone app and minimally supported by a nurse. CONEMO demonstrated effectiveness in reducing depressive symptoms through a randomized controlled trial (RCT) among patients with diabetes, hypertension, or both, in Lima, Peru. However, in addition to clinical outcomes, it is important to explore users’ experiences, satisfaction, and perceptions of usability and acceptability, which can affect their engagement with the intervention. Objective: This study aimed to explore the RCT participants’ experiences with CONEMO in Peru, complemented with information provided by the nurses who monitored them. Methods: In 2018, semistructured interviews were conducted with a sample of 29 (13.4%) patients from the 217 patients who participated in the CONEMO intervention in Peru and the 3 hired nurses who supported its delivery. Interviewees were selected at random based on their adherence to the digital intervention (0-5, 10-14, and 15-18 sessions completed), to include different points of view. Content analysis was conducted to analyze the interviews. Results: Participants’ mean age was 64.4 (SD 8.5) years, and 79% (23/29) of them were women. Most of the interviewed participants (21/29, 72%) stated that CONEMO fulfilled their expectations and identified positive changes in their physical and mental health after using it. Some of these improvements were related to their thoughts and feelings (eg, think differently, be more optimistic, and feel calmer), whereas others were related to their routines (eg, go out more and improve health-related habits). Most participants (19/29, 66%) reported not having previous experience with using smartphones, and despite experiencing some initial difficulties, they managed to use CONEMO. The most valued features of the app were the videos and activities proposed for the participant to perform. Most participants (27/29, 93%) had a good opinion about the study nurses and reported feeling supported by them. A few participants provided suggestions to improve the intervention, which included adding more videos, making the sessions’ text simple, extending the length of the intervention, and improving the training session with long explanations. Conclusions: The findings of this qualitative study provide further support and contextualize the positive results found in the CONEMO RCT, including insights into the key features that made the intervention effective and engaging. The participants’ experience with the smartphone and CONEMO app reveal that it is feasible to be used by people with little knowledge of technology. In addition, the study identified suggestions to improve the CONEMO intervention for its future scale-up. Trial Registration: ClinicalTrials.gov NCT03026426; https://clinicaltrials.gov/ct2/show/NCT03026426 %M 36107482 %R 10.2196/35486 %U https://humanfactors.jmir.org/2022/3/e35486 %U https://doi.org/10.2196/35486 %U http://www.ncbi.nlm.nih.gov/pubmed/36107482 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 9 %P e36978 %T Comparability of Patients in Trials of eHealth and Face-to-Face Psychotherapeutic Interventions for Depression: Meta-synthesis %A Aemissegger,Vera %A Lopez-Alcalde,Jesus %A Witt,Claudia M %A Barth,Jürgen %+ Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Sonneggstrasse 6, Zurich, 8091, Switzerland, 41 44 255 48 96, mail@juergen-barth.de %K depression %K mental health %K digital intervention %K eHealth %K web-based %K randomized controlled trial %K RCT %K meta-analysis %K epidemiology %K epidemiological %K depressive disorder %K mental illness %K mental condition %K mental disorder %K psychotherapy %K psychotherapeutic intervention %K CBT %K iCBT %K cognitive behavioral therapy %K face-to-face %K cognitive therapy %K interpersonal therapy %D 2022 %7 14.9.2022 %9 Review %J J Med Internet Res %G English %X Background: Depressive disorders (DDs) are a public health problem. Face-to-face psychotherapeutic interventions are a first-line option for their treatment in adults. There is a growing interest in eHealth interventions to maximize accessibility for effective treatments. Thus, the number of randomized controlled trials (RCTs) of eHealth psychotherapeutic interventions has increased, and these interventions are being offered to patients. However, it is unknown whether patients with DDs differ in internet-based and face-to-face intervention trials. This information is essential to gain knowledge about eHealth trials’ external validity. Objective: We aimed to compare the baseline characteristics of patients with DDs included in the RCTs of eHealth and face-to-face psychotherapeutic interventions with a cognitive component. Methods: In this meta-epidemiological study, we searched 5 databases between 1990 and November 2017 (MEDLINE, Embase, PsycINFO, Google Scholar, and the database of Cuijpers et al). We included RCTs of psychotherapeutic interventions with a cognitive component (eg, cognitive therapy, cognitive behavioral therapy [CBT], or interpersonal therapy) delivered face-to-face or via the internet to adults with DDs. Each included study had a matching study for predefined criteria to allow a valid comparison of characteristics and was classified as a face-to-face (CBT) or eHealth (internet CBT) intervention trial. Two authors selected the studies, extracted data, and resolved disagreements by discussion. We tested whether predefined baseline characteristics differed in face-to-face and internet-based trials using a mixed-effects model and testing for differences with z tests (statistical significance set at .05). For continuous outcomes, we also estimated the difference in means between subgroups with 95% CI. Results: We included 58 RCTs (29 matching pairs) with 3846 participants (female: n=2803, 72.9%) and mean ages ranging from 20-74 years. White participants were the most frequent (from 63.6% to 100%). Other socioeconomic characteristics were poorly described. The participants presented DDs of different severity measured with heterogeneous instruments. Internet CBT trials had a longer depression duration at baseline (7.19 years higher, CI 95% 2.53-11.84; 10.0 vs 2.8 years; P=.002), but the proportion of patients with previous depression treatment was lower (24.8% vs 42%; P=.04). Subgroup analyses found no evidence of differences for the remaining baseline characteristics: age, gender, education, living area, depression severity, history of depression, actual antidepressant medication, actual physical comorbidity, actual mental comorbidity, study dropout, quality of life, having children, family status, and employment. We could not compare proficiency with computers due to the insufficient number of studies. Conclusions: The baseline characteristics of patients with DDs included in the RCTs of eHealth and face-to-face psychotherapeutic interventions are generally similar. However, patients in eHealth trials had a longer duration of depression, and a lower proportion had received previous depression treatment, which might indicate that eHealth trials attract patients who postpone earlier treatment attempts. Trial Registration: PROSPERO CRD42019085880; https://tinyurl.com/4xufwcyr %M 36103217 %R 10.2196/36978 %U https://www.jmir.org/2022/9/e36978 %U https://doi.org/10.2196/36978 %U http://www.ncbi.nlm.nih.gov/pubmed/36103217 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 9 %P e37287 %T Motive-Oriented, Personalized, Internet-Based Interventions for Depression: Nonclinical Experimental Study %A Bücker,Lara %A Berger,Thomas %A Bruhns,Alina %A Westermann,Stefan %+ Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany, 49 040 7410 55868, l.buecker@uke.de %K internet-based interventions %K depression %K adherence %K motive orientation %K personalization %D 2022 %7 13.9.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The low level of adherence in internet-based self-help interventions for depression suggests that in many existing programs, the motivational fit between the program and the user is unsatisfactory (eg, the user seeks autonomy, but the program provides directive guidance). Personalized, motive-oriented, self-help interventions could enable participants who interact with a program and its contents to have more engaging and less aversive experiences and thus increase adherence. Objective: In an experimental study with a nonclinical analogue sample, we aimed to test the hypotheses that a better motivational person-program fit is linked with higher anticipated adherence, working alliance, and satisfaction with the program. Methods: Motivational person-program fit was examined with respect to the 2 contrasting motives being autonomous and being supported. The hypotheses were tested by specifically varying the motivational person-program fit in a nonclinical sample (N=55), where participants were asked to work on, and subsequently evaluate, a limited set of individual pages of a self-help program with guidance (in the form of text messages) for depression. The sections of the self-help program were redesigned to either particularly address the autonomy motive or the support motive. For the quasi-experimental variation of the motivational person-program characteristics, we divided the 55 participants into 2 groups (autonomy group: n=27, 49%; support group: n=28, 51%) by screening method (using the Inventory of Approach and Avoidance Motivation), corresponding to the 2 motives. Both groups evaluated (in randomized order) 2 excerpts of the program—one that matched their motive (fit) and one that was contrary to it (no fit). Immediately after the evaluation of each excerpt, anticipated adherence, working alliance, and treatment satisfaction were assessed. Results: Regarding being supported, the satisfaction with or violation of this motive had an impact on (optimal) anticipated adherence as well as working alliance and satisfaction with the intervention; a congruent person-program fit resulted in significantly higher anticipated adherence (t27=3.00; P=.006), working alliance (t27=3.20; P=.003), and satisfaction (t27=2.86; P=.008) than a noncongruent fit. However, a similar impact could not be found for the motive being autonomous. Several correlations were found that supported our hypotheses (eg, for the congruent person-program fit autonomy motive and autonomy group, support satisfaction negatively correlated with optimal anticipated adherence). Conclusions: This first experimental study gives reason to assume that motive orientation may have a positive influence on adherence, working alliance, and satisfaction in internet-based self-help interventions for depression and other mental disorders. Future studies should conduct randomized controlled trials with clinical samples and assess clinical outcomes. %M 36098989 %R 10.2196/37287 %U https://formative.jmir.org/2022/9/e37287 %U https://doi.org/10.2196/37287 %U http://www.ncbi.nlm.nih.gov/pubmed/36098989 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 9 %P e36130 %T Predicting Depression in Patients With Knee Osteoarthritis Using Machine Learning: Model Development and Validation Study %A Nowinka,Zuzanna %A Alagha,M Abdulhadi %A Mahmoud,Khadija %A Jones,Gareth G %+ MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, South Kensington Campus, London, SW7 2AZ, United Kingdom, 44 020 7589 5111, h.alagha@imperial.ac.uk %K knee osteoarthritis %K depression %K machine learning %K predictive modeling %D 2022 %7 13.9.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Knee osteoarthritis (OA) is the most common form of OA and a leading cause of disability worldwide. Chronic pain and functional loss secondary to knee OA put patients at risk of developing depression, which can also impair their treatment response. However, no tools exist to assist clinicians in identifying patients at risk. Machine learning (ML) predictive models may offer a solution. We investigated whether ML models could predict the development of depression in patients with knee OA and examined which features are the most predictive. Objective: The primary aim of this study was to develop and test an ML model to predict depression in patients with knee OA at 2 years and to validate the models using an external data set. The secondary aim was to identify the most important predictive features used by the ML algorithms. Methods: Osteoarthritis Initiative Study (OAI) data were used for model development and external validation was performed using Multicenter Osteoarthritis Study (MOST) data. Forty-two features were selected, which denoted routinely collected demographic and clinical data such as patient demographics, past medical history, knee OA history, baseline examination findings, and patient-reported outcome measures. Six different ML classification models were trained (logistic regression, least absolute shrinkage and selection operator [LASSO], ridge regression, decision tree, random forest, and gradient boosting machine). The primary outcome was to predict depression at 2 years following study enrollment. The presence of depression was defined using the Center for Epidemiological Studies Depression Scale. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and F1 score. The most important features were extracted from the best-performing model on external validation. Results: A total of 5947 patients were included in this study, with 2969 in the training set, 742 in the test set, and 2236 in the external validation set. For the test set, the AUC ranged from 0.673 (95% CI 0.604-0.742) to 0.869 (95% CI 0.824-0.913), with an F1 score of 0.435 to 0.490. On external validation, the AUC varied from 0.720 (95% CI 0.685-0.755) to 0.876 (95% CI 0.853-0.899), with an F1 score of 0.456 to 0.563. LASSO modeling offered the highest predictive performance. Blood pressure, baseline depression score, knee pain and stiffness, and quality of life were the most predictive features. Conclusions: To our knowledge, this is the first study to apply ML classification models to predict depression in patients with knee OA. Our study showed that ML models can deliver a clinically acceptable level of performance (AUC>0.7) in predicting the development of depression using routinely available demographic and clinical data. Further work is required to address the class imbalance in the training data and to evaluate the clinical utility of the models in facilitating early intervention and improved outcomes. %M 36099008 %R 10.2196/36130 %U https://formative.jmir.org/2022/9/e36130 %U https://doi.org/10.2196/36130 %U http://www.ncbi.nlm.nih.gov/pubmed/36099008 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 9 %P e36177 %T Quality of Late-Life Depression Information on the Internet: Website Evaluation Study %A Pryor,Teaghan A M %A Reynolds,Kristin A %A Kirby,Paige L %A Bernstein,Matthew T %+ Department of Psychology, University of Manitoba, 190 Dysart Rd, Winnipeg, MB, R3T 2N2, Canada, 1 2044749528, kristin.reynolds@umanitoba.ca %K late-life %K depression %K older adults %K internet %K websites %K information quality %K usability %K readability %D 2022 %7 12.9.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The internet can increase the accessibility of mental health information and improve the mental health literacy of older adults. The quality of mental health information on the internet can be inaccurate or biased, leading to misinformation. Objective: This study aims to evaluate the quality, usability, and readability of websites providing information concerning depression in later life. Methods: Websites were identified through a Google search and evaluated by assessing quality (DISCERN), usability (Patient Education Materials Assessment Tool), and readability (Simple Measure of Gobbledygook). Results: The overall quality of late-life depression websites (N=19) was adequate, and the usability and readability were poor. No significant relationship was found between the quality and readability of the websites. Conclusions: The websites can be improved by enhancing information quality, usability, and readability related to late-life depression. The use of high-quality websites may improve mental health literacy and shared treatment decision-making for older adults. %M 36094802 %R 10.2196/36177 %U https://formative.jmir.org/2022/9/e36177 %U https://doi.org/10.2196/36177 %U http://www.ncbi.nlm.nih.gov/pubmed/36094802 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 9 %P e39454 %T Effectiveness and Minimum Effective Dose of App-Based Mobile Health Interventions for Anxiety and Depression Symptom Reduction: Systematic Review and Meta-Analysis %A Lu,Sheng-Chieh %A Xu,Mindy %A Wang,Mei %A Hardi,Angela %A Cheng,Abby L %A Chang,Su-Hsin %A Yen,Po-Yin %+ Department of Symptom Research, University of Texas MD Anderson Cancer Center, 6565 MD Anderson Blvd, Houston, TX, 77030, United States, 1 7137944453, Slu4@mdanderson.org %K mental health %K mobile health %K smartphone apps %K intervention dose effectiveness %K systematic review and meta-analysis %D 2022 %7 7.9.2022 %9 Review %J JMIR Ment Health %G English %X Background: Mobile health (mHealth) apps offer new opportunities to deliver psychological treatments for mental illness in an accessible, private format. The results of several previous systematic reviews support the use of app-based mHealth interventions for anxiety and depression symptom management. However, it remains unclear how much or how long the minimum treatment “dose” is for an mHealth intervention to be effective. Just-in-time adaptive intervention (JITAI) has been introduced in the mHealth domain to facilitate behavior changes and is positioned to guide the design of mHealth interventions with enhanced adherence and effectiveness. Objective: Inspired by the JITAI framework, we conducted a systematic review and meta-analysis to evaluate the dose effectiveness of app-based mHealth interventions for anxiety and depression symptom reduction. Methods: We conducted a literature search on 7 databases (ie, Ovid MEDLINE, Embase, PsycInfo, Scopus, Cochrane Library (eg, CENTRAL), ScienceDirect, and ClinicalTrials, for publications from January 2012 to April 2020. We included randomized controlled trials (RCTs) evaluating app-based mHealth interventions for anxiety and depression. The study selection and data extraction process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We estimated the pooled effect size using Hedge g and appraised study quality using the revised Cochrane risk-of-bias tool for RCTs. Results: We included 15 studies involving 2627 participants for 18 app-based mHealth interventions. Participants in the intervention groups showed a significant effect on anxiety (Hedge g=–.10, 95% CI –0.14 to –0.06, I2=0%) but not on depression (Hedge g=–.08, 95% CI –0.23 to 0.07, I2=4%). Interventions of at least 7 weeks’ duration had larger effect sizes on anxiety symptom reduction. Conclusions: There is inconclusive evidence for clinical use of app-based mHealth interventions for anxiety and depression at the current stage due to the small to nonsignificant effects of the interventions and study quality concerns. The recommended dose of mHealth interventions and the sustainability of intervention effectiveness remain unclear and require further investigation. %M 36069841 %R 10.2196/39454 %U https://mental.jmir.org/2022/9/e39454 %U https://doi.org/10.2196/39454 %U http://www.ncbi.nlm.nih.gov/pubmed/36069841 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 9 %P e37753 %T Effects of Serious Games on Depression in Older Adults: Systematic Review and Meta-analysis of Randomized Controlled Trials %A Kim,Yesol %A Hong,Soomin %A Choi,Mona %+ Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2 2228 3341, monachoi@yuhs.ac %K effectiveness %K serious game %K exergaming %K video games %K virtual reality %K depression %K older adults %K systematic review %K meta-analysis %K mobile phone %D 2022 %7 6.9.2022 %9 Review %J J Med Internet Res %G English %X Background: Depression is a severe psychological concern that negatively affects health in older adults. Serious games applied in various fields are considered appropriate interventions, especially in mental health care. However, there is a lack of evidence regarding the effects of serious games on depression in older adults. Objective: This study aimed to investigate the characteristics and effectiveness of serious games for depression in older adults. Methods: A systematic review and meta-analysis of randomized controlled trials were conducted. In total, 5 electronic databases (PubMed, CINAHL, Embase, PsycINFO, and Cochrane Library) were searched to identify relevant studies published until July 6, 2021. A total of 2 reviewers independently conducted study selection, data extraction, and quality appraisals. The risk of bias in the included studies was assessed using the JBI Critical Appraisal Checklist. For the meta-analysis, the effect size was calculated as the standardized mean difference (SMD) by using a random effects model. Results: A total of 17 studies with 1280 older adults were included in the systematic review, and 15 studies were included in the meta-analysis. Serious game interventions were classified into 3 types: physical activity (PA), cognitive function, and both PA and cognitive function. The meta-analysis demonstrated that serious games reduced depression in older adults (SMD −0.54, 95% CI −0.79 to −0.29; P<.001). Serious games had a more significant effect size in community or home settings (SMD −0.61, 95% CI −0.95 to −0.26; P<.001) than in hospital settings (SMD −0.46, 95% CI −0.85 to −0.08; P=.02); however, the difference between groups was not significant. Among the types of games, games for PA (SMD −0.60, 95% CI −0.95 to −0.25; P<.001) and games for both (SMD −0.73, 95% CI −1.29 to −0.17; P=.01) had a significant effect on reducing depression in older adults. However, no significant correlations were observed between the duration or number of serious games and depression. Conclusions: Serious games were beneficial in reducing depression in older adults. Regardless of the study setting, serious games appeared to reduce depression. Particularly, serious games including PA had a significant impact on reducing depression. Furthermore, high-quality randomized controlled trials are needed to establish substantial evidence for the effectiveness of serious games on depression in older adults. Trial Registration: PROSPERO CRD42021242573; https://tinyurl.com/26xf7ym5 %M 36066964 %R 10.2196/37753 %U https://www.jmir.org/2022/9/e37753 %U https://doi.org/10.2196/37753 %U http://www.ncbi.nlm.nih.gov/pubmed/36066964 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 8 %P e32736 %T Assessment and Prediction of Depression and Anxiety Risk Factors in Schoolchildren: Machine Learning Techniques Performance Analysis %A Qasrawi,Radwan %A Vicuna Polo,Stephanny Paola %A Abu Al-Halawa,Diala %A Hallaq,Sameh %A Abdeen,Ziad %+ Department of Computer Science, Al-Quds University, Schools Street, Number 140, 5th FL, Ramallah, 51000, Occupied Palestinian Territory, 1 970592660417, radwan@staff.alquds.edu %K machine learning %K depression %K anxiety %K schoolchildren %K school-age children %K children %K youth %K young adult %K transition-aged youth %K early childhood education %K prediction %K random forest %D 2022 %7 31.8.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression and anxiety symptoms in early childhood have a major effect on children’s mental health growth and cognitive development. The effect of mental health problems on cognitive development has been studied by researchers for the last 2 decades. Objective: In this paper, we sought to use machine learning techniques to predict the risk factors associated with schoolchildren’s depression and anxiety. Methods: The study sample consisted of 3984 students in fifth to ninth grades, aged 10-15 years, studying at public and refugee schools in the West Bank. The data were collected using the health behaviors schoolchildren questionnaire in the 2013-2014 academic year and analyzed using machine learning to predict the risk factors associated with student mental health symptoms. We used 5 machine learning techniques (random forest [RF], neural network, decision tree, support vector machine [SVM], and naive Bayes) for prediction. Results: The results indicated that the SVM and RF models had the highest accuracy levels for depression (SVM: 92.5%; RF: 76.4%) and anxiety (SVM: 92.4%; RF: 78.6%). Thus, the SVM and RF models had the best performance in classifying and predicting the students’ depression and anxiety. The results showed that school violence and bullying, home violence, academic performance, and family income were the most important factors affecting the depression and anxiety scales. Conclusions: Overall, machine learning proved to be an efficient tool for identifying and predicting the associated factors that influence student depression and anxiety. The machine learning techniques seem to be a good model for predicting abnormal depression and anxiety symptoms among schoolchildren, so the deployment of machine learning within the school information systems might facilitate the development of health prevention and intervention programs that will enhance students’ mental health and cognitive development. %M 35665695 %R 10.2196/32736 %U https://formative.jmir.org/2022/8/e32736 %U https://doi.org/10.2196/32736 %U http://www.ncbi.nlm.nih.gov/pubmed/35665695 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 8 %P e38261 %T Predictors of Dropout in a Digital Intervention for the Prevention and Treatment of Depression in Patients With Chronic Back Pain: Secondary Analysis of Two Randomized Controlled Trials %A Moshe,Isaac %A Terhorst,Yannik %A Paganini,Sarah %A Schlicker,Sandra %A Pulkki-Råback,Laura %A Baumeister,Harald %A Sander,Lasse B %A Ebert,David Daniel %+ Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, P.O. Box 63, Helsinki, 00014, Finland, 358 406324442, isaac.moshe@helsinki.fi %K adherence %K dropout %K law of attrition %K attrition %K digital health %K internet intervention %K depression %K back pain %K comorbidity %K mental health %K eHealth %K mobile phone %D 2022 %7 30.8.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is a common comorbid condition in individuals with chronic back pain (CBP), leading to poorer treatment outcomes and increased medical complications. Digital interventions have demonstrated efficacy in the prevention and treatment of depression; however, high dropout rates are a major challenge, particularly in clinical settings. Objective: This study aims to identify the predictors of dropout in a digital intervention for the treatment and prevention of depression in patients with comorbid CBP. We assessed which participant characteristics may be associated with dropout and whether intervention usage data could help improve the identification of individuals at risk of dropout early on in treatment. Methods: Data were collected from 2 large-scale randomized controlled trials in which 253 patients with a diagnosis of CBP and major depressive disorder or subclinical depressive symptoms received a digital intervention for depression. In the first analysis, participants’ baseline characteristics were examined as potential predictors of dropout. In the second analysis, we assessed the extent to which dropout could be predicted from a combination of participants’ baseline characteristics and intervention usage variables following the completion of the first module. Dropout was defined as completing <6 modules. Analyses were conducted using logistic regression. Results: From participants’ baseline characteristics, lower level of education (odds ratio [OR] 3.33, 95% CI 1.51-7.32) and both lower and higher age (a quadratic effect; age: OR 0.62, 95% CI 0.47-0.82, and age2: OR 1.55, 95% CI 1.18-2.04) were significantly associated with a higher risk of dropout. In the analysis that aimed to predict dropout following completion of the first module, lower and higher age (age: OR 0.60, 95% CI 0.42-0.85; age2: OR 1.59, 95% CI 1.13-2.23), medium versus high social support (OR 3.03, 95% CI 1.25-7.33), and a higher number of days to module completion (OR 1.05, 95% CI 1.02-1.08) predicted a higher risk of dropout, whereas a self-reported negative event in the previous week was associated with a lower risk of dropout (OR 0.24, 95% CI 0.08-0.69). A model that combined baseline characteristics and intervention usage data generated the most accurate predictions (area under the receiver operating curve [AUC]=0.72) and was significantly more accurate than models based on baseline characteristics only (AUC=0.70) or intervention usage data only (AUC=0.61). We found no significant influence of pain, disability, or depression severity on dropout. Conclusions: Dropout can be predicted by participant baseline variables, and the inclusion of intervention usage variables may improve the prediction of dropout early on in treatment. Being able to identify individuals at high risk of dropout from digital health interventions could provide intervention developers and supporting clinicians with the ability to intervene early and prevent dropout from occurring. %M 36040780 %R 10.2196/38261 %U https://www.jmir.org/2022/8/e38261 %U https://doi.org/10.2196/38261 %U http://www.ncbi.nlm.nih.gov/pubmed/36040780 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 8 %P e37851 %T Digital Interventions to Enhance Readiness for Psychological Therapy: Scoping Review %A Jardine,Jacinta %A Bowman,Robert %A Doherty,Gavin %+ School of Computer Science and Statistics, Trinity College Dublin, Hamilton Building, College Green, Dublin, D02 W272, Ireland, 353 861505715, jjardine@tcd.ie %K readiness for change %K stages of change %K digital %K motivation %K engagement %K uptake %K mental health %K mental illness %K mobile phone %D 2022 %7 30.8.2022 %9 Review %J J Med Internet Res %G English %X Background: Psychological therapy is an effective treatment method for mental illness; however, many people with mental illness do not seek treatment or drop out of treatment early. Increasing client uptake and engagement in therapy is key to addressing the escalating global problem of mental illness. Attitudinal barriers, such as a lack of motivation, are a leading cause of low engagement in therapy. Digital interventions to increase motivation and readiness for change hold promise as accessible and scalable solutions; however, little is known about the range of interventions being used and their feasibility as a means to increase engagement with therapy. Objective: This review aimed to define the emerging field of digital interventions to enhance readiness for psychological therapy and detect gaps in the literature. Methods: A literature search was conducted in PubMed, PsycINFO, PsycARTICLES, Scopus, Embase, ACM Guide to Computing Literature, and IEEE Xplore Digital Library from January 1, 2006, to November 30, 2021. The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology was applied. Publications were included when they concerned a digitally delivered intervention, a specific target of which was enhancing engagement with further psychological treatment, and when this intervention occurred before the target psychological treatment. Results: A total of 45 publications met the inclusion criteria. The conditions included depression, unspecified general mental health, comorbid anxiety and depression, smoking, eating disorders, suicide, social anxiety, substance use, gambling, and psychosis. Almost half of the interventions (22/48, 46%) were web-based programs; the other formats included screening tools, videos, apps, and websites. The components of the interventions included psychoeducation, symptom assessment and feedback, information on treatment options and referrals, client testimonials, expectation management, and pro-con lists. Regarding feasibility, of the 16 controlled studies, 7 (44%) measuring actual behavior or action showed evidence of intervention effectiveness compared with controls, 7 (44%) found no differences, and 2 (12%) indicated worse behavioral outcomes. In general, the outcomes were mixed and inconclusive owing to variations in trial designs, control types, and outcome measures. Conclusions: Digital interventions to enhance readiness for psychological therapy are broad and varied. Although these easily accessible digital approaches show potential as a means of preparing people for therapy, they are not without risks. The complex nature of stigma, motivation, and individual emotional responses toward engaging in treatment for mental health difficulties suggests that a careful approach is needed when developing and evaluating digital readiness interventions. Further qualitative, naturalistic, and longitudinal research is needed to deepen our knowledge in this area. %M 36040782 %R 10.2196/37851 %U https://www.jmir.org/2022/8/e37851 %U https://doi.org/10.2196/37851 %U http://www.ncbi.nlm.nih.gov/pubmed/36040782 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 8 %P e37061 %T Digital Content-Free Speech Analysis Tool to Measure Affective Distress in Mental Health: Evaluation Study %A Tonn,Peter %A Seule,Lea %A Degani,Yoav %A Herzinger,Shani %A Klein,Amit %A Schulze,Nina %+ Neuropsychiatric Center of Hamburg, Stresemannstr 23, Hamburg, 22769, Germany, 49 40 5330738, tonn@npz-hamburg.de %K mobile health %K mHealth %K depression %K assessment %K voice analysis %K evaluation %K speech %K speech analysis %K tool %K distress %K mental health %K mood %K diagnosis %K measurement %K questionnaire %K mobile phone %D 2022 %7 30.8.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Mood disorders and depression are pervasive and significant problems worldwide. These represent severe health and emotional impairments for individuals and a considerable economic and social burden. Therefore, fast and reliable diagnosis and appropriate treatment are of great importance. Verbal communication can clarify the speaker’s mental state—regardless of the content, via speech melody, intonation, and so on. In both everyday life and clinical conditions, a listener with appropriate previous knowledge or a trained specialist can grasp helpful knowledge about the speaker's psychological state. Using automated speech analysis for the assessment and tracking of patients with mental health issues opens up the possibility of remote, automatic, and ongoing evaluation when used with patients’ smartphones, as part of the current trends toward the increasing use of digital and mobile health tools. Objective: The primary aim of this study is to evaluate the measurements of the presence or absence of depressive mood in participants by comparing the analysis of noncontentual speech parameters with the results of the Patient Health Questionnaire-9. Methods: This proof-of-concept study included participants in different affective phases (with and without depression). The inclusion criteria included a neurological or psychiatric diagnosis made by a specialist and fluent use of the German language. The measuring instrument was the VoiceSense digital voice analysis tool, which enables the analysis of 200 specific speech parameters based on machine learning and the assessment of the findings using Patient Health Questionnaire-9. Results: A total of 292 psychiatric and voice assessments were performed with 163 participants (males: n=47, 28.8%) aged 15 to 82 years. Of the 163 participants, 87 (53.3%) were not depressed at the time of assessment, and 88 (53.9%) participants had clinically mild to moderate depressive phases. Of the 163 participants, 98 (32.5%) showed subsyndromal symptoms, and 19 (11.7%) participants were severely depressed. In the speech analysis, a clear differentiation between the individual depressive levels, as seen in the Patient Health Questionnaire-9, was also shown, especially the clear differentiation between nondepressed and depressed participants. The study showed a Pearson correlation of 0.41 between clinical assessment and noncontentual speech analysis (P<.001). Conclusions: The use of speech analysis shows a high level of accuracy, not only in terms of the general recognition of a clinically relevant depressive state in the participants. Instead, there is a high degree of agreement regarding the extent of depressive impairment with the assessment of experienced clinical practitioners. From our point of view, the application of the noncontentual analysis system in everyday clinical practice makes sense, especially with the idea of a quick and unproblematic assessment of the state of mind, which can even be carried out without personal contact. Trial Registration: ClinicalTrials.gov NCT03700008; https://clinicaltrials.gov/ct2/show/NCT03700008 %M 36040767 %R 10.2196/37061 %U https://formative.jmir.org/2022/8/e37061 %U https://doi.org/10.2196/37061 %U http://www.ncbi.nlm.nih.gov/pubmed/36040767 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 8 %P e35563 %T Analyzing Suicide Risk From Linguistic Features in Social Media: Evaluation Study %A Lao,Cecilia %A Lane,Jo %A Suominen,Hanna %+ School of Computing, College of Engineering and Computer Science, The Australian National University, 145 Science Road, Canberra, ACT, 2600, Australia, 61 416236920, cecilia.lao@anu.edu.au %K evaluation study %K interdisciplinary research %K linguistics %K machine learning %K mental health %K natural language processing %K social media %K suicide risk %D 2022 %7 30.8.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Effective suicide risk assessments and interventions are vital for suicide prevention. Although assessing such risks is best done by health care professionals, people experiencing suicidal ideation may not seek help. Hence, machine learning (ML) and computational linguistics can provide analytical tools for understanding and analyzing risks. This, therefore, facilitates suicide intervention and prevention. Objective: This study aims to explore, using statistical analyses and ML, whether computerized language analysis could be applied to assess and better understand a person’s suicide risk on social media. Methods: We used the University of Maryland Suicidality Dataset comprising text posts written by users (N=866) of mental health–related forums on Reddit. Each user was classified with a suicide risk rating (no, low, moderate, or severe) by either medical experts or crowdsourced annotators, denoting their estimated likelihood of dying by suicide. In language analysis, the Linguistic Inquiry and Word Count lexicon assessed sentiment, thinking styles, and part of speech, whereas readability was explored using the TextStat library. The Mann-Whitney U test identified differences between at-risk (low, moderate, and severe risk) and no-risk users. Meanwhile, the Kruskal-Wallis test and Spearman correlation coefficient were used for granular analysis between risk levels and to identify redundancy, respectively. In the ML experiments, gradient boost, random forest, and support vector machine models were trained using 10-fold cross validation. The area under the receiver operator curve and F1-score were the primary measures. Finally, permutation importance uncovered the features that contributed the most to each model’s decision-making. Results: Statistically significant differences (P<.05) were identified between the at-risk (671/866, 77.5%) and no-risk groups (195/866, 22.5%). This was true for both the crowd- and expert-annotated samples. Overall, at-risk users had higher median values for most variables (authenticity, first-person pronouns, and negation), with a notable exception of clout, which indicated that at-risk users were less likely to engage in social posturing. A high positive correlation (ρ>0.84) was present between the part of speech variables, which implied redundancy and demonstrated the utility of aggregate features. All ML models performed similarly in their area under the curve (0.66-0.68); however, the random forest and gradient boost models were noticeably better in their F1-score (0.65 and 0.62) than the support vector machine (0.52). The features that contributed the most to the ML models were authenticity, clout, and negative emotions. Conclusions: In summary, our statistical analyses found linguistic features associated with suicide risk, such as social posturing (eg, authenticity and clout), first-person singular pronouns, and negation. This increased our understanding of the behavioral and thought patterns of social media users and provided insights into the mechanisms behind ML models. We also demonstrated the applicative potential of ML in assisting health care professionals to assess and manage individuals experiencing suicide risk. %M 36040781 %R 10.2196/35563 %U https://formative.jmir.org/2022/8/e35563 %U https://doi.org/10.2196/35563 %U http://www.ncbi.nlm.nih.gov/pubmed/36040781 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 8 %P e39387 %T Predicting Psychological Symptoms When Facebook’s Digital Well-being Features Are Used: Cross-sectional Survey Study %A Barsova,Tamara %A Cheong,Zi Gi %A Mak,Ann R %A Liu,Jean CJ %+ Yale-NUS College, 28 College Avenue West, #01-501, Singapore, 138533, Singapore, 65 66013694, jeanliu@yale-nus.edu.sg %K mental health %K social media %K digital well-being %K depression %K anxiety %K stress %D 2022 %7 29.8.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Prior research has linked social media usage to poorer mental health. To address these concerns, social media platforms have introduced digital well-being tools to help users monitor their engagement. Nonetheless, little is known about the effectiveness of these tools. Objective: In this study, we focused on Facebook to assess users’ awareness and usage of the following six Facebook well-being tools: the Unfollow, Snooze, Off-Facebook Activity, Your Time on Facebook, Set Daily Reminders, and Notification Settings features. Additionally, we examined whether the use of these tools was associated with better mental health outcomes. Methods: We conducted a cross-sectional survey of 598 Facebook users. The survey comprised questions about (1) baseline Facebook use, (2) the adoption of Facebook’s digital well-being tools, and (3) participant demographics. These were used to predict the primary outcome measure—scores on the 21-item Depression, Anxiety, and Stress Scale. Results: Most participants (580/598, 97%) knew about Facebook’s digital well-being tools, but each tool was used by only 17.4% (104/598) to 55.5% (332/598) of participants. In turn, the use of two tools was associated with better well-being; although participants who spent more time on Facebook reported higher levels of depression, anxiety, and stress, those who managed their feed content or notifications by using the Unfollow or Notification Settings features had lower scores on each of these measures. However, the use of the Snooze, Off-Facebook Activity, Your Time on Facebook, or Set Time Reminder features was not associated with lower depression, anxiety, or stress scores. Conclusions: Of the 6 Facebook digital well-being tools, only 2 were associated with better mental health among users. This underscores the complexity of designing social media platforms to promote user welfare. Consequently, we urge further research into understanding the efficacy of various digital well-being tools. Trial Registration: ClinicalTrials.gov NCT04967846; https://clinicaltrials.gov/ct2/show/study/NCT04967846 %M 36036971 %R 10.2196/39387 %U https://formative.jmir.org/2022/8/e39387 %U https://doi.org/10.2196/39387 %U http://www.ncbi.nlm.nih.gov/pubmed/36036971 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 8 %P e25716 %T Self-help Digital Interventions Targeted at Improving Psychological Well-being in Young People With Perceived or Clinically Diagnosed Reduced Well-being: Systematic Review %A Babbage,Camilla M %A Jackson,Georgina M %A Davies,E Bethan %A Nixon,Elena %+ National Institute for Health and Care Research (NIHR) MindTech Medtech Co-operative, Mental Health & Clinical Neurosciences, Institute of Mental Health, University of Nottingham, University Of Nottingham Innovation Park, Nottingham, NG7 2TU, United Kingdom, 44 1158232438, Camilla.Babbage@nottingham.ac.uk %K digital health interventions %K psychological well-being %K mental well-being %K mental disorders %K mental health %K children and young people %K self-help %K systematic review %D 2022 %7 26.8.2022 %9 Review %J JMIR Ment Health %G English %X Background: Levels of well-being are declining, whereas rates of mental health problems remain high in young people. The World Health Organization defines mental health as not merely the absence of mental disorder but also includes social and psychological well-being as integral to positive mental health, highlighting that mental health is applicable to young people with mental health conditions and those without a diagnosis of a mental health condition. Reduced mental well-being have been identified in studies of young people with clinical populations, as well as in populations consisting of nonclinical young people. Self-help digital interventions can be delivered at mass at a low cost and without the need for trained input, thereby facilitating access to support for well-being. Self-help interventions are effective in young people with mental health conditions, but systematic reviews of such studies have been limited to randomized controlled trials, have not included reduced well-being as an inclusion criterion, and do not consider engagement factors such as retention. Objective: The objective of this study was to systematically review all controlled studies of digitally delivered, self-administered interventions for young people aged 9 to 25 years, with perceived or clinically diagnosed reduced psychological well-being. Participant retention and effectiveness of the interventions were also explored. Methods: A systematic search of the PsycInfo, EMBASE, Cochrane, Scopus, and MEDLINE databases from inception to 2021, reference searches of relevant papers, and gray literature was carried out for digitally controlled studies conducted with young people with perceived or clinically diagnosed reduced well-being, aimed at improving psychological well-being. Data were extracted to identify the effectiveness and retention rates of the interventions and the quality of the studies. Results: Overall, 1.04% (12/1153) of studies met the inclusion criteria: 83% (10/12) of studies were randomized controlled trials and 17% (2/12) were controlled pre-post studies. Most (6/12, 50%) studies aimed to improve symptoms of depression; 3 interventions aimed at both anxiety and depressive symptoms and 2 studies aimed at improving social functioning difficulties. Owing to the high risk of bias across interventions and lack of similar outcome measures, a meta-analysis was not conducted. Retention rates across studies were regarded as good, with moderate to high retention. Overall, the findings indicated that predominantly self-administered self-help interventions improved well-being in the areas targeted by the intervention and identified additional areas of well-being that were positively affected by interventions. Few interventions supported psychological well-being that was different from those used by young people with a clinical diagnosis of mental illness or young people from neurodiverse backgrounds. Conclusions: The findings, along with the advantages of self-help interventions, highlight the need for upscaling self-help interventions to better support vulnerable populations of young people who experience poor psychological well-being. Trial Registration: PROSPERO CRD42019129321; https://tinyurl.com/4fb2t4fz %M 36018675 %R 10.2196/25716 %U https://mental.jmir.org/2022/8/e25716 %U https://doi.org/10.2196/25716 %U http://www.ncbi.nlm.nih.gov/pubmed/36018675 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 8 %N 8 %P e32968 %T The Role of Depressive Symptoms and Physical Activity Levels in Mediating the Association Between HIV Status and Neurocognitive Functions Among Individuals Aged at Least 50 Years in China: Cross-sectional Study %A Qin,Pei %A He,Jianmei %A Yang,Xue %A Chen,Siyu %A Chen,Xi %A Jiang,Hui %A Fung,Ada Wai Tung %A Wang,Zixin %A Lau,Joseph Tak Fai %+ Affilliated Kangning Hospital of Wenzhou Medical University, Wenzhou Medical University, No. 1 Shengjin Road, Huanglong Residential Area, Wenzhou, 325000, China, 86 400 000 2120, jlau@cuhk.edu.hk %K neurocognitive performance %K HIV sero-status %K depressive symptoms %K level of physical activity %K mediation effects %K HIV %K depression %K physical activity %K neurocognitive %K mental health %K public health %D 2022 %7 19.8.2022 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Neurocognitive impairments are prevalent among older people in China. It is more problematic among older people living with HIV. Objective: This study aims to compare neurocognitive performance between older people living with HIV and HIV-negative controls, and to explore whether the association between HIV status and neurocognitive performance was mediated by depressive symptoms and level of physical activity. Methods: A cross-sectional study was conducted in Yongzhou, China. All people living with HIV aged ≥50 years listed in the registry were invited. Frequency matching was used to sample HIV-negative controls from the general population according to the distribution of age, sex, and years of formal education of older people living with HIV. A total of 315 older people living with HIV and 350 HIV-negative controls completed the face-to-face interview and comprehensive neuropsychological assessment of seven domains (learning, memory, working memory, verbal fluency, processing speed, executive function, and motor skills). Results: As compared to HIV-negative controls, older people living with HIV performed worse in global score and all seven domains (P<.05). HIV infection was associated with higher depressive symptoms (P<.001) and lower level of physical activity (P<.001). Depressive symptoms and physical activity were negatively correlated (P<.001). Depressive symptoms and level of physical activity mediated the association between HIV status and global z-score and four domain z-scores of neurocognitive performance (learning, memory, verbal fluency, and processing speed). Conclusions: Change in mental health and physical activity after HIV infection may partially explain why older people living with HIV are more susceptible to neurocognitive impairment. Promoting mental health and physical activity are potential entry points to slow down the progress of neurocognitive impairment among older people living with HIV. %M 35984684 %R 10.2196/32968 %U https://publichealth.jmir.org/2022/8/e32968 %U https://doi.org/10.2196/32968 %U http://www.ncbi.nlm.nih.gov/pubmed/35984684 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 8 %P e37640 %T Appropriate Use and Operationalization of Adherence to Digital Cognitive Behavioral Therapy for Depression and Anxiety in Youth: Systematic Review %A Li,Sophie H %A Achilles,Melinda R %A Werner-Seidler,Aliza %A Beames,Joanne R %A Subotic-Kerry,Mirjana %A O'Dea,Bridianne %+ Black Dog Institute and School of Psychology, The University of New South Wales, Hospital Road, Randwick, 2031, Australia, 61 411116615, s.h.li@blackdog.org.au %K adherence %K youth %K digital %K cognitive behavioral therapy %K review %K mobile phone %D 2022 %7 17.8.2022 %9 Review %J JMIR Ment Health %G English %X Background: Digital, self-guided cognitive behavioral therapy (CBT) interventions circumvent many barriers to in-person therapy for young people (aged 12-24 years), although adherence to these interventions is low. The absence or insufficient disclosure of recommendations or instructions for appropriate use may account for this. As such, many young people may not self-administer these interventions appropriately or receive the optimal degree of treatment. Objective: This systematic review aims to synthesize the literature on digital CBT for depression and anxiety in young people to describe how appropriate use has been defined and communicated to users as instructions for use, to describe how adherence has been measured, and to determine the associations between adherence and treatment outcomes. Methods: A systematic review was conducted with 2 reviewers (SHL and MRA) extracting data independently. Overall, 4 electronic databases (Embase, MEDLINE, PsycINFO, and Cochrane Library) were searched in April 2021 for studies that met the following inclusion criteria: participants aged between 12 and 24 years, evaluated a digital CBT intervention targeting depression or anxiety, and reported instructions or recommendations for use or measures of adherence. Studies that evaluated non-CBT interventions or cognitive- or behavioral-only interventions were excluded. Methodological quality was assessed using the Cochrane Risk of Bias Tool and the Integrated Quality Criteria for the Review of Multiple Study Designs. Results: There were 32 manuscripts that met the inclusion criteria, of which 28 (88%) were unique studies (N=16,578 youths). Definitions of appropriate use varied among the different interventions in terms of intended recipients, duration and frequency of use, and the features used to support engagement and adherence to appropriate use definitions. Reporting of appropriate use definitions in studies was inconsistent, with no study systematically describing components of appropriate use or providing information on how recommendations for use were relayed to users. Most often, definitions of appropriate use were derived from the study protocol and descriptions of intervention features. Adherence was mostly operationalized as the degree of intervention completion; however, reporting of adherence data was heterogeneous. There was little evidence of an association between degree of use and outcomes in the 9 studies that examined this. Conclusions: Definitions of appropriate use are unique to each digital CBT intervention. However, statements of appropriate use are not systematically reported in the literature. Furthermore, the extent to which recommendations for use are communicated to users is not routinely reported. Despite unique definitions of appropriate use, adherence was most often generically operationalized as the degree of intervention completion and was not consistently associated with outcomes. We proposed a framework to promote systematic reporting of definitions of appropriate use for digital interventions to provide guidance to users and to assist the development of appropriate and nuanced measures of adherence. Trial Registration: PROSPERO CRD42020208668; https://tinyurl.com/4bu2yram %M 35976180 %R 10.2196/37640 %U https://mental.jmir.org/2022/8/e37640 %U https://doi.org/10.2196/37640 %U http://www.ncbi.nlm.nih.gov/pubmed/35976180 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 8 %P e26615 %T A Game-Based School Program for Mental Health Literacy and Stigma on Depression (Moving Stories): Cluster Randomized Controlled Trial %A Tuijnman,Anouk %A Kleinjan,Marloes %A Olthof,Merlijn %A Hoogendoorn,Evert %A Granic,Isabela %A Engels,Rutger CME %+ Behavioural Science Institute, Radboud University Nijmegen, Postbus 9104, Nijmegen, 6500 HE, Netherlands, 31 243610082, anouk.tuijnman@ru.nl %K depression %K help-seeking behavior %K helping behavior %K health literacy %K stigma %K video games %K adolescence %K secondary schools %K mental health %K digital health %D 2022 %7 17.8.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depressive symptoms are highly prevalent among adolescents in Western countries. However, although treatment for depressive symptoms is available, many adolescents do not seek help when they need it. Important barriers to help-seeking among adolescents include low mental health literacy and high stigma. Therefore, we have developed a game-based school program, Moving Stories, which combines mental health literacy training for depression with contact with someone with lived experience both in the digital and nondigital world. Objective: The aim of this study is to conduct a first test of the effectiveness of the newly developed game-based program, Moving Stories, using a cluster randomized controlled trial. Methods: A total of 185 adolescents participated, divided over 10 classes from 4 schools. Half of the classes were randomly selected to follow the Moving Stories program, whereas the other half were in the control group, where no intervention was provided. The adolescents filled out digital questionnaires at 4 time points, with questions on mental health literacy, stigma, depressive symptoms, and the program itself (before the program, after the program, 3-month follow-up, and 6-month follow-up). Using R (R Foundation for Statistical Computing), we ran linear mixed-effects models for all continuous outcome variables and generalized linear mixed-effects models for all binary outcome variables. Results: Compared with the control group, participants in the Moving Stories group improved after the program in personal stigma (b=−0.53, 95% CI −1.02 to −0.03; t179.16=−2.08; P=.04). Effects on personal stigma lasted over time (3-month follow-up: b=−0.57, 95% CI −1.11 to −0.03; t174.39=−2.07; P=.04). Most adolescents in the Moving Stories group participated in the introduction (97/99, 98%) and contact session (93/99, 94%), played the game for 4 or 5 days (83/99, 83%), and indicated that they would recommend the game to their peers (90/98, 92%). Conclusions: The results of this study show the potential of Moving Stories as a stigma reduction program. With changes in the program to improve its effects on mental health literacy, Moving Stories could be implemented in schools to improve help-seeking in adolescents and reduce the negative consequences and burden of depressive symptoms. Trial Registration: Dutch Trial Register NTR7033; https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7033 International Registered Report Identifier (IRRID): RR2-10.2196/11255 %M 35976200 %R 10.2196/26615 %U https://mental.jmir.org/2022/8/e26615 %U https://doi.org/10.2196/26615 %U http://www.ncbi.nlm.nih.gov/pubmed/35976200 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 8 %P e39807 %T Using Voice Biomarkers to Classify Suicide Risk in Adult Telehealth Callers: Retrospective Observational Study %A Iyer,Ravi %A Nedeljkovic,Maja %A Meyer,Denny %+ Centre for Mental Health, Swinburne University of Technology, 34 Wakefield Street, Hawthorn, 3122, Australia, 61 454565575, raviiyer@swin.edu.au %K voice biometrics %K suicide prevention %K machine learning %K telehealth %K suicide %K telehealth %K risk prediction %K prediction model %K voice biomarker %K mental health %D 2022 %7 15.8.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Artificial intelligence has the potential to innovate current practices used to detect the imminent risk of suicide and to address shortcomings in traditional assessment methods. Objective: In this paper, we sought to automatically classify short segments (40 milliseconds) of speech according to low versus imminent risk of suicide in a large number (n=281) of telephone calls made to 2 telehealth counselling services in Australia. Methods: A total of 281 help line telephone call recordings sourced from On The Line, Australia (n=266, 94.7%) and 000 Emergency services, Canberra (n=15, 5.3%) were included in this study. Imminent risk of suicide was coded for when callers affirmed intent, plan, and the availability of means; level of risk was assessed by the responding counsellor and reassessed by a team of clinical researchers using the Columbia Suicide Severity Rating Scale (=5/6). Low risk of suicide was coded for in an absence of intent, plan, and means and via Columbia suicide Severity Scale Ratings (=1/2). Preprocessing involved normalization and pre-emphasis of voice signals, while voice biometrics were extracted using the statistical language r. Candidate predictors were identified using Lasso regression. Each voice biomarker was assessed as a predictor of suicide risk using a generalized additive mixed effects model with splines to account for nonlinearity. Finally, a component-wise gradient boosting model was used to classify each call recording based on precoded suicide risk ratings. Results: A total of 77 imminent-risk calls were compared with 204 low-risk calls. Moreover, 36 voice biomarkers were extracted from each speech frame. Caller sex was a significant moderating factor (β=–.84, 95% CI –0.85, –0.84; t=6.59, P<.001). Candidate biomarkers were reduced to 11 primary markers, with distinct models developed for men and women. Using leave-one-out cross-validation, ensuring that the speech frames of no single caller featured in both training and test data sets simultaneously, an area under the precision or recall curve of 0.985 was achieved (95% CI 0.97, 1.0). The gamboost classification model correctly classified 469,332/470,032 (99.85%) speech frames. Conclusions: This study demonstrates an objective, efficient, and economical assessment of imminent suicide risk in an ecologically valid setting with potential applications to real-time assessment and response. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12622000486729; https://www.anzctr.org.au/ACTRN12622000486729.aspx %M 35969444 %R 10.2196/39807 %U https://mental.jmir.org/2022/8/e39807 %U https://doi.org/10.2196/39807 %U http://www.ncbi.nlm.nih.gov/pubmed/35969444 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 8 %P e38934 %T Clinical Targets and Attitudes Toward Implementing Digital Health Tools for Remote Measurement in Treatment for Depression: Focus Groups With Patients and Clinicians %A de Angel,Valeria %A Lewis,Serena %A White,Katie M %A Matcham,Faith %A Hotopf,Matthew %+ Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, E3.08, 3rd floor East Wing, 16 De Crespigny Park, London, SE5 8AF , United Kingdom, 44 7415838882, valeria.de_angel@kcl.ac.uk %K depression %K digital health tools %K implementation %K qualitative %K wearable devices %K smartphone %K passive sensing %K sensor data %K mobile health %K mHealth %K mood disorders %K digital phenotyping %K mobile phone %D 2022 %7 15.8.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Remote measurement technologies, such as smartphones and wearable devices, can improve treatment outcomes for depression through enhanced illness characterization and monitoring. However, little is known about digital outcomes that are clinically meaningful to patients and clinicians. Moreover, if these technologies are to be successfully implemented within treatment, stakeholders’ views on the barriers to and facilitators of their implementation in treatment must be considered. Objective: This study aims to identify clinically meaningful targets for digital health research in depression and explore attitudes toward their implementation in psychological services. Methods: A grounded theory approach was used on qualitative data from 3 focus groups of patients with a current diagnosis of depression and clinicians with >6 months of experience with delivering psychotherapy (N=22). Results: Emerging themes on clinical targets fell into the following two main categories: promoters and markers of change. The former are behaviors that participants engage in to promote mental health, and the latter signal a change in mood. These themes were further subdivided into external changes (changes in behavior) or internal changes (changes in thoughts or feelings) and mapped with potential digital sensors. The following six implementation acceptability themes emerged: technology-related factors, information and data management, emotional support, cognitive support, increased self-awareness, and clinical utility. Conclusions: The promoters versus markers of change differentiation have implications for a causal model of digital phenotyping in depression, which this paper presents. Internal versus external subdivisions are helpful in determining which factors are more susceptible to being measured by using active versus passive methods. The implications for implementation within psychotherapy are discussed with regard to treatment effectiveness, service provision, and patient and clinician experience. %M 35969448 %R 10.2196/38934 %U https://mental.jmir.org/2022/8/e38934 %U https://doi.org/10.2196/38934 %U http://www.ncbi.nlm.nih.gov/pubmed/35969448 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 8 %P e37231 %T Testing Behavioral Nudges and Prompts in Digital Courses for the Self-guided Treatment of Depression and Anxiety: Protocol for a 3-Arm Randomized Controlled Trial %A Rondina,Renante %A van Mierlo,Trevor %A Fournier,Rachel %+ Rotman School of Mangement, University of Toronto, 105 St George St, Toronto, ON, M5S 3E6, Canada, 1 647 212 7209, renante.rondina@rotman.utoronto.ca %K behavioral economics %K digital health %K attrition %K engagement %K nudges %K mood disorder %K anxiety %K depression %K depressive disorder %K mental health %K nudge %K prompt %K behavior change %K randomized controlled trial %K present bias tip %K future gain tip %K health platform %K mental illness %D 2022 %7 15.8.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Despite showing strong evidence of positive outcomes, a common problem in the field of digital health is poor engagement and adherence. Non–health care, for-profit digital ventures, such as Facebook, LinkedIn, and Twitter, conduct behavioral experiments to increase user engagement. To our knowledge, digital health organizations have not published similar types of experiments in ad libitum environments, and there are limited published data indicating whether nudges and prompts can be leveraged to increase engagement with digital health interventions. Objective: The main objective of our 3-arm randomized controlled trial is to test whether registered members in two well-established digital health courses for anxiety and depression will engage with four different types of nudges and prompts, and whether engaging with nudges and prompts increases engagement within the courses. Methods: New members who register for the self-guided anxiety and depression courses on the Evolution Health platform will be randomized into 1 of 3 arms. The first control arm will feature a member home page without any behavioral nudges or prompts. The second arm will feature a member home page with a Tip-of-the-Day section containing directive content. Arm 3 will feature a member home page with a Tip-of-the-Day section containing social proof and present bias content. The third arm will also feature a to-do item checklist. Results: The experiment was designed in August 2021 and was launched in November 2021. Initially, we will measure engagement with the tips and the to-do checklist by calculating the frequency of use by age and gender. If members do engage, we will then, according to age and gender, examine whether nudges and prompts result in higher course completion rates and whether specific types of prompts and nudges are more popular than others. Conclusions: Our 3-arm randomized controlled trial will be the first to compare four distinct types of behavioral prompts and nudges in two self-guided digital health courses that were designed to treat mental health issues. We expect the results to generate insights into which types of behavioral prompts and nudges work best in the population. If they are shown to increase engagement, the insights will then be used to apply prompts and nudges to the platform’s addiction-focused courses. Based on the results of the experiment, the insights will be applied to using artificial intelligence to train the platform to recognize different usage patterns and provide specific engagement recommendations to stratified users. International Registered Report Identifier (IRRID): DERR1-10.2196/37231 %M 35969446 %R 10.2196/37231 %U https://www.researchprotocols.org/2022/8/e37231 %U https://doi.org/10.2196/37231 %U http://www.ncbi.nlm.nih.gov/pubmed/35969446 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 10 %N 8 %P e37818 %T Emotion-Based Reinforcement Attention Network for Depression Detection on Social Media: Algorithm Development and Validation %A Cui,Bin %A Wang,Jian %A Lin,Hongfei %A Zhang,Yijia %A Yang,Liang %A Xu,Bo %+ College of Computer Science and Technology, Dalian University of Technology, Number 2, Linggong Road, Ganjingzi District, Dalian, Liaoning 116024, China, 86 13604119266, wangjian@dlut.edu.cn %K depression detection %K emotional semantic features %K social media %K sentence-level attention %K emotion-based reinforcement %D 2022 %7 9.8.2022 %9 Original Paper %J JMIR Med Inform %G English %X Background: Depression detection has recently received attention in the field of natural language processing. The task aims to detect users with depression based on their historical posts on social media. However, existing studies in this area use the entire historical posts of the users and select depression indicator posts. Moreover, these methods fail to effectively extract deep emotional semantic features or simply concatenate emotional representation. To solve this problem, we propose a model to extract deep emotional semantic features and select depression indicator posts based on the emotional states. Objective: This study aims to develop an emotion-based reinforcement attention network for depression detection of users on social media. Methods: The proposed model is composed of 2 components: the emotion extraction network, which is used to capture deep emotional semantic information, and the reinforcement learning (RL) attention network, which is used to select depression indicator posts based on the emotional states. Finally, we concatenated the output of these 2 parts and send them to the classification layer for depression detection. Results: Experimental results of our model on the multimodal depression data set outperform the state-of-the-art baselines. Specifically, the proposed model achieved accuracy, precision, recall, and F1-score of 90.6%, 91.2%, 89.7%, and 90.4%, respectively. Conclusions: The proposed model utilizes historical posts of users to effectively identify users’ depression tendencies. The experimental results show that the emotion extraction network and the RL selection layer based on emotional states can effectively improve the accuracy of detection. In addition, sentence-level attention layer can capture core posts. %M 35943770 %R 10.2196/37818 %U https://medinform.jmir.org/2022/8/e37818 %U https://doi.org/10.2196/37818 %U http://www.ncbi.nlm.nih.gov/pubmed/35943770 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 8 %P e39516 %T The Effect of Mental Health App Customization on Depressive Symptoms in College Students: Randomized Controlled Trial %A Six,Stephanie G %A Byrne,Kaileigh A %A Aly,Heba %A Harris,Maggie W %+ Department of Psychology, Clemson University, 418 Brackett Hall, Clemson University, Clemson, SC, 29634-0001, United States, 1 864 656 3935, kaileib@clemson.edu %K depression %K mental health apps %K customization %K personalization %K cognitive behavioral therapy %K avatars %K mobile phone %D 2022 %7 9.8.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental health apps have shown promise in improving mental health symptoms, including depressive symptoms. However, limited research has been aimed at understanding how specific app features and designs can optimize the therapeutic benefits and adherence to such mental health apps. Objective: The primary purpose of this study is to investigate the effect of avatar customization on depressive symptoms and adherence to use a novel cognitive behavioral therapy (CBT)–based mental health app. The secondary aim is to examine whether specific app features, including journaling, mood tracking, and reminders, affect the usability of the mental health app. Methods: College students were recruited from a university study recruitment pool website and via flyer advertisements throughout campus. A total of 94 participants completed a randomized controlled trial in which they were randomized to either customization or no customization version of the app. Customization involved personalizing a virtual avatar and a travel vehicle to one’s own preferences and use of one’s name throughout the app. Participants completed a 14-day trial using a novel CBT-based mental health app called AirHeart. Self-report scores for depressive symptoms, anxiety, and stress were measured at baseline and after the intervention. Postintervention survey measures also included usability and avatar identification questionnaires. Results: Of the 94 enrolled participants, 83 (88%) completed the intervention and postintervention assessments. AirHeart app use significantly reduced symptoms of depression (P=.006) from baseline to the end of the 2-week intervention period for all participants, regardless of the customization condition. However, no differences in depressive symptoms (P=.17) or adherence (P=.80) were observed between the customization (39/83, 47%) and no customization (44/83, 53%) conditions. The frequency of journaling, usefulness of mood tracking, and helpfulness of reminders were not associated with changes in depressive symptoms or adherence (P>.05). Exploratory analyses showed that there were 3 moderate positive correlations between avatar identification and depressive symptoms (identification: r=−0.312, P=.02; connection: r=−0.305, P=.02; and lack of relatability: r=0.338, P=.01). Conclusions: These results indicate that CBT mental health apps, such as AirHeart, have the potential to reduce depressive symptoms over a short intervention period. The randomized controlled trial results demonstrated that customization of app features, such as avatars, does not further reduce depressive symptoms over and above the CBT modules and standard app features, including journal, reminders, and mood tracking. However, further research elucidating the relationship between virtual avatar identification and mental health systems is needed as society becomes increasingly more digitized. These findings have potential implications for improving the optimization of mental health app designs. Trial Registration: Open Science Framework t28gm; https://osf.io/t28gm %M 35943788 %R 10.2196/39516 %U https://mental.jmir.org/2022/8/e39516 %U https://doi.org/10.2196/39516 %U http://www.ncbi.nlm.nih.gov/pubmed/35943788 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 5 %N 3 %P e36515 %T Mitigating Feelings of Loneliness and Depression by Means of Web-Based or Print-Based Physical Activity Interventions: Pooled Analysis of 2 Community-Based Intervention Trials %A Lippke,Sonia %A Ratz,Tiara %A Keller,Franziska Maria %A Juljugin,Dennis %A Peters,Manuela %A Pischke,Claudia %A Voelcker-Rehage,Claudia %+ Psychology & Methods, Jacobs University Bremen, Campus Ring 1, Bremen, 28759, Germany, 49 421200 ext 4730, s.lippke@jacobs-university.de %K physical activity %K older adults %K intervention %K loneliness %K depression %K eHealth %K mobile health %K mHealth %D 2022 %7 9.8.2022 %9 Original Paper %J JMIR Aging %G English %X Background: Physical activity (PA) is associated with benefits, such as fewer depressive symptoms and loneliness. Web- and print-based PA interventions can help older individuals accordingly. Objective: We aimed to test the following research questions: Do PA interventions delivered in a web- or print-based mode improve self-reported PA stage of change, social-cognitive determinants of PA, loneliness, and symptoms of depression? Is subjective age a mediator and stage of change a moderator of this effect? Methods: Overall, 831 adults aged ≥60 years were recruited and either allocated to a print-based or web-based intervention group or assigned to a wait-list control group (WLCG) in 2 community-based PA intervention trials over 10 weeks. Missing value imputation using an expectation-maximization algorithm was applied. Frequency analyses, multivariate analyses of variance, and moderated mediation analyses were conducted. Results: The web-based intervention outperformed (47/59, 80% of initially inactive individuals being adopters, and 396/411, 96.4% of initially active individuals being maintainers of the recommended PA behavior) the print-based intervention (20/25, 80% of adopters, and 63/69, 91% of maintainers) and the WLCG (5/7, 71% of adopters; 141/150, 94% of maintainers). The pattern regarding adopters was statistically significant (web vs print Z=–1.94; P=.02; WLCG vs web Z=3.8367; P=.01). The pattern was replicated with stages (χ24=79.1; P<.001; contingency coefficient 0.314; P<.001); in the WLCG, 40.1% (63/157) of the study participants moved to or remained in action stage. This number was higher in the groups receiving web-based (357/470, 76%) or print-based interventions (64/94, 68.1%). A significant difference was observed favoring the 2 intervention groups over and above the WLCG (F19, 701=4.778; P<.001; η2=0.098) and a significant interaction of time and group (F19, 701=2.778; P<.001; η2=0.070) for predictors of behavior. The effects of the interventions on subjective age, loneliness, and depression revealed that both between-group effects (F3, 717=8.668; P<.001; η2=0.018) and the interaction between group and time were significant (F3, 717=6.101; P<.001; η2=0.025). In a moderated mediation model, both interventions had a significant direct effect on depression in comparison with the WLCG (web-based: c′ path −0.86, 95% CI −1.58 to −0.13, SE 0.38; print-based: c′ path −1.96, 95% CI −2.99 to −0.92, SE 0.53). Furthermore, subjective age was positively related to depression (b path 0.14, 95% CI 0.05-0.23; SE 0.05). An indirect effect of the intervention on depression via subjective age was only present for participants who were in actor stage and received the web-based intervention (ab path −0.14, 95% CI −0.34 to −0.01; SE 0.09). Conclusions: Web-based interventions appear to be as effective as print-based interventions. Both modes might help older individuals remain or become active and experience fewer depression symptoms, especially if they feel younger. Trial Registration: German Registry of Clinical Trials DRKS00010052 (PROMOTE 1); https://tinyurl.com/nnzarpsu and DRKS00016073 (PROMOTE 2); https://tinyurl.com/4fhcvkwy International Registered Report Identifier (IRRID): RR2-10.2196/15168 %M 35943790 %R 10.2196/36515 %U https://aging.jmir.org/2022/3/e36515 %U https://doi.org/10.2196/36515 %U http://www.ncbi.nlm.nih.gov/pubmed/35943790 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 3 %P e34514 %T Consumer Perspectives on the Use of Artificial Intelligence Technology and Automation in Crisis Support Services: Mixed Methods Study %A Ma,Jennifer S %A O’Riordan,Megan %A Mazzer,Kelly %A Batterham,Philip J %A Bradford,Sally %A Kõlves,Kairi %A Titov,Nickolai %A Klein,Britt %A Rickwood,Debra J %+ Discipline of Psychology, Faculty of Health, University of Canberra, 11 Kirinari Street, Bruce, ACT, 2617, Australia, 61 (0)2 6201 2701, Debra.Rickwood@canberra.edu.au %K consumer %K community %K help-seeker %K perspective %K technology %K artificial intelligence %K crisis %K support %K acceptability %D 2022 %7 5.8.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Emerging technologies, such as artificial intelligence (AI), have the potential to enhance service responsiveness and quality, improve reach to underserved groups, and help address the lack of workforce capacity in health and mental health care. However, little research has been conducted on the acceptability of AI, particularly in mental health and crisis support, and how this may inform the development of responsible and responsive innovation in the area. Objective: This study aims to explore the level of support for the use of technology and automation, such as AI, in Lifeline’s crisis support services in Australia; the likelihood of service use if technology and automation were implemented; the impact of demographic characteristics on the level of support and likelihood of service use; and reasons for not using Lifeline’s crisis support services if technology and automation were implemented in the future. Methods: A mixed methods study involving a computer-assisted telephone interview and a web-based survey was undertaken from 2019 to 2020 to explore expectations and anticipated outcomes of Lifeline’s crisis support services in a nationally representative community sample (n=1300) and a Lifeline help-seeker sample (n=553). Participants were aged between 18 and 93 years. Quantitative descriptive analysis, binary logistic regression models, and qualitative thematic analysis were conducted to address the research objectives. Results: One-third of the community and help-seeker participants did not support the collection of information about service users through technology and automation (ie, via AI), and approximately half of the participants reported that they would be less likely to use the service if automation was introduced. Significant demographic differences were observed between the community and help-seeker samples. Of the demographics, only older age predicted being less likely to endorse technology and automation to tailor Lifeline’s crisis support service and use such services (odds ratio 1.48-1.66, 99% CI 1.03-2.38; P<.001 to P=.005). The most common reason for reluctance, reported by both samples, was that respondents wanted to speak to a real person, assuming that human counselors would be replaced by automated robots or machine services. Conclusions: Although Lifeline plans to always have a real person providing crisis support, help-seekers automatically fear this will not be the case if new technology and automation such as AI are introduced. Consequently, incorporating innovative use of technology to improve help-seeker outcomes in such services will require careful messaging and assurance that the human connection will continue. %M 35930334 %R 10.2196/34514 %U https://humanfactors.jmir.org/2022/3/e34514 %U https://doi.org/10.2196/34514 %U http://www.ncbi.nlm.nih.gov/pubmed/35930334 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 8 %P e39010 %T Passive Mobile Self-tracking of Mental Health by Veterans With Serious Mental Illness: Protocol for a User-Centered Design and Prospective Cohort Study %A Young,Alexander S %A Choi,Abigail %A Cannedy,Shay %A Hoffmann,Lauren %A Levine,Lionel %A Liang,Li-Jung %A Medich,Melissa %A Oberman,Rebecca %A Olmos-Ochoa,Tanya T %+ Semel Institute for Neuroscience & Human Behavior, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, 300 UCLA Medical Plaza, Los Angeles, CA, 90095, United States, 1 310 794 7219, ayoung@ucla.edu %K serious mental illness %K mobile health %K mental health %K passive sensing %K health informatics %K behavior %K sensor %K self-tracking %K predict %K assessment %D 2022 %7 5.8.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Serious mental illnesses (SMI) are common, disabling, and challenging to treat, requiring years of monitoring and treatment adjustments. Stress or reduced medication adherence can lead to rapid worsening of symptoms and behaviors. Illness exacerbations and relapses generally occur with little or no clinician awareness in real time, leaving limited opportunity to modify treatments. Previous research suggests that passive mobile sensing may be beneficial for individuals with SMI by helping them monitor mental health status and behaviors, and quickly detect worsening mental health for prompt assessment and intervention. However, there is too little research on its feasibility and acceptability and the extent to which passive data can predict changes in behaviors or symptoms. Objective: The aim of this research is to study the feasibility, acceptability, and safety of passive mobile sensing for tracking behaviors and symptoms of patients in treatment for SMI, as well as developing analytics that use passive data to predict changes in behaviors and symptoms. Methods: A mobile app monitors and transmits passive mobile sensor and phone utilization data, which is used to track activity, sociability, and sleep in patients with SMI. The study consists of a user-centered design phase and a mobile sensing phase. In the design phase, focus groups, interviews, and usability testing inform further app development. In the mobile sensing phase, passive mobile sensing occurs with participants engaging in weekly assessments for 9 months. Three- and nine-month interviews study the perceptions of passive mobile sensing and ease of app use. Clinician interviews before and after the mobile sensing phase study the usefulness and feasibility of app utilization in clinical care. Predictive analytic models are built, trained, and selected, and make use of machine learning methods. Models use sensor and phone utilization data to predict behavioral changes and symptoms. Results: The study started in October 2020. It has received institutional review board approval. The user-centered design phase, consisting of focus groups, usability testing, and preintervention clinician interviews, was completed in June 2021. Recruitment and enrollment for the mobile sensing phase began in October 2021. Conclusions: Findings may inform the development of passive sensing apps and self-tracking in patients with SMI, and integration into care to improve assessment, treatment, and patient outcomes. Trial Registration: ClinicalTrials.gov NCT05023252; https://clinicaltrials.gov/ct2/show/NCT05023252 International Registered Report Identifier (IRRID): DERR1-10.2196/39010 %M 35930336 %R 10.2196/39010 %U https://www.researchprotocols.org/2022/8/e39010 %U https://doi.org/10.2196/39010 %U http://www.ncbi.nlm.nih.gov/pubmed/35930336 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 7 %P e38942 %T Impacts of Digital Care Programs for Musculoskeletal Conditions on Depression and Work Productivity: Longitudinal Cohort Study %A Costa,Fabíola %A Janela,Dora %A Molinos,Maria %A Moulder,Robert %A Bento,Vírgilio %A Lains,Jorge %A Scheer,Justin %A Yanamadala,Vijay %A Cohen,Steven %A Dias Correia,Fernando %+ SWORD Health Inc, 65 E Wadsworth Park Drive, Suite 230, Draper, UT, 84020, United States, 1 385 308 8034, fcorreia@swordhealth.com %K musculoskeletal %K pain %K depression %K anxiety %K mental health %K comorbidity %K productivity %K digital health %K remote care %K rehabilitation %K telehealth %K telemedicine %K eHealth %K digital health %K digital care %K multimodal %K digital intervention %K recovery %K engagement %K activities of daily living %K work %K job %K occupational health %K longitudinal cohort %D 2022 %7 25.7.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Comorbidity between musculoskeletal (MSK) pain and depression is highly common, and is associated with a greater symptom burden and greater loss of work productivity than either condition alone. Multimodal care programs tackling both physical and mental health components may maximize productivity recovery and return to work. Digital delivery of such programs can facilitate access, ensure continuity of care, and enhance patient engagement. Objective: The aim of this study was to assess the impact of a completely remote multimodal digital care program (DCP) for MSK pain on mental health and work-related outcomes stratified by baseline depression levels. Methods: Ad hoc analysis of an interventional, single-arm, cohort study of individuals with MSK pain undergoing a DCP was performed. Three subgroups with different baseline depression severity levels were established based on responses to the Patient Health Questionnaire (PHQ-9): cluster 1 (score<5: minimal depression), cluster 2 (scores 5-10: mild depression), and cluster 3 (score≥10: moderate depression). The mean changes in depression, anxiety, fear-avoidance beliefs, work productivity, and activity impairment and adherence between baseline and end of program (8-12 weeks) were assessed across subgroups by latent growth curve analysis. Results: From a total of 7785 eligible participants, 6137 (78.83%) were included in cluster 1, 1158 (14.87%) in cluster 2, and 490 (6.29%) in cluster 3. Significant improvements in depression and anxiety scores were observed in clusters 2 and 3 but not in cluster 1, with average end-of-the program scores in clusters 2 and 3 below the initially defined cluster thresholds (score of 5 and 10, respectively). All clusters reported significant improvements in productivity impairment scores (mean changes from –16.82, 95% CI –20.32 to –13.42 in cluster 1 to –20.10, 95% CI –32.64 to –7.57 in cluster 3). Higher adherence was associated with higher improvements in depression in clusters 2 and 3, and with greater recovery in activities of daily living in cluster 3. Overall patient satisfaction was 8.59/10.0 (SD 1.74). Conclusions: A multimodal DCP was able to promote improvements in productivity impairment scores comparable to those previously reported in the literature, even in participants with comorbid depression and anxiety. These results reinforce the need to follow a biopsychosocial framework to optimize outcomes in patients with MSK pain. Trial Registration: ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946 %M 35714099 %R 10.2196/38942 %U https://www.jmir.org/2022/7/e38942 %U https://doi.org/10.2196/38942 %U http://www.ncbi.nlm.nih.gov/pubmed/35714099 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 7 %P e36417 %T Multimodal Assessment of Schizophrenia and Depression Utilizing Video, Acoustic, Locomotor, Electroencephalographic, and Heart Rate Technology: Protocol for an Observational Study %A Cotes,Robert O %A Boazak,Mina %A Griner,Emily %A Jiang,Zifan %A Kim,Bona %A Bremer,Whitney %A Seyedi,Salman %A Bahrami Rad,Ali %A Clifford,Gari D %+ Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 10 Park Place SE, Suite 620, Atlanta, GA, 30303, United States, 1 1 404 727 3755, robert.o.cotes@emory.edu %K digital biomarker %K machine learning %K computer vision %K schizophrenia %K depression %K multimodal %K technology %K acoustic %K heart rate %K biomarker %D 2022 %7 13.7.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Current standards of psychiatric assessment and diagnostic evaluation rely primarily on the clinical subjective interpretation of a patient’s outward manifestations of their internal state. While psychometric tools can help to evaluate these behaviors more systematically, the tools still rely on the clinician’s interpretation of what are frequently nuanced speech and behavior patterns. With advances in computing power, increased availability of clinical data, and improving resolution of recording and sensor hardware (including acoustic, video, accelerometer, infrared, and other modalities), researchers have begun to demonstrate the feasibility of cutting-edge technologies in aiding the assessment of psychiatric disorders. Objective: We present a research protocol that utilizes facial expression, eye gaze, voice and speech, locomotor, heart rate, and electroencephalography monitoring to assess schizophrenia symptoms and to distinguish patients with schizophrenia from those with other psychiatric disorders and control subjects. Methods: We plan to recruit three outpatient groups: (1) 50 patients with schizophrenia, (2) 50 patients with unipolar major depressive disorder, and (3) 50 individuals with no psychiatric history. Using an internally developed semistructured interview, psychometrically validated clinical outcome measures, and a multimodal sensing system utilizing video, acoustic, actigraphic, heart rate, and electroencephalographic sensors, we aim to evaluate the system’s capacity in classifying subjects (schizophrenia, depression, or control), to evaluate the system’s sensitivity to within-group symptom severity, and to determine if such a system can further classify variations in disorder subtypes. Results: Data collection began in July 2020 and is expected to continue through December 2022. Conclusions: If successful, this study will help advance current progress in developing state-of-the-art technology to aid clinical psychiatric assessment and treatment. If our findings suggest that these technologies are capable of resolving diagnoses and symptoms to the level of current psychometric testing and clinician judgment, we would be among the first to develop a system that can eventually be used by clinicians to more objectively diagnose and assess schizophrenia and depression with the possibility of less risk of bias. Such a tool has the potential to improve accessibility to care; to aid clinicians in objectively evaluating diagnoses, severity of symptoms, and treatment efficacy through time; and to reduce treatment-related morbidity. International Registered Report Identifier (IRRID): DERR1-10.2196/36417 %M 35830230 %R 10.2196/36417 %U https://www.researchprotocols.org/2022/7/e36417 %U https://doi.org/10.2196/36417 %U http://www.ncbi.nlm.nih.gov/pubmed/35830230 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 7 %P e37583 %T Proximal Risk for Suicide: Protocol for an Ecological Momentary Assessment Study %A Sharma,Pravesh %A Peck,Robert %A Sinicrope,Anthony R %A Pavey,Thomas %A Muehlenkamp,Jennifer J %+ Department of Psychiatry and Psychology, Mayo Clinic Health Systems, 1221, Whipple St, Eau Claire, WI, 54703, United States, 1 (715) 838 5222, sharma.pravesh@mayo.edu %K suicide %K suicide risk %K suicide ideation %K suicide prevention %K diary %K ecological momentary assessment %K Integrative-Volitional-Motivational Theory %D 2022 %7 12.7.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is a prevalent public health concern in the United States across all age groups. Research has emphasized the need to identify risk markers that prevent suicide along shorter timeframes, such as days to weeks. Furthermore, little has been done to explore the relative significance of factors that can predict short-term suicide risk or to evaluate how daily variability in these factors impacts suicidal ideation or behavior. This proposed project aims to identify risk factors that best predict near-time changes in suicidal ideation and examine potential interactions between these factors to predict transitions into suicidal thinking or behaviors. Objective: The aim of this proposed study is threefold: (1) To identify which psychological risk factors are most strongly associated with proximal changes in suicide risk across days and weeks. (2) To evaluate theoretical assumptions of the Integrative-Motivational-Volitional Theory of Suicide. (3) To determine how disruptions in physiological arousal interact with theoretical mechanisms of risk to predict concurrent and short-term prospective increase in suicidal thoughts and behaviors. Methods: A daily diary or ecological momentary assessment design will be utilized with 200 participants. Participants will complete 2 in-person visits separated by 3 weeks during which they will complete 3 brief daily assessments within their natural environments using the ilumivu research app on a smart device. Research will occur at the Mayo Clinic Health System (MCHS) Eau Claire site. Participants will be recruited through chart review and standard care delivery assessment. Results: This manuscript outlines the protocol that will guide the conduct of the forthcoming study. Conclusions: The proposed project aims to lead efforts using technological advances to capture microchanges in suicidal thinking/behavior over shorter timeframes and thereby guide future clinical assessment and management of suicidal patients. Results of this study will generate robust evidence to evaluate which risk factors predict proximal changes in suicidal ideation and behaviors. They will also provide the ability to examine potential interactions with multiple theoretically derived risk factors to predict proximal transitions into worsening suicidal thinking or behaviors. Such information will provide new targets for intervention that could ultimately reduce suicide-related morbidity and mortality. International Registered Report Identifier (IRRID): PRR1-10.2196/37583 %M 35819832 %R 10.2196/37583 %U https://www.researchprotocols.org/2022/7/e37583 %U https://doi.org/10.2196/37583 %U http://www.ncbi.nlm.nih.gov/pubmed/35819832 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 8 %N 3 %P e39003 %T Exploring the Association of Cancer and Depression in Electronic Health Records: Combining Encoded Diagnosis and Mining Free-Text Clinical Notes %A Leis,Angela %A Casadevall,David %A Albanell,Joan %A Posso,Margarita %A Macià,Francesc %A Castells,Xavier %A Ramírez-Anguita,Juan Manuel %A Martínez Roldán,Jordi %A Furlong,Laura I %A Sanz,Ferran %A Ronzano,Francesco %A Mayer,Miguel A %+ Department of Medicine and Life Sciences, Universitat Pompeu Fabra, C/Aiguader 88, Barcelona, 08003, Spain, 34 933160539, francesco.ronzano@upf.edu %K cancer %K depression %K electronic health records %K text mining %K natural language processing %D 2022 %7 11.7.2022 %9 Original Paper %J JMIR Cancer %G English %X Background: A cancer diagnosis is a source of psychological and emotional stress, which are often maintained for sustained periods of time that may lead to depressive disorders. Depression is one of the most common psychological conditions in patients with cancer. According to the Global Cancer Observatory, breast and colorectal cancers are the most prevalent cancers in both sexes and across all age groups in Spain. Objective: This study aimed to compare the prevalence of depression in patients before and after the diagnosis of breast or colorectal cancer, as well as to assess the usefulness of the analysis of free-text clinical notes in 2 languages (Spanish or Catalan) for detecting depression in combination with encoded diagnoses. Methods: We carried out an analysis of the electronic health records from a general hospital by considering the different sources of clinical information related to depression in patients with breast and colorectal cancer. This analysis included ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis codes and unstructured information extracted by mining free-text clinical notes via natural language processing tools based on Systematized Nomenclature of Medicine Clinical Terms that mentions symptoms and drugs used for the treatment of depression. Results: We observed that the percentage of patients diagnosed with depressive disorders significantly increased after cancer diagnosis in the 2 types of cancer considered—breast and colorectal cancers. We managed to identify a higher number of patients with depression by mining free-text clinical notes than the group selected exclusively on ICD-9-CM codes, increasing the number of patients diagnosed with depression by 34.8% (441/1269). In addition, the number of patients with depression who received chemotherapy was higher than those who did not receive this treatment, with significant differences (P<.001). Conclusions: This study provides new clinical evidence of the depression-cancer comorbidity and supports the use of natural language processing for extracting and analyzing free-text clinical notes from electronic health records, contributing to the identification of additional clinical data that complements those provided by coded data to improve the management of these patients. %M 35816382 %R 10.2196/39003 %U https://cancer.jmir.org/2022/3/e39003 %U https://doi.org/10.2196/39003 %U http://www.ncbi.nlm.nih.gov/pubmed/35816382 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 7 %P e38626 %T Psychological Effects of Aromatherapy on Smokers With Depressive Tendencies During Smoking Cessation Treatment: Protocol for a Pre-Post Single-Arm Clinical Trial %A Hata,Akiko %A Komiyama,Maki %A Yasoda,Akihiro %A Wada,Hiromichi %A Yamakage,Hajime %A Satoh-Asahara,Noriko %A Morimoto,Tatsuya %A Takahashi,Yuko %A Hasegawa,Koji %+ Clinical Research Institute, National Hospital Organization Kyoto Medical Center, 1-1, fukakusamukaihata-cho, fushimi-ku, Kyoto, 612-8555, Japan, 81 756419161, ako0717@gmail.com %K smoking cessation %K aromatherapy %K depression %K cardiovascular risk %K inhaler %K complementary and alternative medicine %D 2022 %7 7.7.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Cessation of smoking can markedly reduce the incidence of cardiovascular disease, improve health economics, and benefit society. Aromatherapy has the potential to be a novel option as an adjuvant therapy for smoking cessation that may alleviate depressive symptoms. However, research on the efficacy of aromatherapy as an adjuvant therapy for smoking cessation is scarce. Objective: The aim of this study was to examine the potential effects of aromatherapy on psychological states in smokers with depressive tendencies and to determine if it is reasonable to proceed to the next step (ie, a phase III trial). Methods: This is a pre-post single-arm clinical trial. Smokers with depression will be subjected to aromatherapy during smoking cessation treatment for 12 weeks. We will evaluate changes in scores on the Zung Self-Rating Depression Scale and the Profile of Mood States from pretreatment screening to 4 weeks and 12 weeks after the start of aromatherapy. Moreover, we will compare the group treated with aromatherapy with the group that received standard treatment in our previous randomized controlled trial (ie, the control group in that study). Furthermore, we will compare successful smoking cessation rates after 12 weeks. In addition, we will conduct an exploratory analysis of the efficacy of aromatherapy. The target sample size is 100, which is the number of subjects expected to be enrolled in this study during the 2-year study period. Results: This study was approved by the Kyoto Medical Center Institutional Review Board (IRB approval No. 19-016). Enrollment started on July 1, 2019. As of May 2022, 76 patients have been recruited. In the original plan, recruitment should have been finished on June 30, 2021. However, the number of subjects decreased due to the COVID-19 pandemic, and the study inclusion period was extended by 1 year (ie, until the end of June 2022) with the approval of the IRB on May 17, 2021. Analyses of the results will be completed subsequently. Conclusions: This study has some limitations. This is not a rigorous validation study because it compares the same subjects who received standard treatment in a previous study. Moreover, the sample size and methods of statistical analysis were not fully set with prior consideration of statistical rigor. To address these limitations, we plan to conduct a phase III trial that will reflect the exploratory findings of this study. This is the first study to evaluate the psychological effects of aromatherapy during a smoking cessation program, and it may help improve the quality of treatment for smoking cessation in the future. Trial Registration: UMIN Clinical Trials Registry UMIN000043102; https://tinyurl.com/tn3hvt9w International Registered Report Identifier (IRRID): DERR1-10.2196/38626 %M 35797095 %R 10.2196/38626 %U https://www.researchprotocols.org/2022/7/e38626 %U https://doi.org/10.2196/38626 %U http://www.ncbi.nlm.nih.gov/pubmed/35797095 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 7 %P e38837 %T Measures of Daily Activities Associated With Mental Health (Things You Do Questionnaire): Development of a Preliminary Psychometric Study and Replication Study %A Titov,Nickolai %A Dear,Blake F %A Bisby,Madelyne A %A Nielssen,Olav %A Staples,Lauren G %A Kayrouz,Rony %A Cross,Shane %A Karin,Eyal %+ eCentreClinic, School of Psychological Sciences, Macquarie University, 73 Talavera Road, Sydney, 2109, Australia, 61 0488 991 122, nick.titov@mq.edu.au %K anxiety %K depression %K satisfaction with life %K COVID-19 %K behavior %K habits %K cognitions %K survey %K mechanisms %K psychological well-being %D 2022 %7 5.7.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: A large body of research has identified modifiable cognitions and behaviors (actions) associated with psychological health. However, little is known regarding the actions that are most strongly associated with psychological health or the frequency with which they should be performed. Objective: This paper described 2 studies that used survey methodology to create the Things You Do Questionnaire (TYDQ), which aims to identify and rank actions (items) and domains of actions (factors) most strongly associated with psychological health. Methods: We used digital marketing strategies to recruit Australian adult participants, who were asked to complete 2 web-based surveys comprising versions of the TYDQ; validated measures of depression, anxiety, and satisfaction with life; and demographic questions. In study 1, a total of 3040 participants rated how often they performed each of the 96 items comprising the TYDQ. This design was replicated in study 2, in which a 59-item version of the TYDQ was completed by 3160 participants. In both studies, the factor structure and validity were examined, as were the associations between individual TYDQ items and 3 mental health outcomes: depression, anxiety, and satisfaction with life. Results: In study 1, factor analyses revealed that a 5-factor model comprising 27 items achieved an optimum balance between brevity and variance and accounted for 38.1%, 31.4%, and 33.2% of the variance in scores on measures of depression, anxiety, and satisfaction with life, respectively. The factors were interpreted as realistic thinking, meaningful activities, goals and plans, healthy habits, and social connections. These 5 factors were more strongly associated with psychological health than those such as practicing kindness, exercising gratitude, and practicing spirituality. This pattern of results was replicated across gender, age groups, and depression severity. The 5-factor solution found in study 1 was replicated in study 2. Analyses revealed that a 21-item version accounted for 46.8%, 38.2%, and 38.1% of the variance in scores on measures of depression, anxiety, and satisfaction with life, respectively. Conclusions: These findings indicate that some actions are more strongly associated with psychological health than others and that these activities fall within 5 broad domains, which represent skills often taught in psychological treatments. Subsequent studies are planned to explore the reliability of these items and results in other samples and to examine patterns of change in scores during treatment for anxiety and depression. If replicated, these efforts will assist in the development of new psychological interventions and provide an evidence base for public mental health campaigns designed to promote good mental health and prevent the emergence of common mental disorders. %M 35788101 %R 10.2196/38837 %U https://formative.jmir.org/2022/7/e38837 %U https://doi.org/10.2196/38837 %U http://www.ncbi.nlm.nih.gov/pubmed/35788101 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 7 %P e38005 %T Improvements in Depression Outcomes Following a Digital Cognitive Behavioral Therapy Intervention in a Polychronic Population: Retrospective Study %A Venkatesan,Aarathi %A Forster,Benjamin %A Rao,Prasanna %A Miller,Melissa %A Scahill,Michael %+ Vida Health, 100 Montgomery St, Ste 750, San Francisco, CA, 94104, United States, 1 14159891017, aarathi.venkatesan@vida.com %K depression %K anxiety %K CBT %K digital mental health intervention %K cognitive behavioral therapy %K digital health %K obesity %K diabetes %K mental health %D 2022 %7 5.7.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital mental health interventions have shown promise in reducing barriers to effective care for depression. Depression and related mental disorders are known to be highly comorbid with common chronic physical conditions, such as obesity and type 2 diabetes. While some research has explored the interaction dynamics of treating populations living with both mental and physical disorders, very little is known about such dynamics in digital care. Objective: We aimed to examine the effectiveness of a 12-week, therapist-supported, app-based cognitive behavioral therapy program in improving symptoms of depression and anxiety. The studied population included adults with a heavy burden of chronic physical disease, including obesity and type 2 diabetes. Methods: A total of 1512 participants with at least moderate depression were enrolled. The treatment cohort consisted of 831 (54.96%) participants who completed a follow-up assessment. The program included structured lessons and tools (ie, exercises and practices) and offered one-on-one weekly video counseling sessions with a licensed therapist for 12 weeks and monthly sessions thereafter. The clinically validated 8-item Patient Health Questionnaire (PHQ-8) and the 7-item Generalized Anxiety Disorder scale (GAD-7) were used to assess depression and anxiety, respectively. Linear mixed-effects modeling was employed to examine changes in depression and anxiety over time. Given correlation among various measures of program usage, a composite variable for depth of usage was used to analyze the correlation between usage and changes in depressive symptoms. Body weight changes from baseline were assessed primarily with digitally connected scales. Results: Out of 831 participants in the treatment cohort, 74.5% (n=619) showed a clinically significant reduction in depressive symptom severity after 12 weeks, where follow-up PHQ-8 scores had shifted downward by at least one diagnostic category. In total, 67.5% (n=561) of the participants showed a reliable improvement in PHQ-8 scores as measured by the reliable change index. There was an average reduction of 5.9 (SD 5.2) points (P<.001) between baseline and follow-up. Greater program usage was correlated with greater likelihood of reliable improvement in depressive symptoms (odds ratio 1.3, 95% CI 1.1-1.5; P=.002). An exploratory analysis of body weight changes with a multilevel, mixed-effect model suggested that reliable improvement in depressive symptoms at follow-up was associated with significantly greater weight loss at 9 months (β=–1.11, P=.002). Conclusions: The results provide further support that digital interventions can support clinically meaningful improvements in depression. Some form of synergy in treatment of comorbid depression and obesity or diabetes could be studied in future research. The study was limited by postintervention participant attrition as well as the retrospective observational study design. %M 35788442 %R 10.2196/38005 %U https://formative.jmir.org/2022/7/e38005 %U https://doi.org/10.2196/38005 %U http://www.ncbi.nlm.nih.gov/pubmed/35788442 %0 Journal Article %@ 2563-6316 %I JMIR Publications %V 3 %N 3 %P e34979 %T Representing Physician Suicide Claims as Nanopublications: Proof-of-Concept Study Creating Claim Networks %A Leung,Tiffany I %A Kuhn,Tobias %A Dumontier,Michel %+ Care and Public Health Research Institute, Maastricht University, Postbus 5800, Maastricht, 6202AZ, Netherlands, 31 43 388 2222, t.leung@maastrichtuniversity.nl %K physician suicide %K suicide %K suicide prevention %K physician well-being %K physician mental health %K nanopublication %K physician %K doctor %K mental health %K semantic publishing %K bibliometrics %K claim network %K information distortion %K misinformation %D 2022 %7 1.7.2022 %9 Original Paper %J JMIRx Med %G English %X Background: In the poorly studied field of physician suicide, various factors can contribute to misinformation or information distortion, which in turn can influence evidence-based policies and prevention of suicide in this unique population. Objective: The aim of this paper is to use nanopublications as a scientific publishing approach to establish a citation network of claims in peer-reviewed publications about the rate of suicide among US physicians. Methods: A list of articles from a previously published scoping literature review on physician suicide was used to identify those articles that commented on or investigated suicidal behaviors of physician populations, including students, postgraduate trainees, and practicing physicians. The included articles were from peer-reviewed publications and asserted a claim about the annual rate of physician suicide. Manual data extraction was performed to collect article (or resource) type, title, authors, digital object identifier or URI, publication year, claim (about annual physician suicide rate), data of last access of the article (eg, for a webpage), and citations supporting the claim. Additional articles, websites, or other links were only added to the set of claims if they were cited by a peer-reviewed article already included in the data set. A nanopublication was created for each article or resource using Nanobench with an investigator-developed literature-based claim nanopublication template. Results: A set of 49 claims concerning the rate of US physician suicide was represented as nanopublications. Analysis of the claim network revealed that (1) the network is not fully connected, (2) no single primary source of the claim could be identified, and (3) all end-point citations had a claim with no further citation, had no apparent claim, or could not be accessed to verify the claim. The nanopublication strategy also enabled the capture of variant claims published on a website. Conclusions: Nanopublications remain to be adopted in broader scientific publishing in medicine, especially in publishing about physician mental health and suicide. This proof-of-concept study highlights an opportunity for more coordinated research efforts in the subject of physician suicide. Our work integrates these various claims and enables the verification of nonauthoritative assertions, thereby better equipping researchers to advance evidence-based knowledge and to make informed statements in the advocacy of physician suicide prevention. Representing physician suicide rate claims as nanopublications can be extended and improved in future work. %M 27725715 %R 10.2196/34979 %U https://med.jmirx.org/2022/3/e34979 %U https://doi.org/10.2196/34979 %U http://www.ncbi.nlm.nih.gov/pubmed/27725715 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 7 %P e36021 %T An mHealth Platform for Augmenting Behavioral Health in Primary Care: Longitudinal Feasibility Study %A Moon,Khatiya Chelidze %A Sobolev,Michael %A Grella,Megan %A Alvarado,George %A Sapra,Manish %A Ball,Trever %+ Zucker Hillside Hospital, Kaufmann Building, Suite k204, 75-59 263rd Street, Glen Oaks, NY, 11004, United States, 1 7184704367, kmoon2@northwell.edu %K collaborative care %K mobile health %K psychiatry %K depression %K virtual care %K psychoeducation %K mobile app %K mobile phone %D 2022 %7 1.7.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The collaborative care model is a well-established system of behavioral health care within primary care settings. There is potential for mobile health (mHealth) technology to augment collaborative behavioral health care in primary care settings, thereby improving scalability, efficiency, and clinical outcomes. Objective: We aimed to assess the feasibility of engaging with and the preliminary clinical outcomes of an mHealth platform that was used to augment an existing collaborative care program in primary care settings. Methods: We performed a longitudinal, single-arm feasibility study of an mHealth platform that was used to augment collaborative care. A total of 3 behavioral health care managers, who were responsible for coordinating disease management in 6 primary care practices, encouraged participants to use a mobile app to augment the collaborative model of behavioral health care. The mHealth platform’s functions included asynchronous chats with the behavioral health care managers, depression self-report assessments, and psychoeducational content. The primary outcome was the feasibility of engagement, which was based on the number and type of participant-generated actions that were completed in the app. The primary clinical end point was a comparison of the baseline and final assessments of the Patient Health Questionnaire-9. Results: Of the 245 individuals who were referred by their primary care provider for behavioral health services, 89 (36.3%) consented to app-augmented behavioral health care. Only 12% (11/89) never engaged with the app during the study period. Across all participants, we observed a median engagement of 7 (IQR 12; mean 10.4; range 0-130) actions in the app (participants: n=78). The chat function was the most popular, followed by psychoeducational content and assessments. The subgroup analysis revealed no significant differences in app usage by age (P=.42) or sex (P=.84). The clinical improvement rate in our sample was 73% (32/44), although follow-up assessments were only available for 49% (44/89) of participants. Conclusions: Our preliminary findings indicate the moderate feasibility of using mHealth technology to augment behavioral health care in primary care settings. The results of this study are applicable to improving the design and implementation of mobile apps in collaborative care. %M 35776491 %R 10.2196/36021 %U https://formative.jmir.org/2022/7/e36021 %U https://doi.org/10.2196/36021 %U http://www.ncbi.nlm.nih.gov/pubmed/35776491 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 6 %P e38582 %T Dynamic Regulatory Processes in the Transition From Suicidal Ideation to Action in Adults Leaving Inpatient Psychiatric Care: Protocol for an Intensive Longitudinal Study %A Victor,Sarah E %A Christensen,Kirsten %A Johnson,Sheri L %A Van Allen,Jason %A Brick,Leslie A %+ Department of Psychological Sciences, Texas Tech University, Box 42051, Lubbock, TX, 79424, United States, 1 806 834 0340, sarah.victor@ttu.edu %K ecological momentary assessment %K suicidal ideation %K suicidal behavior %K actigraphy %K sleep %K cognitive control %K longitudinal %K affect %K impulsivity %D 2022 %7 30.6.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: US suicide rates have risen steadily in the past decade, and suicide risk is especially high in the months after discharge from inpatient psychiatric treatment. However, suicide research has lagged in examining dynamic within-person processes that contribute to risk over time among individuals known to be at high risk of suicide. Almost no research has examined how affective, cognitive, and physiological processes change over minutes, hours, or days to confer risk of suicidal behavior in daily life. Objective: This protocol describes a longitudinal study designed to examine real-world changes in risk of suicide across multiple assessment domains. Specifically, the study involves following adults known to be at high risk of suicide after discharge from inpatient psychiatric care using self-report, interview, actigraphy, and behavioral methods to identify proximal contributors to suicidal thoughts and behaviors. First, we hypothesize that negative affective experiences, which are featured in most major suicide theories, will comprise a latent factor indicative of psychache (emotional pain), which will predict increases in suicidal thinking over time. Second, we hypothesize that poor inhibitory control in the context of negative affective stimuli, as well as emotion-related impulsivity, will predict the transition from suicidal thinking to suicidal behavior over time. Third, we hypothesize that short sleep duration will precede within-person increases in suicidal ideation as well as increased odds of suicidal behavior among those reporting suicidal thoughts. Methods: The desired sample size is 130 adults with past-week suicidal thoughts or behaviors who are receiving inpatient psychiatric treatment. Participants will complete a battery of measures while on the inpatient unit to assess negative affective experiences, emotion-related impulsivity, inhibitory control, typical sleep patterns, and relevant covariates. After discharge from inpatient care, participants will complete 4 weeks of signal-contingent ecological momentary assessment surveys, as well as mobile behavioral measures of inhibitory control, while wearing an actigraphy device that will gather objective data on sleep. Participants will complete interviews regarding suicidal thoughts and behaviors at 4 and 8 weeks after discharge. Results: The study was funded by the National Institutes of Health in November 2020. Recruitment began in April 2021. Data analysis will begin after completion of data collection. Conclusions: This study will elucidate how affective, cognitive, and physiological risk factors contribute (or do not contribute) to within-person fluctuations in suicide risk in daily life, with important implications for extant theories of suicide. Of import, the examined risk factors are all modifiable; thus, the results will inform identification of key targets for just-in-time, flexible, personalized, digital interventions that can be used to decrease emotional distress and prevent suicide among those at highest risk. International Registered Report Identifier (IRRID): DERR1-10.2196/38582 %M 35771618 %R 10.2196/38582 %U https://www.researchprotocols.org/2022/6/e38582 %U https://doi.org/10.2196/38582 %U http://www.ncbi.nlm.nih.gov/pubmed/35771618 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 6 %P e36809 %T Long-term Effects of a Social Media–Based Intervention (Run4Love) on Depressive Symptoms of People Living With HIV: 3-Year Follow-up of a Randomized Controlled Trial %A Guo,Yan %A Li,Yingqi %A Yu,Chuanchuan %A Xu,He %A Hong,Y Alicia %A Wang,Xiaolan %A Zhang,Nanxiang %A Zeng,Yu %A Monroe-Wise,Aliza %A Li,Linghua %A Liu,Cong %A Cai,Weiping %A Lin,Aihua %+ Department of Medical Statistics, School of Public Health, Sun Yat-sen University, #74 Zhongshan 2nd Road, Guangzhou, 510080, China, 86 020 87334202, Yan.Guo1@umassmed.edu %K HIV %K depressive symptoms %K mobile health %K mHealth %K social media–based %K long-term intervention effect %D 2022 %7 28.6.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Emerging studies have shown the effectiveness of mobile health (mHealth) interventions in reducing depressive symptoms among people living with HIV. Most of these studies included only short-term follow-up, with limited data on long-term effects. Objective: The purpose of this study is to assess the long-term effects of a randomized controlled trial called Run4Love on depressive symptoms among people living with HIV at 1-year and 3-year follow-ups. Methods: A total of 300 people living with HIV with depressive symptoms were recruited and randomized to an intervention or a control group in Guangzhou, China, from September 2017 to January 2018. The intervention group received a 3-month Run4Love program, including adapted evidence-based cognitive behavioral stress management courses and exercise promotion via WeChat (Tencent), a popular social media app. The control group received usual care and a brochure on nutrition. The primary outcome was reduction in depressive symptoms, measured using the Center for Epidemiological Studies–Depression (CES-D) scale. Data used in this study were collected at baseline and at the 1-year and 3-year follow-ups. Generalized estimating equations were used to examine the group differences at 1-year and 3-year follow-ups. Results: Approximately half of the participants completed the assessment at 1-year (149/300, 49.7%) and 3-year (177/300, 59%) follow-ups. At 1-year follow-up, participants in the intervention group reported significant reduction in depressive symptoms compared with the control group (CES-D: from 23.9 to 18.1 in the intervention group vs from 24.3 to 23.3 in the control group; mean −4.79, SD 13.56; 95% CI −7.78 to −1.81; P=.002). At 3-year follow-up, between-group difference in CES-D remained statistically significant (from 23.9 to 20.5 in the intervention group vs from 24.3 to 24.4 in the control group; mean −3.63, SD 13.35; 95% CI −6.71 to −0.54; P=.02). No adverse events were reported during the 3-year follow-up period. Conclusions: The mHealth intervention, Run4Love, significantly reduced depressive symptoms among people living with HIV, and the intervention effects were sustained at 1-year and 3-year follow-ups. Further research is needed to explore the mechanisms of the long-term effects of mHealth interventions such as Run4Love and to implement these effective interventions among people living with HIV. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR-IPR-17012606 International Registered Report Identifier (IRRID): RR2-10.2196/10274 %M 35763324 %R 10.2196/36809 %U https://www.jmir.org/2022/6/e36809 %U https://doi.org/10.2196/36809 %U http://www.ncbi.nlm.nih.gov/pubmed/35763324 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 6 %P e36050 %T Impact of a Long Lockdown on Mental Health and the Role of Media Use: Web-Based Survey Study %A Grygarová,Dominika %A Adámek,Petr %A Juríčková,Veronika %A Horáček,Jiří %A Bakštein,Eduard %A Fajnerová,Iveta %A Kesner,Ladislav %+ Center for Advanced Studies of Brain and Consciousness, National Institute of Mental Health, Topolová 748, Klecany, 250 67, Czech Republic, 420 283 088 264, dominika.grygarova@nudz.cz %K mental health %K COVID-19 %K lockdown %K media use %K anxiety %K depression %K nationally representative data %K survey %K longitudinal study %K pandemic %K social isolation %K social media %K psychological trauma %K mental stress %K media news %D 2022 %7 28.6.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Due to the COVID-19 pandemic, the Czech population experienced a second lockdown lasting for about half a year, restricting free movement and imposing social isolation. However, it is not known whether the impact of this long lockdown resulted in habituation to the adverse situation or in the traumatization of the Czech population, and whether the media and specific media use contributed to these effects. Objective: The aim of this study was to elucidate the effect of the long lockdown on the mental health of the Czech population, and the role of exposure to COVID-19 news reports and specific forms of media news use in mental health. Methods: We conducted two consecutive surveys in the early (November 2020) and late (March/April 2021) phases of the nationwide lockdown on the same nationally representative group of Czech adults (N=1777) participating in a longitudinal panel study. Results: Our findings showed that the self-reported symptoms of anxiety and depression increased in the second observation period, confirming the negative effect of the pandemic lockdown as it unfolded, suggesting that restrictive measures and continuous exposure to a collective stressor did not result in the strengthening of resilience but rather in ongoing traumatization. The results also suggest a negative role of the media’s coverage of the COVID-19 pandemic in mental health during the early, and particularly late, phases of the lockdown. Furthermore, we found several risk and protective factors of specific media news use. The media practice in news consumption connected to social media use was the strongest predictor of exacerbated mental health symptoms, particularly in the late phase of the lockdown. Moreover, news media use characterized by internalization of information learned from the news, as well as negative attitudes toward media news, were associated with higher levels of anxiety and depression. Conversely, the use of infotainment, together with an in-depth and contextual style of reading news articles, were related to improvement of mental health. Conclusions: Our study showed that the long lockdown resulted in traumatization rather than habituation, and in more pronounced effects (both negative and positive) of media use in mental health. %M 35605112 %R 10.2196/36050 %U https://mental.jmir.org/2022/6/e36050 %U https://doi.org/10.2196/36050 %U http://www.ncbi.nlm.nih.gov/pubmed/35605112 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 6 %P e35807 %T Predicting Depression in Adolescents Using Mobile and Wearable Sensors: Multimodal Machine Learning–Based Exploratory Study %A Mullick,Tahsin %A Radovic,Ana %A Shaaban,Sam %A Doryab,Afsaneh %+ Department of Engineering Systems and Environment, University of Virginia, Olsson Hall, 151 Engineer's Way, Charlottesville, VA, 22904, United States, 1 434 243 5823, tum7q@virginia.edu %K adolescent %K depression %K uHealth %K machine learning %K mobile phone %D 2022 %7 24.6.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression levels in adolescents have trended upward over the past several years. According to a 2020 survey by the National Survey on Drug Use and Health, 4.1 million US adolescents have experienced at least one major depressive episode. This number constitutes approximately 16% of adolescents aged 12 to 17 years. However, only 32.3% of adolescents received some form of specialized or nonspecialized treatment. Identifying worsening symptoms earlier using mobile and wearable sensors may lead to earlier intervention. Most studies on predicting depression using sensor-based data are geared toward the adult population. Very few studies look into predicting depression in adolescents. Objective: The aim of our work was to study passively sensed data from adolescents with depression and investigate the predictive capabilities of 2 machine learning approaches to predict depression scores and change in depression levels in adolescents. This work also provided an in-depth analysis of sensor features that serve as key indicators of change in depressive symptoms and the effect of variation of data samples on model accuracy levels. Methods: This study included 55 adolescents with symptoms of depression aged 12 to 17 years. Each participant was passively monitored through smartphone sensors and Fitbit wearable devices for 24 weeks. Passive sensors collected call, conversation, location, and heart rate information daily. Following data preprocessing, 67% (37/55) of the participants in the aggregated data set were analyzed. Weekly Patient Health Questionnaire-9 surveys answered by participants served as the ground truth. We applied regression-based approaches to predict the Patient Health Questionnaire-9 depression score and change in depression severity. These approaches were consolidated using universal and personalized modeling strategies. The universal strategies consisted of Leave One Participant Out and Leave Week X Out. The personalized strategy models were based on Accumulated Weeks and Leave One Week One User Instance Out. Linear and nonlinear machine learning algorithms were trained to model the data. Results: We observed that personalized approaches performed better on adolescent depression prediction compared with universal approaches. The best models were able to predict depression score and weekly change in depression level with root mean squared errors of 2.83 and 3.21, respectively, following the Accumulated Weeks personalized modeling strategy. Our feature importance investigation showed that the contribution of screen-, call-, and location-based features influenced optimal models and were predictive of adolescent depression. Conclusions: This study provides insight into the feasibility of using passively sensed data for predicting adolescent depression. We demonstrated prediction capabilities in terms of depression score and change in depression level. The prediction results revealed that personalized models performed better on adolescents than universal approaches. Feature importance provided a better understanding of depression and sensor data. Our findings can help in the development of advanced adolescent depression predictions. %M 35749157 %R 10.2196/35807 %U https://formative.jmir.org/2022/6/e35807 %U https://doi.org/10.2196/35807 %U http://www.ncbi.nlm.nih.gov/pubmed/35749157 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 6 %P e36521 %T Predictors of Disengagement and Symptom Improvement Among Adults With Depression Enrolled in Talkspace, a Technology-Mediated Psychotherapy Platform: Naturalistic Observational Study %A Darnell,Doyanne %A Pullmann,Michael D %A Hull,Thomas D %A Chen,Shiyu %A Areán,Patricia %+ Department of Psychiatry & Behavioral Sciences, University of Washington, 325 Ninth Avenue, Box 359911, Seattle, WA, 98104, United States, 1 206 744 9108, darnelld@uw.edu %K depression %K psychotherapy %K disengagement %K internet %K web-based %K technology-mediated psychotherapy %D 2022 %7 22.6.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression is a common psychiatric condition with an estimated lifetime prevalence for major depression of 16.6% in the US adult population and is effectively treated through psychotherapy. The widespread availability of the internet and personal devices such as smartphones are changing the landscape of delivery of psychotherapy; however, little is known about whether and for whom this type of therapy is beneficial, and whether having synchronous video-based sessions provides additional benefits to clients above and beyond messaging-based therapy. Objective: This study examined the outcomes associated with the use of a digital platform (Talkspace) for technology-mediated psychotherapy. We examined the duration of client engagement in therapy and client depression score trajectories over 16 weeks. We explored the association of client characteristics, therapist characteristics, and service plan type with time-to-disengagement and trajectories of change in depression scores. Methods: This naturalistic observational study assessed data collected routinely by the platform between January 2016 and January 2018 and examined psychotherapy outcomes among a large representative sample of adult clients with clinically significant depression. Treatment disengagement was defined as a lack of client-initiated communication for more than 4 weeks. Clients completed the Patient Health Questionnaire-8 item (PHQ-8) at intake and every 3 weeks via an in-app survey. Cox regression analysis was used to examine the time until and predictors of disengagement. Changes in depression scores and predictors of change over time were examined using mixed-effects regression. Results: The study included 5890 clients and 1271 therapists. Client scores on the PHQ-8 declined over time, with the average client improving from a score of 15 to below the clinical cutoff of 10 by week 6. At the same time point, 37% of clients had disengaged from the therapy. When combined into a final Cox regression model, those who were more likely to disengage were clients aged 18 to 25 years versus those aged ≥50 years (odds ratio [OR] 0.82, 95% CI 0.74-0.9; P<.001), had higher education (OR 1.14, 95% CI 1.06-1.22; P<.001), had been in therapy before (OR 1.09, 95% CI 1.02-1.17; P=.01), and were living with a partner but unmarried versus single (OR 1.14, 95% CI 1.02-1.27; P=.02). Having a therapist with >10 years of experience was related to lower odds of disengagement (OR 0.87, 95% CI 0.8-0.94; P=.01). When combined into a final regression model predicting improvement in depression scores over time, clients showing more improvement were those with an associate’s degree or higher (linear estimate=−0.07, P=.002) and higher intake PHQ-8 scores (estimate=3.73, P<.001). There were no differences based on the plan type. Conclusions: Our findings add to the growing literature showing the benefits of technology-mediated psychotherapy over a relatively brief period (16 weeks). %M 35731563 %R 10.2196/36521 %U https://formative.jmir.org/2022/6/e36521 %U https://doi.org/10.2196/36521 %U http://www.ncbi.nlm.nih.gov/pubmed/35731563 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 6 %P e35496 %T Conceptual Invariance, Trajectories, and Outcome Associations of Working Alliance in Unguided and Guided Internet-Based Psychological Interventions: Secondary Analysis of a Randomized Controlled Trial %A Luo,Xiaochen %A Bugatti,Matteo %A Molina,Lucero %A Tilley,Jacqueline L %A Mahaffey,Brittain %A Gonzalez,Adam %+ Department of Counseling Psychology, Santa Clara University, 500 El Camino Real, Santa Clara, CA, 95050, United States, 1 408 554 4000, xluo@scu.edu %K working alliance %K internet-based psychological interventions %K video support %K text support %K trajectory %K MyCompass %D 2022 %7 21.6.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: The role of working alliance remains unclear for many forms of internet-based interventions (IBIs), a set of effective psychotherapy alternatives that do not require synchronous interactions between patients and therapists. Objective: This study examined the conceptual invariance, trajectories, and outcome associations of working alliance across an unguided IBI and guided IBIs that incorporated clinician support through asynchronous text messaging or video messaging. Methods: Adults with high education attainment (n=145) with subclinical levels of anxiety, stress, or depressive symptoms were randomized to 1 of 3 treatment conditions for 7 weeks. All participants received treatments from MyCompass, an unguided IBI using cognitive behavior therapy. Participants in condition 2 and 3 received supplemental, asynchronous clinician support through text and video, respectively. Working alliance with the IBIs was measured weekly using select items from the 12-item version of the Agnew Relationship Measure. Symptom and functional outcomes were assessed at baseline, at the end of treatment, and 1-month follow-up. Results: Working alliance with the IBIs was conceptually invariant across the 3 conditions. Working alliance followed a quadratic pattern of change over time for all conditions and declined significantly only in the text-support condition. After controlling for baseline symptoms, higher baseline levels of working alliance predicted less depression and less functional impairment at follow-up, whereas faster increases in working alliance predicted less worry at the end of treatment and at follow-up, all of which only occurred in the video-support condition. Conclusions: Working alliance with the IBIs was generally established in the initial sessions. Although working alliance is conceptually invariant across IBIs with or without clinician support, the associations between working alliance and treatment outcomes among IBIs may differ depending on clinician involvement and the modalities of support. Trial Registration: ClinicalTrials.gov NCT05122429; https://clinicaltrials.gov/ct2/show/NCT05122429 %M 35727626 %R 10.2196/35496 %U https://mental.jmir.org/2022/6/e35496 %U https://doi.org/10.2196/35496 %U http://www.ncbi.nlm.nih.gov/pubmed/35727626 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 6 %P e33036 %T Predicting Mental Health Status in Remote and Rural Farming Communities: Computational Analysis of Text-Based Counseling %A Antoniou,Mark %A Estival,Dominique %A Lam-Cassettari,Christa %A Li,Weicong %A Dwyer,Anne %A Neto,Abìlio de Almeida %+ The MARCS Institute for Brain, Behaviour and Development, Western Sydney University, Locked Bag 1797, Penrith, 2751, Australia, 61 2 9772 6673, m.antoniou@westernsydney.edu.au %K e-mental health %K text-based %K counseling %K Linguistic Inquiry and Word Count %K LIWC %K depression %K anxiety %K stress %D 2022 %7 21.6.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Australians living in rural and remote areas are at elevated risk of mental health problems and must overcome barriers to help seeking, such as poor access, stigma, and entrenched stoicism. e-Mental health services circumvent such barriers using technology, and text-based services are particularly well suited to clients concerned with privacy and self-presentation. They allow the client to reflect on the therapy session after it has ended as the chat log is stored on their device. The text also offers researchers an opportunity to analyze language use patterns and explore how these relate to mental health status. Objective: In this project, we investigated whether computational linguistic techniques can be applied to text-based communications with the goal of identifying a client’s mental health status. Methods: Client-therapist text messages were analyzed using the Linguistic Inquiry and Word Count tool. We examined whether the resulting word counts related to the participants’ presenting problems or their self-ratings of mental health at the completion of counseling. Results: The results confirmed that word use patterns could be used to differentiate whether a client had one of the top 3 presenting problems (depression, anxiety, or stress) and, prospectively, to predict their self-rated mental health after counseling had been completed. Conclusions: These findings suggest that language use patterns are useful for both researchers and clinicians trying to identify individuals at risk of mental health problems, with potential applications in screening and targeted intervention. %M 35727623 %R 10.2196/33036 %U https://formative.jmir.org/2022/6/e33036 %U https://doi.org/10.2196/33036 %U http://www.ncbi.nlm.nih.gov/pubmed/35727623 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 6 %P e33637 %T Applying the Health Belief Model to Characterize Racial/Ethnic Differences in Digital Conversations Related to Depression Pre- and Mid-COVID-19: Descriptive Analysis %A Castilla-Puentes,Ruby %A Pesa,Jacqueline %A Brethenoux,Caroline %A Furey,Patrick %A Gil Valletta,Liliana %A Falcone,Tatiana %+ Center for Public Health Practice, Drexel University, 530 S 2nd st Suite 743, Philadelphia, PA, 19147, United States, 1 6108642528, rcastil4@its.jnj.com %K depression %K COVID-19 %K treatment %K race/ethnicity %K digital conversations %K health belief model %K artificial intelligence %K natural language processing %D 2022 %7 20.6.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The prevalence of depression in the United States is >3 times higher mid-COVID-19 versus prepandemic. Racial/ethnic differences in mindsets around depression and the potential impact of the COVID-19 pandemic are not well characterized. Objective: This study aims to describe attitudes, mindsets, key drivers, and barriers related to depression pre- and mid-COVID-19 by race/ethnicity using digital conversations about depression mapped to health belief model (HBM) concepts. Methods: Advanced search, data extraction, and artificial intelligence–powered tools were used to harvest, mine, and structure open-source digital conversations of US adults who engaged in conversations about depression pre- (February 1, 2019-February 29, 2020) and mid-COVID-19 pandemic (March 1, 2020-November 1, 2020) across the internet. Natural language processing, text analytics, and social data mining were used to categorize conversations that included a self-identifier into racial/ethnic groups. Conversations were mapped to HBM concepts (ie, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy). Results are descriptive in nature. Results: Of 2.9 and 1.3 million relevant digital conversations pre- and mid-COVID-19, race/ethnicity was determined among 1.8 million (62.2%) and 979,000 (75.3%) conversations, respectively. Pre-COVID-19, 1.3 million (72.1%) conversations about depression were analyzed among non-Hispanic Whites (NHW), 227,200 (12.6%) among Black Americans (BA), 189,200 (10.5%) among Hispanics, and 86,800 (4.8%) among Asian Americans (AS). Mid-COVID-19, a total of 736,100 (75.2%) conversations about depression were analyzed among NHW, 131,800 (13.5%) among BA, 78,300 (8.0%) among Hispanics, and 32,800 (3.3%) among AS. Conversations among all racial/ethnic groups had a negative tone, which increased pre- to mid-COVID-19; finding support from others was seen as a benefit among most groups. Hispanics had the highest rate of any racial/ethnic group of conversations showing an avoiding mindset toward their depression. Conversations related to external barriers to seeking treatment (eg, stigma, lack of support, and lack of resources) were generally more prevalent among Hispanics, BA, and AS than among NHW. Being able to benefit others and building a support system were key drivers to seeking help or treatment for all racial/ethnic groups. Conclusions: There were considerable racial/ethnic differences in drivers and barriers to seeking help and treatment for depression pre- and mid-COVID-19. As expected, COVID-19 has made conversations about depression more negative and with frequent discussions of barriers to seeking care. Applying concepts of the HBM to data on digital conversation about depression allowed organization of the most frequent themes by race/ethnicity. Individuals of all groups came online to discuss their depression. These data highlight opportunities for culturally competent and targeted approaches to addressing areas amenable to change that might impact the ability of people to ask for or receive mental health help, such as the constructs that comprise the HBM. %M 35275834 %R 10.2196/33637 %U https://formative.jmir.org/2022/6/e33637 %U https://doi.org/10.2196/33637 %U http://www.ncbi.nlm.nih.gov/pubmed/35275834 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 6 %P e35194 %T Possible Contribution of Meaning in Life in Patients With Chronic Pain and Suicidal Ideation: Observational Study %A Chytas,Vasileios %A Costanza,Alessandra %A Mazzola,Viridiana %A Luthy,Christophe %A Galani,Vasiliki %A Bondolfi,Guido %A Cedraschi,Christine %+ Department of Psychiatry, Service of Liaison Psychiatry and Crisis Intervention, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, 1205, Switzerland, 41 079 553 41 55, Vasileios.Chytas@hcuge.ch %K meaning in life %K suicidal ideation %K chronic pain %K pain %K suicide %D 2022 %7 13.6.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Chronic pain is associated with an elevated risk of suicidal ideation (SI). Objective: We aimed to examine if the presence or the search for Meaning in Life (MiL) are associated with less SI and explore whether MiL profiles emerge in our cohort. These profiles can be described as high presence–high search, high presence–low search, low presence–low search, and low presence–high search. Methods: In this observational study, we recruited 70 patients who were referred to the Multidisciplinary Pain Center of the Geneva University Hospitals and who answered positively to question 9 on the Beck Depression Inventory, 2nd Edition, investigating SI. Patients who agreed to participate in the study were further investigated; they participated in a structured diagnostic interview to screen for psychiatric diagnoses. During this interview, they completed the Meaning in Life Questionnaire and the semistructured Scale for Suicide Ideation (SSI) to assess the characteristics and severity of SI. Results: There was a statistically significant correlation between the presence of MiL subscale and the SSI. These 2 scales had a negative and statistically highly significant correlation (R=–.667; P<.001). The results also showed a negative and statistically highly significant correlation between the score of the search for MiL and the SSI (R=–.456; P<.001). The results thus pointed to the presence of MiL as a potential protective factor against the severity of SI, while the search for MiL is also a possible resiliency factor, although to a lesser extent. The profile low presence–low search grouped the vast majority (47%) of the patients; in these patients, the mean SSI score was 14.36 (SD 5.86), much higher compared with that of the other subgroups. Conclusions: This study’s results point to MiL as a concept of interest regarding devising psychotherapeutic interventions for chronic pain patients in order to reduce the suicidal risk and more accurately determine patients’ suffering. %M 35699974 %R 10.2196/35194 %U https://formative.jmir.org/2022/6/e35194 %U https://doi.org/10.2196/35194 %U http://www.ncbi.nlm.nih.gov/pubmed/35699974 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 6 %P e23879 %T Feasibility and Acceptability of Internet-Based Interpersonal Psychotherapy for Stress, Anxiety, and Depression in Prenatal Women: Thematic Analysis %A Bright,Katherine S %A Stuart,Scott %A Mcneil,Deborah A %A Murray,Lindsay %A Kingston,Dawn E %+ Faculty of Nursing, University of Calgary, PF2500B, 2500 University Drive NW,, Calgary, AB, T2N 1N4, Canada, 1 403 220 6262, ksbright@ucalgary.ca %K internet-based %K interpersonal psychotherapy %K mental health %K prenatal %K anxiety %K depression %K stress %K mobile phone %D 2022 %7 10.6.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Prenatal mental health is a global health concern. Despite the far-reaching impact of prenatal mental health issues, many women do not receive the psychological care they require. Women in their childbearing years are frequent users of the internet and smartphone apps. Prenatal women are prime candidates for internet-based support for mental health care. Objective: This study aimed to examine the feasibility and acceptability of internet-based interpersonal psychotherapy (IPT) for prenatal women. Methods: Semistructured interviews were conducted with women who had received internet-based IPT modules with guided support as a component of a randomized controlled trial evaluating the scale-up implementation of a digital mental health platform (The Healthy Outcomes of Pregnancy and Postpartum Experiences digital platform) for pregnant women. Qualitative thematic analysis was used to explore and describe women’s experiences. Data were analyzed for emerging themes, which were identified and coded. Results: A total of 15 prenatal women were interviewed to examine their experiences and views on the feasibility and acceptability of internet-based IPT modules. Participants found the content informative and appreciated the ways in which the digital mental health platform made the IPT modules accessible to users. Participants voiced some differing requirements regarding the depth and the way information was presented and accessed on the digital mental health platform. The important areas for improvement that were identified were acknowledging greater depth and clarity of content, the need for sociability and relationships, and refinement of the digital mental health platform to a smartphone app. Conclusions: This study provides useful evidence regarding treatment format and content preferences, which may inform future development. It also provides research data on the feasibility and acceptability of web-based applications for prenatal mental health care. Trial Registration: ClinicalTrials.gov NCT01901796; https://clinicaltrials.gov/ct2/show/NCT01901796 %M 35687403 %R 10.2196/23879 %U https://formative.jmir.org/2022/6/e23879 %U https://doi.org/10.2196/23879 %U http://www.ncbi.nlm.nih.gov/pubmed/35687403 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 6 %P e33793 %T General Demographics and Behavioral Patterns of Visitors Using a Self-help Website for Identification of and Intervention in Alcoholism and Common Mental Disorders in Suriname: Descriptive Study %A Jadnanansing,Raj %A Dekker,Jack %A Etwaroo,Kajal %A Dwarkasing,Rudi %A Lumsden,Vincent %A Bipat,Robbert %A Blankers,Matthijs %+ Psychiatrisch Centrum Suriname, L. Vriesdelaan, Paramaribo, Suriname, 597 8781948, raj.jadnanansing@pcs.sr %K eHealth %K mental health %K alcohol use disorder %K depression %K anxiety %K Facebook %K alcohol disorder %K alcohol %K self-help %K alcoholism %K Suriname %D 2022 %7 9.6.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital health applications have been shown to be an accepted means to provide mental health information and advice in various high- and middle-income countries. Started in 2015, ehealth.sr was the first website to offer preventive information, self-tests, and unguided digital self-help for depression, anxiety symptoms, and problematic alcohol use in Suriname, an upper middle-income country in South America. Objective: This study aimed to assess the general demographics and behavioral patterns of the visitors of ehealth.sr, as well as to evaluate different promotional channels to attract the target audience to the website. Methods: Data collection for this study took place between August 2015 and December 2020. Conventional promotion channels such as newspaper and radio advertisements as well as social media advertisements were used to attract users to the website. The number of visits and activity on the website was registered using Google analytics and the website’s internal activity log. Results: On average, about 115 unique visitors accessed the website per month. The average number of visits to the website increased notably when social media advertisement campaigns were conducted (266 per month in 2018) compared to when traditional advertisements campaigns through papers, radio, and television were used (34 per month in 2019). Of the 1908 new visitors, 1418 (74.32%) were female. On average, visitors accessed 2 (SD 0.3) pages of the website and a session lasted 2.6 (SD 0.9) minutes. The most popular pages for intervention on the website were those for the mood or anxiety screening (731/942, 77.6%) as opposed to those for alcohol screening (211/942, 22.4%). People aged <45 years (on average, 2.2 pages per session for 3.2 minutes) made more use of the website than people aged ≥45 years (on average, 1.7 pages per session for 2 minutes). Conclusions: Promotion via social media led to more visitors to the website than newspaper or radio advertisements. Younger age groups and females visited the website more often. The pages on preventive information and brief self-tests were visited more frequently than the self-help modules. In general, user adherence to the website in terms of the average session duration and number of viewed pages per session is low and is a key point of concern for the successful implementation of digital mental health websites. %M 35679108 %R 10.2196/33793 %U https://formative.jmir.org/2022/6/e33793 %U https://doi.org/10.2196/33793 %U http://www.ncbi.nlm.nih.gov/pubmed/35679108 %0 Journal Article %@ 2561-1011 %I JMIR Publications %V 6 %N 1 %P e29926 %T Internet-Based Cognitive Behavioral Therapy and its Association With Self-efficacy, Depressive Symptoms, and Physical Activity: Secondary Analysis of a Randomized Controlled Trial in Patients With Cardiovascular Disease %A Johansson,Peter %A Lundgren,Johan %A Andersson,Gerhard %A Svensson,Erland %A Mourad,Ghassan %+ Department of Health, Medicine and Caring Sciences, Linköping University, Kungsgatan 40, Norrköping, 601 74, Sweden, 46 0700896548, peter.b.johansson@liu.se %K internet-based cognitive behavioral therapy %K cardiovascular disease %K depression %K self-efficacy %K physical activity %K mental health %K depression %K digital health %K online health %K digital therapy %K cognition %K self-care %K CVD %K internet-based %K cardiology %K heart disease %K cardiac health %K cognitive behavioral therapy %D 2022 %7 3.6.2022 %9 Original Paper %J JMIR Cardio %G English %X Background: In patients with cardiovascular disease (CVD), knowledge about the associations among changes in depressive symptoms, self-efficacy, and self-care activities has been requested. This is because such knowledge can be helpful in the design of behavioral interventions aimed to improve self-efficacy, reduce depressive symptoms, and improve performance of self-care activities in CVD patients. Objective: We aim to evaluate if internet-based cognitive behavioral therapy (iCBT) improves self-efficacy and explore the relationships among changes in depressive symptoms, self-efficacy, and physical activity, as well as the influence of iCBT on these relationships. Methods: This study received funding in January 2015. Participant recruitment took place between January 2017 and February 2018, and the main findings were published in 2019. This study is a secondary analysis of data collected in a randomized controlled study evaluating the effects of a 9-week iCBT program compared to an online discussion forum (ODF) on depressive symptoms in patients with CVD (N=144). Data were collected at baseline and at the 9-week follow-up. Analysis of covariance was used to evaluate the differences in self-efficacy between the iCBT and ODF groups. Structural equation modeling explored the relationships among changes in depressive symptoms, self-efficacy, and physical activity, as well as the influence of iCBT on these relationships. Results: At follow-up, a significant difference in the increase in self-efficacy favoring iCBT was found (P=.04, Cohen d=0.27). We found an indirect association between changes in depressive symptoms and physical activity (β=–.24, P<.01), with the change in self-efficacy acting as a mediator. iCBT had a direct effect on the changes in depressive symptoms, which in turn influenced the changes in self-efficacy (β=.23, P<.001) and physical activity (β=.12, P<.001). Conclusions: Self-efficacy was improved by iCBT. However, the influence of iCBT on self-efficacy and physical activity was mostly mediated by improvements in depressive symptoms. Trial Registration: ClinicalTrials.gov NCT02778074; https://clinicaltrials.gov/ct2/show/NCT02778074 %M 35657674 %R 10.2196/29926 %U https://cardio.jmir.org/2022/1/e29926 %U https://doi.org/10.2196/29926 %U http://www.ncbi.nlm.nih.gov/pubmed/35657674 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 5 %P e34154 %T Adolescent Health Promotion Interventions Using Well-Care Visits and a Smartphone Cognitive Behavioral Therapy App: Randomized Controlled Trial %A Nagamitsu,Shinichiro %A Kanie,Ayako %A Sakashita,Kazumi %A Sakuta,Ryoichi %A Okada,Ayumi %A Matsuura,Kencho %A Ito,Masaya %A Katayanagi,Akiko %A Katayama,Takashi %A Otani,Ryoko %A Kitajima,Tasuku %A Matsubara,Naoki %A Inoue,Takeshi %A Tanaka,Chie %A Fujii,Chikako %A Shigeyasu,Yoshie %A Ishii,Ryuta %A Sakai,Sayaka %A Matsuoka,Michiko %A Kakuma,Tatsuyuki %A Yamashita,Yushiro %A Horikoshi,Masaru %+ Department of Pediatrics, Fukuoka University Faculty of Medicine, 7-45-1, Nanakuma, Jonan-ku, Fukuoka, Japan, 81 92 801 1011, snagamit@fukuoka-u.ac.jp %K health promotion %K well-care visit %K cognitive behavioral therapy %K app %K randomized controlled trial %K RCT %K mobile phone %D 2022 %7 23.5.2022 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Adolescent health promotion is important in preventing risk behaviors and improving mental health. Health promotion during adolescence has been shown to contribute to the prevention of late onset of the mental health disease. However, scalable interventions have not been established yet. Objective: This study was designed to test the efficacy of two adolescent health promotion interventions: a well-care visit (WCV) with a risk assessment interview and counseling and self-monitoring with a smartphone cognitive behavioral therapy (CBT) app. Our hypothesis was that participants who had received both WCV and the CBT app would have better outcomes than those who had received only WCV or those who had not received any intervention. We conducted a prospective multi-institutional randomized controlled trial. Methods: Participants were 217 adolescents aged 13-18 years. They were randomly divided into two intervention groups (WCV group and WCV with CBT app group) and a nonintervention group. WCV comprised a standardized physical examination along with a structured interview and counseling for youth risk assessment, which was designed with reference to the Guideline for Health Supervision of Adolescents of Bright Futures. A smartphone-based CBT program was developed based on the CBT approach. The CBT app comprised a 1-week psychoeducation component and a 1-week self-monitoring component. During the CBT program, participants created several self-monitoring sheets based on the CBT model with five window panels: event, thoughts, feelings, body response, and actions. The primary outcome was the change in scores for depressive symptoms. Secondary outcomes included changes in scores for self-esteem, quality of life, self-monitoring, and an adolescent health promotion scale. These outcomes were evaluated at baseline and at 1, 2, and 4 months after baseline. The exploratory outcome was the presence of suicidal ideation during the observation period. Intervention effects were estimated using mixed effect models. Results: In total, 94% (204/217) of the participants completed the 4-month evaluation. Both intervention groups showed a significant effect in the form of reduced scores for depressive symptoms at 1 month in high school students; however, these effects were not observed at 2 and 4 months. The intervention effect was significantly more predominant in those scoring above cutoff for depressive symptoms. There was significantly less suicidal ideation in the intervention groups. As for secondary outcomes, there was significant increase in health promotion scale scores at the 4-month follow-up among junior high school students in the WCV group. Moreover, the CBT app was significantly effective in terms of obtaining self-monitoring skills and reducing depressive symptoms. Conclusions: Although adolescent health promotion interventions may have short-term benefits, the frequency of WCV and further revision of the CBT app should be considered to evaluate long-term effectiveness. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry UMIN 000036343; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000041246 %M 35604760 %R 10.2196/34154 %U https://mhealth.jmir.org/2022/5/e34154 %U https://doi.org/10.2196/34154 %U http://www.ncbi.nlm.nih.gov/pubmed/35604760 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 5 %P e34711 %T Efficacy and Tolerability of Two Novel “Standard of Care” Treatments—Intranasal Esketamine Versus Intravenous Ketamine—for Treatment-Resistant Depression in Naturalistic Clinical Practice: Protocol for a Pilot Observational Study %A Gutierrez,Gilmar %A Rosenblat,Joshua %A Hawken,Emily %A Swainson,Jennifer %A Vazquez,Gustavo %+ Department of Psychiatry, Faculty of Health Sciences, Queen's University, 15 Arch Street, Kingston, ON, K7L3L4, Canada, 1 6135444900, g.vazquez@queensu.ca %K major depressive disorder %K antidepressant %K treatment %K intervention %K pharmacology %K pharmacological %K Treatment resistant depression %K esketamine %K ketamine %K psychopharmacotherapy %K pharmacotherapy %K depression %K depressive disorder %K treatment %K observational study %D 2022 %7 23.5.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Intravenous (IV) ketamine and intranasal (IN) esketamine have been studied as novel alternatives to manage treatment-resistant depression (TRD). The objective of this observational pilot study is to compare the real-world effectiveness and tolerability of IV ketamine and IN esketamine in the management of unipolar TRD. Objective: To compare the effectiveness (primary outcome measure) and tolerability (secondary outcome measure) of racemic ketamine and esketamine in the management of TRD in adults and provide an expert qualitative commentary on the application of IV ketamine and IN esketamine in clinical practice (exploratory objective), focusing on the recruitment process, patient retention, effectiveness, and tolerability of the treatments. Methods: This is a multicenter prospective observational study of naturalistic clinical practice. We expect to recruit 10 patients per treatment arm—IV ketamine or IN esketamine per center (2 centers, total 40 subjects). Patients experiencing moderate to severe TRD and who are candidates for receiving low-dose IV ketamine treatments or IN esketamine as part of their standard-of-care treatments will be recruited. We will measure the effectiveness of each treatment arm by measuring the severity of depression symptoms using the Montgomery and Åsberg Depression Rating Scale; tolerability, side effects, and the appearance of dissociation symptoms using the simplified 6-item version of the Clinician Administered Dissociative Symptom Scale (CADSS-6); and potential for abuse using a Likeability and Craving Questionnaire. Logistic regression will examine odds ratios, number needed to treat for response and remission, number needed to harm, and likelihood to be helped or harmed of each treatment. Covariate analysis will assess the impact of site and demographic variables on treatment efficacy. Results: This observational trial was approved by the Queen’s University Health Science and Affiliated Teaching Hospital’s Research Ethics Board in February 2021. The two research centers involved have started patient recruitment. Our research center (Providence Care Hospital, Kingston, Ontario) has recruited 9 patients so far. We expect to finalize data gathering by August 2022. The manuscript is expected to be published by December 2022. Conclusions: We hypothesize that both treatments will have comparable rapid and robust antidepressant effects and similar tolerability profiles in a real-world setting for the management of TRD. International Registered Report Identifier (IRRID): DERR1-10.2196/34711 %M 35604752 %R 10.2196/34711 %U https://www.researchprotocols.org/2022/5/e34711 %U https://doi.org/10.2196/34711 %U http://www.ncbi.nlm.nih.gov/pubmed/35604752 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 5 %P e30907 %T Screening Depressive Symptoms and Incident Major Depressive Disorder Among Chinese Community Residents Using a Mobile App–Based Integrated Mental Health Care Model: Cohort Study %A Zhang,Huimin %A Liao,Yuhua %A Han,Xue %A Fan,Beifang %A Liu,Yifeng %A Lui,Leanna M W %A Lee,Yena %A Subramaniapillai,Mehala %A Li,Lingjiang %A Guo,Lan %A Lu,Ciyong %A McIntyre,Roger S %+ Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, No.74, Zhongshan 2nd, Guangzhou, 510080, China, 86 020 87332477, luciyong@mail.sysu.edu.cn %K screening %K depressive symptoms %K incident major depressive disorder %K Chinese community residents %K electronic-based integrated mental health care model %D 2022 %7 20.5.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is associated with significant morbidity and human capital costs globally. Early screening for depressive symptoms and timely depressive disorder case identification and intervention may improve health outcomes and cost-effectiveness among affected individuals. China’s public and academic communities have reached a consensus on the need to improve access to early screening, diagnosis, and treatment of depression. Objective: This study aims to estimate the screening prevalence and associated factors of subthreshold depressive symptoms among Chinese residents enrolled in the cohort study using a mobile app–based integrated mental health care model and investigate the 12-month incidence rate and related factors of major depressive disorder (MDD) among those with subthreshold depressive symptoms. Methods: Data were drawn from the Depression Cohort in China (DCC) study. A total of 4243 community residents aged 18 to 64 years living in Nanshan district, Shenzhen city, in Guangdong province, China, were encouraged to participate in the DCC study when visiting the participating primary health care centers, and 4066 (95.83%) residents who met the DCC study criteria were screened for subthreshold depressive symptoms using the Patient Health Questionnaire-9 at baseline. Of the 4066 screened residents, 3168 (77.91%) with subthreshold depressive symptoms were referred to hospitals to receive a psychiatric diagnosis of MDD within 12 months. Sleep duration, anxiety symptoms, well-being, insomnia symptoms, and resilience were also investigated. The diagnosis of MDD was provided by trained psychiatrists using the Mini-International Neuropsychiatric Interview. Univariate and multivariate logistic regression models were performed to explore the potential factors related to subthreshold depressive symptoms at baseline, and Cox proportional hazards models were performed to explore the potential factors related to incident MDD. Results: Anxiety symptoms (adjusted odds ratio [AOR] 1.63, 95% CI 1.42-1.87) and insomnia symptoms (AOR 1.13, 95% CI 1.05-1.22) were associated with an increased risk of subthreshold depressive symptoms, whereas well-being (AOR 0.93, 95% CI 0.87-0.99) was negatively associated with depressive symptoms. During the follow-up period, the 12-month incidence rate of MDD among participants with subthreshold depressive symptoms was 5.97% (189/3168). After incorporating all significant variables from the univariate analyses, the multivariate Cox proportional hazards model reported that a history of comorbidities (adjusted hazard ratio [AHR] 1.49, 95% CI 1.04-2.14) and anxiety symptoms (AHR 1.13, 95% CI 1.09-1.17) were independently associated with an increased risk of incident MDD. The 5-item World Health Organization Well-Being Index was associated with a decreased risk of incident MDD (AHR 0.90, 95% CI 0.86-0.94). Conclusions: Elevated anxiety symptoms and unfavorable general well-being were significantly associated with subthreshold depressive symptoms and incident MDD among Chinese residents in Shenzhen. Early screening for subthreshold depressive symptoms and related factors may be helpful for identifying populations at high risk of incident MDD. %M 35594137 %R 10.2196/30907 %U https://www.jmir.org/2022/5/e30907 %U https://doi.org/10.2196/30907 %U http://www.ncbi.nlm.nih.gov/pubmed/35594137 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 8 %N 5 %P e31800 %T Exploring the Risk of Suicide in Real Time on Spanish Twitter: Observational Study %A García-Martínez,Claudia %A Oliván-Blázquez,Bárbara %A Fabra,Javier %A Martínez-Martínez,Ana Belén %A Pérez-Yus,María Cruz %A López-Del-Hoyo,Yolanda %+ Department of Psychology and Sociology, University of Zaragoza, Institute for Health Research Aragón, Pedro Cerbuna, 12, Zaragoza, 50009, Spain, 34 630030125, yolandal@unizar.es %K suicide %K prevention %K social media %K Twitter %K emotional analysis %K eHealth %K big data %K content analysis %K emotional content %K risk factors %K mental health %K public health %K suicide prevention %D 2022 %7 17.5.2022 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Social media is now a common context wherein people express their feelings in real time. These platforms are increasingly showing their potential to detect the mental health status of the population. Suicide prevention is a global health priority and efforts toward early detection are starting to develop, although there is a need for more robust research. Objective: We aimed to explore the emotional content of Twitter posts in Spanish and their relationships with severity of the risk of suicide at the time of writing the tweet. Methods: Tweets containing a specific lexicon relating to suicide were filtered through Twitter's public application programming interface. Expert psychologists were trained to independently evaluate these tweets. Each tweet was evaluated by 3 experts. Tweets were filtered by experts according to their relevance to the risk of suicide. In the tweets, the experts evaluated: (1) the severity of the general risk of suicide and the risk of suicide at the time of writing the tweet (2) the emotional valence and intensity of 5 basic emotions; (3) relevant personality traits; and (4) other relevant risk variables such as helplessness, desire to escape, perceived social support, and intensity of suicidal ideation. Correlation and multivariate analyses were performed. Results: Of 2509 tweets, 8.61% (n=216) were considered to indicate suicidality by most experts. Severity of the risk of suicide at the time was correlated with sadness (ρ=0.266; P<.001), joy (ρ=–0.234; P=.001), general risk (ρ=0.908; P<.001), and intensity of suicidal ideation (ρ=0.766; P<.001). The severity of risk at the time of the tweet was significantly higher in people who expressed feelings of defeat and rejection (P=.003), a desire to escape (P<.001), a lack of social support (P=.03), helplessness (P=.001), and daily recurrent thoughts (P=.007). In the multivariate analysis, the intensity of suicide ideation was a predictor for the severity of suicidal risk at the time (β=0.311; P=.001), as well as being a predictor for fear (β=–0.009; P=.01) and emotional valence (β=0.007; P=.009). The model explained 75% of the variance. Conclusions: These findings suggest that it is possible to identify emotional content and other risk factors in suicidal tweets with a Spanish sample. Emotional analysis and, in particular, the detection of emotional variations may be key for real-time suicide prevention through social media. %M 35579921 %R 10.2196/31800 %U https://publichealth.jmir.org/2022/5/e31800 %U https://doi.org/10.2196/31800 %U http://www.ncbi.nlm.nih.gov/pubmed/35579921 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 5 %P e33817 %T The Association Between Sleep Disturbance and Suicidality in Psychiatric Inpatients Transitioning to the Community: Protocol for an Ecological Momentary Assessment Study %A Dewa,Lindsay H %A Pappa,Sofia %A Greene,Talya %A Cooke,James %A Mitchell,Lizzie %A Hadley,Molly %A Di Simplicio,Martina %A Woodcock,Thomas %A Aylin,Paul %+ School of Public Health, Imperial College London, Reynolds Building, St Dunstan's Road, London, W6 8RP, United Kingdom, 44 020 7594 0815, l.dewa@imperial.ac.uk %K sleep %K suicide %K psychiatric inpatient %K ecological momentary assessment %K EMA %K experience sampling %K coproduction %K sleep disturbance %K discharge %D 2022 %7 17.5.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Patients are at high risk of suicidal behavior and death by suicide immediately following discharge from inpatient psychiatric hospitals. Furthermore, there is a high prevalence of sleep problems in inpatient settings, which is associated with worse outcomes following hospitalization. However, it is unknown whether poor sleep is associated with suicidality following initial hospital discharge. Objective: Our study objective is to describe a protocol for an ecological momentary assessment (EMA) study that aims to examine the relationship between sleep and suicidality in discharged patients. Methods: Our study will use an EMA design based on a wearable device to examine the sleep-suicide relationship during the transition from acute inpatient care to the community. Prospectively discharged inpatients 18 to 35 years old with mental disorders (N=50) will be assessed for eligibility and recruited across 2 sites. Data on suicidal ideation, behavior, and imagery; nonsuicidal self-harm and imagery; defeat, entrapment, and hopelessness; affect; and sleep will be collected on the Pro-Diary V wrist-worn electronic watch for up to 14 days. Objective sleep and daytime activity will be measured using the inbuilt MotionWare software. Questionnaires will be administered face-to-face at baseline and follow up, and data will also be collected on the acceptability and feasibility of using the Pro-Diary V watch to monitor the transition following discharge. The study has been, and will continue to be, coproduced with young people with experience of being in an inpatient setting and suicidality. Results: South Birmingham Research Ethics Committee (21/WM/0128) approved the study on June 28, 2021. We expect to see a relationship between poor sleep and postdischarge suicidality. Results will be available in 2022. Conclusions: This protocol describes the first coproduced EMA study to examine the relationship between sleep and suicidality and to apply the integrated motivational volitional model in young patients transitioning from a psychiatric hospital to the community. We expect our findings will inform coproduction in suicidology research and clarify the role of digital monitoring of suicidality and sleep before and after initial hospital discharge. International Registered Report Identifier (IRRID): PRR1-10.2196/33817 %M 35579920 %R 10.2196/33817 %U https://www.researchprotocols.org/2022/5/e33817 %U https://doi.org/10.2196/33817 %U http://www.ncbi.nlm.nih.gov/pubmed/35579920 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 5 %P e37736 %T A Machine Learning Approach for Detecting Digital Behavioral Patterns of Depression Using Nonintrusive Smartphone Data (Complementary Path to Patient Health Questionnaire-9 Assessment): Prospective Observational Study %A Choudhary,Soumya %A Thomas,Nikita %A Ellenberger,Janine %A Srinivasan,Girish %A Cohen,Roy %+ Research, Behavidence Inc, 99 Wall Street #4004, New York, NY, 10005, United States, 1 6372493366, soumya@behavidence.com %K mobile phone %K depression %K digital phenotyping %K digital mental health %D 2022 %7 16.5.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression is a major global cause of morbidity, an economic burden, and the greatest health challenge leading to chronic disability. Mobile monitoring of mental conditions has long been a sought-after metric to overcome the problems associated with the screening, diagnosis, and monitoring of depression and its heterogeneous presentation. The widespread availability of smartphones has made it possible to use their data to generate digital behavioral models that can be used for both clinical and remote screening and monitoring purposes. This study is novel as it adds to the field by conducting a trial using private and nonintrusive sensors that can help detect and monitor depression in a continuous, passive manner. Objective: This study demonstrates a novel mental behavioral profiling metric (the Mental Health Similarity Score), derived from analyzing passively monitored, private, and nonintrusive smartphone use data, to identify and track depressive behavior and its progression. Methods: Smartphone data sets and self-reported Patient Health Questionnaire-9 (PHQ-9) depression assessments were collected from 558 smartphone users on the Android operating system in an observational study over an average of 10.7 (SD 23.7) days. We quantified 37 digital behavioral markers from the passive smartphone data set and explored the relationship between the digital behavioral markers and depression using correlation coefficients and random forest models. We leveraged 4 supervised machine learning classification algorithms to predict depression and its severity using PHQ-9 scores as the ground truth. We also quantified an additional 3 digital markers from gyroscope sensors and explored their feasibility in improving the model’s accuracy in detecting depression. Results: The PHQ-9 2-class model (none vs severe) achieved the following metrics: precision of 85% to 89%, recall of 85% to 89%, F1 of 87%, and accuracy of 87%. The PHQ-9 3-class model (none vs mild vs severe) achieved the following metrics: precision of 74% to 86%, recall of 76% to 83%, F1 of 75% to 84%, and accuracy of 78%. A significant positive Pearson correlation was found between PHQ-9 questions 2, 6, and 9 within the severely depressed users and the mental behavioral profiling metric (r=0.73). The PHQ-9 question-specific model achieved the following metrics: precision of 76% to 80%, recall of 75% to 81%, F1 of 78% to 89%, and accuracy of 78%. When a gyroscope sensor was added as a feature, the Pearson correlation among questions 2, 6, and 9 decreased from 0.73 to 0.46. The PHQ-9 2-class model+gyro features achieved the following metrics: precision of 74% to 78%, recall of 67% to 83%, F1 of 72% to 78%, and accuracy of 76%. Conclusions: Our results demonstrate that the Mental Health Similarity Score can be used to identify and track depressive behavior and its progression with high accuracy. %M 35420993 %R 10.2196/37736 %U https://formative.jmir.org/2022/5/e37736 %U https://doi.org/10.2196/37736 %U http://www.ncbi.nlm.nih.gov/pubmed/35420993 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 5 %N 2 %P e33551 %T Internet-Delivered Interventions for Depression and Anxiety Symptoms in Children and Young People: Systematic Review and Meta-analysis %A Eilert,Nora %A Wogan,Rebecca %A Leen,Aisling %A Richards,Derek %+ e-Mental Health Group, School of Psychology, University of Dublin Trinity College, College Green, Dublin, D02 PN40, Ireland, 353 18961886, neilert@tcd.ie %K internet-delivered interventions %K children and young people %K depression %K anxiety %K digital health %D 2022 %7 12.5.2022 %9 Review %J JMIR Pediatr Parent %G English %X Background: Mental health difficulties in children and adolescents are highly prevalent; however, only a minority receive adequate mental health care. Internet-delivered interventions offer a promising opportunity to increase access to mental health treatment. Research has demonstrated their effectiveness as a treatment for depression and anxiety in adults. This work provides an up-to-date examination of the available intervention options and their effectiveness for children and young people (CYP). Objective: In this systematic review and meta-analysis, we aimed to determine the evidence available for the effectiveness of internet-delivered interventions for treating anxiety and depression in CYP. Methods: Systematic literature searches were conducted throughout November 2020 using PubMed, PsycINFO, and EBSCO academic search complete electronic databases to find outcome trials of internet-delivered interventions treating symptoms of anxiety and/or depression in CYP by being either directly delivered to the CYP or delivered via their parents. Studies were eligible for meta-analysis if they were randomized controlled trials. Risk of bias and publication biases were evaluated, and Hedges g between group effect sizes evaluating intervention effects after treatment were calculated. Meta-analyses used random-effects models as per protocol. Results: A total of 23 studies met the eligibility criteria for the systematic review, of which 16 were included in the meta-analyses, including 977 participants in internet-delivered treatment conditions and 1008 participants in control conditions across 21 comparisons. Random-effects models detected a significant small effect for anxiety symptoms (across 20 comparisons; Hedges g=−0.25, 95% CI −0.38 to −0.12; P<.001) and a small but not significant effect for depression (across 13 comparisons; Hedges g=−0.27, 95% CI −0.55 to 0.01; P=.06) in favor of internet-delivered interventions compared with control groups. Regarding secondary outcomes, there was a small effect of treatment across 9 comparisons for impaired functioning (Hedges g=0.52, 95% CI 0.24-0.80; P<.001), and 5 comparisons of quality of life showed no effect (Hedges g=−0.01, 95% CI −0.23 to 0.21; P=.94). Conclusions: The results show that the potential of internet-delivered interventions for young people with symptoms of anxiety or depression has not been tapped into to date. This review highlights an opportunity for the development of population-specific interventions and their research to expand our current knowledge and build an empirical base for digital interventions for CYP. Trial Registration: PROSPERO CRD42020220171; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=220171 %M 35551071 %R 10.2196/33551 %U https://pediatrics.jmir.org/2022/2/e33551 %U https://doi.org/10.2196/33551 %U http://www.ncbi.nlm.nih.gov/pubmed/35551071 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 5 %P e34436 %T The Value of Extracting Clinician-Recorded Affect for Advancing Clinical Research on Depression: Proof-of-Concept Study Applying Natural Language Processing to Electronic Health Records %A Panaite,Vanessa %A Devendorf,Andrew R %A Finch,Dezon %A Bouayad,Lina %A Luther,Stephen L %A Schultz,Susan K %+ Research Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, United States, 1 813 558 3979, vanessa.panaite2@va.gov %K depression %K affect %K natural language processing %K electronic health records %K vocabularies %D 2022 %7 12.5.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Affective characteristics are associated with depression severity, course, and prognosis. Patients’ affect captured by clinicians during sessions may provide a rich source of information that more naturally aligns with the depression course and patient-desired depression outcomes. Objective: In this paper, we propose an information extraction vocabulary used to pilot the feasibility and reliability of identifying clinician-recorded patient affective states in clinical notes from electronic health records. Methods: Affect and mood were annotated in 147 clinical notes of 109 patients by 2 independent coders across 3 pilots. Intercoder discrepancies were settled by a third coder. This reference annotation set was used to test a proof-of-concept natural language processing (NLP) system using a named entity recognition approach. Results: Concepts were frequently addressed in templated format and free text in clinical notes. Annotated data demonstrated that affective characteristics were identified in 87.8% (129/147) of the notes, while mood was identified in 97.3% (143/147) of the notes. The intercoder reliability was consistently good across the pilots (interannotator agreement [IAA] >70%). The final NLP system showed good reliability with the final reference annotation set (mood IAA=85.8%; affect IAA=80.9%). Conclusions: Affect and mood can be reliably identified in clinician reports and are good targets for NLP. We discuss several next steps to expand on this proof of concept and the value of this research for depression clinical research. %M 35551066 %R 10.2196/34436 %U https://formative.jmir.org/2022/5/e34436 %U https://doi.org/10.2196/34436 %U http://www.ncbi.nlm.nih.gov/pubmed/35551066 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 5 %P e30900 %T Exploring Use Patterns and Racial and Ethnic Differences in Real Time Affective States During Social Media Use Among a Clinical Sample of Adolescents With Depression: Prospective Cohort Study %A Nereim,Cameron %A Bickham,David %A Rich,Michael %+ Division of Adolescent Medicine, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Suite 5053, Tampa, FL, 33606, United States, 1 813 259 8695, cnereim@usf.edu %K depression %K race/ethnicity %K ecological momentary assessment %K internet %K mental health %K mood %K social media %K mobile phone %D 2022 %7 12.5.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Increasing youth mental health problems over time correlate with increasing rates of social media use (SMU); however, a proposed contributory relationship remains unproven. To better understand how SMU impacts mental health requires a more nuanced understanding of the relationship between different patterns of SMU and specific individual factors. Studies suggest that more active forms of SMU may offer mental health benefits when compared with more passive forms. Furthermore, the literature suggests important differences in patterns of SMU and affective states among those identifying as racial and ethnic minorities. Objective: Using ecological momentary assessment (EMA), this study aims to investigate potential differences in affective states during active and passive forms of SMU and whether such differences vary by race and ethnicity. Methods: We recruited patients seeking care at a large urban adolescent medicine clinic who exhibited at least mild depressive symptoms based on Patient Health Questionnaire-9 (PHQ-9) scores. Participants completed an enrollment survey and a 7-day EMA protocol, receiving 5 EMA questionnaires per day, which assessed real time SMU behaviors and affective states using the Positive and Negative Affect Schedule–Expanded form subscales. To correct for nonindependent data with EMA responses clustered within individuals, data were analyzed using mixed-effects modeling, allowing for a random intercept at the individual level to examine associations between EMA-reported SMU and affective states while adjusting results for age, gender, race and ethnicity, PHQ-9 score, and EMA response rate. Results: A racially and ethnically diverse group of 55 adolescents aged 14 to 19 years provided a total of 976 EMA responses, averaging 17.76 (SD 8.76) responses per participant, with a response rate of 51.15%. Participants reported higher mean levels of negative affect during active SMU (F1,215=3.86; SE 0.05; t1,215=1.96; P=.05) and lower mean levels of positive affect during passive SMU (F1,369=3.90; SE 0.09; t1,369=–1.98; P=.049). However, within different racial and ethnic groups, higher levels of negative affect during moments of active SMU were seen only among Black non-Hispanic participants: F1,81=6.31; SE 0.05; t81=2.51; P=.01). Similarly, lower levels of positive affect during passive SMU were seen only among White non-Hispanic participants (F1,295=10.52; SE 0.13; t295=–3.24; P=.001). Conclusions: Although in aggregate, adolescents with depressive symptoms experienced more negative affect during active SMU and less positive affect during passive SMU, these mean outcomes were driven solely by greater negative affect during active SMU by Black non-Hispanic participants and lower positive affect during passive SMU by White non-Hispanic participants. Differences in intentionality, content, context, and expectations of SMU among youths across racial and ethnic groups may result in different affective outcomes. Exploration of the interactions among cultural differences in SMU strategies and characteristics will be critical to furthering our understanding of the impact of SMU on youth mental health. %M 35550316 %R 10.2196/30900 %U https://formative.jmir.org/2022/5/e30900 %U https://doi.org/10.2196/30900 %U http://www.ncbi.nlm.nih.gov/pubmed/35550316 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 5 %P e34769 %T The Effect of Dissemination Pathways on Uptake and Relative Costs for a Transdiagnostic, Self-guided Internet Intervention for Reducing Depression, Anxiety, and Suicidal Ideation: Comparative Implementation Study %A Batterham,Philip J %A Gulliver,Amelia %A Kurz,Ella %A Farrer,Louise M %A Vis,Christiaan %A Schuurmans,Josien %A Calear,Alison L %+ Centre for Mental Health Research, The Australian National University, 63 Eggleston Rd, Canberra, 2601, Australia, 61 261251031, philip.batterham@anu.edu.au %K implementation %K mental health %K adherence %K uptake %K internet %D 2022 %7 6.5.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Self-guided web-based programs are effective; however, inadequate implementation of these programs limits their potential to provide effective and low-cost treatment for common mental health problems at scale. There is a lack of research examining optimal methods for the dissemination of web-based programs in the community. Objective: This study aimed to compare the uptake, reach, relative costs, and adherence associated with 3 community-based pathways for delivering a low-intensity web-based transdiagnostic mental health program. The 3 dissemination pathways were social media advertising, advertising in general practice, and advertising in pharmacies. Methods: Participants were recruited on the web, from general practices, or from community pharmacies; completed a screener for psychological distress; and were offered the 4-week FitMindKit program—a 12-module psychotherapeutic intervention. Uptake was defined as the number of participants who enrolled in the web-based program; reach was defined as the rate of uptake per exposure; and costs were calculated based on staff time, equipment, and advertising. Adherence was assessed as the number of modules of FitMindKit completed by the participants. Results: Uptake comprised 1014 participants who were recruited through the 3 dissemination pathways: on the web (991/1014, 97.73%), in general practice (16/1014, 1.58%), and in pharmacy (7/1014, 0.69%). Reach was highest for social media: 1 in every 50 people exposed to web-based advertising took up the intervention compared with 1 in every 441 in general practitioner clinics and 1 in every 1708 in pharmacies. The dissemination cost was US $4.87 per user on social media, US $557 per user for general practitioner clinics, and US $1272 per user for pharmacy dissemination. No significant differences in adherence were observed between the conditions, whereas all pathways showed an underrepresentation of men and linguistic diversity. Conclusions: The web-based dissemination pathway was the most efficient and cost-effective for delivering a self-guided internet-based mental health program to people in the community. More research is needed to identify how best to engage men and those with culturally diverse backgrounds in web-based interventions. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618001688279; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376113 %M 35522458 %R 10.2196/34769 %U https://www.jmir.org/2022/5/e34769 %U https://doi.org/10.2196/34769 %U http://www.ncbi.nlm.nih.gov/pubmed/35522458 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e35526 %T Virtual Reality Behavioral Activation for Adults With Major Depressive Disorder: Feasibility Randomized Controlled Trial %A Paul,Margot %A Bullock,Kim %A Bailenson,Jeremy %+ PGSP-Stanford PsyD Consortium, Palo Alto University, 1791 Arastradero Rd, Palo Alto, CA, 94304, United States, 1 800 818 6136, mdpaul@stanford.edu %K virtual reality %K major depressive disorder %K behavioral activation %K depression %D 2022 %7 6.5.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Major depressive disorder (MDD) is a global crisis with increasing incidence and prevalence. There are many established evidence-based psychotherapies (EBPs) for depression, but numerous barriers still exist; most notably, access and dissemination. Virtual reality (VR) may offer some solutions to existing constraints of EBPs for MDD. Objective: We aimed to examine the feasibility, acceptability, and tolerability of using VR as a method of delivering behavioral activation (BA) for adults diagnosed with MDD during a global pandemic and to explore for signs of clinical efficacy by comparing VR-enhanced BA (VR BA) to a standard BA treatment and a treatment as usual control group for individuals diagnosed with MDD. Methods: A feasibility trial using a 3-armed, unblinded, randomized controlled pilot design was conducted. The study took place remotely via Zoom telehealth visits between April 8, 2020, and January 15, 2021. This study used a 3-week, 4-session protocol in which VR BA participants used a VR headset to complete their BA homework. Feasibility was measured using dropout rates, serious adverse events, completion of homework, an adapted telepresence scale, the Simulator Sickness Questionnaire, the Brief Agitation Measure, and an adapted Technology Acceptance Model. Efficacy was assessed using the Patient Health Questionnaire–9. Results: Of the 35 participants assessed for eligibility, 13 (37%) were randomized into VR BA (n=5, 38%), traditional BA (n=4, 31%), or a treatment as usual control (n=4, 31%). The mean age of the 13 participants (5/13, 38% male; 7/13, 54% female; and 1/13, 8% nonbinary or third gender) was 35.4 (SD 12.3) years. This study demonstrated VR BA feasibility in participants with MDD through documented high levels of acceptability and tolerability while engaging in VR-induced pleasurable activities in conjunction with a brief BA protocol. No adverse events were reported. This study also illustrated that VR BA may have potential clinical utility for treating MDD, as the average VR BA participant’s clinical severity decreased by 5.67 points, signifying a clinically meaningful change in severity from a moderate to a mild level of depression as per the Patient Health Questionnaire–9 score. Conclusions: The findings of this study demonstrate that VR BA is safe and feasible to explore for the treatment of MDD. This study documented evidence that VR BA may be efficacious and justifies further examination in an adequately powered randomized controlled trial. This pilot study highlights the potential utility that VR technology may offer patients with MDD, especially those who have difficulty accessing real-world pleasant activities. In addition, for those having difficulty accessing care, VR BA could be adapted as a first step to help people improve their mood and increase their motivation while waiting to connect with a health care professional for other EBPs. Trial Registration: ClinicalTrials.gov NCT04268316; https://clinicaltrials.gov/ct2/show/NCT04268316 International Registered Report Identifier (IRRID): RR2-10.2196/24331 %M 35404830 %R 10.2196/35526 %U https://mental.jmir.org/2022/5/e35526 %U https://doi.org/10.2196/35526 %U http://www.ncbi.nlm.nih.gov/pubmed/35404830 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e37292 %T A Group-Facilitated, Internet-Based Intervention to Promote Mental Health and Well-Being in a Vulnerable Population of University Students: Randomized Controlled Trial of the Be Well Plan Program %A Fassnacht,Daniel B %A Ali,Kathina %A van Agteren,Joep %A Iasiello,Matthew %A Mavrangelos,Teri %A Furber,Gareth %A Kyrios,Michael %+ College of Education, Psychology and Social Work, Flinders University, Sturt Road, Bedford Park, Adelaide, 5042, Australia, 61 8 8201 2621, dan.fassnacht@flinders.edu.au %K COVID-19 %K mental health %K well-being %K depression %K anxiety %K online %K digital %K intervention %K Be Well Plan %K health outcome %K online health %K digital health %K health intervention %K primary outcome %K cognition %K randomized control trial %K resilience %K participant satisfaction %K student %D 2022 %7 5.5.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: A growing literature supports the use of internet-based interventions to improve mental health outcomes. However, most programs target specific symptoms or participant groups and are not tailored to facilitate improvements in mental health and well-being or do not allow for needs and preferences of individual participants. The Be Well Plan, a 5-week group-facilitated, internet-based mental health and well-being group intervention addresses these gaps, allowing participants to select a range of activities that they can tailor to their specific characteristics, needs, and preferences. Objective: This study aims to test whether the Be Well Plan program was effective in improving primary outcomes of mental well-being, resilience, anxiety, and depression compared to a waitlist control group during the COVID-19 pandemic; secondary outcomes included self-efficacy, a sense of control, and cognitive flexibility. The study further seeks to examine participants’ engagement and satisfaction with the program. Methods: A randomized controlled trial (RCT) was conducted with 2 parallel arms, an intervention and a waitlist control group. The intervention involved 5 weekly 2-hour sessions, which were facilitated in group format using Zoom videoconferencing software. University students were recruited via social media posts, lectures, emails, flyers, and posters. Results: Using an intentional randomization 2:1 allocation strategy, we recruited 215 participants to the trial (n=126, 58.6%, intervention group; n=89, 41.4%, waitlist control group). Of the 126 participants assigned to the intervention group, 75 (59.5%) commenced the program and were included in modified intention-to-treat (mITT) analyses. mITT intervention participants attended, on average, 3.41 sessions (SD 1.56, median 4); 55 (73.3%) attended at least 4 sessions, and 25 (33.3%) attended all 5 sessions. Of the 49 intervention group participants who completed the postintervention assessment, 47 (95.9%) were either very satisfied (n=31, 66%) or satisfied (n=16, 34%). The mITT analysis for well-being (F1,162=9.65, P=.002, Cohen d=0.48) and resilience (F1,162=7.85, P=.006, Cohen d=0.44) showed significant time × group interaction effects, suggesting that both groups improved over time, but the Be Well Plan (intervention) group showed significantly greater improvement compared to the waitlist control group. A similar pattern of results was observed for depression and anxiety (Cohen d=0.32 and 0.37, respectively), as well as the secondary outcomes (self-efficacy, Cohen d=0.50; sense of control, Cohen d=0.42; cognitive flexibility, Cohen d=0.65). Larger effect sizes were observed in the completer analyses. Reliable change analysis showed that the majority of mITT participants (58/75, 77.3%) demonstrated a significant reliable improvement in at least 1 of the primary outcomes. Conclusions: The Be Well Plan program was effective in improving mental health and well-being, including mental well-being, resilience, depression, and anxiety. Participant satisfaction scores and attendance indicated a high degree of engagement and satisfaction with the program. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12621000180819; https://tinyurl.com/2p8da5sk %M 35471196 %R 10.2196/37292 %U https://mental.jmir.org/2022/5/e37292 %U https://doi.org/10.2196/37292 %U http://www.ncbi.nlm.nih.gov/pubmed/35471196 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e35549 %T Smartphone Sensor Data for Identifying and Monitoring Symptoms of Mood Disorders: A Longitudinal Observational Study %A Braund,Taylor A %A Zin,May The %A Boonstra,Tjeerd W %A Wong,Quincy J J %A Larsen,Mark E %A Christensen,Helen %A Tillman,Gabriel %A O’Dea,Bridianne %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney, 2031, Australia, 61 2 9065 9255, t.braund@blackdog.org.au %K depression %K bipolar disorder %K sensors %K mobile app %K circadian rhythm %K mobile phone %D 2022 %7 4.5.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mood disorders are burdensome illnesses that often go undetected and untreated. Sensor technologies within smartphones may provide an opportunity for identifying the early changes in circadian rhythm and social support/connectedness that signify the onset of a depressive or manic episode. Objective: Using smartphone sensor data, this study investigated the relationship between circadian rhythm, which was determined by GPS data, and symptoms of mental health among a clinical sample of adults diagnosed with major depressive disorder or bipolar disorder. Methods: A total of 121 participants were recruited from a clinical setting to take part in a 10-week observational study. Self-report questionnaires for mental health outcomes, social support, social connectedness, and quality of life were assessed at 6 time points throughout the study period. Participants consented to passively sharing their smartphone GPS data for the duration of the study. Circadian rhythm (ie, regularity of location changes in a 24-hour rhythm) was extracted from GPS mobility patterns at baseline. Results: Although we found no association between circadian rhythm and mental health functioning at baseline, there was a positive association between circadian rhythm and the size of participants’ social support networks at baseline (r=0.22; P=.03; R2=0.049). In participants with bipolar disorder, circadian rhythm was associated with a change in anxiety from baseline; a higher circadian rhythm was associated with an increase in anxiety and a lower circadian rhythm was associated with a decrease in anxiety at time point 5. Conclusions: Circadian rhythm, which was extracted from smartphone GPS data, was associated with social support and predicted changes in anxiety in a clinical sample of adults with mood disorders. Larger studies are required for further validations. However, smartphone sensing may have the potential to monitor early symptoms of mood disorders. %M 35507385 %R 10.2196/35549 %U https://mental.jmir.org/2022/5/e35549 %U https://doi.org/10.2196/35549 %U http://www.ncbi.nlm.nih.gov/pubmed/35507385 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 5 %P e32226 %T Feasibility of a Web-Based Intervention to Prevent Perinatal Depression and Promote Human Milk Feeding: Randomized Pilot Trial %A Pezley,Lacey %A Tussing-Humphreys,Lisa %A Koenig,Mary Dawn %A Maki,Pauline %A Odoms-Young,Angela %A Freels,Sally %A DiPiazza,Brittany %A Cann,Felicity %A Cares,Kate %A Depa,Courtney %A Klejka,Gintare %A Lima Oliveira,Manoela %A Prough,Jilian %A Roe,Taylor %A Buscemi,Joanna %A Duffecy,Jennifer %+ Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois at Chicago, 1919 W. Taylor St., Chicago, IL, 60612, United States, 1 312 355 5521, lwissl2@uic.edu %K breastfeeding %K chestfeeding %K perinatal %K depression %K anxiety %D 2022 %7 3.5.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Mothers who identify as Black or African American are more likely to report depressed moods in late pregnancy and early postpartum and have the lowest rates of human milk feeding compared with all other racial groups in the United States. Internet interventions offer the potential to extend preventative and supportive services as they address key barriers, particularly for those navigating the complex and vulnerable early postpartum period. However, there is limited evidence on the feasibility of such interventions for preventing perinatal mental health disorders and improving human milk feeding outcomes in Black mothers. Objective: This pilot study aimed to assess the feasibility and preliminary findings of a web-based cognitive behavioral therapy–based internet intervention, with and without human milk feeding education and support, to prevent perinatal depression and promote human milk feeding in Black mothers. Methods: Participants were Black-identifying individuals between 20 and 28 weeks of pregnancy with human milk feeding intention and mild to moderate depressive symptoms (Patient Health Questionnaire scores 5-14). Participants were randomized to either Sunnyside, a 6-week cognitive behavioral therapy–based web-based intervention, or Sunnyside Plus, which included additional education and support to promote human milk feeding. Assessments occurred at baseline, third trimester (end of antenatal treatment), 6 weeks postpartum (end of postpartum treatment), and 12 weeks postpartum. The primary focus of this randomized pilot trial was the feasibility and preliminary outcomes of mental health and human milk feeding. Results: A total of 22 tertiary-educated participants were randomized. The mean number of log-ins was 7.3 (SD 5.3) for Sunnyside and 13.8 (SD 10.5) for Sunnyside Plus. Scores of depression and anxiety measures remained below the clinical threshold for referral to treatment in both groups. All the participants initiated human milk feeding (18/18, 100%). Most participants reported at least some human milk feeding at both 6 and 12 weeks postpartum (6/7, 86%; 11/11, 100%, or 10/10, 100%, for Sunnyside and Sunnyside Plus, respectively). Conclusions: The results suggest that tertiary-educated Black mothers at risk for perinatal depression and who intended to human milk feed were receptive to and satisfied with a web-based cognitive behavioral therapy–based internet intervention, with and without human milk feeding education and support. Preliminary findings indicate that both Sunnyside and Sunnyside Plus interventions have the potential to affect symptoms of depression, anxiety, and human milk feeding outcomes. Trial Registration: ClinicalTrials.gov NCT04128202; https://www.clinicaltrials.gov/ct2/show/NCT04128202 %M 35503244 %R 10.2196/32226 %U https://formative.jmir.org/2022/5/e32226 %U https://doi.org/10.2196/32226 %U http://www.ncbi.nlm.nih.gov/pubmed/35503244 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e35048 %T Engagement, Predictors, and Outcomes of a Trauma Recovery Digital Mental Health Intervention: Longitudinal Study %A Yeager,Carolyn M %A Benight,Charles C %+ Lyda Hill Institute for Human Resilience, University of Colorado Colorado Springs, Fourth Floor, 4863 North Nevada Avenue, Colorado Springs, CO, 80918, United States, 1 (719) 413 8075, cyeager@uccs.edu %K engagement %K digital health %K digital mental health intervention %K social cognitive theory %K SCT %K self-efficacy %K outcome expectations %K trauma %K posttraumatic stress disorder %K PTSD %D 2022 %7 2.5.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Worldwide, exposure to potentially traumatic events is extremely common, and many individuals develop posttraumatic stress disorder (PTSD) along with other disorders. Unfortunately, considerable barriers to treatment exist. A promising approach to overcoming treatment barriers is a digital mental health intervention (DMHI). However, engagement with DMHIs is a concern, and theoretically based research in this area is sparse and often inconclusive. Objective: The focus of this study is on the complex issue of DMHI engagement. On the basis of the social cognitive theory framework, the conceptualization of engagement and a theoretically based model of predictors and outcomes were investigated using a DMHI for trauma recovery. Methods: A 6-week longitudinal study with a national sample of survivors of trauma was conducted to measure engagement, predictors of engagement, and mediational pathways to symptom reduction while using a trauma recovery DMHI (time 1: N=915; time 2: N=350; time 3: N=168; and time 4: N=101). Results: Confirmatory factor analysis of the engagement latent constructs of duration, frequency, interest, attention, and affect produced an acceptable model fit (χ22=8.3; P=.02; comparative fit index 0.973; root mean square error of approximation 0.059; 90% CI 0.022-0.103). Using the latent construct, the longitudinal theoretical model demonstrated adequate model fit (comparative fit index 0.929; root mean square error of approximation 0.052; 90% CI 0.040-0.064), indicating that engagement self-efficacy (β=.35; P<.001) and outcome expectations (β=.37; P<.001) were significant predictors of engagement (R2=39%). The overall indirect effect between engagement and PTSD symptom reduction was significant (β=–.065; P<.001; 90% CI –0.071 to –0.058). This relationship was serially mediated by both skill activation self-efficacy (β=.80; P<.001) and trauma coping self-efficacy (β=.40; P<.001), which predicted a reduction in PTSD symptoms (β=−.20; P=.02). Conclusions: The results of this study may provide a solid foundation for formalizing the nascent science of engagement. Engagement conceptualization comprised general measures of attention, interest, affect, and use that could be applied to other applications. The longitudinal research model supported 2 theoretically based predictors of engagement: engagement self-efficacy and outcome expectancies. A total of 2 task-specific self-efficacies—skill activation and trauma coping—proved to be significant mediators between engagement and symptom reduction. Taken together, this model can be applied to other DMHIs to understand engagement, as well as predictors and mechanisms of action. Ultimately, this could help improve the design and development of engaging and effective trauma recovery DMHIs. %M 35499857 %R 10.2196/35048 %U https://mental.jmir.org/2022/5/e35048 %U https://doi.org/10.2196/35048 %U http://www.ncbi.nlm.nih.gov/pubmed/35499857 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 5 %P e28072 %T Effect of a Virtual Reality Contact-Based Educational Intervention on the Public Stigma of Depression: Randomized Controlled Pilot Study %A Lem,Wey Guan %A Kohyama-Koganeya,Ayako %A Saito,Toki %A Oyama,Hiroshi %+ Department of Clinical Information Engineering, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan, 81 3 5841 1893, vyrolwg@m.u-tokyo.ac.jp %K major depressive disorder %K depression stigma %K virtual reality %K contact-based educational intervention %K virtual patient %D 2022 %7 2.5.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Public stigma against depression contributes to low employment rates among individuals with depression. Contact-based educational (CBE) interventions have been shown to reduce this public stigma. Objective: We investigated the ability of our Virtual Reality Antistigma (VRAS) app developed for CBE interventions to reduce the stigma of depression. Methods: Sixteen medical students were recruited and randomized 1:1 to the intervention group, who used the VRAS app (VRAS group), and the control group, who watched a video on depression. The depression stigma score was assessed using the Depression Stigma Scale (DSS) and Attitudinal Social Distance (ASD) questionnaire at pre- and postintervention. Feasibility was assessed in both groups and usability was assessed only in the VRAS group after the intervention. A qualitative study was performed on the acquisition of knowledge about stigma in both groups based on participants’ answers to open-ended questions and interviews after the intervention. Results: The feasibility score was significantly higher in the VRAS group (mean 5.63, SD 0.74) than in the control group (mean 3.88, SD 1.73; P=.03). However, no significant differences were apparent between the VRAS and control groups for the DSS (VRAS: mean 35.13, SD 5.30; control: mean 35.38, SD 4.50; P=.92) or ASD (VRAS: mean 12.25, SD 3.33; control: mean 11.25, SD 1.91; P=.92). Stigma scores tended to decrease; however, the stigma-reducing effects of the VRAS app were not significant for the DSS (pre: mean 33.00, SD 4.44; post: mean 35.13, SD 5.30; P=.12) or ASD (pre: mean 13.25, SD 3.92; post: mean 12.25, SD 3.33; P=.12). Qualitative analysis suggested that the VRAS app facilitated perspective-taking and promoted empathy toward the patient. Conclusions: The CBE intervention using virtual reality technology (VRAS app) was as effective as the video intervention. The results of the qualitative study suggested that the virtual reality intervention was able to promote perspective-taking and empathy toward patients. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) UMIN000043020; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000049109 %M 35499865 %R 10.2196/28072 %U https://formative.jmir.org/2022/5/e28072 %U https://doi.org/10.2196/28072 %U http://www.ncbi.nlm.nih.gov/pubmed/35499865 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 4 %P e33080 %T Comparing the Ratio of Therapist Support to Internet Sessions in a Blended Therapy Delivered to Trauma-Exposed Veterans: Quasi-experimental Comparison Study %A Cloitre,Marylene %A Amspoker,Amber Bush %A Fletcher,Terri L %A Hogan,Julianna B %A Jackson,Christie %A Jacobs,Adam %A Shammet,Rayan %A Speicher,Sarah %A Wassef,Miryam %A Lindsay,Jan %+ National Center for PTSD Dissemination and Training Division, Veterans Administration Palo Alto Health Care System, 795 Willow Road, Palo Alto, CA, 94025, United States, 1 415 603 8093, marylene.cloitre@gmail.com %K PTSD %K depression %K veterans %K blended therapy %K iCBT %K web-based %K webSTAIR %K noninferiority %K mental health %K digital health %D 2022 %7 27.4.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Blended models of therapy, which incorporate elements of both internet and face-to-face methods, have been shown to be effective, but therapists and patients have expressed concerns that fewer face-to-face therapy sessions than self-guided internet sessions may be associated with lower therapeutic alliance, lower program completion rates, and poorer outcomes. Objective: A multisite quasi-experimental comparison study with a noninferiority design implemented in routine clinical care was used to assess webSTAIR, a 10-module blended therapy derived from STAIR (skills training in affective and interpersonal regulation) for trauma-exposed individuals delivered with 10 weekly therapist sessions (termed Coach10) compared to 5 biweekly sessions (Coach5). It was hypothesized that Coach5 would be as good as Coach10 in a range of outcomes. Methods: A total of 202 veterans were enrolled in the study with 101 assigned to Coach5 and 101 to Coach10. Posttraumatic stress disorder (PTSD) symptoms, depression, emotion regulation, interpersonal problems, and social functioning measures were collected pre-, mid-, and posttreatment, and at a 3-month follow-up. Noninferiority analyses were conducted on symptom outcome measures. Comparisons were made of continuous and categorical measures regarding participant and therapist activities. Results: Participants reported moderate to severe levels of baseline PTSD, depression, or both. Significant reductions were obtained in all symptom measures posttreatment and at the 3-month follow up. Coach5 was not inferior to Coach10 in any outcome. Therapeutic alliance was at an equivalently high level across the 2 treatment conditions; completion rates and web usage were similar. Total session time was substantially less for the Coach5 therapists than the Coach10 therapists. Both programs were associated with a low, but equal number of therapist activities related to scheduling and crisis or motivational sessions. Conclusions: A blended model delivered with 5 sessions of therapist support was noninferior to 10 sessions in individuals with moderate to severe symptoms. Future studies identifying patient characteristics as moderators of outcomes with high versus low doses of therapist support will help create flexible, technology-based intervention programming. %M 35475777 %R 10.2196/33080 %U https://mental.jmir.org/2022/4/e33080 %U https://doi.org/10.2196/33080 %U http://www.ncbi.nlm.nih.gov/pubmed/35475777 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 2 %P e35671 %T Understanding People With Chronic Pain Who Use a Cognitive Behavioral Therapy–Based Artificial Intelligence Mental Health App (Wysa): Mixed Methods Retrospective Observational Study %A Meheli,Saha %A Sinha,Chaitali %A Kadaba,Madhura %+ Wysa Inc, 131 Dartmouth St, Boston, MA, United States, 1 916 753 7824, chaitali@wysa.io %K chronic pain %K digital mental health %K mobile health %K mHealth %K pain management %K artificial intelligence %K cognitive behavioral therapy %K conversational agent %K software agent %K pain conditions %K depression %K anxiety %D 2022 %7 27.4.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Digital health interventions can bridge barriers in access to treatment among individuals with chronic pain. Objective: This study aimed to evaluate the perceived needs, engagement, and effectiveness of the mental health app Wysa with regard to mental health outcomes among real-world users who reported chronic pain and engaged with the app for support. Methods: Real-world data from users (N=2194) who reported chronic pain and associated health conditions in their conversations with the mental health app were examined using a mixed methods retrospective observational study. An inductive thematic analysis was used to analyze the conversational data of users with chronic pain to assess perceived needs, along with comparative macro-analyses of conversational flows to capture engagement within the app. Additionally, the scores from a subset of users who completed a set of pre-post assessment questionnaires, namely Patient Health Questionnaire-9 (PHQ-9) (n=69) and Generalized Anxiety Disorder Assessment-7 (GAD-7) (n=57), were examined to evaluate the effectiveness of Wysa in providing support for mental health concerns among those managing chronic pain. Results: The themes emerging from the conversations of users with chronic pain included health concerns, socioeconomic concerns, and pain management concerns. Findings from the quantitative analysis indicated that users with chronic pain showed significantly greater app engagement (P<.001) than users without chronic pain, with a large effect size (Vargha and Delaney A=0.76-0.80). Furthermore, users with pre-post assessments during the study period were found to have significant improvements in group means for both PHQ-9 and GAD-7 symptom scores, with a medium effect size (Cohen d=0.60-0.61). Conclusions: The findings indicate that users look for tools that can help them address their concerns related to mental health, pain management, and sleep issues. The study findings also indicate the breadth of the needs of users with chronic pain and the lack of support structures, and suggest that Wysa can provide effective support to bridge the gap. %M 35314422 %R 10.2196/35671 %U https://humanfactors.jmir.org/2022/2/e35671 %U https://doi.org/10.2196/35671 %U http://www.ncbi.nlm.nih.gov/pubmed/35314422 %0 Journal Article %@ 2563-6316 %I JMIR Publications %V 3 %N 2 %P e22912 %T Using Structural Equation Modelling in Routine Clinical Data on Diabetes and Depression: Observational Cohort Study %A Ronaldson,Amy %A Freestone,Mark %A Zhang,Haoyuan %A Marsh,William %A Bhui,Kamaldeep %+ Wolfson Institute of Population Health, Queen Mary University of London, Centre for Psychiatry and Mental Health, Yvonne Carter Building, London, E1 2AB, United Kingdom, 44 02078822033 ext 2033, m.c.freestone@qmul.ac.uk %K depression %K diabetes %K electronic health records %K acute care %K PLS-SEM %K path analysis %K equation modelling %K accident %K emergency care %K emergency %K structural equation modelling %K clinical data %D 2022 %7 27.4.2022 %9 Original Paper %J JMIRx Med %G English %X Background: Large data sets comprising routine clinical data are becoming increasingly available for use in health research. These data sets contain many clinical variables that might not lend themselves to use in research. Structural equation modelling (SEM) is a statistical technique that might allow for the creation of “research-friendly” clinical constructs from these routine clinical variables and therefore could be an appropriate analytic method to apply more widely to routine clinical data. Objective: SEM was applied to a large data set of routine clinical data developed in East London to model well-established clinical associations. Depression is common among patients with type 2 diabetes, and is associated with poor diabetic control, increased diabetic complications, increased health service utilization, and increased health care costs. Evidence from trial data suggests that integrating psychological treatment into diabetes care can improve health status and reduce costs. Attempting to model these known associations using SEM will test the utility of this technique in routine clinical data sets. Methods: Data were cleaned extensively prior to analysis. SEM was used to investigate associations between depression, diabetic control, diabetic care, mental health treatment, and Accident & Emergency (A&E) use in patients with type 2 diabetes. The creation of the latent variables and the direction of association between latent variables in the model was based upon established clinical knowledge. Results: The results provided partial support for the application of SEM to routine clinical data. Overall, 19% (3106/16,353) of patients with type 2 diabetes had received a diagnosis of depression. In line with known clinical associations, depression was associated with worse diabetic control (β=.034, P<.001) and increased A&E use (β=.071, P<.001). However, contrary to expectation, worse diabetic control was associated with lower A&E use (β=–.055, P<.001) and receipt of mental health treatment did not impact upon diabetic control (P=.39). Receipt of diabetes care was associated with better diabetic control (β=–.072, P<.001), having depression (β=.018, P=.007), and receiving mental health treatment (β=.046, P<.001), which might suggest that comprehensive integrated care packages are being delivered in East London. Conclusions: Some established clinical associations were successfully modelled in a sample of patients with type 2 diabetes in a way that made clinical sense, providing partial evidence for the utility of SEM in routine clinical data. Several issues relating to data quality emerged. Data improvement would have likely enhanced the utility of SEM in this data set. %M 37725546 %R 10.2196/22912 %U https://med.jmirx.org/2022/2/e22912 %U https://doi.org/10.2196/22912 %U http://www.ncbi.nlm.nih.gov/pubmed/37725546 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 4 %P e34832 %T Effectiveness of an Online Peer Gatekeeper Training Program for Postsecondary Students on Suicide Prevention in Japan: Protocol for a Randomized Controlled Trial %A Nozawa,Kyosuke %A Ishii,Ayaka %A Asaoka,Hiroki %A Iwanaga,Mai %A Kumakura,Yousuke %A Oyabu,Yuri %A Shinozaki,Tomohiro %A Imamura,Kotaro %A Kawakami,Norito %A Miyamoto,Yuki %+ Department of Psychiatric Nursing, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan, 81 358413611, yyuki@m.u-tokyo.ac.jp %K gatekeeper %K suicide prevention %K mental health %K youth %K school %K student %K peer support %K depression %K self-efficacy %K suicide %K prevention %K online training %K online program %K protocol %K RCT %K control trial %D 2022 %7 26.4.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Postsecondary student suicide is one of Japan’s most severe public health problems. Gatekeeper training (GKT) programs are a generally recommended suicide prevention intervention in Japan. For suicide countermeasures, an online program tailored to students may enhance self-efficacy as a gatekeeper. Objective: This study aims to describe a research protocol to investigate the effect of a newly developed internet-delivered online peer GKT program to improve postsecondary student self-efficacy as gatekeepers for suicide countermeasures in Japan. Methods: This study is a 2-arm, parallel, randomized controlled trial with a 1:1 (intervention: waiting list) allocation. Participants (n=320) will be recruited, and those who meet the inclusion criteria will be randomly allocated to the intervention or waiting list control group. An approximately 85-minute, 6-section, internet-based gatekeeper program for postsecondary students has been developed that includes videos to help participants acquire skills as gatekeepers. The intervention group will complete the program within 10 days. The primary outcome, self-efficacy as a gatekeeper, is measured using the Gatekeeper Self-Efficacy Scale at baseline, immediately after taking the program, and 2 months after the survey after completing the program follow-up. To compare the primary outcomes, a t test, where the significance level is 5% (2-sided), will be used to test the intervention effect on an intention-to-treat basis. Results: The study was at the stage of data collection at the time of submission. We recruited participants for this study during August and September 2021, and data collection will continue until December 2021. The data analysis related to the primary outcome will start in December 2021, and we hope to publish the results in 2022 or 2023. Conclusions: This is the first study to investigate the effectiveness of an online GKT program for postsecondary students to improve self-efficacy as a gatekeeper using a randomized controlled trial design. The study will explore the potential of an online peer gatekeeper program for postsecondary students that can be disseminated online to a large number of students with minimal cost. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry UMIN000045325; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000051685 International Registered Report Identifier (IRRID): DERR1-10.2196/34832 %M 35471412 %R 10.2196/34832 %U https://www.researchprotocols.org/2022/4/e34832 %U https://doi.org/10.2196/34832 %U http://www.ncbi.nlm.nih.gov/pubmed/35471412 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 4 %P e31835 %T Computerized Cognitive Behavioral Therapy Intervention for Depression Among Veterans: Acceptability and Feasibility Study %A Stearns-Yoder,Kelly A %A Ryan,Arthur T %A Smith,Alexandra A %A Forster,Jeri E %A Barnes,Sean M %A Brenner,Lisa A %+ Veterans Affairs Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, 1700 N Wheeling Street, Aurora, CO, 80045, United States, 1 7204151717, kelly.stearns@va.gov %K computerized cognitive behavioral therapy %K depression %K veterans %K acceptability %K feasibility %D 2022 %7 25.4.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Computerized cognitive behavioral therapies (cCBTs) have been developed to deliver efficient, evidence-based treatment for depression and other mental health conditions. Beating the Blues (BtB) is one of the most empirically supported cCBTs for depression. The previous trial of BtB with veterans included regular guidance by health care personnel, which increased the complexity and cost of the intervention. Objective: This study, conducted by researchers at a Veterans Affairs Medical Center, aims to test the acceptability and feasibility of unguided cCBT for depression among US military veterans. Methods: To examine the acceptability of BtB delivered without additional peer or other mental health care provider support, a before-and-after trial was conducted among United States (US) military veterans experiencing mild to moderate depressive symptoms. The feasibility of the study design for a future efficacy trial was also evaluated. Results: In total, 49 veterans completed preintervention assessments and received access to BtB, and 29 participants completed all postintervention assessments. The predetermined acceptability criterion for the intervention was met. Although the predetermined feasibility criteria regarding screening eligibility rate, number of BtB modules completed, and completion of a posttreatment assessment were not met, the results were comparable with those of other cCBT studies. Conclusions: This is the first study among US military veterans to demonstrate support for the implementation of cCBT for depression without the assistance of a mental health professional or a peer support specialist, suggesting that stand-alone computer-aided interventions may be viable. Ideas for improving feasibility in future trials based on this study are discussed. %M 35468088 %R 10.2196/31835 %U https://formative.jmir.org/2022/4/e31835 %U https://doi.org/10.2196/31835 %U http://www.ncbi.nlm.nih.gov/pubmed/35468088 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 4 %P e30218 %T Conditions for the Successful Integration of an eHealth Tool "StopBlues" Into Community-Based Interventions in France: Results From a Multiple Correspondence Analysis %A Turmaine,Kathleen %A Dumas,Agnès %A Chevreul,Karine %A , %+ Université Paris Cité, ECEVE, UMR 1123, Inserm, 10 avenue de Verdun, Paris, 75010, France, 33 1 57 27 86 89, kathleen.turmaine@inserm.fr %K eHealth %K internet-based intervention %K community participation %K health promotion %K prevention %K mental health %D 2022 %7 22.4.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: For over a decade, digital health has held promise for enabling broader access to health information, education, and services for the general population at a lower cost. However, recent studies have shown mixed results leading to a certain disappointment regarding the benefits of eHealth technologies. In this context, community-based health promotion represents an interesting and efficient conceptual framework that could help increase the adoption of digital health solutions and facilitate their evaluation. Objective: To understand how the local implementation of the promotion of an eHealth tool, StopBlues (SB), aimed at preventing psychological distress and suicide, varied according to local contexts and if the implementation was related to the use of the tool. Methods: The study was nested within a cluster-randomized controlled trial that was conducted to evaluate the effectiveness of the promotion, with before and after observation (NCT03565562). Data from questionnaires, observations, and institutional sources were collected in 27 localities where SB was implemented. A multiple correspondence analysis was performed to assess the relations between context, type of implementation and promotion, and use of the tool. Results: Three distinct promotion patterns emerged according to the profiles of the localities that were associated with specific SB utilization rates. From highest to lowest utilization rates, they are listed as follows: the privileged urban localities, investing in health that implemented a high-intensity and digital promotion, demonstrating a greater capacity to take ownership of the project; the urban, but less privileged localities that, in spite of having relatively little experience in health policy implementation, managed to implement a traditional and high-intensity promotion; and the rural localities, with little experience in addressing health issues, that implemented low-intensity promotion but could not overcome the challenges associated with their local context. Conclusions: These findings indicate the substantial influence of local context on the reception of digital tools. The urban and socioeconomic status profiles of the localities, along with their investment and pre-existing experience in health, appear to be critical for shaping the promotion and implementation of eHealth tools in terms of intensity and use of digital communication. The more digital channels used, the higher the utilization rates, ultimately leading to the overall success of the intervention. International Registered Report Identifier (IRRID): RR2-10.1186/s13063-020-04464-2 %M 35451977 %R 10.2196/30218 %U https://www.jmir.org/2022/4/e30218 %U https://doi.org/10.2196/30218 %U http://www.ncbi.nlm.nih.gov/pubmed/35451977 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 4 %P e30138 %T Cannabis Use in Adults Who Screen Positive for Attention Deficit/Hyperactivity Disorder: CANreduce 2.0 Randomized Controlled Trial Subgroup Analysis %A Ahlers,Joachim %A Baumgartner,Christian %A Augsburger,Mareike %A Wenger,Andreas %A Malischnig,Doris %A Boumparis,Nikolaos %A Berger,Thomas %A Stark,Lars %A Ebert,David D %A Haug,Severin %A Schaub,Michael P %+ Swiss Research Institute for Public Health and Addiction, University of Zurich, Konradstrasse 32, Zurich, 8005, Switzerland, 41 444481160, joachim.ahlers@wisemed.ch %K attention deficit/hyperactivity disorder %K ADHD %K cannabis %K cannabis use disorder %K CANreduce %K web-based self-help tool %K online tool %K online health %K mental health %K digital health %K anxiety %K depression %D 2022 %7 20.4.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Prevalence rates for lifetime cannabis use and cannabis use disorder are much higher in people with attention deficit/hyperactivity disorder than in those without. CANreduce 2.0 is an intervention that is generally effective at reducing cannabis use in cannabis misusers. This self-guided web-based intervention (6-week duration) consists of modules grounded in motivational interviewing and cognitive behavioral therapy. Objective: We aimed to evaluate whether the CANreduce 2.0 intervention affects cannabis use patterns and symptom severity in adults who screen positive for attention deficit/hyperactivity disorder more than in those who do not. Methods: We performed a secondary analysis of data from a previous study with the inclusion criterion of cannabis use at least once weekly over the last 30 days. Adults with and without attention deficit/hyperactivity disorder (based on the Adult Attention deficit/hyperactivity disorder Self-Report screener) who were enrolled to the active intervention arms of CANreduce 2.0 were compared regarding the number of days cannabis was used in the preceding 30 days, the cannabis use disorder identification test score (CUDIT) and the severity of dependence scale score (SDS) at baseline and the 3-month follow-up. Secondary outcomes were Generalized Anxiety Disorder score, Center for Epidemiological Studies Depression scale score, retention, intervention adherence, and safety. Results: Both adults with (n=94) and without (n=273) positive attention-deficit/hyperactivity disorder screening reported significantly reduced frequency (reduction in consumption days: with: mean 11.53, SD 9.28, P<.001; without: mean 8.53, SD 9.4, P<.001) and severity of cannabis use (SDS: with: mean 3.57, SD 3.65, P<.001; without: mean 2.47, SD 3.39, P<.001; CUDIT: with: mean 6.38, SD 5.96, P<.001; without: mean 5.33, SD 6.05, P<.001), as well as anxiety (with: mean 4.31, SD 4.71, P<.001; without: mean 1.84, SD 4.22, P<.001) and depression (with: mean 10.25, SD 10.54; without: mean 4.39, SD 10.22, P<.001). Those who screened positive for attention deficit/hyperactivity disorder also reported significantly decreased attention deficit/hyperactivity disorder scores (mean 4.65, SD 4.44, P<.001). There were no significant differences in change in use (P=.08), dependence (P=.95), use disorder (P=.85), attention deficit/hyperactivity disorder status (P=.84), depression (P=.84), or anxiety (P=.26) between baseline and final follow-up, dependent on positive attention-deficit/hyperactivity disorder screening. Attention deficit/hyperactivity disorder symptom severity at baseline was not associated with reduced cannabis use frequency or severity but was linked to greater reductions in depression (Spearman ρ=.33) and anxiety (Spearman ρ=.28). Individuals with positive attention deficit/hyperactivity disorder screening were significantly less likely to fill out the consumption diary (P=.02), but the association between continuous attention deficit/hyperactivity disorder symptom severity and retention (Spearman ρ=−0.10, P=.13) was nonsignificant. There also was no significant intergroup difference in the number of completed modules (with: mean 2.10, SD 2.33; without: mean 2.36, SD 2.36, P=.34), and there was no association with attention deficit/hyperactivity disorder symptom severity (Spearman ρ=−0.09; P=.43). The same was true for the rate of adverse effects (P=.33). Conclusions: Cannabis users screening positive for attention deficit/hyperactivity disorder may benefit from CANreduce 2.0 to decrease the frequency and severity of cannabis dependence and attenuate symptoms of depression and attention deficit/hyperactivity disorder-related symptoms. This web-based program’s advantages include its accessibility for remote users and a personalized counselling option that may contribute to increased adherence and motivation to change among program users. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 11086185; http://www.isrctn.com/ISRCTN11086185 %M 35442196 %R 10.2196/30138 %U https://www.jmir.org/2022/4/e30138 %U https://doi.org/10.2196/30138 %U http://www.ncbi.nlm.nih.gov/pubmed/35442196 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 4 %P e29842 %T Computerized Cognitive Behavioral Therapy for Treatment of Depression and Anxiety in Adolescents: Systematic Review and Meta-analysis %A Wickersham,Alice %A Barack,Tamara %A Cross,Lauren %A Downs,Johnny %+ Institute of Psychiatry, Psychology & Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, United Kingdom, 44 (0)20 7848 0002, alice.wickersham@kcl.ac.uk %K adolescent %K anxiety %K depression %K meta-analysis %D 2022 %7 11.4.2022 %9 Review %J J Med Internet Res %G English %X Background: Depression and anxiety are major public health concerns among adolescents. Computerized cognitive behavioral therapy (cCBT) has emerged as a potential intervention, but its efficacy in adolescents remains unestablished. Objective: This review aimed to systematically review and meta-analyze findings on the efficacy of cCBT for the treatment of adolescent depression and anxiety. Methods: Embase, PsycINFO, and Ovid MEDLINE were systematically searched for randomized controlled trials in English, which investigated the efficacy of cCBT for reducing self-reported depression or anxiety in adolescents aged 11 to 19 years. Titles, abstracts, and full texts were screened for eligibility by 2 independent researchers (TB and LC). A random-effects meta-analysis was conducted to pool the effects of cCBT on depression and anxiety symptom scores compared with the control groups. Study quality was assessed using the Cochrane Collaboration Risk of Bias tool. Results: A total of 16 randomized controlled trials were eligible for inclusion in this review, of which 13 (81%) were included in the meta-analysis. The quality of the studies was mixed, with 5 (31%) studies rated as good overall, 2 (13%) rated as fair, and 9 (56%) rated as poor. Small but statistically significant effects of cCBT were detected, with cCBT conditions showing lower symptom scores at follow-up compared with control conditions for both anxiety (standardized mean difference −0.21, 95% CI −0.33 to −0.09; I2=36.2%) and depression (standardized mean difference −0.23, 95% CI −0.39 to −0.07; I2=59.5%). Secondary analyses suggested that cCBT may be comparable with alternative, active interventions (such as face-to-face therapy or treatment as usual). Conclusions: This meta-analysis reinforces the efficacy of cCBT for the treatment of anxiety and depression and is the first to examine this exclusively in adolescents. Future research could aim to identify the active components of these interventions toward optimizing their development and increasing the feasibility and acceptability of cCBT in this age group. Trial Registration: PROSPERO CRD42019141941; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=141941 %M 35404263 %R 10.2196/29842 %U https://www.jmir.org/2022/4/e29842 %U https://doi.org/10.2196/29842 %U http://www.ncbi.nlm.nih.gov/pubmed/35404263 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 4 %P e21111 %T Improving Web-Based Treatment Intake for Multiple Mental and Substance Use Disorders by Text Mining and Machine Learning: Algorithm Development and Validation %A Wiegersma,Sytske %A Hidajat,Maurice %A Schrieken,Bart %A Veldkamp,Bernard %A Olff,Miranda %+ Department of Research Methodology, Measurement and Data Analysis, University of Twente, PO Box 217, Enschede, 7500 AE, Netherlands, 31 53 489 3349, sytske@wiegersma.nl %K supervised text classification %K multi-class classification %K screening %K mental health disorders %K computerized CBT %K automated intake and referral %D 2022 %7 11.4.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Text mining and machine learning are increasingly used in mental health care practice and research, potentially saving time and effort in the diagnosis and monitoring of patients. Previous studies showed that mental disorders can be detected based on text, but they focused on screening for a single predefined disorder instead of multiple disorders simultaneously. Objective: The aim of this study is to develop a Dutch multi-class text-classification model to screen for a range of mental disorders to refer new patients to the most suitable treatment. Methods: On the basis of textual responses of patients (N=5863) to a questionnaire currently used for intake and referral, a 7-class classifier was developed to distinguish among anxiety, panic, posttraumatic stress, mood, eating, substance use, and somatic symptom disorders. A linear support vector machine was fitted using nested cross-validation grid search. Results: The highest classification rate was found for eating disorders (82%). The scores for panic (55%), posttraumatic stress (52%), mood (50%), somatic symptom (50%), anxiety (35%), and substance use disorders (33%) were lower, likely because of overlapping symptoms. The overall classification accuracy (49%) was reasonable for a 7-class classifier. Conclusions: A classification model was developed that could screen text for multiple mental health disorders. The screener resulted in an additional outcome score that may serve as input for a formal diagnostic interview and referral. This may lead to a more efficient and standardized intake process. %M 35404261 %R 10.2196/21111 %U https://mental.jmir.org/2022/4/e21111 %U https://doi.org/10.2196/21111 %U http://www.ncbi.nlm.nih.gov/pubmed/35404261 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 4 %P e29726 %T Comparing Online and On-Site Cognitive Behavior Therapy in Major Depressive Disorder: Protocol for a Noninferiority Randomized Controlled Trial %A Ritvo,Paul %A Gratzer,David %A Knyahnytska,Yuliya %A Ortiz,Abigail %A Walters,Clarice %A Katz,Joel %A Laposa,Judith %A Baldissera,Christopher %A Wayne,Noah %A Pfefer-Litman,Donna %A Tomlinson,George %A Daskalakis,Zafiris %+ School of Kinesiology and Health Science, York University, C/O School of Kinesiology and Health Science, Bethune Building, York University, 4700 Keele St., Toronto, ON, M3J1P3, Canada, 1 4165808021, pritvo@yorku.ca %K online intervention %K randomized controlled trial %K major depressive disorder %D 2022 %7 8.4.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: The incidence of mental health disorders in Canada is increasing with costs of CAD $51 billion (US $40 billion) per year. Depression is the most prevalent cause of disability while cognitive behavioral therapy (CBT) is the best validated behavioral depression treatment. CBT, when combined with mindfulness meditation (CBT-M), has strong evidence for increased efficacy. While randomized controlled trials (RCTs) have demonstrated online CBT-M efficacy, comparisons with in-office delivery are lacking. Objective: The aim of this research is to assess whether online group CBT-M (with standard psychiatric care) is non-inferior in efficacy and more cost-effective than office-based, on-site group CBT-M at post-intervention and 6-months follow-up in major depressive disorder. The study will also assess whether digitally recorded data (ie, online workbooks completed, Fitbit step count, and online text messages) predict depression symptom reduction in online participants. Methods: This single-center, two-arm, noninferiority RCT employs assessor-blinded and self-report outcomes and economic evaluation. The research site is the Centre for Addiction and Mental Health (Toronto), a research-based psychiatry institution where participants will be identified from service wait lists and through contacts with other Toronto clinics. Inclusion criteria are as follows: (1) aged 18-60 years, any ethnicity; (2) Beck Depression Inventory-II (BDI-II) of mild severity (score ≥14) with no upper severity limit; (3) Mini-International Neuropsychiatric Interview-confirmed, psychiatric major depressive disorder diagnosis; (4) fluent in English. All patients are diagnosed by staff psychiatrists. Exclusion criteria are as follows: (1) receipt of weekly structured psychotherapy; (2) observation of Diagnostic and Statistical Manual of Mental Disorders (5th Edition) criteria for severe alcohol or substance use disorder (in past 3 months), borderline personality disorder, schizophrenia (or other primary psychotic disorder), bipolar disorder, or obsessive-compulsive disorder; (3) clinically significant suicidal ideation (imminent intent or attempted suicide in the past 6 months); and (4) treatment-resistant depression. All participants receive standard psychiatric care, experimental participants receive online group CBT-M, and controls receive standard care in-office group CBT-M. The online group program (in collaboration with NexJ Health, Inc) combines smartphone and computer-accessed workbooks with mental health phone counselling (16 hours in 16 weeks) that coordinates software interactions (eg, secure text messaging and Fitbit-tracked walking). The primary outcome is BDI-II, and secondary outcomes are anxiety (Beck Anxiety Inventory), depression (ie, Quick Inventory of Depressive Symptomatology and 17-item Hamilton Depression Rating Scale), mindfulness (Five-Facet Mindfulness Questionnaire), quality of life (European Quality of Life Five Dimension), and pain (Brief Pain Inventory). Results: Based on prior studies with the BDI-II and 80% power to reject an inferiority hypothesis with a 1-sided type I error rate of 5%, a sample of 78 per group is adequate to detect small-to-medium–effect sizes. Conclusions: This study assesses online CBT-M efficacy and noninferiority in relation to in-person CBT, and the cost-effectiveness of both interventions. Trial Registration: ClinicalTrials.gov NCT04825535; https://www.clinicaltrials.gov/ct2/show/NCT04825535 International Registered Report Identifier (IRRID): DERR1-10.2196/29726 %M 35393942 %R 10.2196/29726 %U https://www.researchprotocols.org/2022/4/e29726 %U https://doi.org/10.2196/29726 %U http://www.ncbi.nlm.nih.gov/pubmed/35393942 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 4 %P e36166 %T Comparing the New Interdisciplinary Health in Work Intervention With Conventional Monodisciplinary Welfare Interventions at Norwegian Workplaces: Protocol for a Pragmatic Cluster Randomized Trial %A Höper,Anje Christina %A Terjesen,Christoffer Lilja %A Fleten,Nils %+ Occupational Health in the North, Department of Community Medicine, UiT The Arctic University of Norway, Postboks 6050 Langnes, Tromsø, 9037, Norway, 47 98022451, anje.hoeper@uit.no %K sickness absence %K work environment %K work environment intervention %K health related quality of life %K cluster randomized trial %K cost-effectiveness-analysis %K cost-benefit-analysis %K health in work %D 2022 %7 7.4.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Musculoskeletal and mental health complaints are the dominant diagnostic categories in long-term sick leave and disability pensions in Norway. Continuing to work despite health complaints is often beneficial, and a good work environment can improve work inclusion for people affected. In 2001, the Norwegian Labour and Welfare Administration began to offer inclusive work measures to improve the psychosocial work environment and work inclusion of people with health complaints. In 2018, the Norwegian Labour and Welfare Administration and specialist health services started offering the new collaborative Health in work program. Its workplace intervention presents health and welfare information that may improve employees’ coping ability regarding common health complaints. It encourages understanding of coworkers’ health complaints and appropriate work adjustments to increase work participation. Objective: This protocol presents an ongoing, 2-arm, pragmatic cluster-randomized trial. Its aim is to compare the effect of monodisciplinary inclusive work measures (treatment as usual) and interdisciplinary Health in work in terms of changes in overall sickness absence, health care use, health-related quality of life, and costs. The secondary objectives are to compare changes in individual sickness absence, psychosocial work environment, job and life satisfaction, health, and health anxiety at both the individual and group levels. Methods: Data will be collected from national registers, trial-specific registrations, and questionnaires. Effects will be explored using difference-in-difference analysis and regression modeling. Multilevel analysis will visualize any cluster effects using intraclass correlation coefficients. Results: Inclusion was completed in July 2021 with 97 workplaces and 1383 individual consents. Data collection will be completed with the last questionnaires to be sent out in July 2023. Conclusions: This trial will contribute to filling knowledge gaps regarding the effectiveness and costs of workplace interventions, thereby benefiting health and welfare services, political decision makers, and the public and business sectors. The findings will be disseminated in reports, peer-reviewed journals, and conferences. Trial Registration: ClinicalTrials.gov NCT04000035; https://clinicaltrials.gov/ct2/show/NCT04000035 International Registered Report Identifier (IRRID): DERR1-10.2196/36166 %M 35388792 %R 10.2196/36166 %U https://www.researchprotocols.org/2022/4/e36166 %U https://doi.org/10.2196/36166 %U http://www.ncbi.nlm.nih.gov/pubmed/35388792 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 8 %N 4 %P e29906 %T Health-Related Quality of Life of HIV-Positive and HIV-Negative Pregnant Women in an Impoverished Area: Cross-sectional Study %A Qu,Shuiling %A Wang,Ailing %A Wang,Xiaoyan %A Yang,Yehuan %A Pan,Xiaoping %A Zhang,Tong %+ Capital Institute of Pediatrics, No 2 Yabao Road, Chaoyang District, Beijing, 100020, China, 86 10 85695188, zt@chinawch.org.cn %K health-related quality of life %K EQ-5D-3L %K HIV %K impoverished area %K public health %K pregnant women %K depression %K anxiety %D 2022 %7 5.4.2022 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Liangshan prefecture of Sichuan province was an impoverished mountainous area in China, where the annual number of HIV-positive pregnant women accounted for approximately 10% of China’s total population in the decades before 2020. In general, pregnant women living here are likely to be physically and mentally different from those in other places. Objective: This study aims to explore the health-related quality of life (HRQoL) of pregnant women living with HIV in an impoverished area. Methods: From December 2018 to January 2019, HIV-positive and HIV-negative parturients within 18 months after delivery were recruited in Liangshan Prefecture, Sichuan Province. Questionnaires were designed to collect their demographic data, while the EuroQol 5-Dimension, 3-Level questionnaire was used to measure their HRQoL when they were in the second trimester from 4 to 6 months of pregnancy, and their quantitative health scores were converted to corresponding healthy utility values by using the Chinese Utility Value Integral System (time trade-off coefficient). Results: A total of 250 pregnant women (133 HIV-positive and 117 HIV-negative) were enrolled in the study. Among them, 55 (41.35%) and 75 (64.10%) of HIV-positive and HIV-negative pregnant women self-reported full health (healthy state 11111), respectively. The median health utility value of the 250 pregnant women was 0.961 (IQR –0.046 to 0.961), and those of the HIV-positive and HIV-negative pregnant women were 0.875 (0.424-0.961) and 0.961 (IQR –0.046 to 0.961), respectively. We observed a significant difference only in the dimension of anxiety or depression between the two groups (P=.002) and no significant difference in the distribution of health utility indices between the two groups in terms of maternal age, education level, occupation, annual household income, prenatal care visits, family size, and medical insurance category. Multivariate ordinal logistic regression analysis showed that age (odds ratio [OR] 0.62, P<.05) and prenatal care visit (OR 0.29, P<.01) were independent risk factors for health status. Conclusions: Most pregnant women self-reported satisfactory HRQoL in this impoverished mountainous area. HIV-negative pregnant women had an edge over HIV-positive pregnant women, and there were significant differences in anxiety or depression dimensions between the two groups. %M 35380543 %R 10.2196/29906 %U https://publichealth.jmir.org/2022/4/e29906 %U https://doi.org/10.2196/29906 %U http://www.ncbi.nlm.nih.gov/pubmed/35380543 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 4 %P e34330 %T Efficacy of a Web-Based Intervention for Depressive Disorders: Three-Arm Randomized Controlled Trial Comparing Guided and Unguided Self-Help With Waitlist Control %A Krämer,Rico %A Köhne-Volland,Lea %A Schumacher,Anna %A Köhler,Stephan %+ Department of Psychiatry and Neuroscience, Charité – Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany, 49 15152515774, stephan.koehler@charite.de %K major depressive disorder %K online intervention %K blended treatment %K public health %K routine practice %K randomized controlled trial %K depression %K disorder %K intervention %K treatment %K efficacy %K self-help %K guidance %D 2022 %7 4.4.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital health apps are efficacious treatment options for mild-to-moderate depressive disorders. However, the extent to which psychological guidance increases the efficacy of these apps is controversial. Objective: We evaluated the efficacy of a web-based intervention, called Selfapy, for unipolar depression. We also investigated differences between psychotherapist-guided and unguided versions. Methods: Selfapy is a cognitive behavioral therapy–based intervention for depressive disorders. Participants with mild-to-severe depressive disorders were assigned randomly to participate in either guided (weekly 25-minute duration telephone calls) intervention, unguided version, or waiting list (control group) for 12 weeks. We assessed depressive symptoms at the start of the study, midway through the intervention (6 weeks), at the end of the intervention (12 weeks), and at follow-up (6 months). The main outcome was difference in the Beck Depression Inventory score between the start of the study and the end of the intervention. Secondary outcomes were the Quick Inventory of Depressive Symptomatology—Self Report, the Hamilton Rating Depression Scale, and the Beck Anxiety Inventory. Results: Of 401 participants, 301 participants (75.1%) completed the intervention. Changes in the Beck Depression Inventory from baseline differed significantly between groups at the postintervention (F2,398=37.20, P<.001). The reductions in scores for both guided and unguided intervention groups were greater than that for the control group, with large between-group effect sizes (guided vs control: d=1.63, 95% CI 1.37 to 1.93; unguided vs control: d=1.47, 95% CI 1.22 to 1.73) at postintervention. No significant differences were found between guided and unguided intervention groups (P=.18). At follow-up (6 months), treatment effects on the primary outcome were maintained for both intervention groups (guided: F1,194=0.62, P>.999; unguided: F1,176=0.13, P>.999). Conclusions: Both guided and unguided versions of the intervention were highly effective in reducing depressive symptoms. Follow-up data suggest that these effects could be maintained. The guided version was not superior to the unguided version. Trial Registration: German Clinical Trials Register DRKS00017191; https://tinyurl.com/2p9h5hnx International Registered Report Identifier (IRRID): RR2-10.1186/s13063-021-05218-4 %M 35105536 %R 10.2196/34330 %U https://formative.jmir.org/2022/4/e34330 %U https://doi.org/10.2196/34330 %U http://www.ncbi.nlm.nih.gov/pubmed/35105536 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 4 %P e32387 %T Effects of COVID-19 on Physical Activity and Its Relationship With Mental Health in a US Community Sample: Cross-sectional, Convenience Sampling–based Online Survey %A Zhang,Wei %A Velez,Dominick %+ Department of Psychology, New Jersey City University, 2039 John F. Kennedy Blvd, Jersey City, NJ, 07305, United States, 1 2012002000 ext 3063, wzhang@njcu.edu %K physical activity %K COVID-19 %K mental health %K depression %K anxiety %K United States %K survey %K cross-sectional %K distress %K risk %D 2022 %7 4.4.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: COVID-19 restrictions may make it difficult for people to engage in the recommended amounts of physical activity (PA). Objective: The influence of the COVID-19 pandemic on PA, as well as the links between PA and mental health, was investigated in this study. Methods: Participants were recruited using convenience sampling and responded to an online survey between April 15 and July 1, 2021, with ages ranging from 18 to 24 years (n=156, 40.9% of the sample) to ≥55 years (n=28, 7.4% of the sample). To assess general psychological distress, depression, anxiety, and pandemic anxiety, a battery of mental health assessments was used. The International Physical Activity Questionnaire - Short Form was used to collect PA data from participants, who were then classified as inactive, minimally active, or highly active. Participants also indicated the locations where they performed PA before and during COVID-19. Results: A sample of 381 individuals was included in this research. The logistic regression analysis results were interpreted as odds ratios (ORs), where an OR higher than 1 indicated a greater chance of an event occurring and an OR less than 1 implied a lower likelihood of an event occurring. Logistic regression results revealed that inactive individuals were more likely to develop psychological distress (OR 2.17, 95% CI 1.27-3.69, P=.004), depression (OR 3.81, 95% CI 1.92-7.57, P<.001), and anxiety (OR 1.86, 95% CI 0.99-3.47, P=.05) as compared to highly active individuals. Furthermore, when compared to highly active people, those who were only minimally active had a higher risk of depression (OR 2.14, 95% CI 1.05-4.33, P=.04). Wilcoxon signed-rank tests revealed that COVID-19 has a greater impact on reducing the chances of less active individuals engaging in PA outside and in public spaces. Highly active people's physical exercise locations had changed less, and their exercise frequency at home increased. Conclusions: Programmatic and policy interventions geared particularly toward enhancing PA among those less active may be a helpful strategy for addressing the worldwide pandemic’s mental health crisis. %M 35302509 %R 10.2196/32387 %U https://formative.jmir.org/2022/4/e32387 %U https://doi.org/10.2196/32387 %U http://www.ncbi.nlm.nih.gov/pubmed/35302509 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 4 %P e29566 %T Satisfaction and Acceptability Ratings of a Web-Based Self-help Intervention for Depression: Retrospective Cross-sectional Study From a Resource-Limited Country %A Lara,Ma. Asunción %A Patiño,Pamela %A Tiburcio,Marcela %A Navarrete,Laura %+ Department of Psychosocial Studies in Specific Population, Division of Epidemiological and Psychosocial Research, Ramón de la Fuente Muñiz National Institute of Psychiatry, Calz. Mexico-Xochimilco 101, Col. San Lorenzo Huipulco, Del. Tlalpan, Mexico City, 14370, Mexico, 52 55 4160 5170, laracan@imp.edu.mx %K depression %K web-based intervention %K unguided intervention %K acceptability %K satisfaction %K resource-limited country %D 2022 %7 4.4.2022 %9 Early Reports %J JMIR Form Res %G English %X Background: Web-based interventions are at an early stage in non–English-speaking low- and middle-income countries, where they remain scarce. Help for Depression (HDep) is one of the few unguided web-based interventions available in Latin America. The results of a use/usability analysis of the original version served as the basis for generating a more user-friendly second version. Objective: The aim of this study is to explore participants’ satisfaction and acceptability for the second version of HDep. Methods: A retrospective cross-sectional design was used. An email invitation to complete a web-based survey was sent to all people who accessed HDep in 2018. The questionnaire included satisfaction and acceptability scales and open-ended questions. Complete questionnaires were retrieved from 191 participants: 35.1% (67/191) from those who visited only the home page (home page users [HPUs]) and 6.47% (124/1916) from those who registered to use the program (program users [PUs]). Results: In all groups, users experienced high levels of depressive symptoms (189/191, 98.9%; Center for Epidemiological Studies Scale-Depression >16). Moderate levels of satisfaction (HPUs: mean 21.9, SD 6.7; PUs: mean 21.1, SD 5.8; range: 8-32) and acceptability (HPUs: mean 13.8, SD 3.9; PUs: mean 13.9, SD 3.2; range: 5-20) were found in both groups. Logistic regression analyses showed that among HPUs, women were more satisfied with HDep (odds ratio [OR] 3.4, 95% CI 1.1-10.0), whereas among PUs, older respondents (OR 1.04, 95% CI 1.01-1.08), those with paid work (OR 3.1, 95% CI 2.4-7.6), those who had not been in therapy (OR 2.42, 95% CI 1.09-5.98), and those who had not attempted suicide (OR 3.4, 95% CI 1.1-11.1) showed higher satisfaction. None of the sociodemographic/mental health variables distinguished the acceptability ratings among HPUs. Among PUs, those with paid work (OR 2.5, 95% CI 1.1-5.5), those who had not been in therapy (OR 3.1, 95% CI 1.3-7.3), those without disability (OR 2.9, 95% CI 1.3-6.6), and those who had not attempted suicide (OR 2.6, 95% CI 1.0-6.6) showed higher acceptability. Conclusions: HDep has good levels of satisfaction and acceptability for approximately half of its users, and the information provided by respondents suggested feasible ways to remedy some of the deficiencies. This qualitative–quantitative study from a low- to middle-income, non–English-speaking country adds to existing knowledge regarding acceptance and satisfaction with web-based interventions for depression in resource-limited countries. This information is important for the creation and adaptation of web-based interventions in low- and middle-income countries, where access to treatment is a major concern, and web-based prevention and treatment programs can help deliver evidence-based alternatives. It is necessary to document the pitfalls, strengths, and challenges of such interventions in this context. Understanding how users perceive an intervention might suggest modifications to increase adherence. %M 35377324 %R 10.2196/29566 %U https://formative.jmir.org/2022/4/e29566 %U https://doi.org/10.2196/29566 %U http://www.ncbi.nlm.nih.gov/pubmed/35377324 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e35253 %T Utilizing Big Data From Google Trends to Map Population Depression in the United States: Exploratory Infodemiology Study %A Wang,Alex %A McCarron,Robert %A Azzam,Daniel %A Stehli,Annamarie %A Xiong,Glen %A DeMartini,Jeremy %+ Department of Psychiatry and Human Behavior, University of California, Irvine, 101 The City Dr S, Orange, CA, 92868, United States, 1 8584059768, wangaj3@uci.edu %K depression %K epidemiology %K internet %K google trends %K big data %K mental health %D 2022 %7 31.3.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: The epidemiology of mental health disorders has important theoretical and practical implications for health care service and planning. The recent increase in big data storage and subsequent development of analytical tools suggest that mining search databases may yield important trends on mental health, which can be used to support existing population health studies. Objective: This study aimed to map depression search intent in the United States based on internet-based mental health queries. Methods: Weekly data on mental health searches were extracted from Google Trends for an 11-year period (2010-2021) and separated by US state for the following terms: “feeling sad,” “depressed,” “depression,” “empty,” “insomnia,” “fatigue,” “guilty,” “feeling guilty,” and “suicide.” Multivariable regression models were created based on geographic and environmental factors and normalized to the following control terms: “sports,” “news,” “google,” “youtube,” “facebook,” and “netflix.” Heat maps of population depression were generated based on search intent. Results: Depression search intent grew 67% from January 2010 to March 2021. Depression search intent showed significant seasonal patterns with peak intensity during winter (adjusted P<.001) and early spring months (adjusted P<.001), relative to summer months. Geographic location correlated with depression search intent with states in the Northeast (adjusted P=.01) having higher search intent than states in the South. Conclusions: The trends extrapolated from Google Trends successfully correlate with known risk factors for depression, such as seasonality and increasing latitude. These findings suggest that Google Trends may be a valid novel epidemiological tool to map depression prevalence in the United States. %M 35357320 %R 10.2196/35253 %U https://mental.jmir.org/2022/3/e35253 %U https://doi.org/10.2196/35253 %U http://www.ncbi.nlm.nih.gov/pubmed/35357320 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 3 %P e33423 %T Effectiveness of a Mindfulness-Based Mobile Application for the Treatment of Depression in Ambulatory Care: Protocol for a Randomized Controlled Trial %A Sarlon,Jan %A Doll,Jessica P K %A Schmassmann,Aline %A Brand,Serge %A Ferreira,Naomi %A Muehlhauser,Markus %A Urech-Meyer,Stefanie %A Schweinfurth,Nina %A Lang,Undine Emmi %A Bruehl,Annette Beatrix %+ University Psychiatric Clinics, University of Basel, Wilhelm Klein-Strasse 27, Basel, 4002, Switzerland, 41 613255097, jan.sarlon@upk.ch %K depression %K mindfulness %K mhealth %K ehealth %K stress level %D 2022 %7 31.3.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Patients with major depressive disorder (MDD) often experience relapses despite regular treatment with pharmacotherapy and psychotherapy. Further, long waiting lists and more demand than treatment capacity characterize ambulatory settings. Mindfulness-based interventions proved to be effective in relapse prevention in MDD. Next, mindfulness-based interventions in the form of free mobile applications can be an effective augmentation of the treatment as usual and can fill a gap in ambulatory care. Objective: Given this background, the aim of this randomized controlled study is to assess the effectiveness of additional MBI via a mobile app on the symptom severity and stress levels, compared to treatment as usual. Methods: A total of 140 individuals with MDD will be randomly allocated to the intervention or control condition. The intervention consists of the daily use of the mindfulness mobile application Headspace for thirty days (up to 10 minutes a day). The control condition will be treatment as usual. At baseline and four weeks later, the following key outcome dimensions will be assessed: self-rated (Beck Depression Inventory) and experts’ rated symptoms of MDD (Hamilton Depression Rating Scale); secondary outcome variables will be blood pressure, heart rate, and respiratory rate and changes in tobacco and alcohol consumption and medication as a proxy of perceived stress. Results: This study was funded in February 2021 and approved by the institutional review board on April 15, 2021, and it started in May 2021. As of December 2021, we enrolled 30 participants. The findings are expected to be published in spring 2023. Conclusions: We hypothesize that compared to the control conditions, individuals with MDD of the mobile app-condition will have both lower self- and experts’ rated symptoms of MDD and more favorable stress-related levels. While the risk for medical events is low, the immediate benefit for participants could be a decrease in symptom severity and reduction of the stress level. Trial Registration: Clinical Trials.gov NCT05060393; https://clinicaltrials.gov/ct2/show/NCT05060393. International Registered Report Identifier (IRRID): DERR1-10.2196/33423 %M 35357325 %R 10.2196/33423 %U https://www.researchprotocols.org/2022/3/e33423 %U https://doi.org/10.2196/33423 %U http://www.ncbi.nlm.nih.gov/pubmed/35357325 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e32824 %T The Current State and Validity of Digital Assessment Tools for Psychiatry: Systematic Review %A Martin-Key,Nayra A %A Spadaro,Benedetta %A Funnell,Erin %A Barker,Eleanor Jane %A Schei,Thea Sofie %A Tomasik,Jakub %A Bahn,Sabine %+ Cambridge Centre for Neuropsychiatric Research, Department of Chemical Engineering and Biotechnology, University of Cambridge, Philippa Fawcett Drive, Cambridge, CB3 0AS, United Kingdom, 44 1223 334151, sb209@cam.ac.uk %K diagnostic accuracy %K digital mental health %K digital questionnaire %K psychiatry %K systematic review %D 2022 %7 30.3.2022 %9 Review %J JMIR Ment Health %G English %X Background: Given the role digital technologies are likely to play in the future of mental health care, there is a need for a comprehensive appraisal of the current state and validity (ie, screening or diagnostic accuracy) of digital mental health assessments. Objective: The aim of this review is to explore the current state and validity of question-and-answer–based digital tools for diagnosing and screening psychiatric conditions in adults. Methods: This systematic review was based on the Population, Intervention, Comparison, and Outcome framework and was carried out in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. MEDLINE, Embase, Cochrane Library, ASSIA, Web of Science Core Collection, CINAHL, and PsycINFO were systematically searched for articles published between 2005 and 2021. A descriptive evaluation of the study characteristics and digital solutions and a quantitative appraisal of the screening or diagnostic accuracy of the included tools were conducted. Risk of bias and applicability were assessed using the revised tool for the Quality Assessment of Diagnostic Accuracy Studies 2. Results: A total of 28 studies met the inclusion criteria, with the most frequently evaluated conditions encompassing generalized anxiety disorder, major depressive disorder, and any depressive disorder. Most of the studies used digitized versions of existing pen-and-paper questionnaires, with findings revealing poor to excellent screening or diagnostic accuracy (sensitivity=0.32-1.00, specificity=0.37-1.00, area under the receiver operating characteristic curve=0.57-0.98) and a high risk of bias for most of the included studies. Conclusions: The field of digital mental health tools is in its early stages, and high-quality evidence is lacking. International Registered Report Identifier (IRRID): RR2-10.2196/25382 %M 35353053 %R 10.2196/32824 %U https://mental.jmir.org/2022/3/e32824 %U https://doi.org/10.2196/32824 %U http://www.ncbi.nlm.nih.gov/pubmed/35353053 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e34744 %T PTSD Coach Version 3.1: A Closer Look at the Reach, Use, and Potential Impact of This Updated Mobile Health App in the General Public %A Hallenbeck,Haijing Wu %A Jaworski,Beth K %A Wielgosz,Joseph %A Kuhn,Eric %A Ramsey,Kelly M %A Taylor,Katherine %A Juhasz,Katherine %A McGee-Vincent,Pearl %A Mackintosh,Margaret-Anne %A Owen,Jason E %+ Dissemination and Training Division, National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Health Care System, 795 Willow Rd, Menlo Park, CA, 94025, United States, 1 650 493 5000, haijing.hallenbeck@stanford.edu %K posttraumatic stress disorder %K trauma %K mental health %K mHealth %K mobile app %K public health %K self-management %K mobile phone %D 2022 %7 29.3.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: With widespread smartphone ownership, mobile health apps (mHealth) can expand access to evidence-based interventions for mental health conditions, including posttraumatic stress disorder (PTSD). Research to evaluate new features and capabilities in these apps is critical but lags behind app development. The initial release of PTSD Coach, a free self-management app developed by the US Departments of Veterans Affairs and Defense, was found to have a positive public health impact. However, major stakeholder-driven updates to the app have yet to be evaluated. Objective: We aimed to characterize the reach, use, and potential impact of PTSD Coach Version 3.1 in the general public. As part of characterizing use, we investigated the use of specific app features, which extended previous work on PTSD Coach. Methods: We examined the naturalistic use of PTSD Coach during a 1-year observation period between April 20, 2020, and April 19, 2021, using anonymous in-app event data to generate summary metrics for users. Results: During the observation period, PTSD Coach was broadly disseminated to the public, reaching approximately 150,000 total users and 20,000 users per month. On average, users used the app 3 times across 3 separate days for 18 minutes in total, with steep drop-offs in use over time; a subset of users, however, demonstrated high or sustained engagement. More than half of users (79,099/128,691, 61.46%) accessed one or more main content areas of the app (ie, Manage Symptoms, Track Progress, Learn, or Get Support). Among content areas, features under Manage Symptoms (including coping tools) were accessed most frequently, by over 40% of users (53,314/128,691, 41.43% to 56,971/128,691, 44.27%, depending on the feature). Users who provided initial distress ratings (56,971/128,691, 44.27%) reported relatively high momentary distress (mean 6.03, SD 2.52, on a scale of 0-10), and the use of a coping tool modestly improved momentary distress (mean −1.38, SD 1.70). Among users who completed at least one PTSD Checklist for DSM-5 (PCL-5) assessment (17,589/128,691, 13.67%), PTSD symptoms were largely above the clinical threshold (mean 49.80, SD 16.36). Among users who completed at least two PCL-5 assessments (4989/128,691, 3.88%), PTSD symptoms decreased from the first to last assessment (mean −4.35, SD 15.29), with approximately one-third (1585/4989, 31.77%) of these users experiencing clinically significant improvements. Conclusions: PTSD Coach continues to fulfill its mission as a public health resource. Version 3.1 compares favorably with version 1 on most metrics related to reach, use, and potential impact. Although benefits appear modest on an individual basis, the app provides these benefits to a large population. For mHealth apps to reach their full potential in supporting trauma recovery, future research should aim to understand the utility of individual app features and identify strategies to maximize overall effectiveness and engagement. %M 35348458 %R 10.2196/34744 %U https://mental.jmir.org/2022/3/e34744 %U https://doi.org/10.2196/34744 %U http://www.ncbi.nlm.nih.gov/pubmed/35348458 %0 Journal Article %@ 2563-6316 %I JMIR Publications %V 3 %N 1 %P e31269 %T Measuring Integrated Novel Dimensions in Neurodevelopmental and Stress-Related Mental Disorders (MIND-SET): Protocol for a Cross-sectional Comorbidity Study From a Research Domain Criteria Perspective %A van Eijndhoven,Philip %A Collard,Rose %A Vrijsen,Janna %A Geurts,Dirk E M %A Vasquez,Alejandro Arias %A Schellekens,Arnt %A van den Munckhof,Eva %A Brolsma,Sophie %A Duyser,Fleur %A Bergman,Annemiek %A van Oort,Jasper %A Tendolkar,Indira %A Schene,Aart %+ Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Reinier Postlaan 10, PO Box 9101, Nijmegen, 6500HB, Netherlands, 31 614260231, philip.vaneijndhoven@radboudumc.nl %K psychiatry %K mental health %K psychiatric disorders %K neuropsychology %K stress %K comorbidity %D 2022 %7 29.3.2022 %9 Protocol %J JMIRx Med %G English %X Background: It is widely acknowledged that comorbidity between psychiatric disorders is common. Shared and diverse underpinnings of psychiatric disorders cannot be systematically understood based on symptom-based categories of mental disorders, which map poorly onto pathophysiological mechanisms. In the Measuring Integrated Novel Dimensions in Neurodevelopmental and Stress-Related Mental Disorders (MIND-SET) study, we make use of current concepts of comorbidity that transcend the current diagnostic categories. We test this approach to psychiatric problems in patients with frequently occurring psychiatric disorders and their comorbidities (excluding psychosis). Objective: The main aim of the MIND-SET project is to determine the shared and specific mechanisms of neurodevelopmental and stress-related psychiatric disorders at different observational levels. Methods: This is an observational cross-sectional study. Data from different observational levels as defined in the Research Domain Criteria (genetics, physiology, neuropsychology, system-level neuroimaging, behavior, self-report, and experimental neurocognitive paradigms) are collected over four time points. Included are adult (aged ≥18 years), nonpsychotic, psychiatric patients with a clinical diagnosis of a stress-related disorder (mood disorder, anxiety disorder, or substance use disorder) or a neurodevelopmental disorder (autism spectrum disorder or attention-deficit/hyperactivity disorder). Individuals with no current or past psychiatric diagnosis are included as neurotypical controls. Data collection started in June 2016 with the aim to include a total of 650 patients and 150 neurotypical controls by 2021. The data collection procedure includes online questionnaires and three subsequent sessions with (1) standardized clinical examination, physical examination, and blood sampling; (2) psychological constructs, neuropsychological tests, and biological marker sampling; and (3) neuroimaging measures. Results: We aim to include a total of 650 patients and 150 neurotypical control participants in the time period between 2016 and 2022. In October 2021, we are at 95% of our target. Conclusions: The MIND-SET study enables us to investigate the mechanistic underpinnings of nonpsychotic psychiatric disorders transdiagnostically. We will identify both shared and disorder-specific markers at different observational levels that can be used as targets for future diagnostic and treatment approaches. %M 37725542 %R 10.2196/31269 %U https://med.jmirx.org/2022/1/e31269 %U https://doi.org/10.2196/31269 %U http://www.ncbi.nlm.nih.gov/pubmed/37725542 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e30754 %T Measuring Adherence Within a Self-Guided Online Intervention for Depression and Anxiety: Secondary Analyses of a Randomized Controlled Trial %A Hanano,Maria %A Rith-Najarian,Leslie %A Boyd,Meredith %A Chavira,Denise %+ Department of Psychology, University of California, Los Angeles, 1285 Franz Hall, Box 951563, Los Angeles, CA, 90095, United States, 1 9493501523, mariahanano@g.ucla.edu %K self-guided %K adherence %K depression %K anxiety %K online intervention %D 2022 %7 28.3.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Self-guided online interventions offer users the ability to participate in an intervention at their own pace and address some traditional service barriers (eg, attending in-person appointments, cost). However, these interventions suffer from high dropout rates, and current literature provides little guidance for defining and measuring online intervention adherence as it relates to clinical outcomes. Objective: This study aims to develop and test multiple measures of adherence to a specific self-guided online intervention, as guided by best practices from the literature. Methods: We conducted secondary analyses on data from a randomized controlled trial of an 8-week online cognitive behavioral program that targets depression and anxiety in college students. We defined multiple behavioral and attitudinal adherence measures at varying levels of effort (ie, low, moderate, and high). Linear regressions were run with adherence terms predicting improvement in the primary outcome measure, the 21-item Depression, Anxiety, and Stress Scale (DASS-21). Results: Of the 947 participants, 747 initiated any activity and 449 provided posttest data. Results from the intent-to-treat sample indicated that high level of effort for behavioral adherence significantly predicted symptom change (F4,746=17.18, P<.001; and β=–.26, P=.04). Moderate level of effort for attitudinal adherence also significantly predicted symptom change (F4,746=17.25, P<.001; and β=–.36, P=.03). Results differed in the initiators-only sample, such that none of the adherence measures significantly predicted symptom change (P=.09-.27). Conclusions: Our findings highlight the differential results of dose-response models testing adherence measures in predicting clinical outcomes. We summarize recommendations that might provide helpful guidance to future researchers and intervention developers aiming to investigate online intervention adherence. Trial Registration: ClinicalTrials.gov NCT04361045; https://clinicaltrials.gov/ct2/show/NCT04361045 %M 35343901 %R 10.2196/30754 %U https://mental.jmir.org/2022/3/e30754 %U https://doi.org/10.2196/30754 %U http://www.ncbi.nlm.nih.gov/pubmed/35343901 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 3 %P e34148 %T Predicting Changes in Depression Severity Using the PSYCHE-D (Prediction of Severity Change-Depression) Model Involving Person-Generated Health Data: Longitudinal Case-Control Observational Study %A Makhmutova,Mariko %A Kainkaryam,Raghu %A Ferreira,Marta %A Min,Jae %A Jaggi,Martin %A Clay,Ieuan %+ Digital Medicine Society, 90 Canal Street, 4th Floor, Boston, MA, 02114, United States, 1 1733095953, ieuan@dimesociety.org %K depression %K machine learning %K person-generated health data %D 2022 %7 25.3.2022 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In 2017, an estimated 17.3 million adults in the United States experienced at least one major depressive episode, with 35% of them not receiving any treatment. Underdiagnosis of depression has been attributed to many reasons, including stigma surrounding mental health, limited access to medical care, and barriers due to cost. Objective: This study aimed to determine if low-burden personal health solutions, leveraging person-generated health data (PGHD), could represent a possible way to increase engagement and improve outcomes. Methods: Here, we present the development of PSYCHE-D (Prediction of Severity Change-Depression), a predictive model developed using PGHD from more than 4000 individuals, which forecasts the long-term increase in depression severity. PSYCHE-D uses a 2-phase approach. The first phase supplements self-reports with intermediate generated labels, and the second phase predicts changing status over a 3-month period, up to 2 months in advance. The 2 phases are implemented as a single pipeline in order to eliminate data leakage and ensure results are generalizable. Results: PSYCHE-D is composed of 2 Light Gradient Boosting Machine (LightGBM) algorithm–based classifiers that use a range of PGHD input features, including objective activity and sleep, self-reported changes in lifestyle and medication, and generated intermediate observations of depression status. The approach generalizes to previously unseen participants to detect an increase in depression severity over a 3-month interval, with a sensitivity of 55.4% and a specificity of 65.3%, nearly tripling sensitivity while maintaining specificity when compared with a random model. Conclusions: These results demonstrate that low-burden PGHD can be the basis of accurate and timely warnings that an individual’s mental health may be deteriorating. We hope this work will serve as a basis for improved engagement and treatment of individuals experiencing depression. %M 35333186 %R 10.2196/34148 %U https://mhealth.jmir.org/2022/3/e34148 %U https://doi.org/10.2196/34148 %U http://www.ncbi.nlm.nih.gov/pubmed/35333186 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 3 %P e29384 %T Internet-Delivered Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Nationwide Routine Care: Effectiveness Study %A Ritola,Ville %A Lipsanen,Jari Olavi %A Pihlaja,Satu %A Gummerus,Eero-Matti %A Stenberg,Jan-Henry %A Saarni,Suoma %A Joffe,Grigori %+ Department of Psychiatry, Helsinki University Hospital and University of Helsinki, P.O. Box 100, Helsinki, 00029 HUS, Finland, 358 405136500, grigori.joffe@hus.fi %K CBT %K iCBT %K cognitive behavioral therapy %K routine care %K generalized anxiety disorder %K internet %K web-based %K digital health %K mental health %D 2022 %7 24.3.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficacious for generalized anxiety disorder (GAD), but few studies are yet to report its effectiveness in routine care. Objective: In this study, we aim to examine whether a new 12-session iCBT program for GAD is effective in nationwide routine care. Methods: We administered a specialized, clinic-delivered, therapist-supported iCBT for GAD in 1099 physician-referred patients. The program was free of charge for patients, and the completion time was not predetermined. We measured symptoms with web-based questionnaires. The primary measure of anxiety was the GAD 7-item scale (GAD-7); secondary measures were, for pathological worry, the Penn State Worry Questionnaire and, for anxiety and impairment, the Overall Anxiety Severity and Impairment Scale. Results: Patients completed a mean 7.8 (SD 4.2; 65.1%) of 12 sessions, and 44.1% (485/1099) of patients completed all sessions. The effect size in the whole sample for GAD-7 was large (Cohen d=0.97, 95% CI 0.88-1.06). For completers, effect sizes were very large (Cohen d=1.34, 95% CI 1.25-1.53 for GAD-7; Cohen d=1.14, 95% CI 1.00-1.27 for Penn State Worry Questionnaire; and Cohen d=1.23, 95% CI 1.09-1.37 for Overall Anxiety Severity and Impairment Scale). Noncompleters also benefited from the treatment. Greater symptomatic GAD-7–measured relief was associated with more completed sessions, older age, and being referred from private or occupational care. Of the 894 patients with a baseline GAD-7 score ≥10, approximately 421 (47.1%) achieved reliable recovery. Conclusions: This nationwide, free-of-charge, therapist-supported HUS Helsinki University Hospital–iCBT for GAD was effective in routine care, but further research must establish effectiveness against other treatments and optimize the design of iCBT for GAD for different patient groups and individual patients. %M 35323119 %R 10.2196/29384 %U https://www.jmir.org/2022/3/e29384 %U https://doi.org/10.2196/29384 %U http://www.ncbi.nlm.nih.gov/pubmed/35323119 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 3 %P e28081 %T App-Based Ecological Momentary Assessment to Enhance Clinical Care for Postpartum Depression: Pilot Acceptability Study %A Krohn,Holly %A Guintivano,Jerry %A Frische,Rachel %A Steed,Jamie %A Rackers,Hannah %A Meltzer-Brody,Samantha %+ Department of Psychiatry, University of North Carolina at Chapel Hill, 333 S. Columbia Street, MacNider 304 CB 7160, Chapel Hill, NC, 27599, United States, 1 919 445 0218, holly_krohn@med.unc.edu %K postpartum care %K depression %K mobile health %K mHealth %K ecological momentary assessment (EMA) %K mobile apps %K personalized care %K mobile phone %D 2022 %7 23.3.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Wearable tracking devices and mobile health technology are increasingly used in an effort to enhance clinical care and the delivery of personalized medical treatment. Postpartum depression is the most frequently diagnosed complication of childbirth; however, significant gaps in screening and treatment remain. Objective: This study aims to investigate the clinical utility, predictive ability, and acceptability of using ecological momentary assessment to collect daily mood, sleep, and activity data through the use of an Apple Watch and mobile app among women with postpartum depression. Methods: This was a pilot study consisting of 3 in-person research visits over the course of a 6-week enrollment period. Questionnaires to assess depression, anxiety, and maternal functioning were periodically collected, along with daily self-reported symptoms and passively collected physiological data via an Apple Watch. Feedback was collected from study participants and the study clinician to determine the utility and acceptability of daily tracking. Logistic regression was used to determine whether mood scores in the 2 weeks before a visit predicted scores at follow-up. Compliance with daily assessments was also measured. Results: Of the 26 women enrolled, 23 (88%) completed the 6-week study period. On average, the participants completed 67% (34.4/51.5 days) of all active daily assessments and 74% (38/51.5 days) of all passive measures. Furthermore, all 23 participants completed the 3 required visits with the research team. Predictive correlations were found between self-reported mood and Edinburgh Postnatal Depression Scale score at follow-up, self-reported anxiety and EDPS, and sleep quality and Edinburgh Postnatal Depression Scale. Conclusions: Using ecological momentary assessment to track daily symptoms of postpartum depression using a wearable device was largely endorsed as acceptable and clinically useful by participants and the study clinician and could be an innovative solution to increase care access during the COVID-19 pandemic. %M 35319483 %R 10.2196/28081 %U https://formative.jmir.org/2022/3/e28081 %U https://doi.org/10.2196/28081 %U http://www.ncbi.nlm.nih.gov/pubmed/35319483 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 3 %P e31308 %T Treatment of Persistent Postconcussion Syndrome With Repetitive Transcranial Magnetic Stimulation Using Functional Near-Infrared Spectroscopy as a Biomarker of Response: Protocol for a Randomized Controlled Clinical Trial %A du Plessis,Sané %A Oni,Ibukunoluwa K %A Lapointe,Andrew P %A Campbell,Christina %A Dunn,Jeff F %A Debert,Chantel T %+ Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N4N1, Canada, 1 9448643, sane.duplessis@ucalgary.ca %K concussion %K mild traumatic brain injury %K persistent postconcussion syndrome %K repetitive transcranial magnetic stimulation %K functional near-infrared spectroscopy %K traumatic brain injury %K TBI %K brain injury %K brain %K symptom burden %K mental health %K quality of life %K neuroscience %K neurology %D 2022 %7 22.3.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Approximately one-third of all concussions lead to persistent postconcussion syndrome (PPCS). Repetitive transcranial magnetic stimulation (rTMS) is a form of noninvasive brain stimulation that has been extensively used to treat refractory major depressive disorder and has a strong potential to be used as a treatment for patients with PPCS. Functional near-infrared spectroscopy (fNIRS) has already been used as a tool to assess patients with PPCS and may provide insight into the pathophysiology of rTMS treatment in patients with PPCS. Objective: The primary objective of this research is to determine whether rTMS treatment improves symptom burden in patients with PPCS compared to sham treatment using the Rivermead postconcussion symptom questionnaire. The secondary objective is to explore the neuropathophysiological changes that occur following rTMS in participants with PPCS using fNIRS. Exploratory objectives include determining whether rTMS treatment in participants with PPCS will also improve quality of life, anxiety, depressive symptoms, cognition, posttraumatic stress, and function secondary to headaches. Methods: A total of 44 adults (18-65 years old) with PPCS (>3 months to 5 years) will participate in a double-blind, sham-controlled, concealed allocation, randomized clinical trial. The participants will engage in either a 4-week rTMS treatment protocol or sham rTMS protocol (20 treatments). The left dorsolateral prefrontal cortex will be located through Montreal Neurologic Institute coordinates. The intensity of the rTMS treatment over the left dorsolateral prefrontal cortex will be 120% of resting motor threshold, with a frequency of 10 Hz, 10 trains of 60 pulses per train (total of 600 pulses), and intertrain interval of 45 seconds. Prior to starting the rTMS treatment, participant and injury characteristics, questionnaires (symptom burden, quality of life, depression, anxiety, cognition, and headache), and fNIRS assessment will be collected. Repeat questionnaires and fNIRS will occur immediately after rTMS treatment and at 1 month and 3 months post rTMS. Outcome parameters will be analyzed by a 2-way (treatment × time) mixed analysis of variance. Results: As of May 6, 2021, 5 participants have been recruited for the study, and 3 have completed the rTMS protocol. The estimated completion date of the trial is May 2022. Conclusions: This trial will expand our knowledge of how rTMS can be used as a treatment option of PPCS and will explore the neuropathophysiological response of rTMS through fNIRS analysis. Trial Registration: ClinicalTrials.gov NCT04568369; https://clinicaltrials.gov/ct2/show/NCT04568369 International Registered Report Identifier (IRRID): DERR1-10.2196/31308 %M 35315783 %R 10.2196/31308 %U https://www.researchprotocols.org/2022/3/e31308 %U https://doi.org/10.2196/31308 %U http://www.ncbi.nlm.nih.gov/pubmed/35315783 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 3 %P e30231 %T Effect of Sleep Disturbance Symptoms on Treatment Outcome in Blended Cognitive Behavioral Therapy for Depression (E-COMPARED Study): Secondary Analysis %A Jensen,Esben Skov %A Ladegaard,Nicolai %A Mellentin,Angelina Isabella %A Ebert,David Daniel %A Titzler,Ingrid %A Araya,Ricardo %A Cerga Pashoja,Arlinda %A Hazo,Jean-Baptiste %A Holtzmann,Jérôme %A Cieslak,Roman %A Smoktunowicz,Ewelina %A Baños,Rosa %A Herrero,Rocio %A García-Palacios,Azucena %A Botella,Cristina %A Berger,Thomas %A Krieger,Tobias %A Holmberg,Trine Theresa %A Topooco,Naira %A Andersson,Gerhard %A van Straten,Annemieke %A Kemmeren,Lise %A Kleiboer,Annet %A Riper,Heleen %A Mathiasen,Kim %+ Centre for Telepsychiatry, Mental Health Services of Southern Denmark, Odense, Denmark, 1 61677747, kmathiasen@health.sdu.dk %K blended care %K bCBT %K cognitive behavioral therapy %K digital intervention %K major depressive disorder %K sleep disturbance %K sleep disorder %K mental health %K digital health %K mobile phone %D 2022 %7 21.3.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Sleep disturbance symptoms are common in major depressive disorder (MDD) and have been found to hamper the treatment effect of conventional face-to-face psychological treatments such as cognitive behavioral therapy. To increase the dissemination of evidence-based treatment, blended cognitive behavioral therapy (bCBT) consisting of web-based and face-to-face treatment is on the rise for patients with MDD. To date, no study has examined whether sleep disturbance symptoms have an impact on bCBT treatment outcomes and whether it affects bCBT and treatment-as-usual (TAU) equally. Objective: The objectives of this study are to investigate whether baseline sleep disturbance symptoms have an impact on treatment outcomes independent of treatment modality and whether sleep disturbance symptoms impact bCBT and TAU in routine care equally. Methods: The study was based on data from the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment Versus Treatment-as-Usual) study, a 2-arm, multisite, parallel randomized controlled, noninferiority trial. A total of 943 outpatients with MDD were randomized to either bCBT (476/943, 50.5%) or TAU consisting of routine clinical MDD treatment (467/943, 49.5%). The primary outcome of this study was the change in depression symptom severity at the 12-month follow-up. The secondary outcomes were the change in depression symptom severity at the 3- and 6-month follow-up and MDD diagnoses at the 12-month follow-up, assessed using the Patient Health Questionnaire-9 and Mini-International Neuropsychiatric Interview, respectively. Mixed effects models were used to examine the association of sleep disturbance symptoms with treatment outcome and treatment modality over time. Results: Of the 943 patients recruited for the study, 558 (59.2%) completed the 12-month follow-up assessment. In the total sample, baseline sleep disturbance symptoms did not significantly affect change in depressive symptom severity at the 12-month follow-up (β=.16, 95% CI –0.04 to 0.36). However, baseline sleep disturbance symptoms were negatively associated with treatment outcome for bCBT (β=.49, 95% CI 0.22-0.76) but not for TAU (β=–.23, 95% CI −0.50 to 0.05) at the 12-month follow-up, even when adjusting for baseline depression symptom severity. The same result was seen for the effect of sleep disturbance symptoms on the presence of depression measured with Mini-International Neuropsychiatric Interview at the 12-month follow-up. However, for both treatment formats, baseline sleep disturbance symptoms were not associated with depression symptom severity at either the 3- (β=.06, 95% CI −0.11 to 0.23) or 6-month (β=.09, 95% CI −0.10 to 0.28) follow-up. Conclusions: Baseline sleep disturbance symptoms may have a negative impact on long-term treatment outcomes in bCBT for MDD. This effect was not observed for TAU. These findings suggest that special attention to sleep disturbance symptoms might be warranted when MDD is treated with bCBT. Future studies should investigate the effect of implementing modules specifically targeting sleep disturbance symptoms in bCBT for MDD to improve long-term prognosis. %M 35311687 %R 10.2196/30231 %U https://www.jmir.org/2022/3/e30231 %U https://doi.org/10.2196/30231 %U http://www.ncbi.nlm.nih.gov/pubmed/35311687 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e25441 %T Usage Intensity of a Relapse Prevention Program and Its Relation to Symptom Severity in Remitted Patients With Anxiety and Depression: Pre-Post Study %A Krijnen-de Bruin,Esther %A Muntingh,Anna DT %A Bourguignon,Evelien M %A Hoogendoorn,Adriaan %A Maarsingh,Otto R %A van Balkom,Anton JLM %A Batelaan,Neeltje M %A van Straten,Annemieke %A van Meijel,Berno %+ Department of Health, Sports and Welfare, Research Group Mental Health Nursing, Inholland University of Applied Sciences, De Boelelaan 1109, Amsterdam, 1081 HV, Netherlands, 31 20 495 1111, esther.krijnendebruin@inholland.nl %K relapse prevention %K anxiety disorder %K depressive disorder %K eHealth %K primary care practice %K usage intensity %K self-management %K mobile phone %D 2022 %7 16.3.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Given that relapse is common in patients in remission from anxiety and depressive disorders, relapse prevention is needed in the maintenance phase. Although existing psychological relapse prevention interventions have proven to be effective, they are not explicitly based on patients’ preferences. Hence, we developed a blended relapse prevention program based on patients’ preferences, which was delivered in primary care practices by mental health professionals (MHPs). This program comprises contact with MHPs, completion of core and optional online modules (including a relapse prevention plan), and keeping a mood and anxiety diary in which patients can monitor their symptoms. Objective: The aims of this study were to provide insight into (1) usage intensity of the program (over time), (2) the course of symptoms during the 9 months of the study, and (3) the association between usage intensity and the course of symptoms. Methods: The Guided E-healTh for RElapse prevention in Anxiety and Depression (GET READY) program was guided by 54 MHPs working in primary care practices. Patients in remission from anxiety and depressive disorders were included. Demographic and clinical characteristics, including anxiety and depressive symptoms, were collected via questionnaires at baseline and after 3, 6, and 9 months. Log data were collected to assess the usage intensity of the program. Results: A total of 113 patients participated in the study. Twenty-seven patients (23.9%) met the criteria for the minimal usage intensity measure. The core modules were used by ≥70% of the patients, while the optional modules were used by <40% of the patients. Usage decreased quickly over time. Anxiety and depressive symptoms remained stable across the total sample; a minority of 15% (12/79) of patients experienced a relapse in their anxiety symptoms, while 10% (8/79) experienced a relapse in their depressive symptoms. Generalized estimating equations analysis indicated a significant association between more frequent face-to-face contact with the MHPs and an increase in both anxiety symptoms (β=.84, 95% CI .39-1.29) and depressive symptoms (β=1.12, 95% CI 0.45-1.79). Diary entries and the number of completed modules were not significantly associated with the course of symptoms. Conclusions: Although the core modules of the GET READY program were used by most of the patients and all patients saw an MHP at least once, usage decreased quickly over time. Most patients remained stable while participating in the study. The significant association between the frequency of contact and the course of symptoms most likely indicates that those who received more support had more symptoms, and thus, it is questionable whether the support offered by the program was sufficient to prevent these patients from relapsing. International Registered Report Identifier (IRRID): RR2-10.1186/s12888-019-2034-6 %M 35293876 %R 10.2196/25441 %U https://mental.jmir.org/2022/3/e25441 %U https://doi.org/10.2196/25441 %U http://www.ncbi.nlm.nih.gov/pubmed/35293876 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e34898 %T Longitudinal Relationships Between Depressive Symptom Severity and Phone-Measured Mobility: Dynamic Structural Equation Modeling Study %A Zhang,Yuezhou %A Folarin,Amos A %A Sun,Shaoxiong %A Cummins,Nicholas %A Vairavan,Srinivasan %A Bendayan,Rebecca %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Conde,Pauline %A Stewart,Callum %A Laiou,Petroula %A Sankesara,Heet %A Matcham,Faith %A White,Katie M %A Oetzmann,Carolin %A Ivan,Alina %A Lamers,Femke %A Siddi,Sara %A Vilella,Elisabet %A Simblett,Sara %A Rintala,Aki %A Bruce,Stuart %A Mohr,David C %A Myin-Germeys,Inez %A Wykes,Til %A Haro,Josep Maria %A Penninx,Brenda WJH %A Narayan,Vaibhav A %A Annas,Peter %A Hotopf,Matthew %A Dobson,Richard JB %A , %+ Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, United Kingdom, 44 20 7848 0473, richard.j.dobson@kcl.ac.uk %K depression %K mobile health %K location data %K mobility %K dynamic structural equation modeling %K mHealth %K mental health %K medical informatics %K modeling %D 2022 %7 11.3.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: The mobility of an individual measured by phone-collected location data has been found to be associated with depression; however, the longitudinal relationships (the temporal direction of relationships) between depressive symptom severity and phone-measured mobility have yet to be fully explored. Objective: We aimed to explore the relationships and the direction of the relationships between depressive symptom severity and phone-measured mobility over time. Methods: Data used in this paper came from a major EU program, called the Remote Assessment of Disease and Relapse–Major Depressive Disorder, which was conducted in 3 European countries. Depressive symptom severity was measured with the 8-item Patient Health Questionnaire (PHQ-8) through mobile phones every 2 weeks. Participants’ location data were recorded by GPS and network sensors in mobile phones every 10 minutes, and 11 mobility features were extracted from location data for the 2 weeks prior to the PHQ-8 assessment. Dynamic structural equation modeling was used to explore the longitudinal relationships between depressive symptom severity and phone-measured mobility. Results: This study included 2341 PHQ-8 records and corresponding phone-collected location data from 290 participants (age: median 50.0 IQR 34.0, 59.0) years; of whom 215 (74.1%) were female, and 149 (51.4%) were employed. Significant negative correlations were found between depressive symptom severity and phone-measured mobility, and these correlations were more significant at the within-individual level than the between-individual level. For the direction of relationships over time, Homestay (time at home) (φ=0.09, P=.01), Location Entropy (time distribution on different locations) (φ=−0.04, P=.02), and Residential Location Count (reflecting traveling) (φ=0.05, P=.02) were significantly correlated with the subsequent changes in the PHQ-8 score, while changes in the PHQ-8 score significantly affected (φ=−0.07, P<.001) the subsequent periodicity of mobility. Conclusions: Several phone-derived mobility features have the potential to predict future depression, which may provide support for future clinical applications, relapse prevention, and remote mental health monitoring practices in real-world settings. %M 35275087 %R 10.2196/34898 %U https://mental.jmir.org/2022/3/e34898 %U https://doi.org/10.2196/34898 %U http://www.ncbi.nlm.nih.gov/pubmed/35275087 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 3 %P e37440 %T Authors’ Reply to: Toward a Better Understanding of Quality Social Connections. Comment on “Quality Social Connection as an Active Ingredient in Digital Interventions for Young People With Depression and Anxiety: Systematic Scoping Review and Meta-analysis” %A Dewa,Lindsay H %A Roberts,Lily %A Lawrance,Emma %A Ashrafian,Hutan %+ Institute of Global Health Innovation, Imperial College London, Reynolds Building, 3rd Floor, London, W6 8RP, United Kingdom, 44 02075940815, l.dewa@imperial.ac.uk %K mental health %K digital interventions %K young people %K quality social connection %K depression %K anxiety %K systematic review %K meta-analysis %K patient and public involvement %K mobile phone %D 2022 %7 11.3.2022 %9 Letter to the Editor %J J Med Internet Res %G English %X   %M 35275072 %R 10.2196/37440 %U https://www.jmir.org/2022/3/e37440 %U https://doi.org/10.2196/37440 %U http://www.ncbi.nlm.nih.gov/pubmed/35275072 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 3 %P e36739 %T Toward a Better Understanding of Quality Social Connections. Comment on “Quality Social Connection as an Active Ingredient in Digital Interventions for Young People With Depression and Anxiety: Systematic Scoping Review and Meta-analysis” %A Deng,Huachu %A Qin,Xingan %+ Department of Gastrointestinal and Gland Surgery, First Affiliated Hospital of Guangxi Medical University, 6 Shuangyong Road, Qingxiu District, Nanning, 530000, China, 86 15277114948, drqinxingan@126.com %K mental health %K digital interventions %K young people %K quality social connection %K depression %K anxiety %K systematic review %K meta-analysis %K patient and public involvement %K mobile phone %D 2022 %7 11.3.2022 %9 Letter to the Editor %J J Med Internet Res %G English %X   %M 35275073 %R 10.2196/36739 %U https://www.jmir.org/2022/3/e36739 %U https://doi.org/10.2196/36739 %U http://www.ncbi.nlm.nih.gov/pubmed/35275073 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 3 %P e30946 %T Implementing Machine Learning Models for Suicide Risk Prediction in Clinical Practice: Focus Group Study With Hospital Providers %A Bentley,Kate H %A Zuromski,Kelly L %A Fortgang,Rebecca G %A Madsen,Emily M %A Kessler,Daniel %A Lee,Hyunjoon %A Nock,Matthew K %A Reis,Ben Y %A Castro,Victor M %A Smoller,Jordan W %+ Center for Precision Psychiatry, Department of Psychiatry, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA, 02114, United States, 1 6177247741, kbentley@mgh.harvard.edu %K suicide %K machine learning %K implementation %K mobile phone %D 2022 %7 11.3.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Interest in developing machine learning models that use electronic health record data to predict patients’ risk of suicidal behavior has recently proliferated. However, whether and how such models might be implemented and useful in clinical practice remain unknown. To ultimately make automated suicide risk–prediction models useful in practice, and thus better prevent patient suicides, it is critical to partner with key stakeholders, including the frontline providers who will be using such tools, at each stage of the implementation process. Objective: The aim of this focus group study is to inform ongoing and future efforts to deploy suicide risk–prediction models in clinical practice. The specific goals are to better understand hospital providers’ current practices for assessing and managing suicide risk; determine providers’ perspectives on using automated suicide risk–prediction models in practice; and identify barriers, facilitators, recommendations, and factors to consider. Methods: We conducted 10 two-hour focus groups with a total of 40 providers from psychiatry, internal medicine and primary care, emergency medicine, and obstetrics and gynecology departments within an urban academic medical center. Audio recordings of open-ended group discussions were transcribed and coded for relevant and recurrent themes by 2 independent study staff members. All coded text was reviewed and discrepancies were resolved in consensus meetings with doctoral-level staff. Results: Although most providers reported using standardized suicide risk assessment tools in their clinical practices, existing tools were commonly described as unhelpful and providers indicated dissatisfaction with current suicide risk assessment methods. Overall, providers’ general attitudes toward the practical use of automated suicide risk–prediction models and corresponding clinical decision support tools were positive. Providers were especially interested in the potential to identify high-risk patients who might be missed by traditional screening methods. Some expressed skepticism about the potential usefulness of these models in routine care; specific barriers included concerns about liability, alert fatigue, and increased demand on the health care system. Key facilitators included presenting specific patient-level features contributing to risk scores, emphasizing changes in risk over time, and developing systematic clinical workflows and provider training. Participants also recommended considering risk-prediction windows, timing of alerts, who will have access to model predictions, and variability across treatment settings. Conclusions: Providers were dissatisfied with current suicide risk assessment methods and were open to the use of a machine learning–based risk-prediction system to inform clinical decision-making. They also raised multiple concerns about potential barriers to the usefulness of this approach and suggested several possible facilitators. Future efforts in this area will benefit from incorporating systematic qualitative feedback from providers, patients, administrators, and payers on the use of these new approaches in routine care, especially given the complex, sensitive, and unfortunately still stigmatized nature of suicide risk. %M 35275075 %R 10.2196/30946 %U https://formative.jmir.org/2022/3/e30946 %U https://doi.org/10.2196/30946 %U http://www.ncbi.nlm.nih.gov/pubmed/35275075 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 3 %P e27654 %T Thematic Analysis on User Reviews for Depression and Anxiety Chatbot Apps: Machine Learning Approach %A Ahmed,Arfan %A Aziz,Sarah %A Khalifa,Mohamed %A Shah,Uzair %A Hassan,Asma %A Abd-Alrazaq,Alaa %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, Liberal Arts and Sciences Building, Education City, Doha Al Luqta St, Ar-Rayyan, Doha, PO Box 5825, Qatar, 974 33223401, mhouseh@hbku.edu.qa %K anxiety %K depression %K chatbots %K conversational agents %K topic modeling %K latent Dirichlet allocation %K thematic analysis %K mobile phone %D 2022 %7 11.3.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Anxiety and depression are among the most commonly prevalent mental health disorders worldwide. Chatbot apps can play an important role in relieving anxiety and depression. Users’ reviews of chatbot apps are considered an important source of data for exploring users’ opinions and satisfaction. Objective: This study aims to explore users’ opinions, satisfaction, and attitudes toward anxiety and depression chatbot apps by conducting a thematic analysis of users’ reviews of 11 anxiety and depression chatbot apps collected from the Google Play Store and Apple App Store. In addition, we propose a workflow to provide a methodological approach for future analysis of app review comments. Methods: We analyzed 205,581 user review comments from chatbots designed for users with anxiety and depression symptoms. Using scraper tools and Google Play Scraper and App Store Scraper Python libraries, we extracted the text and metadata. The reviews were divided into positive and negative meta-themes based on users’ rating per review. We analyzed the reviews using word frequencies of bigrams and words in pairs. A topic modeling technique, latent Dirichlet allocation, was applied to identify topics in the reviews and analyzed to detect themes and subthemes. Results: Thematic analysis was conducted on 5 topics for each sentimental set. Reviews were categorized as positive or negative. For positive reviews, the main themes were confidence and affirmation building, adequate analysis, and consultation, caring as a friend, and ease of use. For negative reviews, the results revealed the following themes: usability issues, update issues, privacy, and noncreative conversations. Conclusions: Using a machine learning approach, we were able to analyze ≥200,000 comments and categorize them into themes, allowing us to observe users’ expectations effectively despite some negative factors. A methodological workflow is provided for the future analysis of review comments. %M 35275069 %R 10.2196/27654 %U https://formative.jmir.org/2022/3/e27654 %U https://doi.org/10.2196/27654 %U http://www.ncbi.nlm.nih.gov/pubmed/35275069 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 3 %P e28942 %T Education on Depression in Mental Health Apps: Systematic Assessment of Characteristics and Adherence to Evidence-Based Guidelines %A Martinengo,Laura %A Stona,Anne-Claire %A Tudor Car,Lorainne %A Lee,Jimmy %A Griva,Konstadina %A Car,Josip %+ Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Rd, Clinical Sciences Building Level 18, Singapore, 308232, Singapore, 65 69047017, josip.car@ntu.edu.sg %K health literacy %K mental health literacy %K depression %K mobile apps %K apps %K telemedicine %K mHealth %K self-management %K mobile phone %D 2022 %7 9.3.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Suboptimal understanding of depression and mental health disorders by the general population is an important contributor to the wide treatment gap in depression. Mental health literacy encompasses knowledge and beliefs about mental disorders and supports their recognition, management, and prevention. Besides knowledge improvement, psychoeducational interventions reduce symptoms of depression, enhance help-seeking behavior, and decrease stigma. Mental health apps often offer educational content, but the trustworthiness of the included information is unclear. Objective: The aim of this study is to systematically evaluate adherence to clinical guidelines on depression of the information offered by mental health apps available in major commercial app stores. Methods: A systematic assessment of the educational content regarding depression in the apps available in the Apple App Store and Google Play was conducted in July 2020. A systematic search for apps published or updated since January 2019 was performed using 42matters. Apps meeting the inclusion criteria were downloaded and assessed using two smartphones: an iPhone 7 (iOS version 14.0.1) and a Sony XPERIA XZs (Android version 8.0.0). The 156-question assessment checklist comprised general characteristics of apps, appraisal of 38 educational topics and their adherence to evidence-based clinical guidelines, as well as technical aspects and quality assurance. The results were tabulated and reported as a narrative review, using descriptive statistics. Results: The app search retrieved 2218 apps, of which 58 were included in the analysis (Android apps: n=29, 50%; iOS apps: n=29, 50%). Of the 58 included apps, 37 (64%) apps offered educational content within a more comprehensive depression or mental health management app. Moreover, 21% (12/58) of apps provided non–evidence-based information. Furthermore, 88% (51/58) of apps included up to 20 of the educational topics, the common ones being listing the symptoms of depression (52/58, 90%) and available treatments (48/58, 83%), particularly psychotherapy. Depression-associated stigma was mentioned by 38% (22/58) of the apps, whereas suicide risk was mentioned by 71% (41/58), generally as an item in a list of symptoms. Of the 58 included apps, 44 (76%) highlighted the importance of help seeking, 29 (50%) emphasized the importance of involving the user’s support network. In addition, 52% (30/58) of apps referenced their content, and 17% (10/58) included advertisements. Conclusions: Information in mental health and depression apps is often brief and incomplete, with 1 in 5 apps providing non–evidence-based information. Given the unmet needs and stigma associated with the disease, it is imperative that apps seize the opportunity to offer quality, evidence-based education or point the users to relevant resources. A multistakeholder consensus on a more stringent development and publication process for mental health apps is essential. %M 35262489 %R 10.2196/28942 %U https://www.jmir.org/2022/3/e28942 %U https://doi.org/10.2196/28942 %U http://www.ncbi.nlm.nih.gov/pubmed/35262489 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 3 %P e27469 %T The Mental Health Impact of the COVID-19 Pandemic Among Physicians, Nurses, and Other Health Care Providers in Alberta: Cross-sectional Survey %A El Gindi,Hany %A Shalaby,Reham %A Gusnowski,April %A Vuong,Wesley %A Surood,Shireen %A Hrabok,Marianne %A Greenshaw,Andrew J %A Agyapong,Vincent %+ Department of Psychiatry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Centre, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 780 215 7771, agyapong@ualberta.ca %K COVID-19 %K health care worker %K mobile technology %K Text4Hope %K anxiety %K depression %K stress %K pandemic %K e-mental health %K mental health %K impact %K physician %K nurse %K Canada %D 2022 %7 9.3.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: During the COVID-19 pandemic, threats to mental health, psychological safety, and well-being are evident, particularly among the first responders and the health care staff. Objective: This study aims to examine the prevalence and potential predictors of the likely stress, generalized anxiety disorder, and major depressive disorder among health care workers (HCWs). Methods: A cross-sectional survey was used through a survey link sent to gather demographic information and responses on several self-report scales, including the Perceived Stress Scale, the Generalized Anxiety Disorder 7-item scale, and the Patient Health Questionnaire-9 among HCWs enrolled in the Text4Hope program. Results: The result from this study suggests that during the COVID-19 pandemic, HCWs reported a high likelihood of moderate-to-high perceived stress (n=840, 81.2%), moderate-to-severe anxiety (n=369, 38.6%), and depression (n=317, 32.7%) symptoms. Nurses and other HCWs were significantly more likely to report depressive symptoms compared to physicians (F(2, 159.47)=15.89, 95% CI –5.05 to –2.04). Younger age groups of HCWs (≤30 years) were more prone to report likely stress, anxiety, and depressive symptoms compared to HCWs 41-50 and >50 years old (odds ratio [OR] 1.82-3.03). Similarly, females and those who reported a lack of social support (separated/divorced and single) among HCWs had a higher likelihood to report likely stress and depressive symptoms, respectively (OR 1.8 and 1.6, respectively). Conclusions: This cross-sectional study explored a high level of mental health burdens during the COVID-19 pandemic among HCWs in Alberta. Levels of psychological symptoms were more noticeable in the female gender and the nursing profession. %M 34995203 %R 10.2196/27469 %U https://formative.jmir.org/2022/3/e27469 %U https://doi.org/10.2196/27469 %U http://www.ncbi.nlm.nih.gov/pubmed/34995203 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 3 %P e27244 %T Detecting and Measuring Depression on Social Media Using a Machine Learning Approach: Systematic Review %A Liu,Danxia %A Feng,Xing Lin %A Ahmed,Farooq %A Shahid,Muhammad %A Guo,Jing %+ Department of Health Policy and Management, School of Public Health, Peking University, 38 Xueyuan Road, Beijing, 100191, China, 86 18086471505, jing624218@bjmu.edu.cn %K depression %K machine learning %K social media %D 2022 %7 1.3.2022 %9 Review %J JMIR Ment Health %G English %X Background: Detection of depression gained prominence soon after this troublesome disease emerged as a serious public health concern worldwide. Objective: This systematic review aims to summarize the findings of previous studies concerning applying machine learning (ML) methods to text data from social media to detect depressive symptoms and to suggest directions for future research in this area. Methods: A bibliographic search was conducted for the period of January 1990 to December 2020 in Google Scholar, PubMed, Medline, ERIC, PsycINFO, and BioMed. Two reviewers retrieved and independently assessed the 418 studies consisting of 322 articles identified through database searching and 96 articles identified through other sources; 17 of the studies met the criteria for inclusion. Results: Of the 17 studies, 10 had identified depression based on researcher-inferred mental status, 5 had identified it based on users’ own descriptions of their mental status, and 2 were identified based on community membership. The ML approaches of 13 of the 17 studies were supervised learning approaches, while 3 used unsupervised learning approaches; the remaining 1 study did not describe its ML approach. Challenges in areas such as sampling, optimization of approaches to prediction and their features, generalizability, privacy, and other ethical issues call for further research. Conclusions: ML approaches applied to text data from users on social media can work effectively in depression detection and could serve as complementary tools in public mental health practice. %M 35230252 %R 10.2196/27244 %U https://mental.jmir.org/2022/3/e27244 %U https://doi.org/10.2196/27244 %U http://www.ncbi.nlm.nih.gov/pubmed/35230252 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 2 %P e33058 %T Methods and Applications of Social Media Monitoring of Mental Health During Disasters: Scoping Review %A Teague,Samantha J %A Shatte,Adrian B R %A Weller,Emmelyn %A Fuller-Tyszkiewicz,Matthew %A Hutchinson,Delyse M %+ Centre for Social and Early Emotional Development, School of Psychology, Deakin University, 1 Gheringhap St, Geelong, 3220, Australia, 61 3 924 68440, sam.teague@deakin.edu.au %K social media %K SNS %K mental health %K disaster %K big data %K digital psychiatry %D 2022 %7 28.2.2022 %9 Review %J JMIR Ment Health %G English %X Background: With the increasing frequency and magnitude of disasters internationally, there is growing research and clinical interest in the application of social media sites for disaster mental health surveillance. However, important questions remain regarding the extent to which unstructured social media data can be harnessed for clinically meaningful decision-making. Objective: This comprehensive scoping review synthesizes interdisciplinary literature with a particular focus on research methods and applications. Methods: A total of 6 health and computer science databases were searched for studies published before April 20, 2021, resulting in the identification of 47 studies. Included studies were published in peer-reviewed outlets and examined mental health during disasters or crises by using social media data. Results: Applications across 31 mental health issues were identified, which were grouped into the following three broader themes: estimating mental health burden, planning or evaluating interventions and policies, and knowledge discovery. Mental health assessments were completed by primarily using lexical dictionaries and human annotations. The analyses included a range of supervised and unsupervised machine learning, statistical modeling, and qualitative techniques. The overall reporting quality was poor, with key details such as the total number of users and data features often not being reported. Further, biases in sample selection and related limitations in generalizability were often overlooked. Conclusions: The application of social media monitoring has considerable potential for measuring mental health impacts on populations during disasters. Studies have primarily conceptualized mental health in broad terms, such as distress or negative affect, but greater focus is required on validating mental health assessments. There was little evidence for the clinical integration of social media–based disaster mental health monitoring, such as combining surveillance with social media–based interventions or developing and testing real-world disaster management tools. To address issues with study quality, a structured set of reporting guidelines is recommended to improve the methodological quality, replicability, and clinical relevance of future research on the social media monitoring of mental health during disasters. %M 35225815 %R 10.2196/33058 %U https://mental.jmir.org/2022/2/e33058 %U https://doi.org/10.2196/33058 %U http://www.ncbi.nlm.nih.gov/pubmed/35225815 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 2 %P e35776 %T A Brief, Daily, Online Mental Health and Well-being Intervention for University Staff During the COVID-19 Pandemic: Program Description and Outcomes Using a Mixed Methods Design %A Parker,Alexandra %A Dash,Sarah %A Bourke,Matthew %A Patten,Rhiannon %A Craike,Melinda %A Baldwin,Peter %A Hosking,Warwick %A Levinger,Itamar %A Apostolopoulos,Vasso %A de Courten,Maximilian %A Sharples,Jenny %A Naslund,Monika %A Stavropoulos,Vasileios %A Woessner,Mary %A Sonn,Christopher %A Stansen,Caroline %A Pascoe,Michaela %+ Institute for Health and Sport, Victoria University, Ballarat Road, Melbourne, 3011, Australia, 61 399195874, alex.parker@vu.edu.au %K workplace mental health %K well-being %K mental health promotion %K online intervention %K telehealth %K COVID-19 pandemic %K COVID-19 %K pandemic %K health promotion %D 2022 %7 25.2.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The unprecedented changes and isolation measures to contain COVID-19 have had multiple psychological and social impacts, with implications for professional and personal functioning. Evidence-informed interventions that can be rapidly implemented under pandemic conditions to support mental health during such times are urgently needed. Objective: The aim of this study was to determine the acceptability and preliminary outcomes of a daily online mental health promotion program for tertiary education staff during the COVID-19 pandemic. Methods: The “Victoria University (VU) Elevenses” program was delivered as an uncontrolled intervention at Victoria University (VU) in the western metropolitan region of Melbourne, Australia. In April 2020, an email invitation was sent to all academic and professional staff inviting them to: (1) participate in the program and (2) opt-in to the research component. The “VU Elevenses” program provided 10-15–minute microinterventions comprising lifestyle and well-being strategies to promote mental health via an online meeting platform at 11 AM each weekday. A mixed methods approach was used to evaluate the program, combining structured questionnaires with semistructured interviews to investigate the experiences of staff who participated in the program. Results: Between 16 and 90 participants provided weekly program feedback. A total of 106 university staff opted into the longitudinal research component and 10 staff participated in the interviews. Participants reported high levels of satisfaction with sessions and perceived benefits for mental health. Approximately one quarter of participants reported moderate to severe symptoms of depression, anxiety, and stress at baseline, with significant reductions in these symptoms in the first 7 weeks of the program, corresponding with easing in mandatory isolation (“lockdown”) restrictions. Symptoms of depression, anxiety, and stress all increased when lockdown measures were reintroduced, but not to the same levels as found during the initial lockdown period. Overall changes in depression and anxiety from baseline to the end of the program were explained by changes in COVID-19–related distress, whereas changes in self-compassion explained changes in stress. Conclusions: We show that it is feasible and acceptable to develop and deliver a program of brief interventions in a timely manner, using a simple and accessible online platform. Although participation in the program was initially associated with reduced symptoms of depression, anxiety, and stress, participants’ mental health worsened with the reintroduction of a “lockdown” period. However, as symptoms of depression, anxiety, and stress did not return to levels observed at the start of the VU Elevenses program, participation in the uncontrolled intervention may have offered a protective benefit against the impact of the second significant lockdown period. %M 35044304 %R 10.2196/35776 %U https://formative.jmir.org/2022/2/e35776 %U https://doi.org/10.2196/35776 %U http://www.ncbi.nlm.nih.gov/pubmed/35044304 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 2 %P e33704 %T The Impact of Long COVID-19 on Mental Health: Observational 6-Month Follow-Up Study %A Houben-Wilke,Sarah %A Goërtz,Yvonne MJ %A Delbressine,Jeannet M %A Vaes,Anouk W %A Meys,Roy %A Machado,Felipe VC %A van Herck,Maarten %A Burtin,Chris %A Posthuma,Rein %A Franssen,Frits ME %A Vijlbrief,Herman %A Spies,Yvonne %A van 't Hul,Alex J %A Spruit,Martijn A %A Janssen,Daisy JA %+ Department of Research and Education, Ciro, Hornerheide 1, Horn, 6085 NM, Netherlands, 31 475587602, sarahwilke@ciro-horn.nl %K SARS-CoV-2 %K corona %K COVID-19 %K post-traumatic stress disorder %K anxiety %K depression %K PASC %D 2022 %7 24.2.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: The psychological impact of COVID-19 can be substantial. However, knowledge about long-term psychological outcomes in patients with COVID-19 is scarce. Objective: In this longitudinal, observational study, we aimed to reveal symptoms of posttraumatic stress disorder (PTSD) and symptoms of anxiety and depression up to 6 months after the onset of COVID-19–related symptoms in patients with confirmed COVID-19 and persistent complaints. To demonstrate the impact in nonhospitalized patients, we further aimed to compare these outcomes between nonhospitalized and hospitalized patients. Methods: Demographics, symptoms of PTSD (Trauma Screening Questionnaire [TSQ] ≥6 points) and symptoms of anxiety and depression (Hospital Anxiety and Depression Scale [HADS] ≥8 points) were assessed at 3 and 6 months after the onset of COVID-19–related symptoms in members of online long COVID-19 peer support groups. Results: Data from 239 patients with confirmed COVID-19 (198/239, 82.8% female; median age: 50 [IQR 39-56] years) were analyzed. At the 3-month follow-up, 37.2% (89/239) of the patients had symptoms of PTSD, 35.6% (85/239) had symptoms of anxiety, and 46.9% (112/239) had symptoms of depression, which remained high at the 6-month follow-up (64/239, 26.8%, P=.001; 83/239, 34.7%, P=.90; 97/239, 40.6%, P=.08, respectively; versus the 3-month follow-up). TSQ scores and HADS anxiety and depression scores were strongly correlated at the 3- and 6-month follow-ups (r=0.63-0.71, P<.001). Symptoms of PTSD, anxiety, and depression were comparable between hospitalized (n=62) and nonhospitalized (n=177) patients. Conclusions: A substantial percentage of patients with confirmed COVID-19 and persistent complaints reported symptoms of PTSD, anxiety, or depression 3 and 6 months after the onset of COVID-19–related symptoms. The prevalence rates of symptoms of PTSD, anxiety, and depression were comparable between hospitalized and nonhospitalized patients and merely improved over time. Health care professionals need to be aware of these psychological complications and intervene on time in post-COVID-19 patients with persistent complaints. Trial Registration: Netherlands Trial Register NTR8705; https://www.trialregister.nl/trial/8705. %M 35200155 %R 10.2196/33704 %U https://mental.jmir.org/2022/2/e33704 %U https://doi.org/10.2196/33704 %U http://www.ncbi.nlm.nih.gov/pubmed/35200155 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 2 %P e33337 %T Digitalized Cognitive Behavioral Interventions for Depressive Symptoms During Pregnancy: Systematic Review %A Wan Mohd Yunus,Wan Mohd Azam %A Matinolli,Hanna-Maria %A Waris,Otto %A Upadhyaya,Subina %A Vuori,Miika %A Korpilahti-Leino,Tarja %A Ristkari,Terja %A Koffert,Tarja %A Sourander,Andre %+ Research Centre for Child Psychiatry, University of Turku, Lemminkäisenkatu 3/Teutori 3. floor, Turku, 20014, Finland, 358 503653447, andsou@utu.fi %K pregnancy %K antenatal depression %K systematic review %K cognitive behavior therapy %K digital interventions %K COVID-19 %D 2022 %7 23.2.2022 %9 Review %J J Med Internet Res %G English %X Background: Studies have shown a high prevalence of depression during pregnancy, and there is also evidence that cognitive behavioral therapy (CBT) is one of the most effective psychosocial interventions. Emerging evidence from randomized controlled trials (RCTs) has shown that technology has been successfully harnessed to provide CBT interventions for other populations. However, very few studies have focused on their use during pregnancy. This approach has become increasingly important in many clinical areas due to the COVID-19 pandemic, and our study aimed to expand the knowledge in this particular clinical area. Objective: Our systematic review aimed to bring together the available research-based evidence on digitalized CBT interventions for depression symptoms during pregnancy. Methods: A systematic review of the Web of Science, Cochrane Central Register of Controlled Trials, CINAHL, MEDLINE, Embase, PsycINFO, Scopus, ClinicalTrials.gov, and EBSCO Open Dissertations databases was carried out from the earliest available evidence to October 27, 2021. Only RCT studies published in English were considered. The PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analyses) guidelines were followed, and the protocol was registered on the Prospective Register of Systematic Reviews. The risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomized trials. Results: The review identified 7 studies from 5 countries (the United States, China, Australia, Norway, and Sweden) published from 2015 to 2021. The sample sizes ranged from 25 to 1342 participants. The interventions used various technological elements, including text, images, videos, games, interactive features, and peer group discussions. They comprised 2 guided and 5 unguided approaches. Using digitalized CBT interventions for depression during pregnancy showed promising efficacy, with guided intervention showing higher effect sizes (Hedges g=1.21) than the unguided interventions (Hedges g=0.14-0.99). The acceptability of the digitalized CBT interventions was highly encouraging, based on user feedback. Attrition rates were low for the guided intervention (4.5%) but high for the unguided interventions (22.1%-46.5%). A high overall risk of bias was present for 6 of the 7 studies. Conclusions: Our search only identified a small number of digitalized CBT interventions for pregnant women, despite the potential of this approach. These showed promising evidence when it came to efficacy and positive outcomes for depression symptoms, and user feedback was positive. However, the overall risk of bias suggests that the efficacy of the interventions needs to be interpreted with caution. Future studies need to consider how to mitigate these sources of biases. Digitalized CBT interventions can provide prompt, effective, evidence-based interventions for pregnant women. This review increases our understanding of the importance of digitalized interventions during pregnancy, including during the COVID-19 pandemic. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020216159; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=216159 %M 35195532 %R 10.2196/33337 %U https://www.jmir.org/2022/2/e33337 %U https://doi.org/10.2196/33337 %U http://www.ncbi.nlm.nih.gov/pubmed/35195532 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 2 %P e30598 %T The Impact of COVID-19 Confinement on Cognition and Mental Health and Technology Use Among Socially Vulnerable Older People: Retrospective Cohort Study %A Dura-Perez,Elena %A Goodman-Casanova,Jessica Marian %A Vega-Nuñez,Amanda %A Guerrero-Pertiñez,Gloria %A Varela-Moreno,Esperanza %A Garolera,Maite %A Quintana,Maria %A Cuesta-Vargas,Antonio I %A Barnestein-Fonseca,Pilar %A Gómez Sánchez-Lafuente,Carlos %A Mayoral-Cleries,Fermin %A Guzman-Parra,Jose %+ Department of Mental Health, Regional University Hospital of Málaga, Biomedical Research Institute of Malaga (IBIMA), Plaza del Hospital, s/n, Málaga, 29009, Spain, 34 660901966, jmariangoodman@gmail.com %K COVID-19 %K cognition %K quality of life %K social isolation %K mental health %K social support %K technology %K physical distancing %K leisure activities %K nursing %D 2022 %7 22.2.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: COVID-19 forced the implementation of restrictive measures in Spain, such as lockdown, home confinement, social distancing, and isolation. It is necessary to study whether limited access to basic services and decreased family and social support could have deleterious effects on cognition, quality of life, and mental health in vulnerable older people. Objective: This study aims to explore the impact of the COVID-19 outbreak on cognition in older adults with mild cognitive impairment or dementia as the main outcome and the quality of life, perceived health status, and depression as secondary outcomes and to analyze the association of living alone and a change in living arrangements with those outcomes and other variables related with the use of technology and health services. Likewise, this study aims to analyze the association of high and low technophilia with those variables, to explore the access and use of health care and social support services, and, finally, to explore the informative-, cognitive-, entertainment-, and socialization-related uses of information and communications technologies (ICTs) during the COVID-19 outbreak. Methods: This cohort study was conducted in Málaga (Spain). In total, 151 participants with mild cognitive impairment or mild dementia, from the SMART4MD (n=75, 49.7%) and TV-AssistDem (n=76, 50.3%) randomized clinical trials, were interviewed by telephone between May 11 and June 26, 2020. All participants had undergone 1-3 assessments (in 6-month intervals) on cognition, quality of life, and mood prior to the COVID-19 breakout. Results: The outbreak did not significantly impact the cognition, quality of life, and mood of our study population when making comparisons with baseline assessments prior to the outbreak. Perceived stress was reported as moderate during the outbreak. After correction for multiple comparisons, living alone, a change in living arrangements, and technophilia were not associated with negative mental health outcomes. However, being alone was nominally associated with self-perceived fear and depression, and higher technophilia with better quality of life, less boredom, perceived stress and depression, and also less calmness. Overall, health care and social support service access and utilization were high. The most used ICTs during the COVID-19 outbreak were the television for informative, cognitive, and entertainment-related uses and the smartphone for socialization. Conclusions: Our findings show that the first months of the outbreak did not significantly impact the cognition, quality of life, perceived health status, and depression of our study population when making comparisons with baseline assessments prior to the outbreak. Living alone and low technophilia require further research to establish whether they are risk factors of mental health problems during lockdowns in vulnerable populations. Moreover, although ICTs have proven to be useful for informative-, cognitive-, entertainment-, and socialization-related uses during the pandemic, more evidence is needed to support these interventions. Trial Registration: ClinicalTrials.gov NCT04385797; https://clinicaltrials.gov/ct2/show/NCT04385797 International Registered Report Identifier (IRRID): RR2-10.2196/26431 %M 35049505 %R 10.2196/30598 %U https://www.jmir.org/2022/2/e30598 %U https://doi.org/10.2196/30598 %U http://www.ncbi.nlm.nih.gov/pubmed/35049505 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 2 %P e31116 %T eHealth Interventions for Treatment and Prevention of Depression, Anxiety, and Insomnia During Pregnancy: Systematic Review and Meta-analysis %A Silang,Katherine A %A Sohal,Pooja R %A Bright,Katherine S %A Leason,Jennifer %A Roos,Leslie %A Lebel,Catherine %A Giesbrecht,Gerald F %A Tomfohr-Madsen,Lianne M %+ Department of Psychology, University of Calgary, 2500 University Drive, NW, Calgary, AB, T2N 1N4, Canada, 1 403 220 2243, ltomfohr@ucalgary.ca %K eHealth %K pregnancy %K depression %K anxiety %K insomnia %K mobile phone %D 2022 %7 21.2.2022 %9 Review %J JMIR Ment Health %G English %X Background: Pregnancy is associated with an increased risk for depression, anxiety, and insomnia. eHealth interventions provide a promising and accessible treatment alternative to face-to-face interventions. Objective: The objective of this systematic review and meta-analysis is to determine the effectiveness of eHealth interventions in preventing and treating depression, anxiety, and insomnia during pregnancy. Secondary aims are to identify demographic and intervention moderators of effectiveness. Methods: A total of 5 databases (PsycINFO, Medline, CINAHL, Embase, and Cochrane) were searched from inception to May 2021. Terms related to eHealth, pregnancy, randomized controlled trials (RCTs), depression, anxiety, and insomnia were included. RCTs and pilot RCTs were included if they reported an eHealth intervention for the prevention or treatment of depression, anxiety, or insomnia in pregnant women. Study screening, data extractions, and quality assessment were conducted independently by 2 reviewers from an 8-member research team (KAS, PRS, Hangsel Sanguino, Roshni Sohail, Jasleen Kaur, Songyang (Mark) Jin, Makayla Freeman, and Beatrice Valmana). Random-effects meta-analyses of pooled effect sizes were conducted to determine the effect of eHealth interventions on prenatal mental health. Meta-regression analyses were conducted to identify potential moderators. Results: In total, 17 studies were included in this review that assessed changes in depression (11/17, 65%), anxiety (10/17, 59%), and insomnia (3/17, 18%). Several studies included both depression and anxiety symptoms as outcomes (7/17, 41%). The results indicated that during pregnancy, eHealth interventions showed small effect sizes for preventing and treating symptoms of anxiety and depression and a moderate effect size for treating symptoms of insomnia. With the exception of intervention type for the outcome of depressive symptoms, where mindfulness interventions outperformed other intervention types, no significant moderators were detected. Conclusions: eHealth interventions are an accessible and promising resource for treating symptoms of anxiety, depression, and insomnia during pregnancy. However, more research is necessary to identify ways to increase the efficacy of eHealth interventions for this population. Trial Registration: PROSPERO (International Prospective Register of Systematic Reviews) CRD42020205954; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=205954 %M 35188471 %R 10.2196/31116 %U https://mental.jmir.org/2022/2/e31116 %U https://doi.org/10.2196/31116 %U http://www.ncbi.nlm.nih.gov/pubmed/35188471 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 2 %P e27584 %T Internet-Based Audiologist-Guided Cognitive Behavioral Therapy for Tinnitus: Randomized Controlled Trial %A W Beukes,Eldré %A Andersson,Gerhard %A Fagelson,Marc %A Manchaiah,Vinaya %+ Vision and Hearing Research Centre, Anglia Ruskin University, East Road, Cambridge, CB1 1TP, United Kingdom, 44 07951113157, eldre.beukes@aru.co.uk %K tinnitus %K cognitive behavioral therapy %K internet intervention %K web-based intervention %K randomized controlled trial %K telehealth %K teleaudiology %K eHealth %D 2022 %7 14.2.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Tinnitus is a symptom that can be very distressing owing to hearing sounds not related to any external sound source. Managing tinnitus is notoriously difficult, and access to evidence-based care is limited. Cognitive behavioral therapy (CBT) is a tinnitus management strategy with the most evidence of effectiveness but is rarely offered to those distressed by tinnitus. The provision of internet-based CBT for tinnitus overcomes accessibility barriers; however, it is not currently readily available in the United States. Objective: The aim of this study is to investigate the efficacy of internet-based CBT compared with that of weekly monitoring for the management of tinnitus in reducing tinnitus distress; reducing tinnitus-related comorbidities, including tinnitus cognitions, insomnia, anxiety, and depression; and assessing the stability of the intervention effects 2 months after the intervention. Methods: A 2-arm randomized clinical trial comparing audiologist-guided internet-based CBT (n=79) to a weekly monitoring group (n=79) with a 2-month follow-up assessed the efficacy of internet-based CBT. Eligible participants included adults seeking help for tinnitus. Recruitment was conducted on the web using an open-access website. Participants were randomized via 1:1 allocation, but blinding was not possible. The study was undertaken by English or Spanish speakers on the web. The primary outcome was a change in tinnitus distress as measured using the Tinnitus Functional Index. Secondary outcome measures included anxiety, depression, insomnia, tinnitus cognition, hearing-related difficulties, and quality of life. Results: Internet-based CBT led to a greater reduction in tinnitus distress (mean 36.57, SD 22) compared with that in weekly monitoring (mean 46.31, SD 20.63; effect size: Cohen d=0.46, 95% CI 0.14-0.77) using an intention-to-treat analysis. For the secondary outcomes, there was a greater reduction in negative tinnitus cognition and insomnia. The results remained stable over the 2-month follow-up period. No important adverse events were observed. Further, 16% (10/158) of participants withdrew, with low overall compliance rates for questionnaire completion of 72.3% (107/148) at T1, 61% (91/148) at T2, and 42% (62/148) at T3. Conclusions: This study is the first to evaluate and indicate the efficacy of audiologist-delivered internet-based CBT in reducing tinnitus distress in a US population. It was also the first study to offer internet-based CBT in Spanish to accommodate the large Hispanic population in the United States. The results have been encouraging, and further work is indicated in view of making such an intervention applicable to a wider population. Further work is required to improve compliance and attract more Spanish speakers. Trial Registration: ClinicalTrials.gov NCT04004260; https://clinicaltrials.gov/ct2/show/NCT04004260 %M 35156936 %R 10.2196/27584 %U https://www.jmir.org/2022/2/e27584 %U https://doi.org/10.2196/27584 %U http://www.ncbi.nlm.nih.gov/pubmed/35156936 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 2 %P e31724 %T In Search of State and Trait Emotion Markers in Mobile-Sensed Language: Field Study %A Carlier,Chiara %A Niemeijer,Koen %A Mestdagh,Merijn %A Bauwens,Michael %A Vanbrabant,Peter %A Geurts,Luc %A van Waterschoot,Toon %A Kuppens,Peter %+ Department of Psychology and Educational Sciences, Katholieke Universiteit Leuven, Tiensestraat 102, Leuven, 3000, Belgium, 32 16 37 44 85, chiara.carlier@student.kuleuven.be %K depression %K emotions %K mobile sensing %K language %K LIWC %K openSMILE %K speech %K writing %K mobile phone %D 2022 %7 11.2.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Emotions and mood are important for overall well-being. Therefore, the search for continuous, effortless emotion prediction methods is an important field of study. Mobile sensing provides a promising tool and can capture one of the most telling signs of emotion: language. Objective: The aim of this study is to examine the separate and combined predictive value of mobile-sensed language data sources for detecting both momentary emotional experience as well as global individual differences in emotional traits and depression. Methods: In a 2-week experience sampling method study, we collected self-reported emotion ratings and voice recordings 10 times a day, continuous keyboard activity, and trait depression severity. We correlated state and trait emotions and depression and language, distinguishing between speech content (spoken words), speech form (voice acoustics), writing content (written words), and writing form (typing dynamics). We also investigated how well these features predicted state and trait emotions using cross-validation to select features and a hold-out set for validation. Results: Overall, the reported emotions and mobile-sensed language demonstrated weak correlations. The most significant correlations were found between speech content and state emotions and between speech form and state emotions, ranging up to 0.25. Speech content provided the best predictions for state emotions. None of the trait emotion–language correlations remained significant after correction. Among the emotions studied, valence and happiness displayed the most significant correlations and the highest predictive performance. Conclusions: Although using mobile-sensed language as an emotion marker shows some promise, correlations and predictive R2 values are low. %M 35147507 %R 10.2196/31724 %U https://mental.jmir.org/2022/2/e31724 %U https://doi.org/10.2196/31724 %U http://www.ncbi.nlm.nih.gov/pubmed/35147507 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 2 %P e33585 %T Depressive Symptoms and Anxiety During the COVID-19 Pandemic: Large, Longitudinal, Cross-sectional Survey %A MacDonald,James J %A Baxter-King,Ryan %A Vavreck,Lynn %A Naeim,Arash %A Wenger,Neil %A Sepucha,Karen %A Stanton,Annette L %+ Department of Psychology, University of California, Los Angeles, 1285 Franz Hall, Los Angeles, CA, 90025-1563, United States, 1 7742701642, jamesjmacdonald7@gmail.com %K COVID-19 %K depression %K anxiety %K pandemic %K mental health %K public health %K psychological variables %K younger adults %K symptom monitoring %K health intervention %D 2022 %7 10.2.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic has influenced the mental health of millions across the globe. Understanding factors associated with depressive symptoms and anxiety across 12 months of the pandemic can help identify groups at higher risk and psychological processes that can be targeted to mitigate the long-term mental health impact of the pandemic. Objective: This study aims to determine sociodemographic features, COVID-19-specific factors, and general psychological variables associated with depressive symptoms and anxiety over 12 months of the pandemic. Methods: Nationwide, cross-sectional electronic surveys were implemented in May (n=14,636), July (n=14,936), October (n=14,946), and December (n=15,265) 2020 and March/April 2021 (n=14,557) in the United States. Survey results were weighted to be representative of the US population. The samples were drawn from a market research platform, with a 69% cooperation rate. Surveys assessed depressive symptoms in the past 2 weeks and anxiety in the past week, as well as sociodemographic features; COVID-19 restriction stress, worry, perceived risk, coping strategies, and exposure; intolerance of uncertainty; and loneliness. Results: Across 12 months, an average of 24% of respondents reported moderate-to-severe depressive symptoms and 32% reported moderate-to-severe anxiety. Of the sociodemographic variables, age was most consistently associated with depressive symptoms and anxiety, with younger adults more likely to report higher levels of those outcomes. Intolerance of uncertainty and loneliness were consistently and strongly associated with the outcomes. Of the COVID-19-specific variables, stress from COVID-19 restrictions, worry about COVID-19, coping behaviors, and having COVID-19 were associated with a higher likelihood of depressive symptoms and anxiety. Conclusions: Depressive symptoms and anxiety were high in younger adults, adults who reported restriction stress or worry about COVID-19 or who had had COVID-19, and those with intolerance of uncertainty and loneliness. Symptom monitoring as well as early and accessible intervention are recommended. %M 35142619 %R 10.2196/33585 %U https://mental.jmir.org/2022/2/e33585 %U https://doi.org/10.2196/33585 %U http://www.ncbi.nlm.nih.gov/pubmed/35142619 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 2 %P e31018 %T Web-Based Interventions to Help Australian Adults Address Depression, Anxiety, Suicidal Ideation, and General Mental Well-being: Scoping Review %A Skaczkowski,Gemma %A van der Kruk,Shannen %A Loxton,Sophie %A Hughes-Barton,Donna %A Howell,Cate %A Turnbull,Deborah %A Jensen,Neil %A Smout,Matthew %A Gunn,Kate %+ Department of Rural Health, Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, 5001, Australia, 61 417852537, kate.gunn@unisa.edu.au %K web-based interventions %K depression %K anxiety %K suicide %K well-being %K mental health %K technology %K access to health care %D 2022 %7 8.2.2022 %9 Review %J JMIR Ment Health %G English %X Background: A large number of Australians experience mental health challenges at some point in their lives. However, in many parts of Australia, the wait times to see general practitioners and mental health professionals can be lengthy. With increasing internet use across Australia, web-based interventions may help increase access to timely mental health care. As a result, this is an area of increasing research interest, and the number of publicly available web-based interventions is growing. However, it can be confusing for clinicians and consumers to know the resources that are evidence-based and best meet their needs. Objective: This study aims to scope out the range of web-based mental health interventions that address depression, anxiety, suicidal ideation, or general mental well-being and are freely available to Australian adults, along with their impact, acceptability, therapeutic approach, and key features. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews (PRISMA-ScR [PRISMA extension for Scoping Reviews]) guided the review process. Keywords for the search were depression, anxiety, suicide, and well-being. The search was conducted using Google as well as the key intervention databases Beacon, Head to Health, and e-Mental Health in Practice. Interventions were deemed eligible if they targeted depression, anxiety, suicidal ideation, or general mental well-being (eg, resilience) in adults; and were web-based, written in English, interactive, free, and publicly available. They also had to be guided by an evidence-based therapeutic approach. Results: Overall, 52 eligible programs were identified, of which 9 (17%) addressed depression, 15 (29%) addressed anxiety, 13 (25%) addressed general mental well-being, and 13 (25%) addressed multiple issues. Only 4% (2/52) addressed distress in the form of suicidal ideation. The most common therapeutic approach was cognitive behavioral therapy. Half of the programs guided users through exercises in a set sequence, and most programs enabled users to log in and complete the activities on their own without professional support. Just over half of the programs had been evaluated for their effectiveness in reducing symptoms, and 11% (6/52) were being evaluated at the time of writing. Program evaluation scores ranged from 44% to 100%, with a total average score of 85%. Conclusions: There are numerous web-based programs for depression, anxiety, suicidal ideation, and general well-being, which are freely and publicly available in Australia. However, identified gaps include a lack of available web-based interventions for culturally and linguistically diverse populations and programs that use newer therapeutic approaches such as acceptance and commitment therapy and dialectical behavior therapy. Despite most programs included in this review being of good quality, clinicians and consumers should pay careful attention when selecting which program to recommend and use, as variations in the levels of acceptability and impact of publicly available programs do exist. %M 35133281 %R 10.2196/31018 %U https://mental.jmir.org/2022/2/e31018 %U https://doi.org/10.2196/31018 %U http://www.ncbi.nlm.nih.gov/pubmed/35133281 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 2 %P e27642 %T Therapist-Assisted Web-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement: Randomized Controlled Trial %A Kaiser,Julia %A Nagl,Michaela %A Hoffmann,Rahel %A Linde,Katja %A Kersting,Anette %+ Department of Psychosomatic Medicine and Psychotherapy, University of Leipzig, Semmelweisstraße 10, Leipzig, 04103, Germany, 49 34197 ext 18943, julia.kaiser@medizin.uni-leipzig.de %K digital interventions %K grief %K traumatic loss %K treatment effectiveness evaluation %K cognitive behavioral therapy %K neoplasms %D 2022 %7 8.2.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Bereavement due to cancer increases the risk of prolonged grief disorder. However, specialized treatment options for prolonged grief after a loss due to illness are still scarce. Objective: The aim of this study is to extend previous findings by evaluating a web-based cognitive behavioral intervention with asynchronous therapist support, consisting of structured writing tasks adapted specifically for prolonged grief after cancer bereavement. Methods: The intervention was evaluated in a purely web-based randomized waitlist-controlled trial. Open-access recruitment of participants was conducted on the web. Prolonged grief (Inventory of Complicated Grief), depression, anxiety, posttraumatic stress, posttraumatic growth, somatization, sleep quality, and mental and physical health were assessed on the web via validated self-report measures. Results: A total of 87 participants were randomized into the intervention group (IG; 44/87, 51%) or the waitlist control group (43/87, 49%). Of the participants, 7% (6/87) dropped out of the study (5/44, 11%, in the IG). Of the 39 completers in the IG, 37 (95%) completed all intervention tasks. The intervention reduced symptoms of prolonged grief (intention-to-treat: P<.001; η2=0.34; Cohen d=0.80) to a clinically significant extent. It had favorable effects on depression, anxiety, posttraumatic stress, posttraumatic growth, and overall mental health but not on somatization, sleep quality, or physical health. Conclusions: The web-based intervention for prolonged grief after cancer bereavement is effective in reducing symptoms of prolonged grief disorder and accompanying syndromes in a timely, easily realizable manner and addresses specific challenges of bereavement to illness. Considering web-based approaches in future mental health care policy and practice can reduce health care gaps for those who are bereaved to cancer. Trial Registration: German Clinical Trial Register U1111–1186-6255; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011001 %M 35133286 %R 10.2196/27642 %U https://mental.jmir.org/2022/2/e27642 %U https://doi.org/10.2196/27642 %U http://www.ncbi.nlm.nih.gov/pubmed/35133286 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 2 %P e27388 %T Characteristics of Mobile Health Platforms for Depression and Anxiety: Content Analysis Through a Systematic Review of the Literature and Systematic Search of Two App Stores %A Leong,Qiao Ying %A Sridhar,Shreya %A Blasiak,Agata %A Tadeo,Xavier %A Yeo,GeckHong %A Remus,Alexandria %A Ho,Dean %+ N.1 Institute for Health, National University of Singapore, 28 Medical Drive, Singapore, 117456, Singapore, 65 86118796, bieamr@nus.edu.sg %K mHealth %K digital medicine %K anxiety %K depression %K systematic review %K mental health conditions %K mobile phone %D 2022 %7 4.2.2022 %9 Review %J J Med Internet Res %G English %X Background: Mobile health (mHealth) platforms show promise in the management of mental health conditions such as anxiety and depression. This has resulted in an abundance of mHealth platforms available for research or commercial use. Objective: The objective of this review is to characterize the current state of mHealth platforms designed for anxiety or depression that are available for research, commercial use, or both. Methods: A systematic review was conducted using a two-pronged approach: searching relevant literature with prespecified search terms to identify platforms in published research and simultaneously searching 2 major app stores—Google Play Store and Apple App Store—to identify commercially available platforms. Key characteristics of the mHealth platforms were synthesized, such as platform name, targeted condition, targeted group, purpose, technology type, intervention type, commercial availability, and regulatory information. Results: The literature and app store searches yielded 169 and 179 mHealth platforms, respectively. Most platforms developed for research purposes were designed for depression (116/169, 68.6%), whereas the app store search reported a higher number of platforms developed for anxiety (Android: 58/179, 32.4%; iOS: 27/179, 15.1%). The most common purpose of platforms in both searches was treatment (literature search: 122/169, 72.2%; app store search: 129/179, 72.1%). With regard to the types of intervention, cognitive behavioral therapy and referral to care or counseling emerged as the most popular options offered by the platforms identified in the literature and app store searches, respectively. Most platforms from both searches did not have a specific target age group. In addition, most platforms found in app stores lacked clinical and real-world evidence, and a small number of platforms found in the published research were available commercially. Conclusions: A considerable number of mHealth platforms designed for anxiety or depression are available for research, commercial use, or both. The characteristics of these mHealth platforms greatly vary. Future efforts should focus on assessing the quality—utility, safety, and effectiveness—of the existing platforms and providing developers, from both commercial and research sectors, a reporting guideline for their platform description and a regulatory framework to facilitate the development, validation, and deployment of effective mHealth platforms. %M 35119370 %R 10.2196/27388 %U https://www.jmir.org/2022/2/e27388 %U https://doi.org/10.2196/27388 %U http://www.ncbi.nlm.nih.gov/pubmed/35119370 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 2 %P e33374 %T An Internet-Based Cognitive Behavioral Therapy Program for Anxiety and Depression (Tranquility): Adaptation Co-design and Fidelity Evaluation Study %A Patterson,Victoria C %A Rossi,Meghan A %A Pencer,Alissa %A Wozney,Lori %+ Department of Psychology and Neuroscience, Dalhousie University, P.O. Box 15000, Halifax, NS, B3H 4R2, Canada, 1 9024944466, alissa.pencer@dal.ca %K cognitive behavioral therapy %K anxiety %K depression %K fidelity %K usability %D 2022 %7 2.2.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Internet-based cognitive behavioral therapy (iCBT) is a necessary step toward increasing the accessibility of mental health services. Yet, few iCBT programs have been evaluated for their fidelity to the therapeutic principles of cognitive behavioral therapy (CBT) or usability standards. In addition, many existing iCBT programs do not include treatments targeting both anxiety and depression, which are commonly co-occurring conditions. Objective: This study aims to evaluate the usability of Tranquility—a novel iCBT program for anxiety—and its fidelity to CBT principles. This study also aims to engage in a co-design process to adapt Tranquility to include treatment elements for depression. Methods: CBT experts (n=6) and mental health–informed peers (n=6) reviewed the iCBT program Tranquility. CBT experts assessed Tranquility’s fidelity to CBT principles and were asked to identify necessary interventions for depression by using 2 simulated client case examples. Mental health–informed peers engaged in 2 co-design focus groups to discuss adaptations to the existing anxiety program and the integration of interventions for depression. Both groups completed web-based surveys assessing the usability of Tranquility and the likelihood that they would recommend the program. Results: The CBT experts’ mean rating of Tranquility’s fidelity to CBT principles was 91%, indicating a high fidelity to CBT. Further, 5 out of 6 CBT experts and all mental health–informed peers (all participants: 11/12, 88%) rated Tranquility as satisfactory, indicating that they may recommend Tranquility to others, and they rated its usability highly (mean 76.56, SD 14.07). Mental health–informed peers provided suggestions on how to leverage engagement with Tranquility (eg, adding incentives and notification control). Conclusions: This preliminary study demonstrated the strong fidelity of Tranquility to CBT and usability standards. The results highlight the importance of involving stakeholders in the co-design process and future opportunities to increase engagement. %M 34910660 %R 10.2196/33374 %U https://formative.jmir.org/2022/2/e33374 %U https://doi.org/10.2196/33374 %U http://www.ncbi.nlm.nih.gov/pubmed/34910660 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 2 %P e31036 %T Promoting Resilience and Well-being Through Co-design (The PRIDE Project): Protocol for the Development and Preliminary Evaluation of a Prototype Resilience-Based Intervention for Sexual and Gender Minority Youth %A Lucassen,Mathijs F G %A Samra,Rajvinder %A Rimes,Katharine A %A Brown,Katherine E %A Wallace,Louise M %+ Department of Health and Social Care, The Open University, Walton Hall, School of Health, Wellbeing and Social Care, Milton Keynes, MK7 6AA, United Kingdom, 44 01908652987, mathijs.lucassen@open.ac.uk %K LGBT %K e-therapy %K depression %K adolescent %K youth %K online %K sexuality %K gender %K resilience %K public health %D 2022 %7 1.2.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Sexual and gender minority youth (SGMY) are at an increased risk of a range of mental health problems. However, few evidence-informed interventions have been developed specifically to support their mental well-being. Interventions that are evidence-informed for the general population and are fine-tuned specifically with SGMY in mind proffer considerable potential. A particular opportunity lies in the delivery of engaging interventions on the web, where the focus is on enhancing the coping skills and building the resilience of SGMY, in a way that is directly relevant to their experiences. On the basis of earlier work related to an intervention called Rainbow SPARX (Smart, Positive, Active, Realistic, X-factor thoughts), we seek to create a new resource, especially for SGMY in the United Kingdom. Objective: This project has 3 main objectives. First, together with SGMY as well as key adult experts, we aim to co-design a media-rich evidence-informed web-based SGMY well-being prototype toolkit aimed at those aged between 13 and 19 years. Second, we will explore how the web-based toolkit can be used within public health systems in the United Kingdom by SGMY and potentially other relevant stakeholders. Third, we aim to conduct a preliminary evaluation of the toolkit, which will inform the design of a future effectiveness study. Methods: The first objective will be met by conducting the following: approximately 10 interviews with SGMY and 15 interviews with adult experts, a scoping review of studies focused on psychosocial coping strategies for SGMY, and co-design workshops with approximately 20 SGMY, which will inform the creation of the prototype toolkit. The second objective will be met by carrying out interviews with approximately 5 selected adult experts and 10 SGMY to explore how the toolkit can be best used and to determine the parameters and user-generated standards for a future effectiveness trial. The final objective will be met with a small-scale process evaluation, using the think out loud methodology, conducted with approximately 10 SGMY. Results: The study commenced on September 1, 2021, and data gathering for phase 1 began in October 2021. Conclusions: A considerable body of work has described the issues faced by the SGMY. However, there is a dearth of research seeking to develop interventions for SGMY so that they can thrive. This project aims to co-design such an intervention. Trial Registration: Research Registry Reference researchregistry6815; https://www.researchregistry.com/browse-the-registry#home/registrationdetails/609e81bda4a706001c94b63a/ International Registered Report Identifier (IRRID): PRR1-10.2196/31036 %M 35103613 %R 10.2196/31036 %U https://www.researchprotocols.org/2022/2/e31036 %U https://doi.org/10.2196/31036 %U http://www.ncbi.nlm.nih.gov/pubmed/35103613 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 1 %P e32552 %T The Impact of the COVID-19 Infodemic on Depression and Sleep Disorders: Focusing on Uncertainty Reduction Strategies and Level of Interpretation Theory %A Jung,Soyoung %A Jung,Sooin %+ The School of Journalism and Communication, Renmin University of China, 59 Zhongguancun Street, Haidian District, Room 502, Mingde Building, Beijing, 100872, China, 86 10 62514835, soyoungjungs@gmail.com %K COVID-19 %K social media %K infodemic %K construal level theory %K uncertainty reduction strategy %K depression %K sleep disorder %K preventive actions, affective reaction %K infodemiology %K misinformation %K uncertainty %K strategy %K mental health %K sleep %K prevention %K survey %K usage %K behavior %D 2022 %7 31.1.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: During the COVID-19 pandemic, information diffusion about the COVID-19 has attracted public attention through social media. The World Health Organization declared an infodemic of COVID-19 on February 15, 2020. Misinformation and disinformation, including overwhelming amounts of information about COVID-19 on social media, could promote adverse psychological effects. Objective: This study used the Psychological Distance and Level of Construal theory (CLT) to predict peoples’ negative psychological symptoms from social media usage. In this study, the CLT intended to show peoples’ psychological proximity to objects and events with respect to the COVID-19 pandemic. Furthermore, this study links the uncertainty reduction strategy (URS) and CLT for COVID-19–related preventive behaviors and affective reactions to assess their effects on mental health problems. Methods: A path model was tested (N=297) with data from a web-based survey to examine how social media usage behaviors are associated with URS and psychological distance with COVID-19 (based on the CLT), leading to preventive behaviors and affective reactions. Finally, the path model was used to examine how preventive behaviors and affective reactions are associated with mental health problems including anxiety and sleep disorder. Results: After measuring participants’ social media usage behavior, we found that an increase in general social media usage led to higher use of the URS and lower construal level on COVID-19. The URS is associated with preventive behaviors, but the CLT did not show any association with preventive behaviors; however, it increases affective reactions. Moreover, increased preventive behavior showed negative associations with symptoms of mental health problems; that is, depression and sleep disorder. However, the affective reaction tends to be positively associated with depression and sleep disorder. Owing to the infodemic of COVID-19, the psychological perception of the pandemic negatively influenced users’ mental health problems. Conclusions: Our results imply that the information from social media usage heightened concerns and had a lower construal level; this does not facilitate taking preventive actions but rather reinforces the negative emotional reaction and mental health problems. Thus, higher URS usage is desirable. %M 34870609 %R 10.2196/32552 %U https://formative.jmir.org/2022/1/e32552 %U https://doi.org/10.2196/32552 %U http://www.ncbi.nlm.nih.gov/pubmed/34870609 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 1 %P e28095 %T The Association Between Home Stay and Symptom Severity in Major Depressive Disorder: Preliminary Findings From a Multicenter Observational Study Using Geolocation Data From Smartphones %A Laiou,Petroula %A Kaliukhovich,Dzmitry A %A Folarin,Amos A %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Conde,Pauline %A Stewart,Callum %A Sun,Shaoxiong %A Zhang,Yuezhou %A Matcham,Faith %A Ivan,Alina %A Lavelle,Grace %A Siddi,Sara %A Lamers,Femke %A Penninx,Brenda WJH %A Haro,Josep Maria %A Annas,Peter %A Cummins,Nicholas %A Vairavan,Srinivasan %A Manyakov,Nikolay V %A Narayan,Vaibhav A %A Dobson,Richard JB %A Hotopf,Matthew %A , %+ Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Memory Lane, London, SE5 8AF, United Kingdom, 44 20 7848 0002, petroula.laiou@kcl.ac.uk %K major depressive disorder %K PHQ-8 %K smartphone %K GPS %K home stay %K mobile phone %D 2022 %7 28.1.2022 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Most smartphones and wearables are currently equipped with location sensing (using GPS and mobile network information), which enables continuous location tracking of their users. Several studies have reported that various mobility metrics, as well as home stay, that is, the amount of time an individual spends at home in a day, are associated with symptom severity in people with major depressive disorder (MDD). Owing to the use of small and homogeneous cohorts of participants, it is uncertain whether the findings reported in those studies generalize to a broader population of individuals with MDD symptoms. Objective: The objective of this study is to examine the relationship between the overall severity of depressive symptoms, as assessed by the 8-item Patient Health Questionnaire, and median daily home stay over the 2 weeks preceding the completion of a questionnaire in individuals with MDD. Methods: We used questionnaire and geolocation data of 164 participants with MDD collected in the observational Remote Assessment of Disease and Relapse–Major Depressive Disorder study. The participants were recruited from three study sites: King’s College London in the United Kingdom (109/164, 66.5%); Vrije Universiteit Medisch Centrum in Amsterdam, the Netherlands (17/164, 10.4%); and Centro de Investigación Biomédica en Red in Barcelona, Spain (38/164, 23.2%). We used a linear regression model and a resampling technique (n=100 draws) to investigate the relationship between home stay and the overall severity of MDD symptoms. Participant age at enrollment, gender, occupational status, and geolocation data quality metrics were included in the model as additional explanatory variables. The 95% 2-sided CIs were used to evaluate the significance of model variables. Results: Participant age and severity of MDD symptoms were found to be significantly related to home stay, with older (95% CI 0.161-0.325) and more severely affected individuals (95% CI 0.015-0.184) spending more time at home. The association between home stay and symptoms severity appeared to be stronger on weekdays (95% CI 0.023-0.178, median 0.098; home stay: 25th-75th percentiles 17.8-22.8, median 20.9 hours a day) than on weekends (95% CI −0.079 to 0.149, median 0.052; home stay: 25th-75th percentiles 19.7-23.5, median 22.3 hours a day). Furthermore, we found a significant modulation of home stay by occupational status, with employment reducing home stay (employed participants: 25th-75th percentiles 16.1-22.1, median 19.7 hours a day; unemployed participants: 25th-75th percentiles 20.4-23.5, median 22.6 hours a day). Conclusions: Our findings suggest that home stay is associated with symptom severity in MDD and demonstrate the importance of accounting for confounding factors in future studies. In addition, they illustrate that passive sensing of individuals with depression is feasible and could provide clinically relevant information to monitor the course of illness in patients with MDD. %M 35089148 %R 10.2196/28095 %U https://mhealth.jmir.org/2022/1/e28095 %U https://doi.org/10.2196/28095 %U http://www.ncbi.nlm.nih.gov/pubmed/35089148 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 1 %P e26049 %T FOCUS mHealth Intervention for Veterans With Serious Mental Illness in an Outpatient Department of Veterans Affairs Setting: Feasibility, Acceptability, and Usability Study %A Buck,Benjamin %A Nguyen,Janelle %A Porter,Shelan %A Ben-Zeev,Dror %A Reger,Greg M %+ Behavioral Research in Technology and Engineering (BRiTE) Center, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, United States, 1 206 221 8518, buckbe@uw.edu %K mHealth %K veterans %K schizophrenia %K serious mental illness %K mobile phone %D 2022 %7 28.1.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Veterans with serious mental illnesses (SMIs) face barriers to accessing in-person evidence-based interventions that improve illness management. Mobile health (mHealth) has been demonstrated to be feasible, acceptable, effective, and engaging among individuals with SMIs in community mental health settings. mHealth for SMIs has not been tested within the Department of Veterans Affairs (VA). Objective: This study examines the feasibility, acceptability, and preliminary effectiveness of an mHealth intervention for SMI in the context of VA outpatient care. Methods: A total of 17 veterans with SMIs were enrolled in a 1-month pilot trial of FOCUS, a smartphone-based self-management intervention for SMI. At baseline and posttest, they completed measures examining symptoms and functional recovery. The participants provided qualitative feedback related to the usability and acceptability of the intervention. Results: Veterans completed on an average of 85.0 (SD 96.1) interactions with FOCUS over the 1-month intervention period. They reported high satisfaction, usability, and acceptability, with nearly all participants (16/17, 94%) reporting that they would recommend the intervention to a fellow veteran. Clinicians consistently reported finding mHealth-related updates useful for informing their care. Qualitative feedback indicated that veterans thought mHealth complemented their existing VA services well and described potential opportunities to adapt FOCUS to specific subpopulations (eg, combat veterans) as well as specific delivery modalities (eg, groups). In the 1-month period, the participants experienced small improvements in self-assessed recovery, auditory hallucinations, and quality of life. Conclusions: The FOCUS mHealth intervention is feasible, acceptable, and usable among veterans. Future work should develop and examine VA-specific implementation approaches of FOCUS for this population. %M 35089151 %R 10.2196/26049 %U https://mental.jmir.org/2022/1/e26049 %U https://doi.org/10.2196/26049 %U http://www.ncbi.nlm.nih.gov/pubmed/35089151 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 1 %P e32731 %T Using the COVID-19 Pandemic to Assess the Influence of News Affect on Online Mental Health-Related Search Behavior Across the United States: Integrated Sentiment Analysis and the Circumplex Model of Affect %A Lekkas,Damien %A Gyorda,Joseph A %A Price,George D %A Wortzman,Zoe %A Jacobson,Nicholas C %+ Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, 46 Centerra Parkway, Suite 300, Office #313S, Lebanon, NH, 03766, United States, 1 603 646 7000, Damien.Lekkas.GR@dartmouth.edu %K affect %K sentiment %K circumplex %K news %K mental health %K online search behavior %K generalized mixed models %K natural language processing %K anxiety %K depression %K coronavirus %K internet %K information seeking %K behavior %K online health information %K COVID-19 %D 2022 %7 27.1.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: The digital era has ushered in an unprecedented volume of readily accessible information, including news coverage of current events. Research has shown that the sentiment of news articles can evoke emotional responses from readers on a daily basis with specific evidence for increased anxiety and depression in response to coverage of the recent COVID-19 pandemic. Given the primacy and relevance of such information exposure, its daily impact on the mental health of the general population within this modality warrants further nuanced investigation. Objective: Using the COVID-19 pandemic as a subject-specific example, this work aimed to profile and examine associations between the dynamics of semantic affect in online local news headlines and same-day online mental health term search behavior over time across the United States. Methods: Using COVID-19–related news headlines from a database of online news stories in conjunction with mental health–related online search data from Google Trends, this paper first explored the statistical and qualitative affective properties of state-specific COVID-19 news coverage across the United States from January 23, 2020, to October 22, 2020. The resultant operationalizations and findings from the joint application of dictionary-based sentiment analysis and the circumplex theory of affect informed the construction of subsequent hypothesis-driven mixed effects models. Daily state-specific counts of mental health search queries were regressed on circumplex-derived features of semantic affect, time, and state (as a random effect) to model the associations between the dynamics of news affect and search behavior throughout the pandemic. Search terms were also grouped into depression symptoms, anxiety symptoms, and nonspecific depression and anxiety symptoms to model the broad impact of news coverage on mental health. Results: Exploratory efforts revealed patterns in day-to-day news headline affect variation across the first 9 months of the pandemic. In addition, circumplex mapping of the most frequently used words in state-specific headlines uncovered time-agnostic similarities and differences across the United States, including the ubiquitous use of negatively valenced and strongly arousing language. Subsequent mixed effects modeling implicated increased consistency in affective tone (SpinVA β=–.207; P<.001) as predictive of increased depression-related search term activity, with emotional language patterns indicative of affective uncontrollability (FluxA β=.221; P<.001) contributing generally to an increase in online mental health search term frequency. Conclusions: This study demonstrated promise in applying the circumplex model of affect to written content and provided a practical example for how circumplex theory can be integrated with sentiment analysis techniques to interrogate mental health–related associations. The findings from pandemic-specific news headlines highlighted arousal, flux, and spin as potentially significant affect-based foci for further study. Future efforts may also benefit from more expansive sentiment analysis approaches to more broadly test the practical application and theoretical capabilities of the circumplex model of affect on text-based data. %M 34932494 %R 10.2196/32731 %U https://www.jmir.org/2022/1/e32731 %U https://doi.org/10.2196/32731 %U http://www.ncbi.nlm.nih.gov/pubmed/34932494 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 1 %P e29621 %T Impact of Smartphone App–Based Psychological Interventions for Reducing Depressive Symptoms in People With Depression: Systematic Literature Review and Meta-analysis of Randomized Controlled Trials %A Serrano-Ripoll,Maria J %A Zamanillo-Campos,Rocío %A Fiol-DeRoque,Maria A %A Castro,Adoración %A Ricci-Cabello,Ignacio %+ Balearic Islands Health Services, Primary Care Research Unit of Mallorca, Escola Graduada, 3, Palma de Mallorca, 07002, Spain, 34 971175883, mjserranor@yahoo.es %K smartphone technology %K mental health interventions %K depression %K eHealth %K mHealth %K apps %K systematic review %K meta-analysis %K mobile phone %D 2022 %7 27.1.2022 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Depression is a serious, disabling mental disorder that severely affects quality of life. Patients with depression often do not receive adequate treatment. App-based psychotherapy is considered to have great potential to treat depression owing to its reach and easy accessibility. Objective: We aim to analyze the impact of app-based psychological interventions for reducing depressive symptoms in people with depression. Methods: We conducted a systematic literature review and meta-analysis. We searched Medline, Embase, PsycINFO, Web of Science, and Cochrane Central Register of Controlled Trials from inception to December 23, 2020. We selected randomized controlled trials to examine the impact of app-based psychological interventions for reducing depressive symptoms in people with depression. Study selection, data extraction, and critical appraisal (using the Cochrane Risk of Bias tool for randomized studies and the ROBINS-I tool for nonrandomized studies) were conducted independently by 2 reviewers. Where possible, we pooled data using random effects meta-analyses to obtain estimates of the effect size of the intervention. We conducted post hoc meta-regression analyses to explore the factors associated with intervention success. Results: After screening 3468 unique references retrieved from bibliographic searches and assessing the eligibility of 79 full texts, we identified 12 trials (2859 participants) evaluating 14 different interventions. Of 14 trials, 7 (58%) were conducted in the United States; 3 (25%) trials, in Asia (Japan, South Korea, and China); 1 (8%) trial, in Australia; and 1 (8%) trial, in Germany. Of the 12 trials, 5 (42%) trials presented a low risk of bias. The mean duration of the interventions was 6.6 (SD 2.8) weeks. Two-thirds of the interventions were based on cognitive behavioral therapy alone or included it in combination with cognitive control therapy, positive psychology, brief behavioral activation, or mindfulness- and acceptance-based therapy. With no evidence of publication bias, a pooled analysis of 83% (10/12) of the trials and 86% (12/14) of the interventions showed that app-based interventions, compared with a control group receiving usual care or minimal intervention, produced a moderate reduction in depressive symptoms (standardized mean difference [SMD] −0.51, 95% CI −0.69 to −0.33; 2018/2859, 70.58% of the participants; I2=70%). Our meta-regression analyses indicated that there was a greater reduction in symptoms of depression (P=.04) in trials that included participants with moderate to severe depression (SMD −0.67, 95% CI −0.79 to −0.55), compared with trials with participants exhibiting mild to moderate depression (SMD −0.15, 95% CI −0.43 to −0.12). Conclusions: App-based interventions targeted at people with depression produce moderate reductions in the symptoms of depression. More methodologically robust trials are needed to confirm our findings, determine which intervention features are associated with greater improvements, and identify those populations most likely to benefit from this type of intervention. Trial Registration: PROSPERO CRD42019145689; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=145689 %M 35084346 %R 10.2196/29621 %U https://mhealth.jmir.org/2022/1/e29621 %U https://doi.org/10.2196/29621 %U http://www.ncbi.nlm.nih.gov/pubmed/35084346 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 1 %P e27641 %T A Novel Virtual Reality Assessment of Functional Cognition: Validation Study %A Porffy,Lilla Alexandra %A Mehta,Mitul A %A Patchitt,Joel %A Boussebaa,Celia %A Brett,Jack %A D’Oliveira,Teresa %A Mouchlianitis,Elias %A Shergill,Sukhi S %+ Institute of Psychiatry, Psychology & Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, United Kingdom, 44 07738244217, lilla.a.porffy@kcl.ac.uk %K virtual reality %K virtual reality assessment %K cognition %K functional cognition %K functional capacity %K neuropsychological testing %D 2022 %7 26.1.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive deficits are present in several neuropsychiatric disorders, including Alzheimer disease, schizophrenia, and depression. Assessments used to measure cognition in these disorders are time-consuming, burdensome, and have low ecological validity. To address these limitations, we developed a novel virtual reality shopping task—VStore. Objective: This study aims to establish the construct validity of VStore in relation to the established computerized cognitive battery, Cogstate, and explore its sensitivity to age-related cognitive decline. Methods: A total of 142 healthy volunteers aged 20-79 years participated in the study. The main VStore outcomes included verbal recall of 12 grocery items, time to collect items, time to select items on a self-checkout machine, time to make the payment, time to order coffee, and total completion time. Construct validity was examined through a series of backward elimination regression models to establish which Cogstate tasks, measuring attention, processing speed, verbal and visual learning, working memory, executive function, and paired associate learning, in addition to age and technological familiarity, best predicted VStore performance. In addition, 2 ridge regression and 2 logistic regression models supplemented with receiver operating characteristic curves were built, with VStore outcomes in the first model and Cogstate outcomes in the second model entered as predictors of age and age cohorts, respectively. Results: Overall VStore performance, as indexed by the total time spent completing the task, was best explained by Cogstate tasks measuring attention, working memory, paired associate learning, and age and technological familiarity, accounting for 47% of the variance. In addition, with λ=5.16, the ridge regression model selected 5 parameters for VStore when predicting age (mean squared error 185.80, SE 19.34), and with λ=9.49 for Cogstate, the model selected all 8 tasks (mean squared error 226.80, SE 23.48). Finally, VStore was found to be highly sensitive (87%) and specific (91.7%) to age cohorts, with 94.6% of the area under the receiver operating characteristic curve. Conclusions: Our findings suggest that VStore is a promising assessment that engages standard cognitive domains and is sensitive to age-related cognitive decline. %M 35080501 %R 10.2196/27641 %U https://www.jmir.org/2022/1/e27641 %U https://doi.org/10.2196/27641 %U http://www.ncbi.nlm.nih.gov/pubmed/35080501 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 1 %P e32211 %T A Virtual Coach (Motibot) for Supporting Healthy Coping Strategies Among Adults With Diabetes: Proof-of-Concept Study %A Bassi,Giulia %A Giuliano,Claudio %A Perinelli,Alessio %A Forti,Stefano %A Gabrielli,Silvia %A Salcuni,Silvia %+ Department of Developmental and Socialization Psychology, University of Padova, Via Venezia 8, Padova, 35131, Italy, 39 3477334405, giulia.bassi@phd.unipd.it %K virtual coach %K diabetes mellitus %K adults %K psychosocial factors %K mindfulness %K proof-of-concept study %K mobile phone %D 2022 %7 21.1.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Motivation is a core component of diabetes self-management because it allows adults with diabetes mellitus (DM) to adhere to clinical recommendations. In this context, virtual coaches (VCs) have assumed a central role in supporting and treating common barriers related to adherence. However, most of them are mainly focused on medical and physical purposes, such as the monitoring of blood glucose levels or following a healthy diet. Objective: This proof-of-concept study aims to evaluate the preliminary efficacy of a VC intervention for psychosocial support before and after the intervention and at follow-up. The intent of this VC is to motivate adults with type 1 DM and type 2 DM to adopt and cultivate healthy coping strategies to reduce symptoms of depression, anxiety, perceived stress, and diabetes-related emotional distress, while also improving their well-being. Methods: A total of 13 Italian adults with DM (18-51 years) interacted with a VC, called Motibot (motivational bot) using the Telegram messaging app. The interaction covered 12 sessions, each lasting 10 to 20 minutes, during which the user could dialogue with the VC by inputting text or tapping an option on their smartphone screen. Motibot is developed within the transtheoretical model of change to deliver the most appropriate psychoeducational intervention based on the user’s motivation to change. Results: Results showed that over the 12 sessions, there were no significant changes before and after the intervention and at follow-up regarding psychosocial factors. However, most users showed a downward trend over the 3 time periods in depression and anxiety symptoms, thereby presenting good psychological well-being and no diabetes-related emotional distress. In addition, users felt motivated, involved, encouraged, emotionally understood, and stimulated by Motibot during the interaction. Indeed, the analyses of semistructured interviews, using a text mining approach, showed that most users reported a perceived reduction in anxiety, depression, and/or stress symptoms. Moreover, users indicated the usefulness of Motibot in supporting and motivating them to find a mindful moment for themselves and to reflect on their own emotions. Conclusions: Motibot was well accepted by users, particularly because of the inclusion of mindfulness practices, which motivated them to adopt healthy coping skills. To this extent, Motibot provided psychosocial support for adults with DM, particularly for those with mild and moderate symptoms, whereas those with severe symptoms may benefit more from face-to-face psychotherapy. %M 35060918 %R 10.2196/32211 %U https://humanfactors.jmir.org/2022/1/e32211 %U https://doi.org/10.2196/32211 %U http://www.ncbi.nlm.nih.gov/pubmed/35060918 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 11 %N 1 %P e32234 %T Microbial Ecosystem Therapeutic-2 Intervention in People With Major Depressive Disorder and Generalized Anxiety Disorder: Phase 1, Open-Label Study %A Chinna Meyyappan,Arthi %A Forth,Evan %A Milev,Roumen %+ Department of Psychiatry, Queen's University, 752 King St. West, Kingston, ON, K7L 4X3, Canada, 1 6135444900, 14acm@queensu.ca %K gut-brain axis %K microbiome %K Microbial Ecosystem Therapeutic %K depression %K anxiety %D 2022 %7 21.1.2022 %9 Original Paper %J Interact J Med Res %G English %X Background: Recent studies have investigated the potential of treatments that modify the gut microbiome, such as fecal microbiota transplantation and probiotics, in individuals with psychiatric illnesses. Objective: The aim of this study was to investigate the safety, tolerability, and efficacy of a novel gut microbiome therapeutic, Microbial Ecosystem Therapuetic-2 (MET-2), in people with depression and anxiety. Methods: In this phase 1, open-label trial, 12 adults diagnosed with major depressive disorder, generalized anxiety disorder, or both were recruited. Over 8 weeks, participants consumed three capsules per day, orally, of an encapsulated microbial therapeutic (MET-2), which contained 40 strains of bacteria that were purified and lab-grown from the stool of a single healthy donor. Participants were assessed biweekly using clinical scales and questionnaires in order to evaluate the safety, efficacy, and tolerability of the therapeutic. Results: The therapeutic was found to be generally safe and tolerable, with limited adverse events and side effects and no serious adverse events. Of the 12 individuals included in this study, 9 (75%) responded to treatment (50% improvement in Montgomery-Asberg Depression Rating Scale [MADRS] scores, 7-item Generalized Anxiety Disorder scale [GAD-7] scores, or both, from baseline to the week-8 visit). Over the course of 10 weeks, MET-2 significantly decreased mean MADRS and GAD-7 scores (MADRS: F2.731, 30.05=8.784, P<.001; GAD-7: F2.778, 30.55= 9.638, P<.001). Multiple comparisons with Bonferroni adjustments showed a significant reduction in MADRS scores from baseline (mean 19.00, SD 4.843) to week 6 (mean 11.25, SD 8.001; P=.009), week 8 (mean 8.667, SD 8.732; P=.002), and week 10 (mean 8.250, SD 9.304; P=.006). Multiple comparisons showed a significant reduction in GAD-7 scores from baseline (mean 13.58, SD 4.010) to week 4 (mean 9.167, SD 5.096; P=.03), week 6 (mean 7.667, SD 4.539; P=.004), week 8 (mean 7.333, SD 6.583; P=.03), and week 10 (mean 7.500, SD 6.448; P=.03). Conclusions: The findings from this study are the first to provide evidence for the role of microbial ecosystem therapy in treating depression and anxiety. However, a double-blind, randomized controlled trial with a larger sample size is needed for more conclusive results. Trial Registration: ClinicalTrials.gov NCT04052451; https://www.clinicaltrials.gov/ct2/show/NCT04052451 International Registered Report Identifier (IRRID): RR2-10.2196/17223 %M 35060914 %R 10.2196/32234 %U https://www.i-jmr.org/2022/1/e32234 %U https://doi.org/10.2196/32234 %U http://www.ncbi.nlm.nih.gov/pubmed/35060914 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 1 %P e31925 %T Connectivity-Guided Theta Burst Transcranial Magnetic Stimulation Versus Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Moderate to Severe Depression: Magnetic Resonance Imaging Protocol and SARS-CoV-2–Induced Changes for a Randomized Double-blind Controlled Trial %A Pszczolkowski,Stefan %A Cottam,William J %A Briley,Paul M %A Iwabuchi,Sarina J %A Kaylor-Hughes,Catherine %A Shalabi,Abdulrhman %A Babourina-Brooks,Ben %A Berrington,Adam %A Barber,Shaun %A Suazo Di Paola,Ana %A Blamire,Andrew %A McAllister-Williams,R Hamish %A Parikh,Jehill %A Abdelghani,Mohamed %A Matthäus,Lars %A Hauffe,Ralf %A Liddle,Peter %A Auer,Dorothee P %A Morriss,Richard %+ Institute of Mental Health, School of Medicine, University of Nottingham, Room C20, Jubilee Campus, Wollaton Road, Nottingham, NG8 1BB, United Kingdom, 44 0115 823 0427, richard.morriss@nottingham.ac.uk %K depression %K magnetic resonance imaging %K image-guidance %K personalized medicine %K transcranial magnetic stimulation %D 2022 %7 20.1.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is a substantial health and economic burden. In approximately one-third of patients, depression is resistant to first-line treatment; therefore, it is essential to find alternative treatments. Transcranial magnetic stimulation (TMS) is a neuromodulatory treatment involving the application of magnetic pulses to the brain that is approved in the United Kingdom and the United States in treatment-resistant depression. This trial aims to compare the clinical effectiveness, cost-effectiveness, and mechanism of action of standard treatment repetitive TMS (rTMS) targeted at the F3 electroencephalogram site with a newer treatment—a type of TMS called theta burst stimulation (TBS) targeted based on measures of functional brain connectivity. This protocol outlines brain imaging acquisition and analysis for the Brain Imaging Guided Transcranial Magnetic Stimulation in Depression (BRIGhTMIND) study trial that is used to create personalized TMS targets and answer the proposed mechanistic hypotheses. Objective: The aims of the imaging arm of the BRIGhTMIND study are to identify functional and neurochemical brain signatures indexing the treatment mechanisms of rTMS and connectivity-guided intermittent theta burst TMS and to identify imaging-based markers predicting response to treatment. Methods: The study is a randomized double-blind controlled trial with 1:1 allocation to either 20 sessions of TBS or standard rTMS. Multimodal magnetic resonance imaging (MRI) is acquired for each participant at baseline (before TMS treatment) with T1-weighted and task-free functional MRI during rest used to estimate TMS targets. For participants enrolled in the mechanistic substudy, additional diffusion-weighted sequences are acquired at baseline and at posttreatment follow-up 16 weeks after treatment randomization. Core data sets of T1-weighted and task-free functional MRI during rest are acquired for all participants and are used to estimate TMS targets. Additional sequences of arterial spin labeling, magnetic resonance spectroscopy, and diffusion-weighted images are acquired depending on the recruitment site for mechanistic evaluation. Standard rTMS treatment is targeted at the F3 electrode site over the left dorsolateral prefrontal cortex, whereas TBS treatment is guided using the coordinate of peak effective connectivity from the right anterior insula to the left dorsolateral prefrontal cortex. Both treatment targets benefit from the level of MRI guidance, but only TBS is provided with precision targeting based on functional brain connectivity. Results: Recruitment began in January 2019 and is ongoing. Data collection is expected to continue until January 2023. Conclusions: This trial will determine the impact of precision MRI guidance on rTMS treatment and assess the neural mechanisms underlying this treatment in treatment-resistant depressed patients. Trial Registration: ISRCTN Registry ISRCTN19674644; https://www.isrctn.com/ISRCTN19674644 International Registered Report Identifier (IRRID): DERR1-10.2196/31925 %M 35049517 %R 10.2196/31925 %U https://www.researchprotocols.org/2022/1/e31925 %U https://doi.org/10.2196/31925 %U http://www.ncbi.nlm.nih.gov/pubmed/35049517 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 1 %P e28647 %T Behavioral and Self-reported Data Collected From Smartphones for the Assessment of Depressive and Manic Symptoms in Patients With Bipolar Disorder: Prospective Observational Study %A Dominiak,Monika %A Kaczmarek-Majer,Katarzyna %A Antosik-Wójcińska,Anna Z %A Opara,Karol R %A Olwert,Anna %A Radziszewska,Weronika %A Hryniewicz,Olgierd %A Święcicki,Łukasz %A Wojnar,Marcin %A Mierzejewski,Paweł %+ Department of Pharmacology and Physiology of the Nervous System, Institute of Psychiatry and Neurology, Sobieskiego 9, Warsaw, 02-957, Poland, 48 507183375, mdominia@wp.pl %K bipolar disorder %K generalized linear model %K mixed-effects regression %K classification %K manic episodes %K depressive episodes %K smartphone %K behavioral markers %K mHealth %K remote monitoring %D 2022 %7 19.1.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Smartphones allow for real-time monitoring of patients’ behavioral activities in a naturalistic setting. These data are suggested as markers for the mental state of patients with bipolar disorder (BD). Objective: We assessed the relations between data collected from smartphones and the clinically rated depressive and manic symptoms together with the corresponding affective states in patients with BD. Methods: BDmon, a dedicated mobile app, was developed and installed on patients’ smartphones to automatically collect the statistics about their phone calls and text messages as well as their self-assessments of sleep and mood. The final sample for the numerical analyses consisted of 51 eligible patients who participated in at least two psychiatric assessments and used the BDmon app (mean participation time, 208 [SD 132] days). In total, 196 psychiatric assessments were performed using the Hamilton Depression Rating Scale and the Young Mania Rating Scale. Generalized linear mixed-effects models were applied to quantify the strength of the relation between the daily statistics on the behavioral data collected automatically from smartphones and the affective symptoms and mood states in patients with BD. Results: Objective behavioral data collected from smartphones were found to be related with the BD states as follows: (1) depressed patients tended to make phone calls less frequently than euthymic patients (β=−.064, P=.01); (2) the number of incoming answered calls during depression was lower than that during euthymia (β=−.15, P=.01) and, concurrently, missed incoming calls were more frequent and increased as depressive symptoms intensified (β=4.431, P<.001; β=4.861, P<.001, respectively); (3) the fraction of outgoing calls was higher in manic states (β=2.73, P=.03); (4) the fraction of missed calls was higher in manic/mixed states as compared to that in the euthymic state (β=3.53, P=.01) and positively correlated to the severity of symptoms (β=2.991, P=.02); (5) the variability of the duration of the outgoing calls was higher in manic/mixed states (β=.0012, P=.045) and positively correlated to the severity of symptoms (β=.0017, P=.02); and (6) the number and length of the sent text messages was higher in manic/mixed states as compared to that in the euthymic state (β=.031, P=.01; β=.015, P=.01; respectively) and positively correlated to the severity of manic symptoms (β=.116, P<.001; β=.022, P<.001; respectively). We also observed that self-assessment of mood was lower in depressive (β=−1.452, P<.001) and higher in manic states (β=.509, P<.001). Conclusions: Smartphone-based behavioral parameters are valid markers for assessing the severity of affective symptoms and discriminating between mood states in patients with BD. This technology opens a way toward early detection of worsening of the mental state and thereby increases the patient’s chance of improving in the course of the illness. %M 34874015 %R 10.2196/28647 %U https://www.jmir.org/2022/1/e28647 %U https://doi.org/10.2196/28647 %U http://www.ncbi.nlm.nih.gov/pubmed/34874015 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 8 %N 1 %P e32140 %T Patterns of Suicide Ideation Across Eight Countries in Four Continents During the COVID-19 Pandemic Era: Repeated Cross-sectional Study %A Schluter,Philip J %A Généreux,Mélissa %A Hung,Kevin KC %A Landaverde,Elsa %A Law,Ronald P %A Mok,Catherine Pui Yin %A Murray,Virginia %A O'Sullivan,Tracey %A Qadar,Zeeshan %A Roy,Mathieu %+ School of Health Sciences, University of Canterbury - Te Whare Wananga o Waitaha, Private Bag 4800, Christchurch, 8140, New Zealand, 64 275106239, philip.schluter@canterbury.ac.nz %K pandemic %K infodemic %K psychosocial impacts %K sense of coherence %K suicide ideation %K epidemiology %K suicide %K pattern %K COVID-19 %K cross-sectional %K mental health %K misinformation %K risk %K prevalence %K gender %K age %K sociodemographic %D 2022 %7 17.1.2022 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The COVID-19 pandemic and countries’ response measures have had a globally significant mental health impact. This mental health burden has also been fueled by an infodemic: an information overload that includes misinformation and disinformation. Suicide, the worst mental health outcome, is a serious public health problem that can be prevented with timely, evidence-based, and often low-cost interventions. Suicide ideation, one important risk factor for suicide, is thus important to measure and monitor, as are the factors that may impact on it. Objective: This investigation had 2 primary aims: (1) to estimate and compare country-specific prevalence of suicide ideation at 2 different time points, overall and by gender and age groups, and (2) to investigate the influence of sociodemographic and infodemic variables on suicide ideation. Methods: A repeated, online, 8-country (Canada, the United States, England, Switzerland, Belgium, Hong Kong, Philippines, and New Zealand), cross-sectional study was undertaken with adults aged ≥18 years, with measurement wave 1 conducted from May 29, 2020 to June 12, 2020 and measurement wave 2 conducted November 6-18, 2021. Self-reported suicide ideation was derived from item 9 of the Patient Health Questionnaire-9 (PHQ-9). Age-standardized suicide ideation rates were reported, a binomial regression model was used to estimate suicide ideation indication rates for each country and measurement wave, and logistic regression models were then employed to relate sociodemographic, pandemic, and infodemic variables to suicide ideation. Results: The final sample totaled 17,833 adults: 8806 (49.4%) from measurement wave 1 and 9027 (50.6%) from wave 2. Overall, 24.2% (2131/8806) and 27.5% (2486/9027) of participants reported suicide ideation at measurement waves 1 and 2, respectively, a difference that was significant (P<.001). Considerable variability was observed in suicide ideation age-standardized rates between countries, ranging from 15.6% in Belgium (wave 1) to 42.9% in Hong Kong (wave 2). Frequent social media usage was associated with increased suicide ideation at wave 2 (adjusted odds ratio [AOR] 1.47, 95% CI 1.25-1.72; P<.001) but not wave 1 (AOR 1.11, 95% CI 0.96-1.23; P=.16). However, having a weaker sense of coherence (SOC; AOR 3.80, 95% CI 3.18-4.55 at wave 1 and AOR 4.39, 95% CI 3.66-5.27 at wave 2; both P<.001) had the largest overall effect size. Conclusions: Suicide ideation is prevalent and significantly increasing over time in this COVID-19 pandemic era, with considerable variability between countries. Younger adults and those residing in Hong Kong carried disproportionately higher rates. Social media appears to have an increasingly detrimental association with suicide ideation, although having a stronger SOC had a larger protective effect. Policies and promotion of SOC, together with disseminating health information that explicitly tackles the infodemic’s misinformation and disinformation, may importantly reduce the rising mental health morbidity and mortality triggered by this pandemic. %M 34727524 %R 10.2196/32140 %U https://publichealth.jmir.org/2022/1/e32140 %U https://doi.org/10.2196/32140 %U http://www.ncbi.nlm.nih.gov/pubmed/34727524 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 1 %P e34915 %T Effects of Aerobic Exercise and High-Intensity Interval Training on the Mental Health of Adolescents Living in Poverty: Protocol for a Randomized Controlled Trial %A Poon,Kean %+ Department of Special Education and Counselling, The Education University of Hong Kong, 10 Lo Ping Road, Tai Po, New Territories, Hong Kong, 852 2948 8303, kean@eduhk.hk %K adolescents %K mental health %K exercise %K socioeconomic status %K intervention %D 2022 %7 17.1.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: The increasing rate of mental health issues among adolescents has recently been a considerable concern in Hong Kong. In particular, adolescents with low socioeconomic status (SES) are likely to experience poor mental health, including low self-esteem and high levels of anxiety, anger, and depression. Previous research has found that physical activities have a positive impact on improving mental health outcomes among adolescents. However, approximately 96% of adolescents in Hong Kong do not engage in regular exercise, which potentially increases the risk of poor mental health. Objective: In this study, we aim to examine whether changes in the 3 indicators (reduced ill-being, enhanced well-being, and cognitive functions) of mental health among adolescents with low SES are evident before and after exercise. In addition, this study compares the effectiveness of aerobic exercise and high-intensity interval training on these indicators among adolescents with low SES. Methods: A total of 78 participants from low-income families aged between 12 and 15 years from 3 to 4 secondary schools will be recruited for this study. They will be randomly assigned to either an aerobic exercise group (26/78, 33%), a high-intensity interval training group (26/78, 33%), or a control group (26/78, 33%). Participants in the first 2 groups will take part in a 10-week training program period. Participants in the control group will participate in other physical activities during the same intervention period. The training sessions will be conducted 3 times per week on nonconsecutive days. A range of neuropsychological tests and psychometric scales will be used to measure the executive functions and indicators of psychological well-being and ill-being, including enjoyment, self-efficacy, mood, depression, anxiety, and stress at pretest, posttest, and follow-up assessments. Results: The project was funded in 2021 by the Research Matching Grant Scheme, through the University Grants Committee of the Hong Kong Special Administrative Region Government. Ethical approval has been obtained from the author’s institution. Participant recruitment will begin in January 2022 and continue through to April 2022. Data collection and follow-up are expected to be completed by the end of 2022. The results are expected to be submitted for publication in 2023. Conclusions: The findings will help inform policy makers and practitioners in promoting the importance of physical exercise to enhance mental health. Trial Registration: ClinicalTrials.gov NCT050293888; https://clinicaltrials.gov/ct2/show/record/NCT05029388 International Registered Report Identifier (IRRID): PRR1-10.2196/34915 %M 35037892 %R 10.2196/34915 %U https://www.researchprotocols.org/2022/1/e34915 %U https://doi.org/10.2196/34915 %U http://www.ncbi.nlm.nih.gov/pubmed/35037892 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 1 %P e30163 %T The Safety, Clinical, and Neurophysiological Effects of Intranasal Ketamine in Patients Who Do Not Respond to Electroconvulsive Therapy: Protocol for a Pilot, Open-Label Clinical Trial %A Knyahnytska,Yuliya %A Zomorrodi,Reza %A Kaster,Tyler %A Voineskos,Daphne %A Trevizol,Alisson %A Blumberger,Daniel %+ Centre for Addiction and Mental Health, 1025 Queen Str West, B1-2104, Toronto, ON, M6J 1H4, Canada, 1 4165358501 ext 34648, Yuliya.Knyahnytska@camh.ca %K intranasal %K racemic ketamine %K NMDA antagonist %K treatment resistant depression %K electroconvulsive therapy nonresponders %K drug %K treatment %K ketamine %K depression %K mental health %K safety %K neurophysiological %K side effect %K biomarker %K clinical trial %K alternative %D 2022 %7 17.1.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Major depressive disorder is among the most disabling illnesses worldwide, with a lifetime prevalence of 16.2%. Research suggests that 20% to 40% of patients with depression do not respond to pharmacotherapy, developing treatment-resistant depression. Electroconvulsive therapy is the gold standard for treating individuals with treatment-resistant depression, with remission rates of approximately 75% to 90%. However, 10% to 25% of patients do not respond to electroconvulsive therapy, and many are unable to tolerate it due to the side effects. Both groups are considered to be patients who do not respond to electroconvulsive therapy, because both groups continue to exhibit symptoms of severe depression, have a limited number of treatment options available, and are in need of rapid treatment. Ketamine, an N-methyl-D-aspartate receptor antagonist, has been shown to exert rapid antidepressant effects in patients with treatment-resistant depression when administered in subanesthetic doses through 40-minute intravenous infusions. Recently, a ketamine compound, esketamine (Spravato), that is administered through the intranasal route received regulatory approval by the US Food and Drug Administration and Health Canada to treat depression. However, esketamine is challenging to access due to high costs and limited availability. Racemic ketamine (rketamine) is cheap and easy to access; however, the effects in patients who have not responded to electroconvulsive therapy have yet to be understood or tested. This study will use transcranial magnetic stimulation to study mechanisms of human brain cortical physiology at the systemic level to identify neurobiomarkers of response. Objective: The objective of this open-label pilot clinical trial is to test the feasibility and safety of intranasal ketamine in patients who have not responded to electroconvulsive therapy. The primary outcome is to determine the feasibility of a larger randomized controlled trial to test the efficacy of intranasal ketamine for patients who have not responded to electroconvulsive therapy for clinical indicators in unipolar depression. The secondary outcome is to determine the preliminary effects of an intervention on clinical outcomes, such as depressive symptoms, suicidal ideation, and quality of living. The third outcome is to explore neurophysiological changes as measured by transcranial magnetic stimulation electromyography and electroencephalography to measure changes in cortical excitability as potential predictors of clinical response. Methods: A sterile solution of racemic ketamine hydrochloride will be administered twice per week for 4 weeks (8 sessions) intranasally to patients with treatment-resistant depression who did not respond to or could not tolerate an acute course of electroconvulsive therapy. We will recruit 25 adults (24-65 years old) over the course of 2 years from an academic psychiatric hospital in Toronto, Canada. Results: This study has received ethics approval, and funding has been secured. The study is currently active. Conclusions: This is the first study to test repeated doses of intranasal rketamine in patients who have not responded to electroconvulsive therapy for depression. Results from this study will (1) inform the development of a larger adequately powered randomized controlled trial to test the efficacy of intranasal ketamine for depression and (2) determine potential neurophysiological markers of clinical response. Trial Registration: Clinical Trials.gov NCT05137938; http://clinicaltrials.gov/ct2/show/NCT05137938 International Registered Report Identifier (IRRID): PRR1-10.2196/30163 %M 34882570 %R 10.2196/30163 %U https://www.researchprotocols.org/2022/1/e30163 %U https://doi.org/10.2196/30163 %U http://www.ncbi.nlm.nih.gov/pubmed/34882570 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e32331 %T The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis %A Abd-Alrazaq,Alaa %A Al-Jafar,Eiman %A Alajlani,Mohannad %A Toro,Carla %A Alhuwail,Dari %A Ahmed,Arfan %A Reagu,Shuja Mohd %A Al-Shorbaji,Najeeb %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, PO Box 34110, Doha Al Luqta St, Ar-Rayyan, Doha, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K serious games %K exergames %K depression %K cognitive behavioral therapy %K systematic reviews %K meta-analysis %D 2022 %7 14.1.2022 %9 Review %J JMIR Serious Games %G English %X Background: Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings. Objective: This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies. Methods: A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine “Google Scholar,” and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games). Results: From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (P=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (P=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (P=.003). Conclusions: Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969 %M 35029530 %R 10.2196/32331 %U https://games.jmir.org/2022/1/e32331 %U https://doi.org/10.2196/32331 %U http://www.ncbi.nlm.nih.gov/pubmed/35029530 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 1 %P e27939 %T Effectiveness of Live Health Professional–Led Group eHealth Interventions for Adult Mental Health: Systematic Review of Randomized Controlled Trials %A Currie,Cheryl L %A Larouche,Richard %A Voss,M Lauren %A Trottier,Maegan %A Spiwak,Rae %A Higa,Erin %A Scott,David R %A Tallow,Treena %+ Faculty of Health Sciences, University of Lethbridge, 4401 University Drive, Lethbridge, AB, T1K 3M4, Canada, 1 4033324060, cheryl.currie@uleth.ca %K systematic review %K telemedicine %K eHealth %K mHealth %K e-therapy %K mobile interventions %K internet %K adult %K mental health %K anxiety %K depression %K substance use %K bereavement %K physical activity %K CBT %K psychotherapy %K group %K synchronous %K videoconference %K teleconference %D 2022 %7 11.1.2022 %9 Review %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has had adverse impacts on mental health and substance use worldwide. Systematic reviews suggest eHealth interventions can be effective at addressing these problems. However, strong positive eHealth outcomes are often tied to the intensity of web-based therapist guidance, which has time and cost implications that can make the population scale-up of more effective interventions difficult. A way to offset cost while maintaining the intensity of therapist guidance is to offer eHealth programs to groups rather than more standard one-on-one formats. Objective: This systematic review aims to assess experimental evidence for the effectiveness of live health professional–led group eHealth interventions on mental health, substance use, or bereavement among community-dwelling adults. Within the articles selected for our primary aim, we also seek to examine the impact of interventions that encourage physical activity compared with those that do not. Methods: Overall, 4 databases (MEDLINE, CINAHL, PsycINFO, and the Cochrane Library) were searched in July 2020. Eligible studies were randomized controlled trials (RCTs) of eHealth interventions led by health professionals and delivered entirely to adult groups by videoconference, teleconference, or webchat. Eligible studies reported mental health, substance use, or bereavement as primary outcomes. The results were examined by outcome, eHealth platform, and intervention length. Postintervention data were used to calculate effect size by study. The findings were summarized using the Synthesis Without Meta-Analysis guidelines. Risk of bias was assessed using the Cochrane Collaboration Tool. Results: Of the 4099 identified studies, 21 (0.51%) RCTs representing 20 interventions met the inclusion criteria. These studies examined mental health outcomes among 2438 participants (sample size range: 47-361 participants per study) across 7 countries. When effect sizes were pooled, live health professional–led group eHealth interventions had a medium effect on reducing anxiety compared with inactive (Cohen d=0.57) or active control (Cohen d=0.48), a medium to small effect on reducing depression compared with inactive (Cohen d=0.61) or active control (Cohen d=0.21), and mixed effects on mental distress and coping. Interventions led by videoconference, and those that provided 8-12 hours of live health professional–led group contact had more robust effects on adult mental health. Risk of bias was high in 91% (19/21) of the studies. Heterogeneity across interventions was significant, resulting in low to very low quality of evidence. No eligible RCT was found that examined substance use, bereavement, or physical activity. Conclusions: Live eHealth group interventions led by health professionals can foster moderate improvements in anxiety and moderate to small improvements in depression among community-based adults, particularly those delivered by videoconference and those providing 8-12 hours of synchronous engagement. Trial Registration: PROSPERO CRD42020187551; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=187551 International Registered Report Identifier (IRRID): RR2-10.1186/s13643-020-01479-3 %M 34878409 %R 10.2196/27939 %U https://www.jmir.org/2022/1/e27939 %U https://doi.org/10.2196/27939 %U http://www.ncbi.nlm.nih.gov/pubmed/34878409 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 1 %P e30565 %T Developing a Web-Based App to Assess Mental Health Difficulties in Secondary School Pupils: Qualitative User-Centered Design Study %A Burn,Anne-Marie %A Ford,Tamsin J %A Stochl,Jan %A Jones,Peter B %A Perez,Jesus %A Anderson,Joanna K %+ Department of Psychiatry, University of Cambridge, Cambridge Biomedical Campus, , Cambridge, CB2 0SZ, United Kingdom, 44 1223 465 192, amb278@medschl.cam.ac.uk %K mental health %K assessment %K young people %K youth %K schools %K computerized adaptive testing %K mobile apps %K user-centered design %K coproduction %K qualitative study %D 2022 %7 10.1.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Secondary schools are an ideal setting to identify young people experiencing mental health difficulties such as anxiety or depression. However, current methods of identification rely on cumbersome paper-based assessments, which are lengthy and time-consuming to complete and resource-intensive for schools to manage. Artemis-A is a prototype web app that uses computerized adaptive testing technology to shorten the length of the assessment and provides schools with a simple and feasible solution for mental health assessment. Objective: The objectives of this study are to coproduce the main components of the Artemis-A app with stakeholders to enhance the user interface, to carry out usability testing and finalize the interface design and functionality, and to explore the acceptability and feasibility of using Artemis-A in schools. Methods: This study involved 2 iterative design feedback cycles—an initial stakeholder consultation to inform the app design and user testing. Using a user-centered design approach, qualitative data were collected through focus groups and interviews with secondary school pupils, parents, school staff, and mental health professionals (N=48). All transcripts were thematically analyzed. Results: Initial stakeholder consultations provided feedback on preferences for the user interface design, school administration of the assessment, and outcome reporting. The findings informed the second iteration of the app design and development. The unmoderated usability assessment indicated that young people found the app easy to use and visually appealing. However, school staff suggested that additional features should be added to the school administration panel, which would provide them with more flexibility for data visualization. The analysis identified four themes relating to the implementation of the Artemis-A in schools, including the anticipated benefits and drawbacks of the app. Actionable suggestions for designing mental health assessment apps are also provided. Conclusions: Artemis-A is a potentially useful tool for secondary schools to assess the mental health of their pupils that requires minimal staff input and training. Future research will evaluate the feasibility and effectiveness of Artemis-A in a range of UK secondary schools. %M 35006079 %R 10.2196/30565 %U https://formative.jmir.org/2022/1/e30565 %U https://doi.org/10.2196/30565 %U http://www.ncbi.nlm.nih.gov/pubmed/35006079 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 1 %P e32550 %T A Text Messaging–Enhanced Intervention for African American Patients With Heart Failure, Depression, and Anxiety (TXT COPE-HF): Protocol for a Pilot Feasibility Study %A Cornelius,Judith %A Whitaker-Brown,Charlene %A Smoot,Jaleesa %A Hart,Sonia %A Lewis,Zandria %A Smith,Olivia %+ School of Nursing, University of North Carolina at Charlotte, 9201 University City Blvd, Charlotte, NC, 28223, United States, 1 7046877978, jbcornel@uncc.edu %K African American %K heart failure %K depression %K anxiety %K assessment %K decision %K administration %K production %K topical expert %K integration %K training and testing model %K text messaging %K SMS %K minorities %K behavior therapy %D 2022 %7 7.1.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: African Americans have a higher incidence rate of heart failure (HF) and an earlier age of HF onset compared to those of other racial and ethnic groups. Scientific literature suggests that by 2030, African Americans will have a 30% increased prevalence rate of HF coupled with depression. In addition to depression, anxiety is a predictor of worsening functional capacity, decreased quality of life, and increased hospital readmission rates. There is no consensus on the best way to treat patients with HF, depression, and anxiety. One promising type of treatment—cognitive behavioral therapy (CBT)—has been shown to significantly improve patients’ quality of life and treatment compliance, but CBT has not been used with SMS text messaging reminders to enhance the effect of reducing symptoms of depression and anxiety in racial and ethnic minority patients with HF. Objective: The objectives of our study are to (1) adapt and modify the Creating Opportunities for Personal Empowerment (COPE) curriculum for delivery to patients with HF by using an SMS text messaging component to improve depression and anxiety symptoms, (2) administer the adapted intervention to 10 patients to examine the feasibility and acceptability of the approach and modify it as needed, and (3) examine trends in depression and anxiety symptoms postintervention. We hypothesize that patients will show an improvement in depression scores and anxiety symptoms postintervention. Methods: The study will comprise a mixed methods approach. We will use the eight steps of the ADAPT-ITT (assessment, decision, administration, production, topical expert, integration, training, and testing) model to adapt the intervention. The first step in this feasibility study will involve assembling individuals from the target population (n=10) to discuss questions on a specific topic. In phase 2, we will examine the feasibility and acceptability of the enhanced SMS text messaging intervention (TXT COPE-HF [Texting With COPE for Patients With HF]) and its preliminary effects with 10 participants. The Beck Depression Inventory will be used to assess depression, the State-Trait Anxiety Inventory will be used to assess anxiety, and the Healthy Beliefs and Lifestyle Behavior surveys will be used to assess participants’ lifestyle beliefs and behavior changes. Changes will be compared from baseline to end point by using paired 2-tailed t tests. An exit focus group (n=10) will be held to examine facilitators and barriers to the SMS text messaging protocol. Results: The pilot feasibility study was funded by the Academy for Clinical Research and Scholarship. Institutional review board approval was obtained in April 2021. Data collection and analysis are expected to conclude by November 2021 and April 2022, respectively. Conclusions: The study results will add to the literature on the effectiveness of an SMS text messaging CBT-enhanced intervention in reducing depression and anxiety among African American patients with HF. International Registered Report Identifier (IRRID): PRR1-10.2196/32550 %M 34994709 %R 10.2196/32550 %U https://www.researchprotocols.org/2022/1/e32550 %U https://doi.org/10.2196/32550 %U http://www.ncbi.nlm.nih.gov/pubmed/34994709 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 1 %P e30077 %T Effectiveness of Digital Counseling Environments on Anxiety, Depression, and Adherence to Treatment Among Patients Who Are Chronically Ill: Systematic Review %A Paalimäki-Paakki,Karoliina %A Virtanen,Mari %A Henner,Anja %A Nieminen,Miika T %A Kääriäinen,Maria %+ Research Unit of Nursing Science and Health Management, University of Oulu, Aapistie 5 A, Oulu, 90220, Finland, 358 505365959, karoliina.paalimaki-paakki@oamk.fi %K mHealth %K mobile health %K eHealth %K digital health %K mobile apps %K smartphone apps %K web-based %K telemedicine %K chronic diseases %K noncommunicable diseases %K web-based interventions %K mobile phone %D 2022 %7 6.1.2022 %9 Review %J J Med Internet Res %G English %X Background: Patients who are chronically ill need novel patient counseling methods to support their self-care at different stages of the disease. At present, knowledge of how effective digital counseling is at managing patients’ anxiety, depression, and adherence to treatment seems to be fragmented, and the development of digital counseling will require a more comprehensive view of this subset of interventions. Objective: This study aims to identify and synthesize the best available evidence on the effectiveness of digital counseling environments at improving anxiety, depression, and adherence to treatment among patients who are chronically ill. Methods: Systematic searches of the EBSCO (CINAHL), PubMed, Scopus, and Web of Science databases were conducted in May 2019 and complemented in October 2020. The review considered studies that included adult patients aged ≥18 years with chronic diseases; interventions evaluating digital (mobile, web-based, and ubiquitous) counseling interventions; and anxiety, depression, and adherence to treatment, including clinical indicators related to adherence to treatment, as outcomes. Methodological quality was assessed using the standardized Joanna Briggs Institute critical appraisal tool for randomized controlled trials or quasi-experimental studies. As a meta-analysis could not be conducted because of considerable heterogeneity in the reported outcomes, narrative synthesis was used to synthesize the results. Results: Of the 2056 records screened, 20 (0.97%) randomized controlled trials, 4 (0.19%) pilot randomized controlled trials, and 2 (0.09%) quasi-experimental studies were included. Among the 26 included studies, 10 (38%) digital, web-based interventions yielded significantly positive effects on anxiety, depression, adherence to treatment, and the clinical indicators related to adherence to treatment, and another 18 (69%) studies reported positive, albeit statistically nonsignificant, changes among patients who were chronically ill. The results indicate that an effective digital counseling environment comprises high-quality educational materials that are enriched with multimedia elements and activities that engage the participant in self-care. Because of the methodological heterogeneity of the included studies, it is impossible to determine which type of digital intervention is the most effective for managing anxiety, depression, and adherence to treatment. Conclusions: This study provides compelling evidence that digital, web-based counseling environments for patients who are chronically ill are more effective than, or at least comparable to, standard counseling methods; this suggests that digital environments could complement standard counseling. %M 34989681 %R 10.2196/30077 %U https://www.jmir.org/2022/1/e30077 %U https://doi.org/10.2196/30077 %U http://www.ncbi.nlm.nih.gov/pubmed/34989681 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 1 %P e34054 %T Multipurpose Mobile Apps for Mental Health in Chinese App Stores: Content Analysis and Quality Evaluation %A Wu,Xiaoqian %A Xu,Lin %A Li,PengFei %A Tang,TingTing %A Huang,Cheng %+ College of Medical Informatics, Chongqing Medical University, No.1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China, 86 023 6848 0060, huangcheng@cqmu.edu.cn %K mobile apps %K app %K mental health %K mHealth %K content analysis %D 2022 %7 4.1.2022 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental disorders impose varying degrees of burden on patients and their surroundings. However, people are reluctant to take the initiative to seek mental health services because of the uneven distribution of resources and stigmatization. Thus, mobile apps are considered an effective way to eliminate these obstacles and improve mental health awareness. Objective: This study aims to evaluate the quality, function, privacy measures, and evidence-based and professional background of multipurpose mental health apps in Chinese commercial app stores. Methods: A systematic search was conducted on iOS and Android platforms in China to identify multipurpose mental health apps. Two independent reviewers evaluated the identified mobile apps using the Mobile App Rating Scale (MARS). Each app was downloaded, and the general characteristics, privacy and security measures, development background, and functional characteristics of each app were evaluated. Results: A total of 40 apps were analyzed, of which 35 (87.5%) were developed by companies and 33 (82.5%) provided links to access the privacy policy; 21 (52.5%) apps did not mention the involvement of relevant professionals or the guidance of a scientific basis in the app development process. The main built-in functions of these apps include psychological education (38/40, 95%), self-assessment (34/40, 85%), and counseling (33/40, 82.5%). The overall quality average MARS score of the 40 apps was 3.54 (SD 0.39), and the total score was between 2.96 and 4.30. The total MARS score was significantly positively correlated with the scores of each subscale (r=0.62-0.88, P<.001). However, the user score of the app market was not significantly correlated with the total MARS score (r=0.17, P=.33). Conclusions: The quality of multipurpose mental health apps in China’s main app market is generally good. However, health professionals are less involved in the development of these apps, and the privacy protection policy of the apps also needs to be described in more detail. This study provides a reference for the development of multipurpose mental health apps. %M 34982717 %R 10.2196/34054 %U https://mhealth.jmir.org/2022/1/e34054 %U https://doi.org/10.2196/34054 %U http://www.ncbi.nlm.nih.gov/pubmed/34982717 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e43850 %T Public Interest in Psilocybin and Psychedelic Therapy in the Context of the COVID-19 Pandemic: Google Trends Analysis %A Danias,George %A Appel,Jacob %+ Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY, 10029, United States, 1 7189153386, george.danias@icahn.mssm.edu %K psilocybin %K Google Trends %K COVID-19 %K medical informatics %K depression %K anxiety %K substance use %K social media %K trend analysis %K antidepressant %D 2023 %7 29.12.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Psychedelic substances have demonstrated promise in the treatment of depression, anxiety, and substance use disorders. Significant media coverage has been dedicated to psychedelic medicine, but it is unclear whether the public associates psilocybin with its potential therapeutic benefits. The COVID-19 pandemic led to an increase in depression, anxiety, and substance abuse in the general population. Objective: This study attempts to link increases in interest in these disorders with increases in interest in psilocybin using Google Trends. Methods: Weekly interest-over-time Google Trends data for 4 years, from the week of March 11, 2018, to the week of March 6, 2022, were obtained for the following terms: “psilocybin,” “psychedelic therapy,” “cannabis,” “cocaine,” “antidepressant,” “depression,” “anxiety,” and “addiction.” Important psilocybin-related news and the declaration of the pandemic were noted. Trends data for each of the queried terms were plotted, and multiple regression analysis was performed to determine the slope of the prepandemic and postpandemic data with 95% CIs. Nonparametric Tau-U analysis was performed correcting for baseline trends. Results from this test were used to make inferences about the pre- and postpandemic trends and inferences about the change in overall level of searches between the 2 groups. Results: Tau values for prepandemic data were significant for stable trends, all ranging –0.4 to 0.4. Tau values for postpandemic data showed positive trends for “psilocybin,” “psychedelic therapy,” and “antidepressant.” All other trends remained stable in the range of –0.4 to 0.4. When comparing Tau values for pre- and postpandemic data, overall increases in relative search volume (RSV) were seen for “psilocybin,” “psychedelic therapy,” and “anxiety,” and overall decreases in RSV were seen for “depression,” “addiction,” and “cocaine.” Overall RSVs for “cannabis” and “antidepressant” remained stable as Tau values ranged between –0.4 and 0.4. In the immediate aftermath of the declaration of the pandemic, drop-offs in interest were seen for all terms except for “anxiety” and “cannabis.” After the initial shock of a global pandemic, “psilocybin” and “psychedelic therapy” groups demonstrated increases in interest trends and overall RSV. Conclusions: These data suggest that overall interest in “psilocybin” and “psychedelic therapy” increased at higher rates and to higher levels after than before the declaration of the pandemic. This is consistent with our hypothesis that interest increased for these treatments after the pandemic as incidence of depression, anxiety, and addiction increased. However, there may be other drivers of interest for these topics, since interest in antidepressants—the typical pharmacologic treatments for depression and anxiety—followed the expected pattern of drop-off and accelerated interest back to prepandemic levels. Interest in “psilocybin” and “psychedelic therapy” may have also been partially driven by popular culture hype and novelty, explaining why interest increased at a higher rate post pandemic and continued to grow, surpassing prior interest. %M 38064635 %R 10.2196/43850 %U https://formative.jmir.org/2023/1/e43850 %U https://doi.org/10.2196/43850 %U http://www.ncbi.nlm.nih.gov/pubmed/38064635 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e51102 %T Efficacy of an Electronic Cognitive Behavioral Therapy Program Delivered via the Online Psychotherapy Tool for Depression and Anxiety Related to the COVID-19 Pandemic: Pre-Post Pilot Study %A Moghimi,Elnaz %A Stephenson,Callum %A Agarwal,Anika %A Nikjoo,Niloofar %A Malakouti,Niloufar %A Layzell,Gina %A O'Riordan,Anne %A Jagayat,Jasleen %A Shirazi,Amirhossein %A Gutierrez,Gilmar %A Khan,Ferwa %A Patel,Charmy %A Yang,Megan %A Omrani,Mohsen %A Alavi,Nazanin %+ Department of Psychiatry, Faculty of Health Sciences, Queen's University, 166 Brock Street, Kingston, ON, K7L 5G23, Canada, 1 6135443310, nazanin.alavitabari@kingstonhsc.ca %K mental health %K depression %K anxiety %K cognitive behavioral therapy %K online %K COVID-19 %K efficacy %K electronic cognitive behavioral therapy %K online psychotherapy tool %K pandemic %K evidence-based treatment %D 2023 %7 25.12.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Lockdowns and social distancing resulting from the COVID-19 pandemic have worsened the population’s mental health and made it more difficult for individuals to receive care. Electronic cognitive behavioral therapy (e-CBT) is a cost-effective and evidence-based treatment for anxiety and depression and can be accessed remotely. Objective: The objective of the study was to investigate the efficacy of online psychotherapy tailored to depression and anxiety symptoms during the pandemic. Methods: The pilot study used a pre-post design to evaluate the efficacy of a 9-week e-CBT program designed for individuals with depression and anxiety affected by the pandemic. Participants were adults (N=59) diagnosed with major depressive disorder and generalized anxiety disorder, whose mental health symptoms initiated or worsened during the COVID-19 pandemic. The online psychotherapy program focused on teaching coping, mindfulness, and problem-solving skills. Symptoms of anxiety and depression, resilience, and quality of life were assessed. Results: Participants demonstrated significant improvements in symptoms of anxiety (P=.02) and depression (P=.03) after the intervention. Similar trends were observed in the intention-to-treat analysis. No significant differences were observed in resilience and quality-of-life measures. The sample comprised mostly females, making it challenging to discern the benefits of the intervention in males. Although a pre-post design is less rigorous than a controlled trial, this design was selected to observe changes in scores during a critical period. Conclusions: e-CBT for COVID-19 is an effective and accessible treatment option. Improvements in clinical symptoms of anxiety and depression can be observed in individuals whose mental health is affected by the COVID-19 pandemic. Trial Registration: ClinicalTrials.gov NCT04476667; https://clinicaltrials.gov/study/NCT04476667 International Registered Report Identifier (IRRID): RR2-10.2196/24913 %M 37993984 %R 10.2196/51102 %U https://mental.jmir.org/2023/1/e51102 %U https://doi.org/10.2196/51102 %U http://www.ncbi.nlm.nih.gov/pubmed/37993984 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e46579 %T Exploring Counselor Practices and Risk Assessment in a Proactive Digital Intervention Through Instagram in Young People: Qualitative Study %A Peart,Natalie %A Hetrick,Sarah %A Gibson,Kerry %A Stasiak,Karolina %+ Department of Psychology, University of Auckland, 23 Symonds Street, Auckland, 1023, New Zealand, 64 276758552, nnatalie.peart@auckland.ac.nz %K counseling %K distress %K empathize %K internet %K mental health %K online text %K proactive %K qualitative study %K risk assessment %K self-harm %K social media %K suicide %K validation %K youth %D 2023 %7 25.12.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Suicide is one of the leading causes of preventable death in young people, and the way young people are communicating suicidality has evolved to include web-based disclosures and help-seeking. To date, mental health intervention services, both on the web and in person, have been conceived in the traditional model, whereby support is provided if a young person (or their family) actively seeks out that support when distressed. On the other hand, proactive outreach is an innovative approach to intervention that has been shown to be effective in other areas of health care. Live for Tomorrow chat was delivered on Instagram and comprised of counselors who reach out to provide brief person-centered intervention to young people who post content indicating distress or suicidality. Objective: Our aim was to explore how counselors engaged young people in a proactive digital intervention and how risk assessment was conducted in this context. Methods: We analyzed 35 transcripts of conversations between counselors and young people aged 13-25 years using the 6-step approach of Braun and Clarke’s reflexive thematic analysis. These transcripts included a counseling intervention and a follow-up chat that was aimed at collecting feedback about the counseling intervention. Results: A total of 7 themes emerged: using microskills to facilitate conversations, building confidence and capacity to cope with change, seeking permission when approaching conversations about suicidality or self-harm, conversations about suicidality following a structured approach, providing assurances of confidentiality, validation of the experience of suicidality, and using conversations about suicidality to identify interventions. Counselors were able to translate counseling microskills and structured questioning regarding suicidality into a digital context. In particular, in the digital context, counselors would use the young person’s post and emojis to further conversations and build rapport. Conclusions: The findings highlight the importance of the counselor’s role to listen, empathize, validate, and empower young people and that all these skills can be transferred to a digital text counseling intervention. Counselors used a structured approach to understanding suicidality in a permission-seeking, validating, and confidential manner to identify interventions with the young person. These practices allowed the conversation to move beyond traditional risk assessment practices to meaningful conversations about suicidality. Moving beyond traditional risk assessment practices and into conversations about suicidality allowed for the validation of the young person’s experience and exploration of interventions and support that made sense and were seen to be helpful to the young person. This study highlighted the benefits of a proactive digital chat-based intervention, which is a novel approach to engaging with young people experiencing psychological distress and suicidality. Furthermore, this research demonstrates the feasibility and benefit of moving mental health intervention and support to a medium where young people are currently disclosing distress and intervening proactively. %M 38145477 %R 10.2196/46579 %U https://formative.jmir.org/2023/1/e46579 %U https://doi.org/10.2196/46579 %U http://www.ncbi.nlm.nih.gov/pubmed/38145477 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e52804 %T Exploring the Number of Web-Based Behavioral Health Coaching Sessions Associated With Symptom Improvement in Youth: Observational Retrospective Analysis %A Lawrence-Sidebottom,Darian %A Huffman,Landry Goodgame %A Beam,Aislinn %A Guerra,Rachael %A Parikh,Amit %A Roots,Monika %A Huberty,Jennifer %+ Bend Health, Inc, 9450 SW Gemini Drive #58509, Beaverton, OR, 97008, United States, 1 7708619131, landry.huffman@bendhealth.com %K adolescents %K anxiety %K children %K depression %K digital mental health intervention %K reliable change %D 2023 %7 18.12.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Rates of anxiety and depression have been increasing among children and adolescents for the past decade; however, many young people do not receive adequate mental health care. Digital mental health interventions (DMHIs) that include web-based behavioral health coaching are widely accessible and can confer significant improvements in youth anxiety and depressive symptoms. However, more research is necessary to determine the number of web-based coaching sessions that confer clinically significant improvements in anxiety and depressive symptoms in youth. Objective: This study uses data from a pediatric DMHI to explore the number of web-based coaching sessions required to confer symptom improvements among children and adolescents with moderate or moderately severe symptoms of anxiety and depression. Methods: We used retrospective data from a pediatric DMHI that offered web-based behavioral health coaching in tandem with self-guided access to asynchronous chat with practitioners, digital mental health resources, and web-based mental health symptom assessments. Children and adolescents who engaged in 3 or more sessions of exclusive behavioral health coaching for moderate to moderately severe symptoms of anxiety (n=66) and depression (n=59) were included in the analyses. Analyses explored whether participants showed reliable change (a decrease in symptom scores that exceeds a clinically established threshold) and stable reliable change (at least 2 successive assessments of reliable change). Kaplan-Meier survival analyses were performed to determine the median number of coaching sessions when the first reliable change and stable reliable change occurred for anxiety and depressive symptoms. Results: Reliable change in anxiety symptoms was observed after a median of 2 (95% CI 2-3) sessions, and stable reliable change in anxiety symptoms was observed after a median of 6 (95% CI 5-8) sessions. A reliable change in depressive symptoms was observed after a median of 2 (95% CI 1-3) sessions, and a stable reliable change in depressive symptoms was observed after a median of 6 (95% CI 5-7) sessions. Children improved 1-2 sessions earlier than adolescents. Conclusions: Findings from this study will inform caregivers and youth seeking mental health care by characterizing the typical time frame in which current participants show improvements in symptoms. Moreover, by suggesting that meaningful symptom improvement can occur within a relatively short time frame, these results bolster the growing body of research that indicates web-based behavioral health coaching is an effective form of mental health care for young people. %M 38109174 %R 10.2196/52804 %U https://formative.jmir.org/2023/1/e52804 %U https://doi.org/10.2196/52804 %U http://www.ncbi.nlm.nih.gov/pubmed/38109174 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e48044 %T Examining Human-Smartphone Interaction as a Proxy for Circadian Rhythm in Patients With Insomnia: Cross-Sectional Study %A Lin,Chen %A Chen,I-Ming %A Chuang,Hai-Hua %A Wang,Zih-Wen %A Lin,Hsiao-Han %A Lin,Yu-Hsuan %+ Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County, 35053, Taiwan, 886 37206166 ext 36383, yuhsuanlin@nhri.edu.tw %K actigraphy %K circadian rhythm %K digital biomarkers %K human-smartphone interaction %K insomnia %K intradaily variability %K mobile apps %D 2023 %7 15.12.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: The sleep and circadian rhythm patterns associated with smartphone use, which are influenced by mental activities, might be closely linked to sleep quality and depressive symptoms, similar to the conventional actigraphy-based assessments of physical activity. Objective: The primary objective of this study was to develop app-defined circadian rhythm and sleep indicators and compare them with actigraphy-derived measures. Additionally, we aimed to explore the clinical correlations of these indicators in individuals with insomnia and healthy controls. Methods: The mobile app “Rhythm” was developed to record smartphone use time stamps and calculate circadian rhythms in 33 patients with insomnia and 33 age- and gender-matched healthy controls, totaling 2097 person-days. Simultaneously, we used standard actigraphy to quantify participants’ sleep-wake cycles. Sleep indicators included sleep onset, wake time (WT), wake after sleep onset (WASO), and the number of awakenings (NAWK). Circadian rhythm metrics quantified the relative amplitude, interdaily stability, and intradaily variability based on either smartphone use or physical activity data. Results: Comparisons between app-defined and actigraphy-defined sleep onsets, WTs, total sleep times, and NAWK did not reveal any significant differences (all P>.05). Both app-defined and actigraphy-defined sleep indicators successfully captured clinical features of insomnia, indicating prolonged WASO, increased NAWK, and delayed sleep onset and WT in patients with insomnia compared with healthy controls. The Pittsburgh Sleep Quality Index scores were positively correlated with WASO and NAWK, regardless of whether they were measured by the app or actigraphy. Depressive symptom scores were positively correlated with app-defined intradaily variability (β=9.786, SD 3.756; P=.01) and negatively correlated with actigraphy-based relative amplitude (β=–21.693, SD 8.214; P=.01), indicating disrupted circadian rhythmicity in individuals with depression. However, depressive symptom scores were negatively correlated with actigraphy-based intradaily variability (β=–7.877, SD 3.110; P=.01) and not significantly correlated with app-defined relative amplitude (β=–3.859, SD 12.352; P=.76). Conclusions: This study highlights the potential of smartphone-derived sleep and circadian rhythms as digital biomarkers, complementing standard actigraphy indicators. Although significant correlations with clinical manifestations of insomnia were observed, limitations in the evidence and the need for further research on predictive utility should be considered. Nonetheless, smartphone data hold promise for enhancing sleep monitoring and mental health assessments in digital health research. %M 38100195 %R 10.2196/48044 %U https://www.jmir.org/2023/1/e48044 %U https://doi.org/10.2196/48044 %U http://www.ncbi.nlm.nih.gov/pubmed/38100195 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e47860 %T A Personalized, Transdiagnostic Smartphone Intervention (Mello) Targeting Repetitive Negative Thinking in Young People With Depression and Anxiety: Pilot Randomized Controlled Trial %A Bell,Imogen %A Arnold,Chelsea %A Gilbertson,Tamsyn %A D’Alfonso,Simon %A Castagnini,Emily %A Chen,Nicola %A Nicholas,Jennifer %A O’Sullivan,Shaunagh %A Valentine,Lee %A Alvarez-Jimenez,Mario %+ Orygen, 35 Poplar Rd, Melbourne, 3052, Australia, 61 3 99669177, imogen.bell@orygen.org.au %K repetitive negative thinking %K rumination %K anxiety %K depression %K mobile app %K just-in-time adaptive interventions %K youth mental health %K adolescent %K mobile phone %D 2023 %7 13.12.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Repetitive negative thinking (RNT) is a key transdiagnostic mechanism underpinning depression and anxiety. Using “just-in-time adaptive interventions” via smartphones may disrupt RNT in real time, providing targeted and personalized intervention. Objective: This pilot randomized controlled trial evaluates the feasibility, acceptability, and preliminary clinical outcomes and mechanisms of Mello—a fully automated, personalized, transdiagnostic, and mechanistic smartphone intervention targeting RNT in young people with depression and anxiety. Methods: Participants with heightened depression, anxiety, and RNT were recruited via social media and randomized to receive Mello or a nonactive control over a 6-week intervention period. Assessments were completed via Zoom sessions at baseline and at 3 and 6 weeks after baseline. Results: The findings supported feasibility and acceptability, with high rates of recruitment (N=55), uptake (55/64, 86% of eligible participants), and retention (52/55, 95% at 6 weeks). Engagement was high, with 90% (26/29) and 59% (17/29) of the participants in the Mello condition still using the app during the third and sixth weeks, respectively. Greater reductions in depression (Cohen d=0.50), anxiety (Cohen d=0.61), and RNT (Cohen d=0.87) were observed for Mello users versus controls. Mediation analyses suggested that changes in depression and anxiety were accounted for by changes in RNT. Conclusions: The results indicate that mechanistic, targeted, and real-time technology-based solutions may provide scalable and effective interventions that advance the treatment of youth mental ill health. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12621001701819; http://tinyurl.com/4d3jfj9f %M 38090786 %R 10.2196/47860 %U https://www.jmir.org/2023/1/e47860 %U https://doi.org/10.2196/47860 %U http://www.ncbi.nlm.nih.gov/pubmed/38090786 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 12 %N %P e46419 %T The Role of Daily Steps in the Treatment of Major Depressive Disorder: Secondary Analysis of a Randomized Controlled Trial of a 6-Month Internet-Based, Mindfulness-Based Cognitive Behavioral Therapy Intervention for Youth %A Dang,Kevin %A Ritvo,Paul %A Katz,Joel %A Gratzer,David %A Knyahnytska,Yuliya %A Ortiz,Abigail %A Walters,Clarice %A Attia,Mohamed %A Gonzalez-Torres,Christina %A Lustig,Andrew %A Daskalakis,Zafiris %+ School of Kinesiology and Health Sciences, York University, 4700 Keele St, Toronto, ON, M3J 1P3, Canada, 1 416 580 8021, pritvo@yorku.ca %K accelerometer %K anxiety %K CBT %K chronic pain %K cognitive behavioral therapy %K controlled trials %K depression %K depressive symptoms %K digital health %K eHealth %K exercise %K fitbit %K intervention study %K longitudinal study %K major depressive disorder %K mHealth %K mindfulness %K mindfulness-based CBT %K objectively measured activity %K online health %K online intervention %K online therapy %K pain %K physical activity %K prospective study %K randomized controlled trial %K RCT %K step %K steps %D 2023 %7 8.12.2023 %9 Original Paper %J Interact J Med Res %G English %X Background: Current evidence supports physical activity (PA) as an adjunctive treatment for major depressive disorder (MDD). Few studies, however, have examined the relationship between objectively measured PA and MDD treatment outcomes using prospective data. Objective: This study is a secondary analysis of data from a 24-week internet-based, mindfulness-based cognitive behavioral therapy program for MDD. The purpose of this analysis was twofold: (1) to examine average daily step counts in relation to MDD symptom improvement, and whether pain moderated this relationship; and (2) to examine whether changes in step activity (ie, step trajectories) during treatment were associated with baseline symptoms and symptom improvement. Methods: Patients from the Centre for Addiction and Mental Health were part of a randomized controlled trial evaluating the effects of internet-based, mindfulness-based cognitive behavioral therapy for young adults (aged 18-30 years old) with MDD. Data from 20 participants who had completed the intervention were analyzed. PA, in the form of objectively measured steps, was measured using the Fitbit-HR Charge 2 (Fitbit Inc), and self-reported depression severity was measured with the Beck Depression Inventory-II (BDI-II). Linear regression analysis was used to test PA’s relationship with depression improvement and the moderating effect of pain severity and pain interference. Growth curve and multivariable regression models were used to test longitudinal associations. Results: Participants walked an average of 8269 steps per day, and each additional +1000-step difference between participants was significantly associated with a 2.66-point greater improvement (reduction) in BDI-II, controlling for anxiety, pain interference, and adherence to Fitbit monitoring (P=.02). Pain severity appeared to moderate (reduce) the positive effect of average daily steps on BDI-II improvement (P=.03). Higher baseline depression and anxiety symptoms predicted less positive step trajectories throughout treatment (Ps≤.001), and more positive step trajectories early in the trial predicted greater MDD improvement at the end of the trial (Ps<.04). However, step trajectories across the full duration of the trial did not significantly predict MDD improvement (Ps=.40). Conclusions: This study used objective measurements to demonstrate positive associations between PA and depression improvement in the context of cognitive behavioral treatment. Pain appeared to moderate this relationship, and baseline symptoms of anxiety and depression predicted PA trajectories. The findings inform future interventions for major depression. Future research with larger samples should consider additional moderators of PA-related treatment success and the extent to which outcomes are related to PA change in multimodal interventions. Trial Registration: Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052 International Registered Report Identifier (IRRID): RR2-10.2196/11591 %M 38064262 %R 10.2196/46419 %U https://www.i-jmr.org/2023/1/e46419 %U https://doi.org/10.2196/46419 %U http://www.ncbi.nlm.nih.gov/pubmed/38064262 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e53293 %T Evaluating Clinical Outcomes in Patients Being Treated Exclusively via Telepsychiatry: Retrospective Data Analysis %A Person,Cheryl %A O'Connor,Nicola %A Koehler,Lucy %A Venkatachalam,Kartik %A Gaveras,Georgia %+ Talkiatry, 109 W 27th Street Suite 5S, New York, NY, 10001, United States, 1 833 351 8255, cheryl.person@talkiatry.com %K telepsychiatry %K PHQ-8 %K GAD-7 %K clinical outcomes %K rural %K commercial insurance %K telehealth %K depression %K anxiety %K telemental health %K psychiatry %K Generalized Anxiety Disorder-7 %K Patient Health Questionnaire-8 %D 2023 %7 8.12.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression and anxiety are highly prevalent conditions in the United States. Despite the availability of suitable therapeutic options, limited access to high-quality psychiatrists represents a major barrier to treatment. Although telepsychiatry has the potential to improve access to psychiatrists, treatment efficacy in the telepsychiatry model remains unclear. Objective: Our primary objective was to determine whether there was a clinically meaningful change in 1 of 2 validated outcome measures of depression and anxiety—the Patient Health Questionnaire–8 (PHQ-8) or the Generalized Anxiety Disorder–7 (GAD-7)—after receiving at least 8 weeks of treatment in an outpatient telepsychiatry setting. Methods: We included treatment-seeking patients enrolled in a large outpatient telepsychiatry service that accepts commercial insurance. All analyzed patients completed the GAD-7 and PHQ-8 prior to their first appointment and at least once after 8 weeks of treatment. Treatments included comprehensive diagnostic evaluation, supportive psychotherapy, and medication management. Results: In total, 1826 treatment-seeking patients were evaluated for clinically meaningful changes in GAD-7 and PHQ-8 scores during treatment. Mean treatment duration was 103 (SD 34) days. At baseline, 58.8% (1074/1826) and 60.1% (1097/1826) of patients exhibited at least moderate anxiety and depression, respectively. In response to treatment, mean change for GAD-7 was –6.71 (95% CI –7.03 to –6.40) and for PHQ-8 was –6.85 (95% CI –7.18 to –6.52). Patients with at least moderate symptoms at baseline showed a 45.7% reduction in GAD-7 scores and a 43.1% reduction in PHQ-8 scores. Effect sizes for GAD-7 and PHQ-8, as measured by Cohen d for paired samples, were d=1.30 (P<.001) and d=1.23 (P<.001), respectively. Changes in GAD-7 and PHQ-8 scores correlated with the type of insurance held by the patients. Greatest reductions in scores were observed among patients with commercial insurance (45% and 43.9% reductions in GAD-7 and PHQ-8 scores, respectively). Although patients with Medicare did exhibit statistically significant reductions in GAD-7 and PHQ-8 scores from baseline (P<.001), these improvements were attenuated compared to those in patients with commercial insurance (29.2% and 27.6% reduction in GAD-7 and PHQ-8 scores, respectively). Pairwise comparison tests revealed significant differences in treatment responses in patients with Medicare versus commercial insurance (P<.001). Responses were independent of patient geographic classification (urban vs rural; P=.48 for GAD-7 and P=.07 for PHQ-8). The finding that treatment efficacy was comparable among rural and urban patients indicated that telepsychiatry is a promising approach to overcome treatment disparities that stem from geographical constraints. Conclusions: In this large retrospective data analysis of treatment-seeking patients using a telepsychiatry platform, we found robust and clinically significant improvement in depression and anxiety symptoms during treatment. The results provide further evidence that telepsychiatry is highly effective and has the potential to improve access to psychiatric care. %M 37991899 %R 10.2196/53293 %U https://formative.jmir.org/2023/1/e53293 %U https://doi.org/10.2196/53293 %U http://www.ncbi.nlm.nih.gov/pubmed/37991899 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e46830 %T Repetitive Transcranial Magnetic Stimulation With and Without Text4Support for the Treatment of Resistant Depression: Protocol for a Patient-Centered Multicenter Randomized Controlled Pilot Trial %A Adu,Medard Kofi %A Dias,Raquel da Luz %A Agyapong,Belinda %A Eboreime,Ejemai %A Sapara,Adegboyega O %A Lawal,Mobolaji A %A Chew,Corina %A Diamond Frost,Karen %A Li,Daniel %A Flynn,Michael %A Hassan,Sameh %A Saleh,Ahmed %A Sridharan,Sanjana %A White,Matt %A Agyapong,Vincent IO %+ Department of Psychiatry, Dalhousie University, 5909 Veterans Memorial Lane, 8th Floor, Abbie J. Lane Memorial Building, QEII Health Sciences Centre, Halifax, NS, B3H 2E2, Canada, 1 780 215 7771, vn602367@dal.ca %K repetitive transcranial magnetic stimulation %K treatment-resistant depression %K cognitive behavioral therapy %K Text4Support %K text messaging %K major depressive disorder %D 2023 %7 7.12.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Treatment-resistant depression (TRD) is the inability of a patient with major depressive disorder (MDD) to accomplish or achieve remission after an adequate trial of antidepressant treatments. Several combinations and augmentation treatment strategies for TRD exist, including the use of repetitive transcranial magnetic stimulation (rTMS), and new therapeutic options are being introduced. Text4Support, a text message–based form of cognitive behavioral therapy that allows patients with MDD to receive daily supportive text messages for correcting or altering negative thought patterns through positive reinforcement, may be a useful augmentation treatment strategy for patients with TRD. It is however currently unknown if adding the Text4Support intervention will enhance the response of patients with TRD to rTMS treatment. Objective: This study aims to assess the initial comparative clinical effectiveness of rTMS with and without the Text4Support program as an innovative patient-centered intervention for the management of patients diagnosed with TRD. Methods: This study is a multicenter, prospective, parallel-design, 2-arm, rater-blinded randomized controlled pilot trial. The recruitment process is scheduled to last 12 months. It will involve active treatment for 6 weeks, observation, and a follow-up period of 6 months for participants in the study arms. In total, 200 participants diagnosed with TRD at rTMS care clinics in Edmonton, Alberta, and rTMS clinics in Halifax, Nova Scotia will be randomized to 1 of 2 treatment arms (rTMS sessions alone or rTMS sessions plus Text4Support intervention). Participants in each group will be made to complete evaluation measures at baseline, and 1, 3, and 6 months. The primary outcome measure will be the mean change in the scores of the Patient Health Questionnaire-9 (PHQ-9). The secondary outcome measures will involve the scores of the 7-item Generalized Anxiety Disorders Scale (GAD-7), Columbia-Suicide Severity Rating Scale (CSSRS), and World Health Organization-Five Well-Being Index (WHO-5). Patient data will be analyzed with descriptive statistics, repeated measures, and correlational analyses. Qualitative data will be analyzed using the thematic analysis framework. Results: The results of the study are expected to be available 18 months from the start of recruitment. We hypothesize that participants enrolled in the rTMS plus Text4Support intervention treatment arm of the study will achieve superior outcomes compared with the outcomes of participants enrolled in the rTMS alone arm. Conclusions: The application of the combination of rTMS and Text4Support has not been investigated previously. Therefore, we hope that this study will provide a concrete base of data to evaluate the practical application and efficacy of using the novel combination of these 2 treatment modalities. International Registered Report Identifier (IRRID): PRR1-10.2196/46830 %M 38060308 %R 10.2196/46830 %U https://www.researchprotocols.org/2023/1/e46830 %U https://doi.org/10.2196/46830 %U http://www.ncbi.nlm.nih.gov/pubmed/38060308 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e50072 %T Circadian Reinforcement Therapy in Combination With Electronic Self-Monitoring to Facilitate a Safe Postdischarge Period for Patients With Major Depression: Randomized Controlled Trial %A Aggestrup,Anne Sofie %A Svendsen,Signe Dunker %A Præstegaard,Anne %A Løventoft,Philip %A Nørregaard,Lasse %A Knorr,Ulla %A Dam,Henrik %A Frøkjær,Erik %A Danilenko,Konstantin %A Hageman,Ida %A Faurholt-Jepsen,Maria %A Kessing,Lars Vedel %A Martiny,Klaus %+ Mental Health Centre Copenhagen, Copenhagen University Hospital, Frederiksberg Hospital, Nordre Fasanvej 57, Hovedvejen 17, 1st floor, Frederiksberg, 2000, Denmark, 45 38647102, klaus.martiny@regionh.dk %K major depression %K internet interventions %K self-monitoring %K sleep %K circadian %K chronobiology %K chronotherapy %K clinician assisted %D 2023 %7 27.11.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Patients with major depression exhibit circadian disturbance of sleep and mood, and when they are discharged from inpatient wards, this disturbance poses a risk of relapse. We developed a circadian reinforcement therapy (CRT) intervention to facilitate the transition from the inpatient ward to the home for these patients. CRT focuses on increasing the zeitgeber strength for the circadian clock through social contact, physical activity, diet, daylight exposure, and sleep timing. Objective: In this study, we aimed to prevent the worsening of depression after discharge by using CRT, supported by an electronic self-monitoring system, to advance and stabilize sleep and improve mood. The primary outcome, which was assessed by a blinded rater, was the change in the Hamilton Depression Rating Scale scores from baseline to the end point. Methods: Participants were contacted while in the inpatient ward and randomized 1:1 to the CRT or the treatment-as-usual (TAU) group. For 4 weeks, participants in both groups electronically self-monitored their daily mood, physical activity, sleep, and medication using the Monsenso Daybuilder (MDB) system. The MDB allowed investigators and participants to simultaneously view a graphical display of registrations. An investigator phoned all participants weekly to coinspect data entry. In the CRT group, participants were additionally phoned between the scheduled calls if specific predefined trigger points for mood and sleep were observed during the daily inspection. Participants in the CRT group were provided with specialized CRT psychoeducation sessions immediately after inclusion, focusing on increasing the zeitgeber input to the circadian system; a PowerPoint presentation was presented; paper-based informative materials and leaflets were reviewed with the participants; and the CRT principles were used during all telephone consultations. In the TAU group, phone calls focused on data entry in the MDB system. When discharged, all patients were treated at a specialized affective disorders service. Results: Overall, 103 participants were included. Participants in the CRT group had a significantly larger reduction in Hamilton Depression Scale score (P=.04) than those in the TAU group. The self-monitored MDB data showed significantly improved evening mood (P=.02) and sleep quality (P=.04), earlier sleep onset (P=.009), and longer sleep duration (P=.005) in the CRT group than in the TAU group. The day-to-day variability of the daily and evening mood, sleep offset, sleep onset, and sleep quality were significantly lower in the CRT group (all P<.001) than in the TAU group. The user evaluation was positive for the CRT method and the MDB system. Conclusions: We found significantly lower depression levels and improved sleep quality in the CRT group than in the TAU group. We also found significantly lower day-to-day variability in daily sleep, mood parameters, and activity parameters in the CRT group than in the TAU group. The delivery of the CRT intervention should be further refined and tested. Trial Registration: ClinicalTrials.gov NCT02679768; https://clinicaltrials.gov/study/NCT02679768 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-019-2101-z %M 37800194 %R 10.2196/50072 %U https://mental.jmir.org/2023/1/e50072 %U https://doi.org/10.2196/50072 %U http://www.ncbi.nlm.nih.gov/pubmed/37800194 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e43260 %T Self-Guided Digital Intervention for Depression in Adolescents: Feasibility and Preliminary Efficacy Study %A Miller,Ian %A Peake,Emily %A Strauss,Gabriel %A Vierra,Elise %A Koepsell,Xin %A Shalchi,Brandon %A Padmanabhan,Aarthi %A Lake,Jessica %+ Big Health Inc, 461 Bush St #200, San Francisco, CA, 94108, United States, 1 415 971 2900, jessica.lake@bighealth.com %K depression %K adolescents %K young adults %K cognitive behavioral therapy %K behavioral activation %K digital health %K mobile interventions %K mobile phone %D 2023 %7 22.11.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression in adolescents is a large and growing problem; however, access to effective mental health care continues to be a challenge. Digitally based interventions may serve to bridge this access gap for adolescents in need of care. Digital interventions that deliver components of cognitive behavioral therapy (CBT) have been shown to reduce symptoms of depression, and virtual reality (VR) may be a promising adjunctive component. However, research on these types of treatments in adolescents and young adults is limited. Objective: This study aims to evaluate the feasibility, acceptability, and preliminary efficacy of Spark (v1.0), a 5-week, self-guided, CBT-based digital program using a mobile app and VR experiences to target symptoms of depression in adolescents. Methods: A single-arm, open-label study of the Spark program was conducted with a community sample of 30 adolescents and young adults aged 12 to 21 years with self-reported moderate to severe depression symptoms. Participants completed a weekly depression assessment (Patient Health Questionnaire-8) in the app during the 5-week intervention period as well as web-based baseline, postintervention, and 1-month follow-up self-report assessments. The participants also completed a qualitative postintervention interview. For participants aged <18 years, caregivers completed assessments at baseline and postintervention time points. Feasibility outcomes included recruitment rate (the proportion of participants who enrolled in the study divided by the total number of participants screened for eligibility) and retention rate (the proportion of participants who completed postintervention assessments divided by the total number of participants who received the intervention). Acceptability outcomes included engagement with the program and quantitative and qualitative feedback about the program. Preliminary efficacy was evaluated based on the Patient Health Questionnaire-8. Results: The study recruitment (31/66, 47%) and retention (29/30, 97%) rates were high. Participants provided higher ratings for the ease of use of the Spark program (8.76 out of 10) and their enjoyment of both the mobile app (7.00 out of 10) and VR components (7.48 out of 10) of the program, whereas they provided lower ratings for the program’s ability to improve mood (4.38 out of 10) or fit into their daily routines (5.69 out of 10). We observed a clinically and statistically significant reduction in depression scores at postintervention (mean difference 5.36; P<.001) and 1-month follow-up (mean difference 6.44; P<.001) time points. Conclusions: The Spark program was found to be a feasible and acceptable way to deliver a self-guided CBT-focused intervention to adolescents and young adults with symptoms of depression. Preliminary data also indicated that the Spark program reduced the symptoms of depression in adolescents and young adults. Future studies should evaluate the efficacy of this intervention in an adequately powered randomized controlled trial. Trial Registration: ClinicalTrials.gov NCT04165681; https://classic.clinicaltrials.gov/ct2/show/NCT04165681 %M 37991839 %R 10.2196/43260 %U https://formative.jmir.org/2023/1/e43260 %U https://doi.org/10.2196/43260 %U http://www.ncbi.nlm.nih.gov/pubmed/37991839 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e42545 %T Selection Bias in Digital Conversations on Depression Before and During COVID-19 %A Lee,Edward %A Agustines,Davin %A Woo,Benjamin K P %+ College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, 4385 Ocean View Blvd, Montrose, CA, 91020, United States, 1 8189260488, edward.lee@westernu.edu %K depression %K COVID-19 %K treatment %K race %K ethnicity %K digital conversations %K health belief model %K artificial intelligence %K AI %K natural language processing %K NLP %D 2023 %7 20.11.2023 %9 Letter to the Editor %J JMIR Form Res %G English %X %M 37983077 %R 10.2196/42545 %U https://formative.jmir.org/2023/1/e42545 %U https://doi.org/10.2196/42545 %U http://www.ncbi.nlm.nih.gov/pubmed/37983077 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e51334 %T mHealth Intervention to Promote Physical Activity Among Employees Using a Deep Learning Model for Passive Monitoring of Depression and Anxiety: Single-Arm Feasibility Trial %A Watanabe,Kazuhiro %A Okusa,Shoichi %A Sato,Mitsuhiro %A Miura,Hideki %A Morimoto,Masahiro %A Tsutsumi,Akizumi %+ Department of Public Health, Kitasato University School of Medicine, 1-15-1 Kitazato, Minami-ku, Sagamihara, 252-0374, Japan, 81 427789352, kzwatanabe-tky@umin.ac.jp %K eHealth %K behavioral change %K mobile phone %K smartphone %K mHealth %K mobile health %K app %K apps %K applications %K monitor %K monitoring %K physical activity %K exercise %K fitness %K application %K workplace %K distress %K depression %K depressive %K anxiety %K mental health %K worker %K workers %K employee %K employees %K occupational health %K satisfaction %K feasibility %K acceptability %D 2023 %7 17.11.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Physical activity effectively prevents depression and anxiety. Although mobile health (mHealth) technologies offer promising results in promoting physical activity and improving mental health, conflicting evidence exists on their effectiveness, and employees face barriers to using mHealth services. To address these problems, we recently developed a smartphone app named ASHARE to prevent depression and anxiety in the working population; it uses a deep learning model for passive monitoring of depression and anxiety from information about physical activity. Objective: This study aimed to preliminarily investigate (1) the effectiveness of the developed app in improving physical activity and reducing depression and anxiety and (2) the app’s implementation outcomes (ie, its acceptability, appropriateness, feasibility, satisfaction, and potential harm). Methods: We conducted a single-arm interventional study. From March to April 2023, employees aged ≥18 years who were not absent were recruited. The participants were asked to install and use the app for 1 month. The ideal usage of the app was for the participants to take about 5 minutes every day to open the app, check the physical activity patterns and results of an estimated score of psychological distress, and increase their physical activity. Self-reported physical activity (using the Global Physical Activity Questionnaire, version 2) and psychological distress (using the 6-item Kessler Psychological Distress Scale) were measured at baseline and after 1 month. The duration of physical activity was also recorded digitally. Paired t tests (two-tailed) and chi-square tests were performed to evaluate changes in these variables. Implementation Outcome Scales for Digital Mental Health were also measured for acceptability, appropriateness, feasibility, satisfaction, and harm. These average scores were assessed by comparing them with those reported in previous studies. Results: This study included 24 employees. On average, the app was used for 12.54 days (44.8% of this study’s period). After using the app, no significant change was observed in physical activity (–12.59 metabolic equivalent hours per week, P=.31) or psychological distress (–0.43 metabolic equivalent hours per week, P=.93). However, the number of participants with severe psychological distress decreased significantly (P=.01). The digitally recorded duration of physical activity increased during the intervention period (+0.60 minutes per day, P=.08). The scores for acceptability, appropriateness, and satisfaction were lower than those in previous mHealth studies, whereas those for feasibility and harm were better. Conclusions: The ASHARE app was insufficient in promoting physical activity or improving psychological distress. At this stage, the app has many issues that are to be addressed in terms of both implementation and effectiveness. The main reason for this low effectiveness might be the poor evaluation of the implementation outcomes by app users. Improving acceptability, appropriateness, and satisfaction are identified as key issues to be addressed in future implementation. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry UMIN000050430; https://tinyurl.com/mrx5ntcmrecptno=R000057438 %M 37976094 %R 10.2196/51334 %U https://formative.jmir.org/2023/1/e51334 %U https://doi.org/10.2196/51334 %U http://www.ncbi.nlm.nih.gov/pubmed/37976094 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e51398 %T Examining the Feasibility of Implementing Digital Mental Health Innovations Into Hospitals to Support Youth in Suicide Crisis: Interview Study With Young People and Health Professionals %A Rheinberger,Demee %A Baffsky,Rachel %A McGillivray,Lauren %A Zbukvic,Isabel %A Dadich,Ann %A Larsen,Mark Erik %A Lin,Ping-I %A Gan,Daniel Z Q %A Kaplun,Catherine %A Wilcox,Holly C %A Eapen,Valsamma %A Middleton,Paul M %A Torok,Michelle %+ Black Dog Institute, University of New South Wales, Hospital Road, Randwick, Sydney, NSW, 2031, Australia, 61 0415677477, m.torok@unsw.edu.au %K mobile health %K mHealth %K digital health %K mental health %K suicide prevention %K self-harm %K young people %K hospitals %K mobile phone %D 2023 %7 16.11.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Hospitals are insufficiently resourced to appropriately support young people who present with suicidal crises. Digital mental health innovations have the potential to provide cost-effective models of care to address this service gap and improve care experiences for young people. However, little is currently known about whether digital innovations are feasible to integrate into complex hospital settings or how they should be introduced for sustainability. Objective: This qualitative study explored the potential benefits, barriers, and collective action required for integrating digital therapeutics for the management of suicidal distress in youth into routine hospital practice. Addressing these knowledge gaps is a critical first step in designing digital innovations and implementation strategies that enable uptake and integration. Methods: We conducted a series of semistructured interviews with young people who had presented to an Australian hospital for a suicide crisis in the previous 12 months and hospital staff who interacted with these young people. Participants were recruited from the community nationally via social media advertisements on the web. Interviews were conducted individually, and participants were reimbursed for their time. Using the Normalization Process Theory framework, we developed an interview guide to clarify the processes and conditions that influence whether and how an innovation becomes part of routine practice in complex health systems. Results: Analysis of 29 interviews (n=17, 59% young people and n=12, 41% hospital staff) yielded 4 themes that were mapped onto 3 Normalization Process Theory constructs related to coherence building, cognitive participation, and collective action. Overall, digital innovations were seen as a beneficial complement to but not a substitute for in-person clinical services. The timing of delivery was important, with the agreement that digital therapeutics could be provided to patients while they were waiting to be assessed or shortly before discharge. Staff training to increase digital literacy was considered key to implementation, but there were mixed views on the level of staff assistance needed to support young people in engaging with digital innovations. Improving access to technological devices and internet connectivity, increasing staff motivation to facilitate the use of the digital therapeutic, and allowing patients autonomy over the use of the digital therapeutic were identified as other factors critical to integration. Conclusions: Integrating digital innovations into current models of patient care for young people presenting to hospital in acute suicide crises is challenging because of several existing resource, logistical, and technical barriers. Scoping the appropriateness of new innovations with relevant key stakeholders as early as possible in the development process should be prioritized as the best opportunity to preemptively identify and address barriers to implementation. %M 37971790 %R 10.2196/51398 %U https://formative.jmir.org/2023/1/e51398 %U https://doi.org/10.2196/51398 %U http://www.ncbi.nlm.nih.gov/pubmed/37971790 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e48740 %T Assessing the Efficacy and Safety of a Digital Therapeutic for Symptoms of Depression in Adolescents: Protocol for a Randomized Controlled Trial %A Furman,Daniella J %A Hall,Shana A %A Avina,Claudia %A Kulikov,Vera N %A Lake,Jessica I %A Padmanabhan,Aarthi %+ Big Health, Inc, 461 Bush St #200, San Francisco, CA, 94108, United States, 1 707 563 1049, daniella.furman@bighealth.com %K randomized controlled trial %K depression %K adolescent %K youth %K mental health %K digital therapeutic %K behavioral activation %K cognitive behavioral therapy %K virtual trial %K efficacy %K treatment %K digital health %K intervention %K mental illness %D 2023 %7 16.11.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is a serious, prevalent, recurrent, and undertreated disorder in adolescents. Low levels of treatment seeking and treatment adherence in this age group, combined with a growing national crisis in access to mental health care, have increased efforts to identify effective treatment alternatives for this demographic. Digital health interventions for mental illness can provide cost-effective, engaging, and accessible means of delivering psychotherapy to adolescents. Objective: This protocol describes a virtual randomized controlled trial designed to evaluate the efficacy and safety of a self-guided, mobile app–based implementation of behavioral activation therapy, SparkRx, for the adjunct treatment of symptoms of depression in adolescents. Methods: Participants are recruited directly through web-based and print advertisements. Following eligibility screening and consenting, participants are randomly assigned to a treatment arm (SparkRx) or a control arm (assessment-enhanced usual care) for 5 weeks. The primary efficacy outcome, total score on the 8-item Patient Health Questionnaire (PHQ-8), is assessed at the end of the 5-week intervention period. Additional participant-reported outcomes are assessed at baseline, the postintervention time point, and 1-month follow-up. The safety of the intervention is assessed by participant report (and legal guardian report, if the participant is younger than 18 years) and by patterns of symptom deterioration on the PHQ-8, as part of a larger clinical safety monitoring protocol. The primary efficacy outcome, total PHQ-8 score at the postintervention time point, will be compared between SparkRx and enhanced usual care arms using mixed effect modeling, with baseline PHQ-8 and current antidepressant medication status included as covariates. Secondary efficacy outcomes, including the proportion of participants exhibiting treatment response, remission, and minimal clinically significant improvement (all derived from total PHQ-8 scores), will be compared between groups using chi-square tests. Symptom severity at 1-month follow-up will also be compared between arms. Planned subgroup analyses will examine the robustness of treatment effects to differences in baseline symptom severity (PHQ-8 score <15 or ≥ 15) and age (younger than 18 years and older than 18 years). The primary safety outcome, the number of psychiatric serious adverse events, will be compared between trial arms using the Fisher exact test. All other adverse events will be presented descriptively. Results: As of May 2023, enrollment into the study has concluded; 223 participants were randomized. The analysis of the efficacy and safety data is expected to be completed by Fall 2023. Conclusions: We hypothesize that the results of this trial will support the efficacy and safety of SparkRx in attenuating symptoms of depression in adolescents. Positive results would more broadly support the prospect of using accessible, scientifically validated, digital therapeutics in the adjunct treatment of mental health disorders in this age range. Trial Registration: ClinicalTrials.gov NCT05462652; https://clinicaltrials.gov/study/NCT05462652 International Registered Report Identifier (IRRID): DERR1-10.2196/48740 %M 37971800 %R 10.2196/48740 %U https://www.researchprotocols.org/2023/1/e48740 %U https://doi.org/10.2196/48740 %U http://www.ncbi.nlm.nih.gov/pubmed/37971800 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e41127 %T Behavioral Activation for Comorbid Depression in People With Noncommunicable Disease in India: Protocol for a Randomized Controlled Feasibility Trial %A Zainab,Rayeesa %A Kandasamy,Arun %A Bhat,Naseer Ahmad %A Dsouza,Chrishma Violla %A Jennings,Hannah %A Jackson,Cath %A Mazumdar,Papiya %A Hewitt,Catherine Elizabeth %A Ekers,David %A Narayanan,Gitanjali %A Rao,Girish N %A Coales,Karen %A Muliyala,Krishna Prasad %A Chaturvedi,Santosh K %A Murthy,Pratima %A Siddiqi,Najma %+ National Institute of Mental Health and Neuro Sciences, Hosur Rd, near Bangalore Milk Dairy, Hombegowda Nagar, Bangalore, 560029, India, 91 08026995250 ext 360, arunnimhans05@gmail.com %K adaption %K behavioral activation %K cancer %K cardiovascular disease %K cultural %K culture %K depression %K diabetes %K feasibility %K India %K language %K linguistic %K mental disorder %K mental health care %K mental health %K non-communicable disease %K Patient Health Questionnaire %K PHQ %K randomized controlled feasibility trial %K respiratory %K retention %K social %K stroke %K therapy %K treatment %D 2023 %7 16.11.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: The increasing burden of depression and noncommunicable disease (NCD) is a global challenge, especially in low- and middle-income countries, considering the resource constraints and lack of trained human resources in these settings. Effective treatment of depression in people with NCDs has the potential to enhance both the mental and physical well-being of this population. It will also result in the effective use of the available health care resources. Brief psychological therapies, such as behavioral activation (BA), are effective for the treatment of depression. BA has not been adapted in the community health care services of India, and the feasibility of using BA as an intervention for depression in NCD and its effectiveness in these settings have not been systematically evaluated. Objective: Our objective is to adapt BA for the Indian NCD context and test the acceptability, feasibility, and implementation of the adapted BA intervention (BEACON intervention package [BIP]). Additionally, we aim to test the feasibility of a randomized controlled trial evaluation of BIP for the treatment of depression compared with enhanced usual care. Methods: Following well-established frameworks for intervention adaptation, we first adapted BA (to fit the linguistic, cultural, and resource context) for delivery in India. The intervention was also adapted for potential remote delivery by telephone. In a randomized controlled trial, we will be testing the acceptability, feasibility, and implementation of the adapted BA intervention (BIP). We shall also test if a randomized controlled feasibility trial can be delivered effectively and estimate important parameters (eg, recruitment and retention rates and completeness of follow-up) needed to design a future definitive trial. Results: Following the receipt of approval from all the relevant agencies, the development of the BIP was started on November 28, 2020, and completed on August 18, 2021, and the quantitative data collection was started on August 23, 2021, and completed on December 10, 2021. Process evaluation (qualitative data) collection is ongoing. Both the qualitative and quantitative data analyses are ongoing. Conclusions: This study may offer insights that could help in closing the gap in the treatment of common mental illness, particularly in nations with limited resources, infrastructure, and systems such as India. To close this gap, BEACON tries to provide BA for depression in NCDs through qualified NCD (BA) counselors integrated within the state-run NCD clinics. The results of this study may aid in understanding whether BA as an intervention is acceptable for the population and how feasible it will be to deliver such interventions for depression in NCD in South Asian countries such as India. The BIP may also be used in the future by Indian community clinics as a brief intervention program. Trial Registration: Clinical Trials Registry of India CTRI/2020/05/025048; https://tinyurl.com/mpt33jv5 International Registered Report Identifier (IRRID): DERR1-10.2196/41127 %M 37971791 %R 10.2196/41127 %U https://www.researchprotocols.org/2023/1/e41127 %U https://doi.org/10.2196/41127 %U http://www.ncbi.nlm.nih.gov/pubmed/37971791 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e50643 %T Designing Implementation Strategies for a Digital Suicide Safety Planning Intervention in a Psychiatric Emergency Department: Protocol for a Multimethod Research Project %A Shin,Hwayeon Danielle %A Zaheer,Juveria %A Torous,John %A Strudwick,Gillian %+ Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada, 1 9022922836, hdanielle.shin@mail.utoronto.ca %K implementation science %K suicide prevention %K eHealth %K mental health %K health informatics %K integrated knowledge translation %K co-design %K research protocol %K mobile phone %D 2023 %7 9.11.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide prevention is currently a national health priority in Canada. Emergency departments (EDs) are critical settings for suicide prevention, and in our local psychiatric ED at the Centre for Addiction and Mental Health, we plan to embed an app-based tool called the Hope app to support suicide safety planning intervention. The app is free and available on app stores, and usability tests have been completed. As a next step to embed this new tool into the routine clinical workflow, research is needed to assess determinants of and design strategies for implementation with the end goal of routinization. Objective: The purpose of this 2-phased research is to implement the app in the routine clinical workflow in our local psychiatric ED. The specific objectives are as follows: (1) understanding ED clinicians’ perceptions and experience of implementing the app in routine practice and identifying barriers to and facilitators of implementation (phase 1) and (2) using findings and outputs from phase 1 and collaborating with service users, families, and ED clinicians to co-design implementation strategies for the app (phase 2). Methods: We will use an integrated knowledge translation approach throughout this project. In phase 1, we will conduct interviews with ED clinicians to identify implementation determinants using a behavior change framework. In phase 2, a co-design team comprising clinicians, ED service users, and families will design implementation strategies that align with the determinants identified in phase 1. Results: This protocol presents detailed information about the entire structure of the 2-phased research project. Ethics approval for conducting the qualitative descriptive study (phase 1) has been obtained, and the recruitment and data collection processes will be completed no later than December 2023. Ethics approval for phase 2 is underway. Conclusions: Involving multiple knowledge user groups early in the research and decision-making process is crucial for successful implementation. Although co-designing is commonly practiced during innovation development, there is often a misconception that the responsibility for implementing what has been designed falls on others. This research aims to fill this methodological gap in the health informatics literature. By the end of this project, we will have developed theory-informed implementation strategies to support Centre for Addiction and Mental Health ED clinicians in adopting the Hope app to complete safety planning intervention. These strategies, guided by a behavior change framework, will target clinicians’ behavior change and seamlessly integrate the app into the routine clinical workflow. In addition, this research project will provide recommendations on how to involve multiple knowledge user groups and offer insights into how the methodology used can be adapted to other areas within the health informatics literature. International Registered Report Identifier (IRRID): PRR1-10.2196/50643 %M 37943582 %R 10.2196/50643 %U https://www.researchprotocols.org/2023/1/e50643 %U https://doi.org/10.2196/50643 %U http://www.ncbi.nlm.nih.gov/pubmed/37943582 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e48804 %T Supporting Clinical Competencies in Men’s Mental Health Using the Men in Mind Practitioner Training Program: User Experience Study %A Seidler,Zac E %A Benakovic,Ruben %A Wilson,Michael J %A Fletcher,Justine %A Oliffe,John L %A Owen,Jesse %A Rice,Simon M %+ Orygen, 35 Poplar Rd, Parkville, Melbourne, 3052, Australia, 61 0432 438 254, zac.seidler@orygen.org.au %K e-learning %K mental health services %K psychotherapy %K men’s mental health %K masculinity %D 2023 %7 7.11.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Engaging men in psychotherapy is essential in male suicide prevention efforts, yet to date, efforts to upskill mental health practitioners in delivering gender-sensitized therapy for men have been lacking. To address this, we developed Men in Mind, an e-learning training program designed to upskill mental health practitioners in engaging men in therapy. Objective: This study involves an in-depth analysis of the user experience of the Men in Mind intervention, assessed as part of a randomized controlled trial of the efficacy of the intervention. Methods: Following completion of the intervention, participants provided qualitative (n=392) and quantitative (n=395) user experience feedback, focused on successes and suggested improvements to the intervention and improvements to their confidence in delivering therapy with specific subpopulations of male clients. We also assessed practitioner learning goals (n=242) and explored the extent to which participants had achieved these goals at follow-up. Results: Participants valued the inclusion of video demonstrations of skills in action alongside the range of evidence-based content dedicated to improving their insight into the engagement of men in therapy. Suggested improvements most commonly reflected the desire for more or more diverse content, alongside the necessary adaptations to improve the learning and user experience. Participants also commonly reported improved confidence in assisting men with difficulty articulating their emotions in therapy and suicidal men. Conclusions: The evidence obtained from this study aids in plans to scale Men in Mind and informs the future development of practitioner training interventions in men’s mental health. International Registered Report Identifier (IRRID): RR2-10.1186/s40359-022-00875-9 %M 37934579 %R 10.2196/48804 %U https://mededu.jmir.org/2023/1/e48804 %U https://doi.org/10.2196/48804 %U http://www.ncbi.nlm.nih.gov/pubmed/37934579 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 10 %N %P e49715 %T Association Between User Interaction and Treatment Response of a Voice-Based Coach for Treating Depression and Anxiety: Secondary Analysis of a Pilot Randomized Controlled Trial %A Lv,Nan %A Kannampallil,Thomas %A Xiao,Lan %A Ronneberg,Corina R %A Kumar,Vikas %A Wittels,Nancy E %A Ajilore,Olusola A %A Smyth,Joshua M %A Ma,Jun %+ Department of Medicine, University of Illinois Chicago, Room 466 (MC 275), 1747 W. Roosevelt Rd, Chicago, IL, 60608, United States, 1 3124139830, maj2015@uic.edu %K user interaction %K treatment alliance %K treatment response %K voice assistant %K depression %K anxiety %D 2023 %7 6.11.2023 %9 Original Paper %J JMIR Hum Factors %G English %X Background: The quality of user interaction with therapeutic tools has been positively associated with treatment response; however, no studies have investigated these relationships for voice-based digital tools. Objective: This study evaluated the relationships between objective and subjective user interaction measures as well as treatment response on Lumen, a novel voice-based coach, delivering problem-solving treatment to patients with mild to moderate depression or anxiety or both. Methods: In a pilot trial, 42 adults with clinically significant depression (Patient Health Questionnaire-9 [PHQ-9]) or anxiety (7-item Generalized Anxiety Disorder Scale [GAD-7]) symptoms or both received Lumen, a voice-based coach delivering 8 problem-solving treatment sessions. Objective (number of conversational breakdowns, ie, instances where a participant’s voice input could not be interpreted by Lumen) and subjective user interaction measures (task-related workload, user experience, and treatment alliance) were obtained for each session. Changes in PHQ-9 and GAD-7 scores at each ensuing session after session 1 measured the treatment response. Results: Participants were 38.9 (SD 12.9) years old, 28 (67%) were women, 8 (19%) were Black, 12 (29%) were Latino, 5 (12%) were Asian, and 28 (67%) had a high school or college education. Mean (SD) across sessions showed breakdowns (mean 6.5, SD 4.4 to mean 2.3, SD 1.8) decreasing over sessions, favorable task-related workload (mean 14.5, SD 5.6 to mean 17.6, SD 5.6) decreasing over sessions, neutral-to-positive user experience (mean 0.5, SD 1.4 to mean 1.1, SD 1.3), and high treatment alliance (mean 5.0, SD 1.4 to mean 5.3, SD 0.9). PHQ-9 (Ptrend=.001) and GAD-7 scores (Ptrend=.01) improved significantly over sessions. Treatment alliance correlated with improvements in PHQ-9 (Pearson r=–0.02 to –0.46) and GAD-7 (r=0.03 to –0.57) scores across sessions, whereas breakdowns and task-related workload did not. Mixed models showed that participants with higher individual mean treatment alliance had greater improvements in PHQ-9 (β=–1.13, 95% CI –2.16 to –0.10) and GAD-7 (β=–1.17, 95% CI –2.13 to –0.20) scores. Conclusions: The participants had fewer conversational breakdowns and largely favorable user interactions with Lumen across sessions. Conversational breakdowns were not associated with subjective user interaction measures or treatment responses, highlighting how participants adapted and effectively used Lumen. Individuals experiencing higher treatment alliance had greater improvements in depression and anxiety. Understanding treatment alliance can provide insights on improving treatment response for this new delivery modality, which provides accessibility, flexibility, comfort with disclosure, and cost-related advantages compared to conventional psychotherapy. Trial Registration: ClinicalTrials.gov NCT04524104; https://clinicaltrials.gov/study/NCT04524104 %M 37930781 %R 10.2196/49715 %U https://humanfactors.jmir.org/2023/1/e49715 %U https://doi.org/10.2196/49715 %U http://www.ncbi.nlm.nih.gov/pubmed/37930781 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e48404 %T Freely Available Training Videos for Suicide Prevention: Scoping Review %A Wislocki,Katherine %A Jager-Hyman,Shari %A Brady,Megan %A Weiss,Michal %A Schaechter,Temma %A Khazanov,Gabriela %A Young,Sophia %A Becker-Haimes,Emily %+ Department of Psychological Science, University of California, Irvine, 214 Pereira Drive, Irvine, CA, 92617, United States, 1 9498246803, kwislock@uci.edu %K freely available videos %K asynchronous training %K suicide prevention %K evidence-based practice %K dissemination %K implementation %D 2023 %7 3.11.2023 %9 Review %J JMIR Ment Health %G English %X Background: Freely available and asynchronous implementation supports can reduce the resource burden of evidence-based practice training to facilitate uptake. Freely available web-based training videos have proliferated, yet there have been no efforts to quantify their breadth, depth, and content for suicide prevention. Objective: This study presents results from a scoping review of freely available training videos for suicide prevention and describes a methodological framework for reviewing such videos. Methods: A scoping review of freely available training videos (≥2 minutes) for suicide prevention practices was conducted using 4 large video-sharing platforms: YouTube, Vimeo, Bing Video, and Google Video. Identified suicide prevention training videos (N=506) were reviewed and coded. Results: Most content was targeted toward gatekeepers or other lay providers (n=370) versus clinical providers (n=136). Videos most commonly provided content related to suicidal thoughts or behaviors (n=420). Many videos (n=274, 54.2%) included content designed for certain communities or organizations. Less than half (n=232, 45.8%) of training videos included formal clinical content pertaining to assessment or intervention for suicide prevention. Conclusions: Results suggested an abundance of videos providing broad informational content (eg, “signs and symptoms of someone at risk for suicide”) and a limited portion of videos with instructional content aimed at clinical providers delivering formal evidence-based assessments or interventions for suicide prevention. Development of resources to address identified gaps may be needed. Future work may leverage machine learning techniques to expedite the review process. %M 37921847 %R 10.2196/48404 %U https://mental.jmir.org/2023/1/e48404 %U https://doi.org/10.2196/48404 %U http://www.ncbi.nlm.nih.gov/pubmed/37921847 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e51824 %T Video-Delivered Family Therapy for Perinatal Women With Depressive Symptoms and Family Conflict: Feasibility, Acceptability, Safety, and Tolerability Results From a Pilot Randomized Trial %A Cluxton-Keller,Fallon %A Hegel,Mark T %A Donnelly,Craig L %A Bruce,Martha L %+ Department of Psychiatry, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH, 03756, United States, 1 603 650 4726, Fallon.P.Cluxton-Keller@dartmouth.edu %K perinatal depression %K family conflict %K family therapy %K family %K conflict %K depression %K depressive %K perinatal %K pregnant %K pregnancy %K video %K videos %K feasibility %K safety %K acceptability %K tolerability %K tolerable %K families %K satisfaction %K resilience %K psychotherapy %D 2023 %7 3.11.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Although individual-level treatments exist for pregnant and postpartum women with depression, family conflict is a significant factor that can contribute to the development and severity of perinatal depressive symptoms. Yet, there is a lack of research on family therapy for perinatal women with moderate to severe depressive symptoms and family conflict. Further, research is needed on the feasibility, acceptability, safety, and tolerability of family therapies for perinatal depression that are delivered using Health Insurance Portability and Accountability Act–compliant videoconferencing technology (VCT). Objective: This paper describes the feasibility, acceptability, safety, and tolerability of a VCT-based family therapeutic intervention, Resilience Enhancement Skills Training (REST), for perinatal women with moderate to severe depressive symptoms and moderate to high conflict with their family members. Methods: This paper includes data from an ongoing randomized trial that compares an experimental family therapeutic intervention (REST) to standard of care (VCT-based problem-solving individual therapy) for the treatment of moderate to severe depressive symptoms in perinatal women with moderate to high family conflict. Both interventions were delivered by masters-level therapists using VCT. A total of 83 perinatal women and their adult family members (N=166 individuals) were recruited for participation in the study. Feasibility, defined as therapist adherence to ≥80% of REST session content, was assessed in audio-recorded sessions by 2 expert raters. Acceptability was defined as ≥80% of families completing REST, including completion of ≥80% homework assignments and family report of satisfaction with REST. Completion of REST was assessed by review of therapist session notes, and satisfaction was assessed by participant completion of a web-based questionnaire. The Beck Depression Inventory-Second Edition was administered to perinatal women by research assistants (blind to study group assignment) to assess safety, defined as a reduction in depressive symptoms during the treatment phase. The Family Environment Scale-Family Conflict subscale was administered by therapists to participants during the treatment phase to assess tolerability, defined as a reduction in family conflict during the treatment phase. Results: On average, the therapists achieved 90% adherence to REST session content. Of the families who started REST, 84% (32/38) of them completed REST, and on average, they completed 89% (8/9) of the homework assignments. Families reported satisfaction with REST. The results showed that REST is safe for perinatal women with moderate to severe depressive symptoms, and none discontinued due to worsened depressive symptoms. The results showed that REST is well tolerated by families, and no families discontinued due to sustained family conflict. Conclusions: The results show that REST is feasible, acceptable, safe, and tolerable for families. These findings will guide our interpretation of REST’s preliminary effectiveness upon completion of outcome data collection. Trial Registration: ClinicalTrials.gov NCT04741776; https://clinicaltrials.gov/ct2/show/NCT04741776 %M 37921846 %R 10.2196/51824 %U https://formative.jmir.org/2023/1/e51824 %U https://doi.org/10.2196/51824 %U http://www.ncbi.nlm.nih.gov/pubmed/37921846 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e49809 %T Behavioral Activation–Based Digital Smoking Cessation Intervention for Individuals With Depressive Symptoms: Randomized Clinical Trial %A Dahne,Jennifer %A Wahlquist,Amy E %A Kustanowitz,Jacob %A Natale,Noelle %A Fahey,Margaret %A Graboyes,Evan M %A Diaz,Vanessa A %A Carpenter,Matthew J %+ Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 86 Jonathan Lucas Street, MSC 955, Charleston, SC, 29425, United States, 1 8438762280, dahne@musc.edu %K smoking cessation %K depression %K digital health %K decentralized trial %K mental health %K depressive %K RCT %K randomized %K controlled trial %K smoking %K smoke %K smoker %K quit %K quitting %K cessation %K digital health %K eHealth %K e-health %K NRT %K nicotine %K mobile health %K mHealth %K app %K apps %K application %K applications %D 2023 %7 1.11.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is common among adults who smoke cigarettes. Existing depression-specific cessation interventions have limited reach and are unlikely to improve smoking prevalence rates among this large subgroup of smokers. Objective: This study aimed to determine whether a mobile app–based intervention tailored for depression paired with a mailed sample of nicotine replacement therapy (NRT) is efficacious for treating depression and promoting smoking cessation. Methods: A 2-arm nationwide remote randomized clinical trial was conducted in the United States. Adults (N=150) with elevated depressive symptoms (Patient Health Questionnaire-8≥10) who smoked were enrolled. The mobile app (“Goal2Quit”) provided behavioral strategies for treating depression and quitting smoking based on Behavioral Activation Treatment for Depression. Goal2Quit participants also received a 2-week sample of combination NRT. Treatment as usual participants received a self-help booklet for quitting smoking that was not tailored for depression. Primary end points included Goal2Quit usability, change in depression (Beck Depression Inventory-II) across 12 weeks, and smoking cessation including reduction in cigarettes per day, incidence of 24-hour quit attempts, floating abstinence, and 7-day point prevalence abstinence (PPA). Results: In total, 150 participants were enrolled between June 25, 2020, and February 23, 2022, of which 80 were female (53.3%) and the mean age was 38.4 (SD 10.3) years. At baseline, participants on average reported moderate depressive symptoms and smoked a mean of 14.7 (SD 7.5) cigarettes per day. Goal2Quit usability was strong with a mean usability rating on the System Usability Scale of 78.5 (SD 16.9), with 70% scoring above the ≥68 cutoff for above-average usability. Retention data for app use were generally strong immediately following trial enrollment and declined in subsequent weeks. Those who received Goal2Quit and the NRT sample reported lower mean depressive symptoms over the trial duration as compared to treatment as usual (difference of mean 3.72, SE 1.37 points less; P=.01). Across time points, all cessation outcomes favored Goal2Quit. Regarding abstinence, Goal2Quit participants reported significantly higher rates of 7-day PPA at weeks 4 (11% vs 0%; P=.02), 8 (7-day PPA: 12% vs 0%; P=.02), and 12 (16% vs 2%; P=.02). Conclusions: A mobile app intervention tailored for depression paired with a sample of NRT was effective for depression treatment and smoking cessation. Findings support the utility of this intervention approach for addressing the currently unmet public health treatment need for tailored, scalable depression-specific cessation treatments. Trial Registration: ClinicalTrials.gov NCT03837379; https://clinicaltrials.gov/ct2/show/NCT03837379 %M 37910157 %R 10.2196/49809 %U https://www.jmir.org/2023/1/e49809 %U https://doi.org/10.2196/49809 %U http://www.ncbi.nlm.nih.gov/pubmed/37910157 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e47233 %T Effects of Bullying on Anxiety, Depression, and Posttraumatic Stress Disorder Among Sexual Minority Youths: Network Analysis %A Li,Jiaqi %A Jin,Yu %A Xu,Shicun %A Wilson,Amanda %A Chen,Chang %A Luo,Xianyu %A Liu,Yuhang %A Ling,Xi %A Sun,Xi %A Wang,Yuanyuan %+ School of Psychology, South China Normal University, 55 West Zhongshan Avenue, Tianhe District, Guangzhou, 510660, China, 86 13138157257, angelayuanyuanwang@gmail.com %K sexual minority youths %K bullying victimization %K anxiety %K depression %K posttraumatic stress disorder %K network analysis %K Bayesian network %D 2023 %7 1.11.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Bullying victimization is highly prevalent among sexual minority youths, particularly in educational settings, negatively affecting their mental health. However, previous studies have scarcely explored the symptomatic relationships among anxiety, depression, and posttraumatic stress disorder (PTSD) among sexual minority youths who experienced bullying on college campuses. Objective: The objectives of our study were to (1) characterize the anxiety-depression-PTSD network structures of gay or lesbian, bisexuals, and other sexual minority youths previously bullied on college campuses; and (2) compare symptomatic associations in the anxiety-depression-PTSD networks among bullied sexual minority youths and heterosexual youths’ groups. Methods: This cross-sectional study recruited college participants from Jilin Province, China. Data were analyzed using a subset of the data extracted after screening for sexual orientation and history of bullying victimization. Sexual minority youths were then divided into 3 subgroups: gay or lesbian (homosexual), bisexual, and other. Mental health symptom severity was assessed using scales: the 7-item Generalized Anxiety Disorder Scale measuring anxiety, the 9-item Patient Health Questionnaire measuring depression, and the 10-item Trauma Screening Questionnaire measuring PTSD symptoms. Combining the undirected and Bayesian network analyses, the anxiety-depression-PTSD networks were compared among sexual minority youths subgroups, and the difference between heterosexual youths and sexual minority youths was investigated. Chi-square tests were used to compare the difference in categorical variables, while independent-sample t tests were run on continuous variables. Results: In this large-scale sample of 89,342 participants, 12,249 identified as sexual minority youths, of which 1603 (13.1%, 95% CI 12.5%-13.7%) reported being bullied on college campuses in the past year. According to the expected influence (EI) and bridge expected influence (bEI) index, in the global network structure of anxiety, depression, and PTSD, sad mood (EI=1.078, bEI=0.635) and irritability (EI=1.077, bEI=0.954) were identified as central and bridge symptoms; emotional cue reactivity (EI=1.015) was a central symptom of PTSD in this global network. In the anxiety-depression-PTSD Bayesian network, anhedonia had the highest prediction priority for activating other symptoms; and feeling afraid linked symptoms from anxiety to the PTSD community. Compared to their heterosexual counterparts, sexual minority youths exhibited a stronger association between difficulty concentrating and appetite. The “sad mood-appetite” edge was strongest in the gay or lesbian network; the “irritability-exaggerated startle response” edge was strongest in the bisexual network. Conclusions: For the first time, this study identified the most central and bridge symptoms (sad mood and irritability) within the depression-anxiety-PTSD network of sexual minority youths with past bullying-victim experiences on college campuses. Emotional cue reactivity, anhedonia, and feeling afraid were other vital symptoms in the comorbid network. Symptomatic relationships existed showing heterogeneity in bullied heterosexual youths and sexual minority youth networks, which also was present within the sexual minority youth subgroups. Consequently, refined targeted interventions are required to relieve anxiety, depression, and PTSD symptoms. %M 37910159 %R 10.2196/47233 %U https://publichealth.jmir.org/2023/1/e47233 %U https://doi.org/10.2196/47233 %U http://www.ncbi.nlm.nih.gov/pubmed/37910159 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e46158 %T Preliminary Evaluation of a Web-Based International Journal Club for Ketamine in Psychiatric Disorders: Cross-Sectional Survey Study %A Lindner,Jacek R %A Ebrahimi,Ashkan %A Kochanowicz,Julian F %A Szczupak,Justyna %A Paris,Timothy %A Abdelsamie,Ahmed %A Parikh,Sagar V %A McShane,Rupert %A Costi,Sara %+ Interventional Psychiatry Service, Warneford Hospital, Oxford Health NHS Foundation Trust, Warneford Lane, Oxford, OX3 7JX, United Kingdom, 44 01865902522, jacek.lindner@oxfordhealth.nhs.uk %K web-based journal club %K journal club %K remote learning %K ketamine %K medical education %K web-based %K survey %K COVID-19 %K psychiatry %K evaluation %K YouTube %K networking %K internet %K format %D 2023 %7 1.11.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: The use of novel rapid-acting antidepressants for psychiatric disorders is expanding. The web-based Ketamine and Related Compounds International Journal Club (KIJC) was created during the COVID-19 pandemic by UK academic psychiatrists and trainees for interested global professionals to discuss papers related to the topic of ketamine for the treatment of psychiatric disorders. The KIJC aimed to facilitate bidirectional discussions, sharing of ideas, and networking among participants. Objective: The aim of this study is a preliminary evaluation of the journal club’s format for satisfaction and impact after the first year of running. Methods: A website, email, and word of mouth were used for recruitment. The journal club was held twice per month using videoconferencing software in 3 parts: a 20-minute presentation, a 15-minute chaired question and answer session, and a 25-minute informal discussion with participants’ cameras on. The first 2 parts were recorded and uploaded to the website alongside links to the corresponding papers. In total, 24 speakers presented from 8 countries, typically within 2 (SD 2) months of publication. The average attendance was 51 (SD 20) audience members, and there were 63 (SD 50) views of each subsequent recording. Two anonymous web-based cross-sectional surveys were conducted from November 2021 to February 2022, one for speakers and another for audience members, separately. Various survey statements, 14 for speakers and 12 for the audience, were categorized according to satisfaction and impact, alongside obtaining participants’ primary career roles and requesting optional written feedback. Responses were compared between both groups and analyzed, including an inductive thematic analysis and a summary of lessons learned. Results: A total of 30 survey responses were obtained, demonstrating overall agreement with the statements. In total, 12 (50%) out of 24 speakers and 18 (35%) out of an average of 51 (SD 20) audience members regarded the journal club’s format as satisfying and impactful. The majority (26/30, 87%) of respondents identified as clinicians (9/30, 30%), researchers (9/30, 30%), and clinician-researchers (8/30, 27%). Additionally, 11 (37%) of the 30 respondents also provided optional written feedback: 3 (10%) speakers and 8 (27%) audience members. From the written feedback, 5 main themes were derived: engagement with the journal club, desire for active participation, improving the platform, positive learning experiences, and suggestions for future sessions. Conclusions: The journal club successfully reached its intended audience and developed into a web-based community. The majority of the participants were satisfied with the format and found it impactful. Overall, the journal club appears to be a valuable tool for knowledge sharing and community building in the field of ketamine use for the treatment of psychiatric disorders. A larger sample size and additional testing methods are required to support the generalizability of the journal club’s format. %M 37910164 %R 10.2196/46158 %U https://mededu.jmir.org/2023/1/e46158 %U https://doi.org/10.2196/46158 %U http://www.ncbi.nlm.nih.gov/pubmed/37910164 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e48112 %T Participants’ Engagement With and Results From a Web-Based Integrative Population Mental Wellness Program (CHAMindWell) During the COVID-19 Pandemic: Program Evaluation Study %A Rosansky,Joseph A %A Okst,Kayley %A Tepper,Miriam C %A Baumgart Schreck,Ana %A Fulwiler,Carl %A Wang,Philip S %A Schuman-Olivier,Zev %+ Department of Psychiatry, Cambridge Health Alliance, 1493 Cambridge St, Cambridge, MA, 02139, United States, 1 617 591 6132, zschuman@cha.harvard.edu %K COVID-19 pandemic %K digital psychiatry %K early identification %K integrative medicine %K mental wellness %K mindfulness %K population mental health %K prevention %K stratified care %D 2023 %7 26.10.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic involved a prolonged period of collective trauma and stress during which substantial increases in mental health concerns, like depression and anxiety, were observed across the population. In this context, CHAMindWell was developed as a web-based intervention to improve resilience and reduce symptom severity among a public health care system’s patient population. Objective: This program evaluation was conducted to explore participants’ engagement with and outcomes from CHAMindWell by retrospectively examining demographic information and mental health symptom severity scores throughout program participation. Methods: We examined participants’ symptom severity scores from repeated, web-based symptom screenings through Computerized Adaptive Testing for Mental Health (CAT-MH) surveys, and categorized participants into symptom severity-based tiers (tier 1=asymptomatic to mild; tier 2=moderate; and tier 3=severe). Participants were provided tier-based mindfulness resources, treatment recommendations, and referrals. Logistic regressions were conducted to evaluate associations between demographic variables and survey completion. The McNemar exact test and paired sample t tests were performed to evaluate changes in the numbers of participants in tier 1 versus tier 2 or 3 and changes in depression, anxiety, and posttraumatic stress disorder severity scores between baseline and follow-up. Results: The program enrolled 903 participants (664/903, 73.5% female; 556/903, 61.6% White; 113/903, 12.5% Black; 84/903, 9.3% Asian; 7/903, 0.8% Native; 36/903, 4% other; and 227/903, 25.1% Hispanic) between December 16, 2020, and March 17, 2022. Of those, 623 (69%) completed a baseline CAT-MH survey, and 196 completed at least one follow-up survey 3 to 6 months after baseline. White racial identity was associated with completing baseline CAT-MH (odds ratio [OR] 1.80, 95% CI 1.14-2.84; P=.01). Participants’ odds of having symptom severity below the clinical threshold (ie, tier 1) were significantly greater at follow-up (OR 2.60, 95% CI 1.40-5.08; P=.001), and significant reductions were observed across symptom domains over time. Conclusions: CHAMindWell is associated with reduced severity of mental health symptoms. Future work should aim to address program engagement inequities and attrition and compare the impacts of CHAMindWell to a control condition to better characterize its effects. %M 37883149 %R 10.2196/48112 %U https://mental.jmir.org/2023/1/e48112 %U https://doi.org/10.2196/48112 %U http://www.ncbi.nlm.nih.gov/pubmed/37883149 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e48912 %T Effect of Individual Virtual Reality Cognitive Training Programs on Cognitive Function and Depression in Middle-Aged Women: Randomized Controlled Trial %A Kim,Du-Ri %A Moon,EunSoo %A Shin,Myung-Jun %A Yang,Yeong-Ae %A Park,Jong-Hwan %+ Health Convergence Medicine Laboratory, Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan, 49241, Republic of Korea, 82 0512407071, parkj@pusan.ac.kr %K cognitive function %K depression %K middle aged %K virtual reality %K women %D 2023 %7 25.10.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Given the increasing incidence of early-onset Alzheimer disease, strategies for early diagnosis and swift treatment interventions are crucial for mitigating cognitive problems in women and middle-aged individuals who face a high risk of cognitive impairment. Objective: This study aimed to assess the effectiveness of individual cognitive training programs based on virtual reality (VR), a nonpharmacological intervention, on cognitive function and depression in middle-aged women at risk of cognitive impairment. It used VR technology, which has recently been recognized as a promising tool. Methods: We administered a VR-based cognitive training program for 30 minutes daily, twice a week, for 12 weeks (24 sessions). This study included middle-aged women residing in older adults’ welfare facilities in G-gu, Busan, from May to August 2021. A total of 60 participants were randomly divided into the training (n=30) and control (n=30) groups. Cognitive and depressive functions were assessed using the Korean versions of the Montreal Cognitive Assessment (K-MoCA), Digit Span Test (DST), Korean-Color Word Stroop Test (K-CWST), and Short Form of the Geriatric Depression Scale (SGDS-K) before the intervention. The training group underwent a VR-based cognitive training program, whereas the control group was educated to maintain regular daily activities. The same assessments were performed 12 weeks after treatment. Results: A comparison of the mean scores before and after K-MoCA in the training group revealed a significant increase from 24.87 (SD 2.62) to 27.50 (SD 1.70; P<.01), indicating substantial cognitive improvement. Similarly, the mean DST forward scores increased significantly from 6.97 (SD 1.10) to 7.90 (SD 1.18; P<.01), suggesting enhanced short-term auditory memory and attention. The mean DST backward scores also showed a significant improvement from 4.10 (SD 0.71) to 4.77 (SD 1.2; P=.01). Notably, the mean SGDS-K scores decreased significantly from 3.97 (SD 2.51) to 2.13 (SD 1.87; P<.01), indicating a reduction in depression within the training group. Conclusions: The VR-based cognitive training programs significantly enhanced cognitive function and reduced depression in middle-aged women. Consequently, these programs are considered beneficial nonpharmacological cognitive training interventions for middle-aged women at high risk of cognitive impairment. Trial Registration: UMIN Clinical Trials Registry UMIN000049752; https://tinyurl.com/z5du989z %M 37878378 %R 10.2196/48912 %U https://mental.jmir.org/2023/1/e48912 %U https://doi.org/10.2196/48912 %U http://www.ncbi.nlm.nih.gov/pubmed/37878378 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e46651 %T Improving Mild to Moderate Depression With an App-Based Self-Guided Intervention: Protocol for a Randomized Controlled Trial %A Beintner,Ina %A Kerber,André %A Dominke,Clara %A Voderholzer,Ulrich %+ MindDoc Health GmbH, Leopoldstraße 159, Munich, 80804, Germany, 49 015128346250, ibeintner@minddoc.de %K depression %K mobile app %K intervention %K unguided %K transdiagnostic %K randomized controlled trial %K e-mental health %K digital app %K self-management %K mental health %K mHealth %K mobile health %K unguided digital intervention %K public health %K digital intervention %K mobile phone %D 2023 %7 25.10.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is one of the most prevalent mental disorders and frequently co-occurs with other mental disorders. Despite the high direct and indirect costs to both individuals and society, more than 80% of those diagnosed with depression remain with their primary care physician and do not receive specialized treatment. Self-guided digital interventions have been shown to improve depression and, due to their scalability, have a large potential public health impact. Current digital interventions often focus on specific disorders, while recent research suggests that transdiagnostic approaches are more suitable. Objective: This paper presents the protocol for a study that aims to assess the efficacy of a self-guided transdiagnostic app-based self-management intervention in patients with mild or moderate depression with and without comorbid mental disorders. Specifically, we are investigating the impact of the intervention on symptoms of depression, quality of life, anxiety symptoms, and mental health–related patient empowerment and self-management skills. Methods: The intervention under investigation, MindDoc with Prescription, is a self-guided digital intervention aimed at supporting individuals with mild to moderate mental disorders from the internalizing spectrum, including depression. The app can be used as a low-threshold psychosocial intervention. Up to 570 adult patients will be randomized to either receive the intervention in addition to care as usual or only care as usual. We are including adults with a permanent residency in Germany and mild or moderate depression according to International Classification of Diseases, 10th Revision, criteria (F32.0, F32.1, F33.0, and F33.1). Clinical interviews will be conducted to confirm the diagnosis. Data will be collected at baseline as well as 8 weeks and 6 months after randomization. The primary outcome will be depression symptom severity after 8 weeks. Secondary outcomes will be quality of life, anxiety symptom severity, and patient empowerment and self-management behaviors. Data will be analyzed using multiple imputations, using the intention-to-treat principle, while sensitivity analyses will be based on additional imputation strategies and a per-protocol analysis. Results: Recruitment for the trial started on February 7, 2023, and the first participant was randomized on February 14, 2023. As of September 5, 2023, 275 participants have been included in the trial and 176 have provided the primary outcome. The rate of missing values in the primary outcome is approximately 20%. Conclusions: Data from this efficacy trial will be used to establish whether access to the intervention is associated with an improvement in depression symptoms in individuals diagnosed with mild or moderate depression. The study will contribute to expanding the evidence base on transdiagnostic digital interventions. Trial Registration: German Registry of Clinical Trials DRKS00030852; https://drks.de/search/de/trial/DRKS00030852 International Registered Report Identifier (IRRID): DERR1-10.2196/46651 %M 37878374 %R 10.2196/46651 %U https://www.researchprotocols.org/2023/1/e46651 %U https://doi.org/10.2196/46651 %U http://www.ncbi.nlm.nih.gov/pubmed/37878374 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e49783 %T Comparing the Acceptability and Quality of Intervention Modalities for Suicidality in the Emergency Department: Randomized Feasibility Trial %A Larkin,Celine %A Tulu,Bengisu %A Djamasbi,Soussan %A Garner,Roscoe %A Varzgani,Fatima %A Siddique,Mariam %A Pietro,John %A Boudreaux,Edwin D %+ Department of Emergency Medicine, University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, United States, 1 5084211436, celine.larkin@umassmed.edu %K suicide %K self-harm %K emergency department %K mobile app %K intervention %K mobile technology %K safety planning %K safety %K suicidal %K emergency %K mHealth %K mobile health %K mental health %K mobile phone %D 2023 %7 24.10.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Emergency departments (EDs) manage many patients with suicide risk, but effective interventions for suicidality are challenging to implement in this setting. ReachCare is a technology-facilitated version of an evidence-based intervention for suicidal ED patients. Here, we present findings on the acceptability and quality of ReachCare in the ED, as well as a comparison of these measures across 3 potential delivery modalities Objective: Our aim was to test the feasibility of the ReachCare intervention in its entirety through conducting a pilot study with patients presenting with suicidality to the ED. We tested three different ways of receiving the ED-based components of ReachCare: (1) self-administered on the tablet app using a chatbot interface, (2) administered by an in-person clinician, or (3) administered by a telehealth clinician. Methods: In total, 47 ED patients who screened positive for suicide risk were randomly allocated to receive one of three delivery modalities of ReachCare in the ED: (1) self-administered on the patient-facing tablet app with a chatbot interface, (2) delivered by an in-person clinician, or (3) delivered by a telehealth clinician, with the latter two using a clinician-facing web app. We measured demographic and clinical characteristics, acceptability and appropriateness of the intervention, and quality and completeness of the resulting safety plans. Results: Patients assigned high ratings for the acceptability (median 4.00/5, IQR 4.00-4.50) and appropriateness (median 4.00/5, IQR 4.00-4.25) of ReachCare’s ED components, and there were no substantial differences across the 3 delivery modalities [H(acceptability)=3.90, P=.14; H(appropriateness)=1.05, P=.59]. The self-administered modality took significantly less time than the 2 clinician modalities (H=27.91, P<.001), and the usability of the self-administered version was in the “very high” range (median 93.75/100, IQR 80.00-97.50). The safety plans created across all 3 modalities were high-quality (H=0.60, P=.74). Conclusions: Patients rated ReachCare in the ED as highly acceptable and appropriate regardless of modality. Self-administration may be a feasible way to ensure patients with suicide risk receive an intervention in resource constrained EDs. Limitations include small sample size and demographic differences between those enrolled versus not enrolled. Further research will examine the clinical outcomes of patients receiving both the in-ED and post-ED components of ReachCare. Trial Registration: ClinicalTrials.gov NCT04720911; https://clinicaltrials.gov/ct2/show/NCT04720911 %M 37874619 %R 10.2196/49783 %U https://mental.jmir.org/2023/1/e49783 %U https://doi.org/10.2196/49783 %U http://www.ncbi.nlm.nih.gov/pubmed/37874619 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e48758 %T Digital Training Program for Line Managers (Managing Minds at Work): Protocol for a Feasibility Pilot Cluster Randomized Controlled Trial %A Thomson,Louise %A Hassard,Juliet %A Frost,Alexandra %A Bartle,Craig %A Yarker,Joanna %A Munir,Fehmidah %A Kneller,Richard %A Marwaha,Steven %A Daly,Guy %A Russell,Sean %A Meyer,Caroline %A Vaughan,Benjamin %A Newman,Kristina %A Blake,Holly %+ School of Medicine, University of Nottingham, Yang Fujia Building, Jubilee Campus, Wollaton Road, Nottingham, NG8 1BB, United Kingdom, 44 1157484314, louise.thomson@nottingham.ac.uk %K acceptability %K anxiety %K burnout %K cluster randomised control trial %K depression %K digital training %K feasibility %K intervention %K intervention %K managers %K mental health %K stress %K usability %K work %K workplace %D 2023 %7 24.10.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mental health problems affect 1 in 6 workers annually and are one of the leading causes of sickness absence, with stress, anxiety, and depression being responsible for half of all working days lost in the United Kingdom. Primary interventions with a preventative focus are widely acknowledged as the priority for workplace mental health interventions. Line managers hold a primary role in preventing poor mental health within the workplace and, therefore, need to be equipped with the skills and knowledge to effectively carry out this role. However, most previous intervention studies have directly focused on increasing line managers’ understanding and awareness of mental health rather than giving them the skills and competencies to take a proactive preventative approach in how they manage and design work. The Managing Minds at Work (MMW) digital training intervention was collaboratively designed to address this gap. The intervention aims to increase line managers’ knowledge and confidence in preventing work-related stress and promoting mental health at work. It consists of 5 modules providing evidence-based interactive content on looking after your mental health, designing and managing work to promote mental well-being, management competencies that prevent work-related stress, developing a psychologically safe workplace, and having conversations about mental health at work. Objective: The primary aim of this study is to pilot and feasibility test MMW, a digital training intervention for line managers. Methods: We use a cluster randomized controlled trial design consisting of 2 arms, the intervention arm and a 3-month waitlist control, in this multicenter feasibility pilot study. Line managers in the intervention arm will complete a baseline questionnaire at screening, immediately post intervention (approximately 6 weeks after baseline), and at 3- and 6-month follow-ups. Line managers in the control arm will complete an initial baseline questionnaire, repeated after 3 months on the waitlist. They will then be granted access to the MMW intervention, following which they will complete the questionnaire post intervention. The direct reports of the line managers in both arms of the trial will also be invited to take part by completing questionnaires at baseline and follow-up. As a feasibility pilot study, a formal sample size is not required. A minimum of 8 clusters (randomized into 2 groups of 4) will be sought to inform a future trial from work organizations of different types and sectors. Results: Recruitment for the study closed in January 2022. Overall, 24 organizations and 224 line managers have been recruited. Data analysis was finished in August 2023. Conclusions: The results from this feasibility study will provide insight into the usability and acceptability of the MMW intervention and its potential for improving line manager outcomes and those of their direct reports. These results will inform the development of subsequent trials. Trial Registration: ClinicalTrials.gov NCT05154019; https://clinicaltrials.gov/study/NCT05154019 International Registered Report Identifier (IRRID): DERR1-10.2196/48758 %M 37874612 %R 10.2196/48758 %U https://www.researchprotocols.org/2023/1/e48758 %U https://doi.org/10.2196/48758 %U http://www.ncbi.nlm.nih.gov/pubmed/37874612 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e48444 %T Patient Health Questionnaire-9 Item Pairing Predictiveness for Prescreening Depressive Symptomatology: Machine Learning Analysis %A Glavin,Darragh %A Grua,Eoin Martino %A Nakamura,Carina Akemi %A Scazufca,Marcia %A Ribeiro dos Santos,Edinilza %A Wong,Gloria H Y %A Hollingworth,William %A Peters,Tim J %A Araya,Ricardo %A Van de Ven,Pepijn %+ Department of Electronic and Computer Engineering, University of Limerick, Plassey Park Road, Limerick, V94 T9PX, Ireland, 353 87 260 7623, Darragh.Glavin@ul.ie %K Patient Health Questionnaire-2 %K PHQ-2 %K Patient Health Questionnaire-9 %K PHQ-9 items %K depressive symptomatology %K ultrabrief questionnaires %K prescreening %K machine learning %K cardinal symptoms %K low energy %K psychomotor dysfunction %K depressed mood %D 2023 %7 19.10.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Anhedonia and depressed mood are considered the cardinal symptoms of major depressive disorder. These are the first 2 items of the Patient Health Questionnaire (PHQ)–9 and comprise the ultrabrief PHQ-2 used for prescreening depressive symptomatology. The prescreening performance of alternative PHQ-9 item pairings is rarely compared with that of the PHQ-2. Objective: This study aims to use machine learning (ML) with the PHQ-9 items to identify and validate the most predictive 2-item depressive symptomatology ultrabrief questionnaire and to test the generalizability of the best pairings found on the primary data set, with 6 external data sets from different populations to validate their use as prescreening instruments. Methods: All 36 possible PHQ-9 item pairings (each yielding scores of 0-6) were investigated using ML-based methods with logistic regression models. Their performances were evaluated based on the classification of depressive symptomatology, defined as PHQ-9 scores ≥10. This gave each pairing an equal opportunity and avoided any bias in item pairing selection. Results: The ML-based PHQ-9 items 2 and 4 (phq2&4), the depressed mood and low-energy item pairing, and PHQ-9 items 2 and 8 (phq2&8), the depressed mood and psychomotor retardation or agitation item pairing, were found to be the best on the primary data set training split. They generalized well on the primary data set test split with area under the curves (AUCs) of 0.954 and 0.946, respectively, compared with an AUC of 0.942 for the PHQ-2. The phq2&4 had a higher AUC than the PHQ-2 on all 6 external data sets, and the phq2&8 had a higher AUC than the PHQ-2 on 3 data sets. The phq2&4 had the highest Youden index (an unweighted average of sensitivity and specificity) on 2 external data sets, and the phq2&8 had the highest Youden index on another 2. The PHQ-2≥2 cutoff also had the highest Youden index on 2 external data sets, joint highest with the phq2&4 on 1, but its performance fluctuated the most. The PHQ-2≥3 cutoff had the highest Youden index on 1 external data set. The sensitivity and specificity achieved by the phq2&4 and phq2&8 were more evenly balanced than the PHQ-2≥2 and ≥3 cutoffs. Conclusions: The PHQ-2 did not prove to be a more effective prescreening instrument when compared with other PHQ-9 item pairings. Evaluating all item pairings showed that, compared with alternative partner items, the anhedonia item underperformed alongside the depressed mood item. This suggests that the inclusion of anhedonia as a core symptom of depression and its presence in ultrabrief questionnaires may be incompatible with the empirical evidence. The use of the PHQ-2 to prescreen for depressive symptomatology could result in a greater number of misclassifications than alternative item pairings. %M 37856186 %R 10.2196/48444 %U https://mental.jmir.org/2023/1/e48444 %U https://doi.org/10.2196/48444 %U http://www.ncbi.nlm.nih.gov/pubmed/37856186 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e46995 %T Relationship Between Depression and Falls Among Nursing Home Residents: Protocol for an Integrative Review %A Matos Queirós,Alcina %A von Gunten,Armin %A Rosselet Amoussou,Joëlle %A Martins,Maria Manuela %A Verloo,Henk %+ Department of Health and Social Welfare, University of Lausanne, Avenue des Casernes 2, Lausanne, CH-1014, Switzerland, 41 0766152937, alcinaqueiros@hotmail.com %K depression %K falls %K nursing homes %K nursing home residents %K older adults %K fall risk %K intervention %D 2023 %7 19.10.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Aging exposes individuals to new health disorders and debilitating chronic diseases, yet most older adults, even in functional decline, do not want to leave their homes. Nevertheless, for many, institutionalization in a nursing home (NH) may become essential to ensure their continued safety and health. Depression is one of the most common psychiatric disorders among older adults, especially among those who are institutionalized. Depressed NH residents face a high risk of future functional decline and falls, decreasing their quality of life. The relationship between depression and falls is complex and bidirectional. Previous reviews have focused on home-dwelling older adults or explored the relationship between antidepressant drugs and falls. To the best of our knowledge, no integrative literature reviews have explored the relationship between depression and falls among NH residents. Objective: Analyze studies on the relationship between depression and falls among NH residents. Methods: We will conduct an integrative literature review of published articles in relevant scientific journals on the relationship between depression and depressive symptomatology and falls among NH residents. As usually defined, we will consider NH residents to be people aged 65 years and older who can no longer live safely and independently in their homes. We will also consider older adults on short-term stays in an NH for rehabilitation after hospital discharge. Retrieved articles will be screened for eligibility and analyzed following previously reported steps. The most pertinent bibliographical databases will be examined for qualitative, quantitative, and mixed methods studies, from inception until August 31, 2023, thus ensuring that all relevant literature is included. We will also hand-search the bibliographies of all the relevant articles found and search for unpublished studies in any language. If appropriate, we will consider conducting a meta-analysis of the studies retrieved. Results: A first round of data collection was completed in March 2023. We retrieved a total of 2276 references. A supplementary literature search to ensure the most up-to-date evidence is ongoing. We anticipate that the review will be completed in late September 2023, and we expect to publish results at the end of December 2023. Conclusions: This integrative review will increase knowledge and understanding of the complex relationship between depression and falls in NH environments. Its findings will be important for developing integrated, multidisciplinary models and care recommendations, adaptable to each NH resident’s situation and health status, and for creating preventive interventions to help them maintain or recover optimal health stability. International Registered Report Identifier (IRRID): DERR1-10.2196/46995 %M 37856175 %R 10.2196/46995 %U https://www.researchprotocols.org/2023/1/e46995 %U https://doi.org/10.2196/46995 %U http://www.ncbi.nlm.nih.gov/pubmed/37856175 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e48365 %T Real-World User Demographics of Three Web-Based Digital Mental Health Interventions Provided by the US Department of Veterans Affairs: Observational Study Using Web Analytics Data %A Ryan,Arthur T %A Stearns-Yoder,Kelly A %A Brenner,Lisa A %+ Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Department of Veterans Affairs, Rocky Mountain Regional Veterans Affairs Medical Center, 1700 N Wheeling St, G-3-116M, Aurora, CO, 80045, United States, 1 720 723 7493, arthur.t.ryan@gmail.com %K digital intervention %K unguided %K web-based %K internet-delivered %K mental health %K veterans %K Google Analytics %K insomnia %K anger %K depression %K mobile phone %D 2023 %7 18.10.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Unguided digital mental health interventions (UDMHIs) have the potential to provide low-cost and effective mental health care at scale. Controlled trials have demonstrated the efficacy of UDMHIs to address mental health symptoms and conditions. However, few previous publications have described the demographics of real-world users of UDMHIs that are freely available to the public. The US Department of Veterans Affairs has created and hosts several UDMHIs on its Veteran Training Portal website. These web-based, free-to-use, and publicly available UDMHIs include Path to Better Sleep, Anger and Irritability Management Skills, and Moving Forward, which focus on insomnia, problematic anger, and depression symptoms, respectively. Objective: This study aimed to examine the user demographics of these 3 UDMHIs in the year 2021. In addition, it aimed to compare the age and gender distribution of the users of those 3 UDMHIs with one another and with the age and gender distribution of the total US veteran population. Methods: Google Analytics was used to collect user data for each of the 3 UDMHIs. The age and gender distribution of the users of each UDMHI was compared with that of the other UDMHIs as well as with that of the overall US veteran population using chi-square tests. Information on the total number of users, the country they were in, and the devices they used to access the UDMHIs was also collected and reported. Results: In 2021, the 3 UDMHIs together recorded 29,306 unique users. The estimated age range and gender were available for 24.12% (7068/29,306) of those users. Each UDMHI’s age and gender distribution significantly differed from that of the other UDMHIs and from that of the overall US veteran population (P<.001 on all chi-square tests). Women and younger age groups were overrepresented among UDMHI users compared with the overall US veteran population. The majority of devices used to access the UDMHIs were desktop or laptop devices, although a substantial proportion of devices used were mobile devices (10,199/29,752, 34.28%). Most users (27,789/29,748, 93.41%) were located in the United States, with users from Canada, the United Kingdom, and Australia accounting for another 2.61% (775/29,748) of total users. Conclusions: Our use of Google Analytics data provided useful information about the users of 3 free and publicly available UDMHIs provided by the US Department of Veterans Affairs. Although our findings should be considered in light of the limitations of autonomously collected web analytics data, they still offer useful information for health care policy makers, administrators, and UDMHI developers. %M 37851501 %R 10.2196/48365 %U https://formative.jmir.org/2023/1/e48365 %U https://doi.org/10.2196/48365 %U http://www.ncbi.nlm.nih.gov/pubmed/37851501 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e49359 %T Identifying Rare Circumstances Preceding Female Firearm Suicides: Validating A Large Language Model Approach %A Zhou,Weipeng %A Prater,Laura C %A Goldstein,Evan V %A Mooney,Stephen J %+ Department of Epidemiology, School of Public Health, University of Washington, Hans Rosling Center for Population Health, 3980 15th Ave NE, Seattle, WA, 98195, United States, 1 206 685 1643, sjm2186@uw.edu %K female firearm suicide %K large language model %K document classification %K suicide prevention %K suicide %K firearm suicide %K machine learning %K mental health for women %K violent death %K mental health %K language models %K women %K female %K depression %K suicidal %D 2023 %7 17.10.2023 %9 Short Paper %J JMIR Ment Health %G English %X Background: Firearm suicide has been more prevalent among males, but age-adjusted female firearm suicide rates increased by 20% from 2010 to 2020, outpacing the rate increase among males by about 8 percentage points, and female firearm suicide may have different contributing circumstances. In the United States, the National Violent Death Reporting System (NVDRS) is a comprehensive source of data on violent deaths and includes unstructured incident narrative reports from coroners or medical examiners and law enforcement. Conventional natural language processing approaches have been used to identify common circumstances preceding female firearm suicide deaths but failed to identify rarer circumstances due to insufficient training data. Objective: This study aimed to leverage a large language model approach to identify infrequent circumstances preceding female firearm suicide in the unstructured coroners or medical examiners and law enforcement narrative reports available in the NVDRS. Methods: We used the narrative reports of 1462 female firearm suicide decedents in the NVDRS from 2014 to 2018. The reports were written in English. We coded 9 infrequent circumstances preceding female firearm suicides. We experimented with predicting those circumstances by leveraging a large language model approach in a yes/no question-answer format. We measured the prediction accuracy with F1-score (ranging from 0 to 1). F1-score is the harmonic mean of precision (positive predictive value) and recall (true positive rate or sensitivity). Results: Our large language model outperformed a conventional support vector machine–supervised machine learning approach by a wide margin. Compared to the support vector machine model, which had F1-scores less than 0.2 for most infrequent circumstances, our large language model approach achieved an F1-score of over 0.6 for 4 circumstances and 0.8 for 2 circumstances. Conclusions: The use of a large language model approach shows promise. Researchers interested in using natural language processing to identify infrequent circumstances in narrative report data may benefit from large language models. %M 37847549 %R 10.2196/49359 %U https://mental.jmir.org/2023/1/e49359 %U https://doi.org/10.2196/49359 %U http://www.ncbi.nlm.nih.gov/pubmed/37847549 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e48152 %T Mental Health Self-Tracking Preferences of Young Adults With Depression and Anxiety Not Engaged in Treatment: Qualitative Analysis %A Beltzer,Miranda L %A Meyerhoff,Jonah %A Popowski,Sarah A %A Mohr,David C %A Kornfield,Rachel %+ Center for Behavior Intervention Technologies, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 312 503 6585, miranda.beltzer@northwestern.edu %K self-tracking %K self-monitoring %K self-help %K depression %K anxiety %K young adults %K mHealth %K technology %K qualitative analysis %K focus group %K personal informatics %K mood %K thematic analysis %D 2023 %7 6.10.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Despite the high prevalence of anxiety and depression among young adults, many do not seek formal treatment. Some may turn to digital mental health tools for support instead, including to self-track moods, behaviors, and other variables related to mental health. Researchers have sought to understand processes and motivations involved in self-tracking, but few have considered the specific needs and preferences of young adults who are not engaged in treatment and who seek to use self-tracking to support mental health. Objective: This study seeks to assess the types of experiences young adults not engaged in treatment have had with digital self-tracking for mood and other mental health data and to assess how young adults not seeking treatment want to engage in self-tracking to support their mental health. Methods: We conducted 2 online asynchronous discussion groups with 50 young adults aged 18 years to 25 years who were not engaged in treatment. Participants were recruited after indicating moderate to severe symptoms of depression or anxiety on screening surveys hosted on the website of Mental Health America. Participants who enrolled in the study responded anonymously to discussion prompts on a message board, as well as to each other’s responses, and 3 coders performed a thematic analysis of their responses. Results: Participants had mixed experiences with self-tracking in the past, including disliking when tracking highlighted unwanted behaviors and discontinuing tracking for a variety of reasons. They had more positive past experiences tracking behaviors and tasks they wanted to increase, using open-ended journaling, and with gamified elements to increase motivation. Participants highlighted several design considerations they wanted self-tracking tools to address, including building self-understanding; organization, reminders, and structure; and simplifying the self-tracking experience. Participants wanted self-tracking to help them identify their feelings and how their feelings related to other variables like sleep, exercise, and events in their lives. Participants also highlighted self-tracking as useful for motivating and supporting basic activities and tasks of daily living during periods of feeling overwhelmed or low mood and providing a sense of accomplishment and stability. Although self-tracking can be burdensome, participants were interested and provided suggestions for simplifying the process. Conclusions: These young adults not engaged in treatment reported interest in using self-tracking to build self-understanding as a goal in and of itself or as a first step in contemplating and preparing for behavior change or treatment-seeking. Alexithymia, amotivation, and feeling overwhelmed may serve both as barriers to self-tracking and opportunities for self-tracking to help. %M 37801349 %R 10.2196/48152 %U https://formative.jmir.org/2023/1/e48152 %U https://doi.org/10.2196/48152 %U http://www.ncbi.nlm.nih.gov/pubmed/37801349 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e48750 %T The Degree of Anxiety and Depression in Patients With Cardiovascular Diseases as Assessed Using a Mobile App: Cross-Sectional Study %A Li,Yongguang %A Cen,Jue %A Wu,Junxia %A Tang,Min %A Guo,Jingyi %A Hang,Jingyu %A Zhao,Qing %A Zhao,Gang %A Huang,Xiaoli %A Han,Beibei %+ Department of Cardiology, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University School of Medicine, 600 Yishan Rd, Shanghai, 200233, China, 86 18930172337, hanbbxu@126.com %K mobile app %K anxiety %K depression %K cardiovascular diseases %K Haodf platform %D 2023 %7 4.10.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression and anxiety are common comorbidities in cardiovascular clinic outpatients. Timely identification and intervention of these mental and psychological disorders can contribute to correct diagnosis, better prognosis, less medical expenses, and improved quality of life. The convenience of online doctor-patient communication platforms has increasingly attracted patients to online consultations. However, online health care and offline health care are very different. Research on how to identify psychological disorders in patients who engage in an online cardiology consultation is lacking. Objective: This study aimed to explore the feasibility of using a self-rating scale to assess mental illness among patients who consult with a cardiologist online and to compare the differences in anxiety and depression between online and offline patients. Methods: From June 2022 to July 2022, we conducted follow-up visits with 10,173 patients on the Haodf platform. We conducted detailed consultations with 286 patients who visited the same cardiologist in the outpatient department. We used the self-rated Generalized Anxiety Disorder (GAD-7) and Patient Health Questionnaire (PHQ-9) scales to assess anxiety and depression, respectively. We analyzed the influencing factors related to the degree of coordination of online patients. We also compared the prevalence of anxiety or depression between online and offline patients and analyzed the factors related to anxiety or depression. Results: Of the 10,173 online consultation patients, only 186 (1.8%) responded effectively. The response rate of the offline consultation patients was 96.5% (276/286). Frequent online communication and watching live video broadcasts were significantly related to effective responses from online patients (P<.001). The prevalence of anxiety (70/160, 43.7% vs 69/266, 25.8%; P<.001) or depression (78/160, 48.7% vs 74/266, 27.7%; P<.001) in online consultation patients was significantly higher than that in offline patients. In bivariate analyses, the factors related to anxiety included female sex, unemployment, no confirmed cardiovascular disease, and the online consultation mode, while smokers and those who underwent COVID-19 quarantine were less likely to present with anxiety. The factors related to depression included female sex, divorced or separated individuals, and the online consultation mode. COVID-19 quarantine was related with a lower likelihood of depression. BMI was negatively correlated with depression. In multiple ordered logistic regression analysis, women were more likely than men to present with anxiety (odds ratio [OR] 2.181, 95% CI 1.365-3.486; P=.001). Women (OR 1.664, 95% CI 1.082-2.559; P=.02) and online patients (OR 2.631, 95% CI 1.305-5.304; P=.007) were more likely to have depression. Conclusions: Online patients had more anxiety or depression than offline patients. Anxiety was more prevalent in women, the unemployed, and those without confirmed cardiovascular disease. Women and divorced or separated individuals were more prone to depression. Increasing the frequency of doctor-patient communication and participating in video interactions can help improve patient cooperation. %M 37792455 %R 10.2196/48750 %U https://www.jmir.org/2023/1/e48750 %U https://doi.org/10.2196/48750 %U http://www.ncbi.nlm.nih.gov/pubmed/37792455 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e36596 %T The Effect of a Digital Mental Health Program on Anxiety and Depression Symptoms: Retrospective Analysis of Clinical Severity %A Dzubur,Eldin %A Yu,Jessica %A Hoffman,Julia %A Painter,Stefanie %A James,Roberta %A Shah,Bimal %+ Teladoc Health, 2 Manhattanville Rd, Purchase, NY, 10577, United States, 1 3123307236, spainter@teladoc.com %K digital health %K mental health %K anxiety %K depression %K digital mental health %K program usage %D 2023 %7 3.10.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Evidence-based digital health programs have shown efficacy in being primary tools to improve emotional and mental health, as well as offering supplementary support to individuals undergoing psychotherapy for anxiety, depression, and other mental health disorders. However, information is lacking about the dose response to digital mental health interventions. Objective: The objective of the study was to examine the effect of time in program and program usage on symptom change among individuals enrolled in a real-world comprehensive digital mental health program (myStrength) who are experiencing severe anxiety or depression. Methods: Eligible participants (N=18,626) were adults aged 18 years and older who were enrolled in myStrength for at least four weeks as part of their employee wellness benefit program, who completed baseline, the 2-week, 2-month, and 6-month surveys querying symptoms of anxiety (Generalized Anxiety Disorder–7 [GAD-7]) and depression (Patient Health Questionnaire–9 [PHQ-9]). Linear growth curve models were used to analyze the effect of average weekly program usage on subsequent GAD-7 and PHQ-9 scores for participants with scores indicating severe anxiety (GAD-7≥15) or depression (PHQ-9≥15). All models were adjusted for baseline score and demographics. Results: Participants in the study (N=1519) were 77.4% female (1176/1519), had a mean age of 45 years (SD 14 years), and had an average enrollment time of 3 months. At baseline, participants reported an average of 9.39 (SD 6.04) on the GAD-7 and 11.0 (SD 6.6) on the PHQ-9. Those who reported 6-month results had an average of 8.18 (SD 6.15) on the GAD-7 and 9.18 (SD 6.79) on the PHQ-9. Participants with severe scores (n=506) experienced a significant improvement of 2.97 (SE 0.35) and 3.97 (SE 0.46) at each time point for anxiety and depression, respectively (t=–8.53 and t=–8.69, respectively; Ps<.001). Those with severe baseline scores also saw a reduction of 0.27 (SE 0.08) and 0.25 (SE 0.09) points in anxiety and depression, respectively, for each additional program activity per week (t=–3.47 and t=–2.66, respectively; Ps<.05). Conclusions: For participants with severe baseline scores, the study found a clinically significant reduction of approximately 9 points for anxiety and 12 points for depression after 6 months of enrollment, suggesting that interventions targeting mental health must maintain active, ongoing engagement when symptoms are present and be available as a continuous resource to maximize clinical impact, specifically in those experiencing severe anxiety or depression. Moreover, a dosing effect was shown, indicating improvement in outcomes among participants who engaged with the program every other day for both anxiety and depression. This suggests that digital mental health programs that provide both interesting and evidence-based activities could be more successful in further improving mental health outcomes. %M 37788069 %R 10.2196/36596 %U https://formative.jmir.org/2023/1/e36596 %U https://doi.org/10.2196/36596 %U http://www.ncbi.nlm.nih.gov/pubmed/37788069 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e47617 %T Individualized Virtual Reality for Increasing Self-Compassion: Evaluation Study %A Halim,Ilona %A Stemmet,Lehan %A Hach,Sylvia %A Porter,Richard %A Liang,Hai-Ning %A Vaezipour,Atiyeh %A Henry,Julie D %A Baghaei,Nilufar %+ School of Electrical Engineering and Computer Science, The University of Queensland, Staff House Road, St Lucia, 4072, Australia, 61 450150234, n.baghaei@uq.edu.au %K individualized virtual reality %K mental health %K self-compassion %K depression %K depressive symptoms %K mobile phone %D 2023 %7 2.10.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression and anxiety are common and debilitating mental disorders with severe negative repercussions at both individual and societal levels. Although virtual reality (VR) has emerged as a safe and effective tool for the treatment of anxiety disorders, studies of the therapeutic application of VR to treat depression are more limited. Objective: The purpose of this study was to test whether a novel type of individualized VR (iVR) can be used to improve self-compassion and decrease depressive symptoms and to evaluate the usability and acceptability of this approach, as rated by participants. The iVR system was designed and developed based on the feedback obtained from a previous study, with improved appearance and feel of the avatar and enhanced graphical quality. Methods: A total of 36 young adult participants were recruited from a university community social media site. Participants were aware that the study was investigating a treatment for depression but were not recruited based on depression diagnosis. Participants were asked to complete 2 iVR sessions, spaced 2 weeks apart. At baseline and upon completion of each iVR session, participants were asked to complete validated measures of self-compassion and depression. Upon completion of both iVR sessions, additional measures were administered to assess participants’ perceptions about the perceived usability and system acceptability of the iVR approach. Results: Self-compassion was assessed at the beginning of session 1 (preintervention baseline) and at the end of session 1 (postintervention assessment). Owing to COVID-19 constraints, 36% (13/36) of the participants were unable to complete the follow-up iVR session. Self-compassion was assessed again for the remaining 64% (23/36) of the participants at the end of session 2 (postintervention assessment). Within-group analyses revealed that self-compassion was significantly increased at the end of both session 1 (P=.01) and session 2 (P=.03) relative to baseline. There was also a nonsignificant trend for depressive symptoms to be low at the end of session 2 relative to baseline. Both quantitative and qualitative participant data supported the iVR approach as being acceptable and usable. Conclusions: Although these data must be treated as preliminary owing to the small sample size and potential selection bias, the data provide encouraging initial evidence that iVR might be a useful tool to enhance self-compassion and reduce depressive symptoms, highlighting the need for randomized controlled trials in the future. %M 37782537 %R 10.2196/47617 %U https://mental.jmir.org/2023/1/e47617 %U https://doi.org/10.2196/47617 %U http://www.ncbi.nlm.nih.gov/pubmed/37782537 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e47556 %T Moderating Effect of eHealth Literacy on the Associations of Coronaphobia With Loneliness, Irritability, Depression, and Stigma in Chinese Young Adults: Bayesian Structural Equation Model Study %A Xu,Richard Huan %A Chan,Ho Hin %A Shi,Lushaobo %A Li,Ting %A Wang,Dong %+ School of Health Management, Southern Medical University, Shatai Nan Road, Guangzhou, 510515, China, 86 61647576, dongw96@smu.edu.cn %K coronaphobia %K eHealth literacy %K Bayesian statistics %K structural equation modeling %K mediating effect %K mental health %D 2023 %7 29.9.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The COVID-19 pandemic has led to an increase in known risk factors for mental health problems. Although medical information available through the internet and smartphones has greatly expanded, people’s ability to seek, eschew, and use reliable web-based medical information and services to promote their mental health remains unknown. Objective: This study aims to explore the associations between coronaphobia and 4 frequently reported mental health problems, loneliness, irritability, depression, and stigma, during the COVID-19 pandemic and to assess the moderating effects of eHealth literacy (eHL) on the adjustment of these relationships in Chinese young adults. Methods: The data used in this study were collected from a web-based survey of the general Chinese population, aged between 18 and 30 years, conducted in China between December 2022 and January 2023. A nonprobability snowball sampling method was used for data collection. A Bayesian structural equation model (BSEM) using parameter expansion was used to estimate the moderating effect of eHL on the relationship between coronaphobia and psychological problems. The posterior mean and 95% highest density intervals (HDIs) were estimated. Results: A total of 4119 participants completed the questionnaire and provided valid responses. Among them, 64.4% (n=2653) were female and 58.7% (n=2417) were rural residents. All measures showed statistically significant but minor-to-moderate associations (correlation coefficients ranged from −0.04 to 0.65). Significant heterogeneity was observed between rural and urban residents at the eHL level, and coronaphobia was observed. The BSEM results demonstrated that eHL was a significant moderator in reducing the negative effects of coronaphobia on loneliness (posterior mean −0.0016, 95% HDI −0.0022 to −0.0011), depression (posterior mean −0.006, 95% HDI −0.0079 to −0.004), stigma (posterior mean −0.0052, 95% HDI −0.0068 to −0.0036), and irritability (posterior mean −0.0037, 95% HDI −0.0052 to −0.0022). The moderating effects of eHL varied across the rural and urban subsamples. Conclusions: Using BSEM, this study demonstrated that improving eHL can significantly mitigate the negative effects of coronaphobia on 4 COVID-19–related mental health problems in Chinese young adults. Future eHL initiatives should target rural communities to ensure equal access to information and resources that can help protect their mental health during the pandemic. %M 37773621 %R 10.2196/47556 %U https://publichealth.jmir.org/2023/1/e47556 %U https://doi.org/10.2196/47556 %U http://www.ncbi.nlm.nih.gov/pubmed/37773621 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e44211 %T Firearm Possession Rates in Home Countries and Firearm Suicide Rates Among US- and Foreign-Born Suicide Decedents in the United States: Analysis of Combined Data from the National Violent Death Reporting System and the Small Arms Survey %A Song,In Han %A Lee,Jin Hyuk %A Shin,Jee Soo %+ ICONS Convergence Academy, Yonsei University, Appenzeller Hall #205, Seoul, 03722, Republic of Korea, 82 221236217, isong@yonsei.ac.kr %K firearm suicide %K US born %K foreign born %K means of suicide %K firearm possession rate %K suicide decedents %D 2023 %7 29.9.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Suicide by firearms is a serious public health issue in the United States. However, little research has been conducted on the relationship between cultural backgrounds and suicide by firearms, specifically in those born and raised in the United States compared to those who have immigrated to the United States. Objective: To better understand the relationship between cultural backgrounds and suicide, this study aimed to examine firearm suicide rates among US- and foreign-born suicide decedents based on the firearm possession rate in the decedent’s home country. Methods: Multivariate logistic regression was performed to analyze data of 28,895 suicide decedents from 37 states obtained from the 2017 National Violent Death Reporting System data set. The firearm possession rate in the home countries of foreign-born suicide decedents was obtained from the 2017 Small Arms Survey. Results: The firearm suicide rate was about twice as high among US-born suicide decedents compared to their foreign-born counterparts. Meanwhile, suicide by hanging was about 75% higher among foreign-born compared to US-born suicide decedents. Those from countries with a low-to-medium firearm possession rate were significantly less likely to use firearms compared to US-born suicide decedents (adjusted odds ratio [AOR]=0.45, 95% CI 0.31-0.65, and AOR=0.46, 95% CI 0.39-0.53, respectively). Meanwhile, firearm suicide rates were not different between US- and foreign-born suicide decedents from countries with a similarly high firearm possession rate. Conclusions: The results suggest that there is an association between using firearms as a means of suicide and the firearm possession rate in the decedent’s home country. Suicide by firearms in the United States needs to be understood in the sociocultural context related to firearm possession. %M 37773604 %R 10.2196/44211 %U https://publichealth.jmir.org/2023/1/e44211 %U https://doi.org/10.2196/44211 %U http://www.ncbi.nlm.nih.gov/pubmed/37773604 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e48177 %T A Suicide Prevention Intervention for Emerging Adult Sexual and Gender Minority Groups: Protocol for a Pilot Hybrid Effectiveness Randomized Controlled Trial %A Brown,Lily A %A Webster,Jessica L %A Tran,Jennifer T %A Wolfe,James R %A Golinkoff,Jesse %A Patel,Esha %A Arcomano,Amanda C %A Ben Nathan,Jennifer %A Azat O'Connor,Alexander %A Zhu,Yiqin %A Oquendo,Maria %A Brown,Gregory K %A Mandell,David %A Mowery,Danielle %A Bauermeister,José A %+ Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street Suite 600 N, Philadelphia, PA, 19147, United States, 1 215 746 3346, lilybr@upenn.edu %K lesbian, gay, bisexual, transgender, queer, plus %K LGBTQ+ health %K suicide %K peer navigator %K emerging adults %K life skills %K mobile phone %D 2023 %7 29.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide attempts and suicide death disproportionately affect sexual and gender minority emerging adults (age 18-24 years). However, suicide prevention strategies tailored for emerging adult sexual and gender minority (EA-SGM) groups are not widely available. The Safety Planning Intervention (SPI) has strong evidence for reducing the risk for suicide in the general population, but it is unclear how best to support EA-SGM groups in their use of a safety plan. Our intervention (Supporting Transitions to Adulthood and Reducing Suicide [STARS]) builds on content from an existing life skills mobile app for adolescent men who have sex with men (iREACH) and seeks to target core risk factors for suicide among EA-SGM groups, namely, positive affect, discrimination, and social disconnection. The mobile app is delivered to participants randomized to STARS alongside 6 peer mentoring sessions to support the use of the safety plan and other life skills from the app to ultimately reduce suicide risk. Objective: We will pilot-test the combination of peer mentoring alongside an app-based intervention (STARS) designed to reduce suicidal ideation and behaviors. STARS will include suicide prevention content and will target positive affect, discrimination, and social support. After an in-person SPI with a clinician, STARS users can access content and activities to increase their intention to use SPI and overcome obstacles to its use. EA-SGM groups will be randomized to receive either SPI alone or STARS and will be assessed for 6 months. Methods: Guided by the RE-AIM (reach, efficacy, adoption, implementation, and maintenance) framework, we will recruit and enroll a racially and ethnically diverse sample of 60 EA-SGM individuals reporting past-month suicidal ideation. Using a type-1 effectiveness-implementation hybrid design, participants will be randomized to receive SPI (control arm) or to receive SPI alongside STARS (intervention arm). We will follow the participants for 6 months, with evaluations at 2, 4, and 6 months. Preliminary effectiveness outcomes (suicidal ideation and behavior) and hypothesized mechanisms of change (positive affect, coping with discrimination, and social support) will serve as our primary outcomes. Secondary outcomes include key implementation indicators, including participants’ willingness and adoption of SPI and STARS and staff’s experiences with delivering the program. Results: Study activities began in September 2021 and are ongoing. The study was approved by the institutional review board of the University of Pennsylvania (protocol number 849500). Study recruitment began on October 14, 2022. Conclusions: This project will be among the first tailored, mobile-based interventions for EA-SGM groups at risk for suicide. This project is responsive to the documented gaps for this population: approaches that address chosen family, focus on a life-course perspective, web approaches, and focus on health equity and provision of additional services relevant to sexual and gender minority youth. Trial Registration: ClinicalTrials.gov NCT05018143; https://classic.clinicaltrials.gov/ct2/show/NCT05018143 International Registered Report Identifier (IRRID): DERR1-10.2196/48177 %M 37773618 %R 10.2196/48177 %U https://www.researchprotocols.org/2023/1/e48177 %U https://doi.org/10.2196/48177 %U http://www.ncbi.nlm.nih.gov/pubmed/37773618 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e46877 %T Efficacy, Safety, and Evaluation Criteria of mHealth Interventions for Depression: Systematic Review %A Duarte-Díaz,Andrea %A Perestelo-Pérez,Lilisbeth %A Gelabert,Estel %A Robles,Noemí %A Pérez-Navarro,Antoni %A Vidal-Alaball,Josep %A Solà-Morales,Oriol %A Sales Masnou,Ariadna %A Carrion,Carme %+ Canary Islands Health Research Institute Foundation (FIISC), Camino Candelaria, 44, El Rosario, 38109, Spain, 34 922478320, andrea.duartediaz@sescs.es %K mobile health %K mHealth %K apps %K depression %K systematic review %K meta-analysis %D 2023 %7 27.9.2023 %9 Review %J JMIR Ment Health %G English %X Background: Depression is a significant public health issue that can lead to considerable disability and reduced quality of life. With the rise of technology, mobile health (mHealth) interventions, particularly smartphone apps, are emerging as a promising approach for addressing depression. However, the lack of standardized evaluation tools and evidence-based principles for these interventions remains a concern. Objective: In this systematic review and meta-analysis, we aimed to evaluate the efficacy and safety of mHealth interventions for depression and identify the criteria and evaluation tools used for their assessment. Methods: A systematic review and meta-analysis of the literature was carried out following the recommendations of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Studies that recruited adult patients exhibiting elevated depressive symptoms or those diagnosed with depressive disorders and aimed to assess the effectiveness or safety of mHealth interventions were eligible for consideration. The primary outcome of interest was the reduction of depressive symptoms, and only randomized controlled trials (RCTs) were included in the analysis. The risk of bias in the original RCTs was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials. Results: A total of 29 RCTs were included in the analysis after a comprehensive search of electronic databases and manual searches. The efficacy of mHealth interventions in reducing depressive symptoms was assessed using a random effects meta-analysis. In total, 20 RCTs had an unclear risk of bias and 9 were assessed as having a high risk of bias. The most common element in mHealth interventions was psychoeducation, followed by goal setting and gamification strategies. The meta-analysis revealed a significant effect for mHealth interventions in reducing depressive symptoms compared with nonactive control (Hedges g=−0.62, 95% CI −0.87 to −0.37, I2=87%). Hybrid interventions that combined mHealth with face-to-face sessions were found to be the most effective. Three studies compared mHealth interventions with active controls and reported overall positive results. Safety analyses showed that most studies did not report any study-related adverse events. Conclusions: This review suggests that mHealth interventions can be effective in reducing depressive symptoms, with hybrid interventions achieving the best results. However, the high level of heterogeneity in the characteristics and components of mHealth interventions indicates the need for personalized approaches that consider individual differences, preferences, and needs. It is also important to prioritize evidence-based principles and standardized evaluation tools for mHealth interventions to ensure their efficacy and safety in the treatment of depression. Overall, the findings of this study support the use of mHealth interventions as a viable method for delivering mental health care. Trial Registration: PROSPERO CRD42022304684; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=304684 %M 37756042 %R 10.2196/46877 %U https://mental.jmir.org/2023/1/e46877 %U https://doi.org/10.2196/46877 %U http://www.ncbi.nlm.nih.gov/pubmed/37756042 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e51324 %T The Effects of Suicide Exposure on Mental Health Outcomes Among Post-9/11 Veterans: Protocol for an Explanatory, Sequential, Mixed Methods Study %A Sayer,Nina A %A Nelson,David B %A Gradus,Jaimie L %A Sripada,Rebecca K %A Murdoch,Maureen %A Teo,Alan R %A Orazem,Robert J %A Cerel,Julie %+ Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, United States, 1 612 467 4623, nina.sayer@va.gov %K veterans %K suicide %K death %K posttraumatic stress disorder %K bereavement %K health services %D 2023 %7 26.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: The toll associated with suicide goes well beyond the individual who died. This study focuses on a risk factor for veteran suicide that has received little previous empirical attention—exposure to the suicide death of another person. Objective: The study’s primary objective is to describe the mental health outcomes associated with suicide exposure among veterans who served on active duty after September 2001 (“post-9/11”). The secondary objective is to elucidate why some veterans develop persistent problems following suicide exposure, whereas others do not. Methods: This is an explanatory, sequential, mixed methods study of a nationally representative sample of post-9/11 veterans enrolled in Department of Veterans Affairs (VA) health care. Our sampling strategy was designed for adequate representation of female and American Indian and Alaska Native veterans to allow for examination of associations between suicide exposure and outcomes within these groups. Primary outcomes comprise mental health problems associated with trauma and loss (posttraumatic stress disorder and prolonged grief disorder) and suicide precursors (suicidal ideation, attempts, and planning). Data collection will be implemented in 3 waves. During wave 1, we will field a brief survey to a national probability sample to assess exposure history (suicide, other sudden death, or neither) and exposure characteristics (eg, closeness with the decedent) among 11,400 respondents. In wave 2, we will include 39.47% (4500/11,400) of the wave-1 respondents, stratified by exposure history (suicide, other sudden death, or neither), to assess health outcomes and other variables of interest. During wave 3, we will conduct interviews with a purposive subsample of 32 respondents exposed to suicide who differ in mental health outcomes. We will supplement the survey and interview data with VA administrative data identifying diagnoses, reported suicide attempts, and health care use. Results: The study began on July 1, 2022, and will end on June 30, 2026. This is the only national, population-based study of suicide exposure in veterans and the first one designed to study differences based on sex and race. Comparing those exposed to suicide with those exposed to sudden death for reasons other than suicide (eg, combat) and those unexposed to any sudden death may allow for the identification of the common and unique contribution of suicide exposure to outcomes and help seeking. Conclusions: Integrating survey, qualitative, and VA administrative data to address significant knowledge gaps regarding the effects of suicide exposure in a national sample will lay the foundation for interventions to address the needs of individuals affected by a suicide death, including female and American Indian and Alaska Native veterans. International Registered Report Identifier (IRRID): DERR1-10.2196/51324 %M 37751271 %R 10.2196/51324 %U https://www.researchprotocols.org/2023/1/e51324 %U https://doi.org/10.2196/51324 %U http://www.ncbi.nlm.nih.gov/pubmed/37751271 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e49698 %T Feasibility Study of Virtual Reality–Based Cognitive Behavioral Therapy for Patients With Depression: Protocol for an Open Trial and Therapeutic Intervention %A Ito,Ai %A Hiyoshi,Fumikazu %A Kanie,Ayako %A Maruyama,Azumi %A Oba,Mari S %A Kito,Shinsuke %+ Department of Clinical Psychology, National Center Hospital, National Center of Neurology and Psychiatry, 4 Chome-1-1 Ogawahigashicho, Kodaira-shi, 187-8551, Japan, 81 42 341 2711, kito@ncnp.go.jp %K depression %K cognitive behavioral therapy %K virtual reality %K CBT %K feasibility study %K open trial %K VR %D 2023 %7 26.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: The clinical usefulness of cognitive behavioral therapy (CBT) for patients with depression who do not remit with pharmacotherapy has been recognized. However, the longer time burden on health care providers associated with conducting CBT and the lack of a system for providing CBT lead to inadequate CBT provision to patients who wish to receive it. Objective: We aim to evaluate the feasibility of introducing virtual reality (VR) into CBT for patients with depression. Methods: This is a single-center, interventional, exploratory, single-arm, nonrandomized, open, pre-post–comparative feasibility study of an unapproved medical device program to evaluate the acceptability, preliminary efficacy, and safety of the study device. Eligible patients meet the diagnostic criteria of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) for major depressive disorder, have a 17-item Hamilton Depression Rating Scale (HAMD-17) score of ≥12, and are aged 18-65 years. The sample will comprise 12 patients. VR-based CBT (CBT-VR) sessions will be conducted once a week in an outpatient setting. CBT-VR has been developed in accordance with 6 stages and 16 sessions in the current CBT therapist manual. VR contents and other components correspond to the themes of these 16 sessions. The flow of CBT-VR treatment is similar to that of normal CBT; however, this product replaces the in-person portion of CBT. The primary end point will be the change in the HAMD-17 score from baseline up to 16 sessions. Secondary end points will be treatment retention; psychiatrist consultation time; satisfaction with the equipment or program; ease of use; homework compliance; change in the HAMD-17 score from baseline up to 8 sessions; change in Montgomery-Åsberg Depression Rating Scale (MADRS), Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR), EQ-5D-5L, and Clinical Global Impressions (CGI) scores from baseline up to 8 and 16 sessions; and change in remission and response rates and HAMD-17, MADRS, QIDS-SR, and EQ-5D-5L scores from baseline to 3 and 6 months post intervention (or discontinuation). CBT-VR’s feasibility will be assessed at baseline, after 8 sessions, after 16 sessions, or treatment discontinuation, by measuring the time required for testing and medical care during each session and with a patient questionnaire. After intervention discontinuation, a follow-up evaluation will be conducted unless the patient withdraws consent or otherwise discontinues participation in the study after 3 and 6 months. Results: Participant recruitment started on November 30, 2022, and data collection is ongoing as of September 2023. Conclusions: This study is the first step in testing the acceptability, feasibility, and preliminary efficacy and safety of CBT-VR for patients with depression without controls in an open-label trial. If its feasibility for depression treatment is confirmed, we intend to proceed to a large-scale validation study. Trial Registration: Japan Registry of Clinical Trials jRCTs032220481; https://jrct.niph.go.jp/en-latest-detail/jRCTs032220481 International Registered Report Identifier (IRRID): DERR1-10.2196/49698 %M 37751242 %R 10.2196/49698 %U https://www.researchprotocols.org/2023/1/e49698 %U https://doi.org/10.2196/49698 %U http://www.ncbi.nlm.nih.gov/pubmed/37751242 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e47350 %T Specifying the Efficacy of Digital Therapeutic Tools for Depression and Anxiety: Retrospective, 2-Cohort, Real-World Analysis %A Fundoiano-Hershcovitz,Yifat %A Breuer Asher,Inbar %A Ritholz,Marilyn D %A Feniger,Eitan %A Manejwala,Omar %A Goldstein,Pavel %+ Dario Health, Ofek 8, 5 Tarshish St, Caesarea, 3079821, Israel, 972 525296979, yifat@dariohealth.com %K mental health %K depression %K anxiety %K digital health %K coaching %K behavioral health %K breathing exercises %K behavioral change %K digital health intervention %K cognitive behavior therapy %K health outcome %K health app %K intervention %K cohort %K retrospective %D 2023 %7 22.9.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression and anxiety are the main sources of work and social disabilities as well as health-related problems around the world. Digital therapeutic solutions using cognitive behavioral therapy have demonstrated efficacy in depression and anxiety. A common goal of digital health apps is to increase user digital engagement to improve outcomes. However, there is a limited understanding of the association between digital platform components and clinical outcomes. Objective: The aim of the study is to investigate the contribution of specific digital engagement tools to mental health conditions. We hypothesized that participation in coaching sessions and breathing exercises would be associated with a reduction in depression and anxiety. Methods: Depression and general anxiety symptoms were evaluated in real-world data cohorts using the digital health platform for digital intervention and monitoring change. This retrospective real-world analysis of users on a mobile platform–based treatment followed two cohorts of people: (1) users who started with moderate levels of depression and completed at least 2 depression assessments (n=519) and (2) users who started with moderate levels of anxiety and completed at least 2 anxiety assessments (n=474). Levels of depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7) were tracked throughout the first 16 weeks. A piecewise mixed-effects model was applied to model the trajectories of the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 mean scores in 2 segments (1-6 weeks and 7-16 weeks). Finally, simple slope analysis was used for the interpretation of the interactions probing the moderators: coaching sessions and breathing exercises in both depression and anxiety cohorts. Results: Analysis revealed a significant decrease in depression symptoms (β=–.37, 95% CI –0.46 to 0.28; P≤.001) during the period of weeks 1-6 of app use, which was maintained during the period of 7-16 weeks. Coach interaction significantly moderated the reduction in depression symptoms during the period of weeks 1-6 (β=–.03, 95% CI –0.05 to –0.001; P=.02). A significant decrease in anxiety symptoms (β=–.41, 95% CI –0.50 to –0.33; P≤.001) was revealed during the period of 1-6 weeks, which was maintained during the period of 7-16 weeks. Breathing exercises significantly moderated the reduction in anxiety symptoms during the period of 1-6 weeks (β=–.07, 95% CI –0.14 to –0.01; P=.04). Conclusions: This study demonstrated general improvement followed by a period of stability of depression and anxiety symptoms associated with cognitive behavioral therapy–based digital intervention. Interestingly, engagement with a coaching session but not a breathing exercise was associated with a reduction in depression symptoms. Moreover, breathing exercise but not engagement with a coaching session was associated with a reduction of anxiety symptoms. These findings emphasize the importance of using a personalized approach to behavioral health during digital health interventions. %M 37738076 %R 10.2196/47350 %U https://www.jmir.org/2023/1/e47350 %U https://doi.org/10.2196/47350 %U http://www.ncbi.nlm.nih.gov/pubmed/37738076 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e42786 %T The Effect of Internet-Based Cognitive Behavioral Therapy on Major Depressive Disorder: Randomized Controlled Trial %A Lin,Ziyi %A Cheng,Lu %A Han,Xue %A Wang,Hongqiong %A Liao,Yuhua %A Guo,Lan %A Shi,Jingman %A Fan,Beifang %A Teopiz,Kayla M %A Jawad,Muhammad Youshay %A Zhang,Huimin %A Chen,Yan %A Lu,Ciyong %A McIntyre,Roger S %+ Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, No. 74 Zhongshan Rd 2, Guangzhou, 510080, China, 86 020 87332477, luciyong@mail.sysu.edu.cn %K depressive symptoms %K major depressive disorder %K internet-based cognitive behavioral therapy %K self-efficacy %K stigma %K social function %K health-related quality of life %K mental health services %D 2023 %7 22.9.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Many people living with major depressive disorder (MDD) in China do not receive treatment owing to a lack of mental health services, along with significant stigma toward mental illness. Internet-based cognitive behavioral therapy (ICBT) has been proposed to increase access to mental health care for people with MDD. Objective: The aims of this study were to (1) evaluate the efficacy of ICBT for depressive symptoms in patients with MDD; (2) evaluate the effect of ICBT on anxiety symptoms, nonspecific psychological distress, general self-efficacy, depression stigma, social function, and health-related quality of life (HRQoL); and (3) explore the acceptability of and satisfaction with the ICBT program among participants. Methods: Patients with MDD were enrolled and randomized to the ICBT group or the waiting-list control (WLC) group. The ICBT group received ICBT delivered through a WeChat mini-program with general support by nonspecialists. Participants in the 2 groups were self-evaluated online at baseline and posttreatment for changes in the primary outcome (ie, depressive symptoms) and secondary outcomes (ie, anxiety symptoms, nonspecific psychological distress, general self-efficacy, depression stigma, social functional impairment, and HRQoL). Changes in outcomes were measured by changes in overall scores on respective scales, and response and remission rates were calculated based on depressive symptoms. The acceptability of and satisfaction with the ICBT program were measured by treatment adherence and participants’ feelings (ie, modules seriously completed, perceived benefit, and satisfaction). Results: We included 40 patients who were randomly assigned to the ICBT group and 44 who were assigned to the WLC group. Compared with the WLC group, the ICBT group had fewer depressive symptoms, fewer anxiety symptoms, less nonspecific psychological distress, and greater general self-efficacy. Moreover, the ICBT group had higher response (18/31, 58%) and remission rates (17/31, 55%). The adherence rate in the ICBT group was 78% (31/40), and the majority of participants who completed all ICBT modules were satisfied with the ICBT program. Conclusions: ICBT demonstrated greater improvements in depressive symptoms, anxiety symptoms, nonspecific psychological distress, and general self-efficacy among selected patients with MDD in comparison with the findings in waiting-list controls. The ICBT program in this study had good acceptability and satisfaction among participants. Trial Registration: Chinese Clinical Trial Registry (ChiCTR2100046425); https://tinyurl.com/bdcrj4zv %M 37738092 %R 10.2196/42786 %U https://www.jmir.org/2023/1/e42786 %U https://doi.org/10.2196/42786 %U http://www.ncbi.nlm.nih.gov/pubmed/37738092 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e46458 %T Efficacy of a Text-Based Mental Health Coaching App in Improving the Symptoms of Stress, Anxiety, and Depression: Randomized Controlled Trial %A Lim,Yee Siew %A Quek,Jia Hui %A Ching,Xiu Wei %A Lim,Dominic Tao Ran %A Lim,Kean Ghee %A Thuraisingham,Chandramani %A George,Parikial Philip %+ International Medical University (IMU), Jalan Rasah, Bukit Rasah, Seremban, 70300, Malaysia, 60 67677798, lim.yeesiew@outlook.com %K digital mental health %K mobile health %K randomized control trial %K mobile phone %K mental health %K Depression, Anxiety, and Stress Scale–21 items %K DASS-21 %K Asia %K Malaysia %D 2023 %7 22.9.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Stress, anxiety, and depression are major mental health concerns worldwide. A wide variety of digital mental health interventions have demonstrated efficacy in improving one’s mental health status, and digital interventions that involve some form of human involvement have been shown to demonstrate greater efficacy than self-guided digital interventions. Studies demonstrating the efficacy of digital mental health interventions within the Asian region are scarce. Objective: This study aimed to investigate the potential efficacy of the digital mental health intervention, ThoughtFullChat, which consists of one-on-one, asynchronous, text-based coaching with certified mental health professionals and self-guided tools, in improving self-reported symptoms of depression, anxiety, and stress. The study also aims to examine the potential differences in efficacy among occupational subgroups and between sexes. Methods: A randomized controlled study was conducted among housemen (trainee physicians), students, faculty members, and corporate staff at International Medical University, Malaysia. A total of 392 participants were enrolled and randomized to the intervention (n=197, 50.3%) and control (n=195, 49.7%) groups. Depression, anxiety, and stress symptoms were measured using the Depression, Anxiety, and Stress Scale–21 items at baseline and after the 3-month intervention period. The Satisfaction with Life Scale and Brief Resilience Scale were also included, along with a questionnaire about demographics. Results: Significant decrease was observed in depression (P=.02) and anxiety (P=.002) scores in the intervention group. A subgroup (corporate staff) also demonstrated significant decrease in stress (P=.005) alongside depression (P=.006) and anxiety (P=.002). Females showed significant improvements in depression (P=.02) and anxiety (P<.001) when compared with males. Conclusions: This study provides evidence that the ThoughtFullChat app is effective in improving the symptoms of depression, anxiety, and stress in individuals, particularly among corporate staff from the educational field. It also supports the notion that mobile mental health apps that connect users to mental health professionals in a discreet and cost-efficient manner can make important contributions to the improvement of mental health outcomes. The differential improvements among occupational subgroups and between sexes in this study indicate the need for future digital mental health app designs to consider an element of personalization focused on systemic components relating to occupation. Trial Registration: Clinicaltrials.gov NCT04944277; https://classic.clinicaltrials.gov/ct2/show/NCT04944277 %M 37738081 %R 10.2196/46458 %U https://formative.jmir.org/2023/1/e46458 %U https://doi.org/10.2196/46458 %U http://www.ncbi.nlm.nih.gov/pubmed/37738081 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45535 %T Technology-Enabled Intervention to Enhance Mindfulness, Safety, and Health Promotion Among Corrections Professionals: Protocol for a Prospective Quasi-Experimental Trial %A Elliot,Diane %A Kuehl,Kerry %A DeFrancesco,Carol %A McGinnis,Wendy %A Ek,Susanna %A Van Horne,Allee %A Kempany,Katherine Ginsberg %+ Health Promotion & Sports Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road CR110, Portland, OR, 97239, United States, 1 5037995598, elliotd@ohsu.edu %K corrections professionals %K mindfulness %K total worker health %K occupational safety %K digital %K health promotion %K safety %K depression %K suicide %K obesity %K cardiovascular disease %K well-being %K stress %K survey %K healthy eating %K physical activity %K mood %K vascular health %K injury %K cop %K police %K security %K undercover %K remand %K detention %K prison %K state correctional %K state corrections %K correction %K penitentiary %D 2023 %7 22.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Correction professionals are a highly stressed workforce with heightened risks for depression, suicide, obesity, cardiovascular disease, and injury. These professionals, largely hidden from view, have received little study concerning means to improve their safety, health, and well-being. In other settings, mindfulness has resulted in lowered stress, along with other benefits. We hypothesized that a program that promoted mindfulness combined with more typical health and safety components could uniquely benefit corrections professionals. Objective: This project will assess a novel scalable, self-administered program to enhance the mindfulness, safety, and health of a vulnerable worker group. Methods: In partnership with the Oregon Department of Corrections, we are conducting a prospective quasi-experimental trial of a safety, health, and mindfulness program among 100 corrections professionals from 2 institutions. Survey and physiologic data will be collected at enrollment, upon weekly program completion (3 months), and at 9 months after enrollment. Primary outcome behaviors promoted by the program are being mindful, healthier eating, more physical activity, and greater restorative sleep. Secondary downstream benefits are anticipated in stress level, mood, positive feelings about the organization, vascular health, and cellular aging, along with job performance, injuries, and economic costs. Participants will meet in-person or in a Zoom-type meeting as 3- to 5-member coworker groups during their usual work hours for 30-minute sessions once a week for 12 weeks. The program uses self-guided web-based learning modules that include brief mindfulness practice, and it is accessible by smartphone, tablet, or laptop. Daily mindfulness practice is encouraged between sessions, which is facilitated by the study website and group format. The modules’ structure emphasizes prerequisite knowledge, peer support, skill practice, self-monitoring, and enhancing self-efficacy for change. The program continues through self-directed use of the Headspace app following the 12 weekly sessions. Results: Participants are being enrolled, and the intervention is ready to launch. Conclusions: Although mindfulness training has gained traction for worker well-being, its usual format requires a skilled trainer, an initial retreat, and weekly 2-hour meetings for several weeks. The content is limited to mindfulness without safety or health promotion aspects. The need for skilled trainers and time commitment limits the scalability of the usual mindfulness interventions. The planned program is an innovative combination of technology, e-learning, and a group format to add mindfulness to a safety and health curriculum. If acceptable and effective, the format would facilitate its widespread use. Trial Registration: ClinicalTrials.gov NCT05608889; https://classic.clinicaltrials.gov/ct2/show/NCT05608889 International Registered Report Identifier (IRRID): PRR1-10.2196/45535 %M 36602914 %R 10.2196/45535 %U https://www.researchprotocols.org/2023/1/e45535 %U https://doi.org/10.2196/45535 %U http://www.ncbi.nlm.nih.gov/pubmed/36602914 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e49043 %T Blending Video Therapy and Digital Self-Help for Individuals With Suicidal Ideation: Intervention Design and a Qualitative Study Within the Development Process %A Büscher,Rebekka %A Sander,Lasse B %A Nuding,Mattis %A Baumeister,Harald %A Teismann,Tobias %+ Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Hebelstr. 29, Freiburg, 79085, Germany, 49 76120395204, rebekka.buescher@mps.uni-freiburg.de %K blended care %K digital interventions %K video therapy %K suicidal ideation %K personalized treatment %K cognitive behavioral therapy %K CBT %K suicide %K suicidal %K digital intervention %K digital health %K video %K web-based module %K blended %K self-help %D 2023 %7 21.9.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital formats have the potential to enhance accessibility to care for individuals with suicidal ideation. However, digital self-help interventions have faced limitations, including small effect sizes in reducing suicidal ideation, low adherence, and safety concerns. Objective: Therefore, we aimed to develop a remote blended cognitive behavioral therapy intervention that specifically targets suicidal ideation by blending video therapy with web-based self-help modules. The objective of this paper is to describe the collaborative development process and the resulting intervention and treatment rationale. Methods: First, we compiled intervention components from established treatment manuals designed for people with suicidal ideation or behavior, resulting in the development of 11 drafts of web-based modules. Second, we conducted a qualitative study, involving 5 licensed psychotherapists and 3 lay counselors specialized in individuals with suicidal ideation who reviewed these module drafts. Data were collected using the think-aloud method and semistructured interviews, and a qualitative content analysis was performed. The 4 a priori main categories of interest were blended care for individuals with suicidal ideation, contents of web-based modules, usability of modules, and layout. Subcategories emerged inductively from the interview transcripts. Finally, informed by previous treatment manuals and qualitative findings, we developed the remote blended treatment program. Results: The participants suggested that therapists should thoroughly prepare the web-based therapy with patients to tailor the therapy to each individual’s needs. Participants emphasized that the web-based modules should explain concepts in a simple manner, convey empathy and validation, and include reminders for the safety plan. In addition, participants highlighted the need for a simple navigation and layout. Taking these recommendations into account, we developed a fully remote blended cognitive behavioral therapy intervention comprising 12 video therapy sessions and up to 31 web-based modules. The treatment involves collaboratively developing a personalized treatment plan to address individual suicidal drivers. Conclusions: This remote treatment takes advantage of the high accessibility of digital formats while incorporating full sessions with a therapist. In a subsequent pilot trial, we will seek input from individuals with lived experience and therapists to test the feasibility of the treatment. %M 37733414 %R 10.2196/49043 %U https://formative.jmir.org/2023/1/e49043 %U https://doi.org/10.2196/49043 %U http://www.ncbi.nlm.nih.gov/pubmed/37733414 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e51232 %T Suicide Risk Assessments Through the Eyes of ChatGPT-3.5 Versus ChatGPT-4: Vignette Study %A Levkovich,Inbar %A Elyoseph,Zohar %+ Department of Psychology and Educational Counseling, The Center for Psychobiological Research, Max Stern Yezreel Valley College, Hatena 14b Kiryat Tivon, Emek Yezreel, 3650414, Israel, 972 54 783 6088, Zohare@yvc.ac.il %K artificial intelligence %K ChatGPT %K diagnosis %K psychological assessment %K psychological %K suicide risk %K risk assessment %K text vignette %K NLP %K natural language processing %K suicide %K suicidal %K risk %K assessment %K vignette %K vignettes %K assessments %K mental %K self-harm %D 2023 %7 20.9.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: ChatGPT, a linguistic artificial intelligence (AI) model engineered by OpenAI, offers prospective contributions to mental health professionals. Although having significant theoretical implications, ChatGPT’s practical capabilities, particularly regarding suicide prevention, have not yet been substantiated. Objective: The study’s aim was to evaluate ChatGPT’s ability to assess suicide risk, taking into consideration 2 discernable factors—perceived burdensomeness and thwarted belongingness—over a 2-month period. In addition, we evaluated whether ChatGPT-4 more accurately evaluated suicide risk than did ChatGPT-3.5. Methods: ChatGPT was tasked with assessing a vignette that depicted a hypothetical patient exhibiting differing degrees of perceived burdensomeness and thwarted belongingness. The assessments generated by ChatGPT were subsequently contrasted with standard evaluations rendered by mental health professionals. Using both ChatGPT-3.5 and ChatGPT-4 (May 24, 2023), we executed 3 evaluative procedures in June and July 2023. Our intent was to scrutinize ChatGPT-4’s proficiency in assessing various facets of suicide risk in relation to the evaluative abilities of both mental health professionals and an earlier version of ChatGPT-3.5 (March 14 version). Results: During the period of June and July 2023, we found that the likelihood of suicide attempts as evaluated by ChatGPT-4 was similar to the norms of mental health professionals (n=379) under all conditions (average Z score of 0.01). Nonetheless, a pronounced discrepancy was observed regarding the assessments performed by ChatGPT-3.5 (May version), which markedly underestimated the potential for suicide attempts, in comparison to the assessments carried out by the mental health professionals (average Z score of –0.83). The empirical evidence suggests that ChatGPT-4’s evaluation of the incidence of suicidal ideation and psychache was higher than that of the mental health professionals (average Z score of 0.47 and 1.00, respectively). Conversely, the level of resilience as assessed by both ChatGPT-4 and ChatGPT-3.5 (both versions) was observed to be lower in comparison to the assessments offered by mental health professionals (average Z score of –0.89 and –0.90, respectively). Conclusions: The findings suggest that ChatGPT-4 estimates the likelihood of suicide attempts in a manner akin to evaluations provided by professionals. In terms of recognizing suicidal ideation, ChatGPT-4 appears to be more precise. However, regarding psychache, there was an observed overestimation by ChatGPT-4, indicating a need for further research. These results have implications regarding ChatGPT-4’s potential to support gatekeepers, patients, and even mental health professionals’ decision-making. Despite the clinical potential, intensive follow-up studies are necessary to establish the use of ChatGPT-4’s capabilities in clinical practice. The finding that ChatGPT-3.5 frequently underestimates suicide risk, especially in severe cases, is particularly troubling. It indicates that ChatGPT may downplay one’s actual suicide risk level. %M 37728984 %R 10.2196/51232 %U https://mental.jmir.org/2023/1/e51232 %U https://doi.org/10.2196/51232 %U http://www.ncbi.nlm.nih.gov/pubmed/37728984 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e47178 %T Developing Suicide Prevention Tools in the Context of Digital Peer Support: Qualitative Analysis of a Workshop With Multidisciplinary Stakeholders %A Cliffe,Bethany %A Gore-Rodney,Jessica %A Linton,Myles-Jay %A Biddle,Lucy %+ Population Health Sciences, Bristol Medical School, University of Bristol, Beacon House, Queens Road, Bristol, BS8 1QU, United Kingdom, 44 01179289000, bethany.cliffe@bristol.ac.uk %K digital interventions %K smartphone app %K suicide prevention %K mental health %K mobile phone %D 2023 %7 20.9.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Suicide is the fourth leading cause of death among young people aged 15-29 years worldwide and suicide rates are increasing. Suicide prevention strategies can be effective but young people face barriers to accessing them. Providing support digitally can facilitate access, but this can also pose risks if there is inappropriate or harmful content. Collaborative approaches are key for developing digital suicide prevention tools to ensure support is appropriate and helpful for young people. Tellmi (previously MeeToo) is a premoderated UK-based peer-support app where people aged 11-25 years can anonymously discuss issues ranging from worries to life challenges. It has procedures to support high-risk users, nevertheless, Tellmi is interested in improving the support they provide to users with more acute mental health needs, such as young people struggling with suicide and self-harm ideation. Further research into the best ways of providing such support for this population is necessary. Objective: The aim of this study is to explore the key considerations for developing and delivering digital suicide prevention tools for young people aged 18-25 years from a multidisciplinary perspective, including the views of young people, practitioners, and academics. Methods: A full-day, in-person workshop was conducted with mental health academics (n=3) and mental health practitioners (n=2) with expertise in suicide prevention, young people with lived experience of suicidal ideation (n=4), and a computer scientist (n=1) and technical staff from the Tellmi app (n=6). Tellmi technical staff presented 14 possible evidence-based adaptations for the app as a basis for the discussions. A range of methods were used to evaluate them, including questionnaires to rate the ideas, annotating printouts of the ideas with post-it notes, and group discussions. A reflexive thematic analysis was performed on the qualitative data to explore key considerations for designing digital suicide prevention tools in the context of peer support. Results: Participants discussed the needs of both those receiving and providing support, noting several key considerations for developing and delivering digital support for high-risk young people. In total, four themes were developed: (1) the aims of the app must be clear and consistent, (2) there are unique considerations for supporting high-risk users: (subtheme) customization helps tailor support to high-risk users, (3) “progress” is a broad and multifaceted concept, and (4) considering the roles of those providing support: (subtheme) expertise required to support app users and (subtheme) mitigating the impact of the role on supporters. Conclusions: This study outlined suggestions that may be beneficial for developing digital suicide prevention tools for young people. Suggestions included apps being customizable, transparent, accessible, visually appealing, and working with users to develop content and language. Future research should further explore this with a diverse group of young people and clinicians. %M 37728967 %R 10.2196/47178 %U https://formative.jmir.org/2023/1/e47178 %U https://doi.org/10.2196/47178 %U http://www.ncbi.nlm.nih.gov/pubmed/37728967 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 6 %N %P e47691 %T Web-Based Cognitive Behavioral Therapy for Depression Among Homebound Older Adults: Development and Usability Study %A Xiang,Xiaoling %A Kayser,Jay %A Ash,Samson %A Zheng,Chuxuan %A Sun,Yihang %A Weaver,Addie %A Dunkle,Ruth %A Blackburn,James A %A Halavanau,Alex %A Xue,Jia %A Himle,Joseph A %+ School of Social Work, University of Michigan-Ann Arbor, 1080 S University Avenue, Ann Arbor, MI, 48109, United States, 1 7347636581, xiangxi@umich.edu %K internet-based cognitive behavioral therapy %K usability %K geriatric depression %K community-engaged research %K web-based %K geriatrics %K geriatric %K depression %K psychotherapy %K mental health %K older adults %K older adult %K cognitive behavioral therapy %K CBT %K design %K development %K community %K user centered design %K digital health %K aging %K old age %K digital mental health %K web-based health %K internet %D 2023 %7 19.9.2023 %9 Original Paper %J JMIR Aging %G English %X Background: Homebound older adults are a high-risk group for depression. However, many of them face barriers to accessing evidence-supported mental health treatments. Digital mental health interventions can potentially improve treatment access, but few web-based interventions are explicitly tailored for depression in older adults. Objective: This paper describes the development process of Empower@Home, a web-delivered intervention for depression in homebound older adults that is based on cognitive behavioral therapy, and reports on the outcomes of usability studies. Methods: Empower@Home was developed in collaboration with community agencies, stakeholders, and older adults, guided by user-centered design principles. User needs were assessed through secondary data analysis, demographic and health profiles from administrative data, and interviews and surveys of community partners. A comparative usability evaluation was conducted with 10 older adults to assess the usability of Empower@Home compared to 2 similar programs. Field testing was conducted with 4 end users to detect additional usability issues. Results: Feedback and recommendations from community partners heavily influenced the content and design of Empower@Home. The intervention consists of 9 sessions, including psychoeducation and an introduction to cognitive behavioral therapy skills and tools through short video clips, in-session exercises, an animated storyline, and weekly out-of-session home practice. A printed workbook accompanies the web-based lessons. In comparative usability testing (N=10), Empower@Home received a System Usability Scale score of 78 (SD 7.4), which was significantly higher than the 2 comparator programs (t9=3.28; P=.005 and t9=2.78; P=.011). Most participants, 80% (n=8), preferred Empower@Home over the comparators. In the longitudinal field test (n=4), all participants reported liking the program procedures and feeling confident in performing program-related tasks. The single-subject line graph showed an overall downward trend in their depression scores over time, offering an encouraging indication of the intervention’s potential effects. Conclusions: Collaboration with community stakeholders and careful consideration of potential implementation issues during the design process can result in more usable, engaging, and effective digital mental health interventions. %M 37725423 %R 10.2196/47691 %U https://aging.jmir.org/2023/1/e47691 %U https://doi.org/10.2196/47691 %U http://www.ncbi.nlm.nih.gov/pubmed/37725423 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e47902 %T Trends in Cause-Specific Injury Mortality in China in 2005-2019: Longitudinal Observational Study %A Ji,Zixiang %A Wu,Hengjing %A Zhu,Rongyu %A Wang,Lu %A Wang,Yuzhu %A Zhang,Lijuan %+ Clinical Center for Intelligent Rehabilitation Research, Shanghai YangZhi Rehabilitation Hospital, Tongji University School of Medicine, Tongji University, 50 Chifeng Road, Yangpu, Shanghai, 201619, China, 86 13817934887, zhangxiaoyi@tongji.edu.cn %K reverse %K age-standardized mortality rate %K injury %K suicide %K trend %K potential years of life lost %K average years of life lost %K crude mortality rate %K falls %K older adults %K young adults %D 2023 %7 15.9.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Over the last few decades, although the age-standardized mortality rate (ASMR) of injury has shown a significant declining trend in China, this pattern has dramatically reversed recently. Objective: We aimed to elucidate the geographical, demographic, and temporal trends of cause-specific injuries, the reversal phenomenon of these trends, and the fluctuations of injury burden from 2005 to 2019 in China. Methods: A longitudinal observational study was performed using the raw data of injury deaths in the National Cause-of-Death surveillance data provided by the disease surveillance points system in 2005-2019. The cause-specific injuries were divided into disparate subgroups by sex, age, urban/rural region, and eastern/central/western areas of China. The burden of injury was assessed using potential years of life lost (PYLL), average years of life lost (AYLL), and PYLL rate (PYLLR). Temporal trends of mortality rates and burden were evaluated using best-fitting joinpoint models. Results: Injury deaths accounted for 7.51% (1,156,504/15,403,835) of all-cause deaths in China in 2005-2019. The crude mortality rate of all-cause injury was 47.74 per 100,000 persons. The top 3 injury types (traffic accident, falls, and suicide) accounted for 70.57% (816,145/1,156,504) of all injury-related deaths. The ASMR of all-cause injury decreased (P=.003), while the crude mortality rate remained unchanged (P=.52) during 2005-2019. A significant reverse trend in ASMR of all-cause injury was observed in urban older adults since 2013, mainly due to the inverted trend in injuries from falls. A reverse trend in ASMR of suicide was observed among individuals aged 10-24 years, with notable increases by 35.18% (annual percentage change 15.4%, 95% CI 4.1%-28.0%) in men since 2017. The AYLL and PYLLR of all-cause injury among older adults showed consistent ascending trends from 2005 to 2019 (average annual percentage change [AAPC] 6.1%, 95% CI 5.4%-6.9%, 129.04% increase for AYLL; AAPC 5.4%, 95% CI 2.4%-8.4%, 105.52% increase for PYLLR). The AYLL due to suicide for individuals aged 10-24 years showed a considerable upswing tendency (AAPC 0.5%, 95% CI 0.4%-0.7%, 8.02% increase). Conclusions: Although the ASMR of all-cause injury decreased in China from 2005 to 2019, the trend in suicide among adolescents and young adults and falls among older adults has been on the rise in recent years. Interventions should be encouraged to mitigate the cause-specific burdens of injury death. %M 37713250 %R 10.2196/47902 %U https://publichealth.jmir.org/2023/1/e47902 %U https://doi.org/10.2196/47902 %U http://www.ncbi.nlm.nih.gov/pubmed/37713250 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e49325 %T An Evaluation of the Boys Do Cry Suicide Prevention Media Campaign on Twitter: Mixed Methods Approach %A Scotti Requena,Simone %A Pirkis,Jane %A Currier,Dianne %A Conway,Mike %A Lee,Simon %A Turnure,Jackie %A Cummins,Jennifer %A Nicholas,Angela %+ Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Level 4, 207 Bouverie Street, Melbourne, 3010, Australia, 61 383444951, simone.scottirequena@unimelb.edu.au %K help-seeking %K masculinity %K media campaign %K men %K men’s health %K mental health %K self-reliance %K social media %K suicide prevention %K suicide %D 2023 %7 7.9.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: In most countries, men are more likely to die by suicide than women. Adherence to dominant masculine norms, such as being self-reliant, is linked to suicide in men in Western cultures. We created a suicide prevention media campaign, “Boys Do Cry,” designed to challenge the “self-reliance” norm and encourage help-seeking in men. A music video was at the core of the campaign, which was an adapted version of the “Boys Don’t Cry” song from “The Cure.” There is evidence that suicide prevention media campaigns can encourage help-seeking for mental health difficulties. Objective: We aimed to explore the reach, engagement, and themes of discussion prompted by the Boys Do Cry campaign on Twitter. Methods: We used Twitter analytics data to investigate the reach and engagement of the Boys Do Cry campaign, including analyzing the characteristics of tweets posted by the campaign’s hosts. Throughout the campaign and immediately after, we also used Twitter data derived from the Twitter Application Programming Interface to analyze the tweeting patterns of users related to the campaign. In addition, we qualitatively analyzed the content of Boys Do Cry–related tweets during the campaign period. Results: During the campaign, Twitter users saw the tweets posted by the hosts of the campaign a total of 140,650 times and engaged with its content a total of 4477 times. The 10 highest-performing tweets by the campaign hosts involved either a video or an image. Among the 10 highest-performing tweets, the first was one that included the campaign’s core video; the second was a screenshot of the tweet posted by Robert Smith, the lead singer of The Cure, sharing the Boys Do Cry campaign’s video and tagging the campaign’s hosts. In addition, the pattern of Twitter activity for the campaign-related tweets was considerably higher during the campaign than in the immediate postcampaign period, with half of the activity occurring during the first week of the campaign when Robert Smith promoted the campaign. Some of the key topics of discussions prompted by the Boys Do Cry campaign on Twitter involved users supporting the campaign; referencing the original song, band, or lead singer; reiterating the campaign’s messages; and having emotional responses to the campaign. Conclusions: This study demonstrates that a brief media campaign such as Boys Do Cry can achieve good reach and engagement and can prompt discussions on Twitter about masculinity and suicide. Such discussions may lead to greater awareness about the importance of seeking help and providing support to those with mental health difficulties. However, this study suggests that longer, more intensive campaigns may be needed in order to amplify and sustain these results. %M 37676723 %R 10.2196/49325 %U https://formative.jmir.org/2023/1/e49325 %U https://doi.org/10.2196/49325 %U http://www.ncbi.nlm.nih.gov/pubmed/37676723 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e42686 %T Changes in Intrapersonal Factors of Participants in the Pregnancy Remote Monitoring Study Who Are at Risk for Pregnancy-Induced Hypertension: Descriptive Quantitative Study %A Lanssens,Dorien %A Vandenberk,Thijs %A Storms,Valerie %A Thijs,Inge %A Grieten,Lars %A Bamelis,Lotte %A Gyselaers,Wilfried %A Tang,Eileen %A Luyten,Patrick %+ Limburg Clinical Research Center/Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, Hasselt, 3500, Belgium, 32 494919476, dorien.lanssens@uhasselt.be %K intrapersonal factors %K peripartum period %K pregnancy %K pregnancy-induced hypertension %K remote monitoring %D 2023 %7 6.9.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: The peripartum period, defined as the period from the beginning of the gestation until 1 year after the delivery, has long been shown to be potentially associated with increased levels of stress and anxiety with regard to one’s transition to the status of parent and the accompanying parental tasks. Yet, no research to date has investigated changes in intrapersonal factors during the peripartum period in women at risk for pregnancy-induced hypertension (PIH). Objective: The aim of this study is to explore and describe changes in intrapersonal factors in participants at risk for PIH. Methods: We used an explorative design in which 3 questionnaires were sent by email to 110 participants the day following enrollment in the Pregnancy Remote Monitoring program for pregnant women at risk for PIH. Women were invited to complete the questionnaires at the beginning of their participation in the Pregnancy Remote Monitoring project (mostly at 14 weeks of gestation) and after approaching 32 weeks of gestational age (GA). The Generalized Anxiety Disorder-7 Scale (GAD-7) and the Patient Health Questionnaire-9 were used to assess anxiety and depression, and adaptation of the Pain Catastrophizing Scale was used to measure trait pain catastrophizing. Results: Scores were significantly higher at 32 weeks of GA than at the moment of enrollment (GAD-7 score=7, range 4-11 vs 5, range 3-8; P=.01; and Patient Health Questionnaire-9 score=6, range 4-10 vs 4, range 2-7; P<.001). The subscale scores of the Pain Catastrophizing Scale were all lower at 32 weeks of GA compared with 14 weeks of GA (rumination: 4, range 1-6 vs 5, range 2-9.5; P=.11; magnification: 3, range 1-5.5 vs 4, range 3-7; P=.04; and helplessness: 5, range 2-9 vs 6, range 3.5-12; P=.06). The proportion of women with a risk for depression (GAD-7 score >10) was 13.3% (10/75) at enrollment and had increased to 35.6% (26/75) at 32 weeks of GA. Conclusions: This study shows that pregnant women at risk for PIH have higher levels of stress and anxiety at 32 weeks of GA than at the moment of enrollment. Further research is recommended to investigate potential strategies to help pregnant women at risk for PIH manage feelings of stress and anxiety. Trial Registration: ClinicalTrials.gov NCT03246737; https://clinicaltrials.gov/study/NCT03246737 %M 37672324 %R 10.2196/42686 %U https://www.jmir.org/2023/1/e42686 %U https://doi.org/10.2196/42686 %U http://www.ncbi.nlm.nih.gov/pubmed/37672324 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43719 %T One-Week Suicide Risk Prediction Using Real-Time Smartphone Monitoring: Prospective Cohort Study %A Barrigon,Maria Luisa %A Romero-Medrano,Lorena %A Moreno-Muñoz,Pablo %A Porras-Segovia,Alejandro %A Lopez-Castroman,Jorge %A Courtet,Philippe %A Artés-Rodríguez,Antonio %A Baca-Garcia,Enrique %+ Department of Psychiatry, Jimenez Diaz Foundation University Hospital, Av Reyes Católicos, 2, Madrid, 28040, Spain, 34 91 541 72 67, ebacgar2@yahoo.es %K e-health %K m-health %K Ecological Mometary Asssessment %K risk prediction %K sensor monitoring %K suicidal %K suicide attempt %K suicide %D 2023 %7 1.9.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is a major global public health issue that is becoming increasingly common despite preventive efforts. Though current methods for predicting suicide risk are not sufficiently accurate, technological advances provide invaluable tools with which we may evolve toward a personalized, predictive approach. Objective: We aim to predict the short-term (1-week) risk of suicide by identifying changes in behavioral patterns characterized through real-time smartphone monitoring in a cohort of patients with suicidal ideation. Methods: We recruited 225 patients between February 2018 and March 2020 with a history of suicidal thoughts and behavior as part of the multicenter SmartCrisis study. Throughout 6 months of follow-up, we collected information on the risk of suicide or mental health crises. All participants underwent voluntary passive monitoring using data generated by their own smartphones, including distance walked and steps taken, time spent at home, and app usage. The algorithm constructs daily activity profiles for each patient according to these data and detects changes in the distribution of these profiles over time. Such changes are considered critical periods, and their relationship with suicide-risk events was tested. Results: During follow-up, 18 (8%) participants attempted suicide, and 14 (6.2%) presented to the emergency department for psychiatric care. The behavioral changes identified by the algorithm predicted suicide risk in a time frame of 1 week with an area under the curve of 0.78, indicating good accuracy. Conclusions: We describe an innovative method to identify mental health crises based on passively collected information from patients’ smartphones. This technology could be applied to homogeneous groups of patients to identify different types of crises. %M 37656498 %R 10.2196/43719 %U https://www.jmir.org/2023/1/e43719 %U https://doi.org/10.2196/43719 %U http://www.ncbi.nlm.nih.gov/pubmed/37656498 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e40197 %T Utility of Smartphone-Based Digital Phenotyping Biomarkers in Assessing Treatment Response to Transcranial Magnetic Stimulation in Depression: Proof-of-Concept Study %A Kelkar,Radhika Suneel %A Currey,Danielle %A Nagendra,Srilakshmi %A Mehta,Urvakhsh Meherwan %A Sreeraj,Vanteemar S %A Torous,John %A Thirthalli,Jagadisha %+ National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore, 560029, India, 91 8026995805, urvakhsh@gmail.com %K theta burst stimulation %K treatment response %K predictive biomarker %K outcome %K digital phenotyping %K transcranial magnetic stimulation %K TMS %K depression %K smartphone %K mobile phone %D 2023 %7 1.9.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Identifying biomarkers of response to transcranial magnetic stimulation (TMS) in treatment-resistant depression is a priority for personalizing care. Clinical and neurobiological determinants of treatment response to TMS, while promising, have limited scalability. Therefore, evaluating novel, technologically driven, and potentially scalable biomarkers, such as digital phenotyping, is necessary. Objective: This study aimed to examine the potential of smartphone-based digital phenotyping and its feasibility as a predictive biomarker of treatment response to TMS in depression. Methods: We assessed the feasibility of digital phenotyping by examining the adherence and retention rates. We used smartphone data from passive sensors as well as active symptom surveys to determine treatment response in a naturalistic course of TMS treatment for treatment-resistant depression. We applied a scikit-learn logistic regression model (l1 ratio=0.5; 2-fold cross-validation) using both active and passive data. We analyzed related variance metrics throughout the entire treatment duration and on a weekly basis to predict responders and nonresponders to TMS, defined as ≥50% reduction in clinician-rated symptom severity from baseline. Results: The adherence rate was 89.47%, and the retention rate was 73%. The area under the curve for correct classification of TMS response ranged from 0.59 (passive data alone) to 0.911 (both passive and active data) for data collected throughout the treatment course. Importantly, a model using the average of all features (passive and active) for the first week had an area under the curve of 0.7375 in predicting responder status at the end of the treatment. Conclusions: The results of our study suggest that it is feasible to use digital phenotyping data to assess response to TMS in depression. Early changes in digital phenotyping biomarkers, such as predicting response from the first week of data, as shown in our results, may also help guide the treatment course. %M 37656496 %R 10.2196/40197 %U https://formative.jmir.org/2023/1/e40197 %U https://doi.org/10.2196/40197 %U http://www.ncbi.nlm.nih.gov/pubmed/37656496 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44514 %T Multidimensional Internet Use, Social Participation, and Depression Among Middle-Aged and Elderly Chinese Individuals: Nationwide Cross-Sectional Study %A Du,Xiwang %A Liao,Jiazhi %A Ye,Qing %A Wu,Hong %+ School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Qiaokou District, Wuhan, , China, 86 13277942186, hongwu@hust.edu.cn %K internet use %K depression %K social participation %K middle-aged and elderly Chinese %K RIDL %D 2023 %7 30.8.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: There is growing evidence that the internet has beneficial effects on the mental health of middle-aged and older people (≥45 years), but the evidence is inconclusive, and the underlying mechanisms are less known. Objective: This study aims to explore the relationship between multidimensional (devices, frequency, and purpose) internet use and depression in middle-aged and elderly Chinese, as well as the mediating effect of social participation. Moreover, this study will explore the moderating effect of the regional informatization development level (RIDL) on the relationships between individual internet use, social participation, and depression. Methods: Data on 17,676 participants aged 45 years or older were obtained from the China Health and Retirement Longitudinal Study (CHARLS) 2018 data set. The 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10) was used to identify the presence of depression. Logistic regression was used to explore the relationship between each dimension of internet use and depression. Multiple linear regression was used to explore the mediating effect of social participation and the moderating effect of the RIDL. Results: The results showed that 28.33% (5008/17,676) of the total population had depression. In terms of regional subgroups, respondents living in the western region exhibited the highest proportion of depression (2041/5884, 34.69%). Internet use was negatively associated with depression (odds ratio 0.613, 95% CI 0.542-0.692; P<.001). Various dimensions of internet use positively contributed to individual social participation and reduced individual depression (devices: β=–.170, 95% CI –0.209 to –0.127; frequency: β=–.065, 95% CI –0.081 to –0.047; and purpose: β=–.043, 95% CI –0.053 to –0.031). In addition, the RIDL weakened the relationship between individual-level internet use and social participation (internet use: F74.12,9.82=7.55, P<.001; devices: F51.65/9.88=5.23, P=.005; frequency: F66.74/10.08=6.62, P=.001; and purpose: F66.52/9.78=6.80, P=.001), and negatively moderated the relationship between the frequency of internet use and depression (frequency: F662.67/188.79=3.51, P=.03). Conclusions: This study found that different dimensions of internet use are associated with lower levels of depression. Social participation partially mediates the association between multidimensional internet use and depression in the eastern, central, and western regions, respectively. Additionally, the RIDL helps individuals further their internet use and social participation, reducing the impact of depression. However, this effect weakens sequentially from the western region to the central region and then to the eastern region. %M 37647119 %R 10.2196/44514 %U https://www.jmir.org/2023/1/e44514 %U https://doi.org/10.2196/44514 %U http://www.ncbi.nlm.nih.gov/pubmed/37647119 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44000 %T Effects of Web-Based Mindfulness-Based Interventions on Anxiety, Depression, and Stress Among Frontline Health Care Workers During the COVID-19 Pandemic: Systematic Review and Meta-Analysis %A Yang,Jia-ming %A Ye,Hua %A Long,Yi %A Zhu,Qiang %A Huang,Hui %A Zhong,Yan-biao %A Luo,Yun %A Yang,Lei %A Wang,Mao-yuan %+ Department of Rehabilitation Medicine, First Affiliated Hospital of Gannan Medical University, 128 Jinling Road, Zhanggong District, Ganzhou City, Jiangxi Province, Ganzhou, 341000, China, 86 13767766152, wmy.gmu.kf@gmail.com %K web-based %K mindfulness-based intervention %K COVID-19 %K health care worker %K mental disorder %D 2023 %7 29.8.2023 %9 Review %J J Med Internet Res %G English %X Background: Since 2019, the COVID-19 outbreak has spread around the world, and health care workers, as frontline workers, have faced tremendous psychological stress. Objective: The purpose of this study is to explore whether web-based mindfulness-based interventions continue to have a positive impact on anxiety, depression, and stress among health care workers during the COVID-19 pandemic. Methods: The inclusion criteria were as follows: (1) participants were frontline health care workers during the COVID-19 pandemic; (2) the experimental group was a web-based mindfulness-based intervention; (3) the control group used either general psychological intervention or no intervention; (4) outcome indicators included scales to assess anxiety, depression, and stress; and (5) the study type was a randomized controlled study. Studies that did not meet the above requirements were excluded. We searched 9 databases, including Web of Science, Embase, PubMed, Cochrane Library, Scopus, ScienceDirect, SinoMed, China National Knowledge Infrastructure (CNKI), and Wanfang Database, for randomized controlled studies on the effects of web-based mindfulness-based interventions on common mental disorder symptoms among health care workers from January 1, 2020, to October 20, 2022. The methodological quality of the included studies was assessed using the Physiotherapy Evidence Database scale. The Cochrane risk of bias tool was used to assess the risk of bias. Subgroup analysis was used to look for sources of heterogeneity and to explore whether the results were the same for subgroups under different conditions. Sensitivity analysis was used to verify the stability of the pooled results. Results: A total of 10 randomized controlled studies with 1311 participants were included. The results showed that web-based mindfulness-based interventions were effective in reducing the symptoms of anxiety (standard mean difference [SMD]=–0.63, 95% CI –0.96 to –0.31, P<.001, I2=87%), depression (SMD=–0.52, 95% CI –0.77 to –0.26, P<.001, I2=75%), and stress (SMD=–0.20, 95% CI –0.35 to –0.05, P=.01, I2=58%) among health care workers during the COVID-19 pandemic, but with wide CIs and high heterogeneity. Conclusions: Web-based mindfulness-based interventions may be effective in reducing the symptoms of anxiety, depression, and stress among frontline health care workers during the COVID-19 pandemic. However, this effect is relatively mild and needs to be further explored by better studies in the future. Trial Registration: PROSPERO CRD42022343727; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=343727 %M 37527546 %R 10.2196/44000 %U https://www.jmir.org/2023/1/e44000 %U https://doi.org/10.2196/44000 %U http://www.ncbi.nlm.nih.gov/pubmed/37527546 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e51799 %T Digital Health Tools Can Support Patient Access to Culturally and Linguistically Competent Behavioral Health Treatment %A Berger,Mitchell %+ US Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD, 200857, United States, 1 5712177722, mazruia@hotmail.com %K African American %K women %K depression %K telemedicine %K mobile health %K mHealth %K mobile apps %K digital health %K mental health %K gender minority %K mobile technology %K mobile phone %D 2023 %7 25.8.2023 %9 Letter to the Editor %J J Med Internet Res %G English %X %M 37624636 %R 10.2196/51799 %U https://www.jmir.org/2023/1/e51799 %U https://doi.org/10.2196/51799 %U http://www.ncbi.nlm.nih.gov/pubmed/37624636 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e44742 %T Efficacy of a Brief Blended Cognitive Behavioral Therapy Program for the Treatment of Depression and Anxiety in University Students: Uncontrolled Intervention Study %A Atik,Ece %A Stricker,Johannes %A Schückes,Magnus %A Pittig,Andre %+ Clinical Psychology Research Group, Department of Experimental Psychology, Heinrich Heine University Düsseldorf, Universitätsstr. 1, Düsseldorf, 40225, Germany, 49 211 81 10850, johannes.stricker@hhu.de %K blended cognitive behavioral therapy %K bCBT %K digital mental health %K e–mental health %K depression %K anxiety disorder %K video psychotherapy %K mobile phone %D 2023 %7 25.8.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Blended cognitive behavioral therapy (bCBT)—the combination of cognitive behavioral therapy and digital mental health applications—has been increasingly used to treat depression and anxiety disorders. As a resource-efficient treatment approach, bCBT appears promising for addressing the growing need for mental health care services, for example, as an early intervention before the chronification of symptoms. However, further research on the efficacy and feasibility of integrated bCBT interventions is needed. Objective: This study aimed to evaluate the efficacy of a novel bCBT program comprising short (25 min), weekly face-to-face therapy sessions combined with a smartphone-based digital health app for treating mild to moderate symptoms of depression or anxiety. Methods: This prospective uncontrolled trial comprised 2 measurement points (before and after treatment) and 2 intervention groups. We recruited university students with mild to moderate symptoms of depression or anxiety. On the basis of the primary symptoms, participants were assigned to either a depression intervention group (n=67 completers) or an anxiety intervention group (n=33 completers). Participants in each group received 6 weekly individual psychotherapy sessions via videoconference and completed modules tailored to their respective symptoms in the smartphone-based digital health app. Results: The depression group displayed medium to large improvements in the symptoms of depression (Cohen d=−0.70 to −0.90; P<.001). The anxiety group experienced significant improvements in the symptoms of generalized anxiety assessed with the Generalized Anxiety Disorder-7 scale with a large effect size (Cohen d=−0.80; P<.001) but not in symptoms of anxiety assessed with the Beck Anxiety Inventory (Cohen d=−0.35; P=.06). In addition, both groups experienced significant improvements in their perceived self-efficacy (Cohen d=0.50; P<.001 in the depression group and Cohen d=0.71; P<.001 in the anxiety group) and quality of life related to psychological health (Cohen d=0.87; P<.001 in the depression group and Cohen d=0.40; P=.03 in the anxiety group). Work and social adjustment of patients improved significantly in the depression group (Cohen d=−0.49; P<.001) but not in the anxiety group (Cohen d=−0.06; P=.72). Patients’ mental health literacy improved in the anxiety group (Cohen d=0.45; P=.02) but not in the depression group (Cohen d=0.21; P=.10). Patient satisfaction with the bCBT program and ratings of the usability of the digital app were high in both treatment groups. Conclusions: This study provides preliminary evidence for the feasibility and efficacy of a novel brief bCBT intervention. The intervention effects were generalized across a broad spectrum of patient-reported outcomes. Hence, the newly developed bCBT intervention appears promising for treating mild to moderate depression and anxiety in young adults. %M 37624631 %R 10.2196/44742 %U https://mental.jmir.org/2023/1/e44742 %U https://doi.org/10.2196/44742 %U http://www.ncbi.nlm.nih.gov/pubmed/37624631 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45963 %T Selective Prevention of Depression in Workers Using a Smartphone App: Randomized Controlled Trial %A Deady,Mark %A Collins,Daniel A J %A Lavender,Isobel %A Mackinnon,Andrew %A Glozier,Nicholas %A Bryant,Richard %A Christensen,Helen %A Harvey,Samuel B %+ Black Dog Institute, Faculty of Medicine and Health, University of New South Wales, Hospital Rd, Randwick, 2031, Australia, 61 02 9065 9144, m.deady@unsw.edu.au %K depression %K smartphone app %K workplace mental health %K randomized controlled trial %K prevention %K stress %K mobile phone %D 2023 %7 24.8.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: There is increasing evidence that depression can be prevented; however, universal approaches have had limited success. Appropriate targeting of interventions to at-risk populations has been shown to have potential, but how to selectively determine at-risk individuals remains unclear. Workplace stress is a risk factor for depression and a target for intervention, but few interventions exist to prevent depression among workers at risk due to heightened stress. Objective: This trial aimed to evaluate the efficacy of a smartphone-based intervention in reducing the onset of depression and improving related outcomes in workers experiencing at least moderate levels of stress. Methods: A randomized controlled trial was conducted with participants who were currently employed and reported no clinically significant depression and at least moderate stress. The intervention group (n=1053) were assigned Anchored, a 30-day self-directed smartphone app-based cognitive behavioral- and mindfulness-based intervention. The attention-control group (n=1031) were assigned a psychoeducation website. Assessment was performed via web-based self-report questionnaires at baseline and at 1-, 3-, and 6-month postbaseline time points. The primary outcome was new depression caseness aggregated over the follow-up period. The secondary outcomes included depressive and anxiety symptoms, stress, well-being, resilience, work performance, work-related burnout, and quality of life. Analyses were conducted within an intention-to-treat framework using mixed modeling. Results: There was no significant between-group difference in new depression caseness (z score=0.69; P=.49); however, those in the Anchored arm had significantly greater depressive symptom reduction at 1 month (Cohen d=0.02; P=.049) and 6 months (Cohen d=0.08; P=.03). Anchored participants also showed significantly greater reduction in anxiety symptoms at 1 month (Cohen d=0.07; P=.04) and increased work performance at 1 month (Cohen d=0.07; P=.008) and 6 months (Cohen d=0.13; P=.01), compared with controls. Notably, for Anchored participants completing at least two-thirds of the intervention, there was a significantly lower rate of depression onset (1.1%, 95% CI 0.0%-3.7%) compared with controls (9.0%, 95% CI 6.8%-12.3%) at 1 month (z score=4.50; P<.001). Significant small to medium effect sizes for most secondary outcomes were seen in the highly engaged Anchored users compared with controls, with effects maintained at the 6-month follow-up for depressive symptoms, well-being, stress, and quality of life. Conclusions: Anchored was associated with a small comparative reduction in depressive symptoms compared with controls, although selective prevention of case-level depression was not observed in the intention-to-treat analysis. When users adequately engaged with the app, significant findings pertaining to depression prevention, overall symptom reduction, and functional improvement were found, compared with controls. There is a need for a greater focus on engagement techniques in future research. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000178943; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378592 %M 37616040 %R 10.2196/45963 %U https://www.jmir.org/2023/1/e45963 %U https://doi.org/10.2196/45963 %U http://www.ncbi.nlm.nih.gov/pubmed/37616040 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e46925 %T Long-Term Efficacy of Internet-Based Cognitive Behavioral Therapy Self-Help Programs for Adults With Depression: Systematic Review and Meta-Analysis of Randomized Controlled Trials %A Mamukashvili-Delau,Megi %A Koburger,Nicole %A Dietrich,Sandra %A Rummel-Kluge,Christine %+ Department of Psychiatry and Psychotherapy, Medical Faculty, Leipzig University, Klinik und Poliklinik für Psychiatrie und Psychotherapie Semmelweisstraße 10, Haus 13, Leipzig, 04103, Germany, 49 0341 97 24464, Christine.Rummel-Kluge@medizin.uni-leipzig.de %K depression %K internet-based cognitive behavioral therapy %K iCBT %K self-help %K minimal guidance %K long-term %K follow-up %K mental health %K psychotherapy %K cognitive behavioral therapy %K CBT %K systematic review %K meta-analysis %K meta-analyses %K review method %D 2023 %7 22.8.2023 %9 Review %J JMIR Ment Health %G English %X Background: Depression is a worldwide mental disorder and a leading cause of disability. Many people with depression do not want to take medication or have the motivation to seek psychotherapy treatment for many reasons. Guided internet-based self-help programs may be a promising solution for addressing these issues. This kind of intervention has proven to be effective in reducing depression symptoms on a short-term scale. However, as treatment often is a long-term rehabilitation process, it is important to examine not only the short-term effects of internet-based cognitive behavioral therapy (iCBT) self-help treatment but also the follow-up or long-term efficacy of this kind of intervention. Objective: This systematic review and meta-analysis aimed to identify studies that examined follow-up data ≥8 weeks after posttreatment measurements and thereby examined the long-term efficacy of iCBT self-help programs with minimal weekly guidance for people with depression. It aimed to analyze the long-term efficacy of iCBT treatments compared to control conditions as well as long-term efficacy within the iCBT treatment conditions. Additionally, it aimed to conduct subgroup analyses according to the follow-up time points for each outcome. Finally, it examined long-term improvements in quality of life. Methods: The Cochrane Collaboration Depression, Anxiety, and Neurosis Controlled Trials Register (CCDANCTR), grey literature, reference lists, and correspondence were used to search for published and unpublished randomized controlled trials (RCTs) that reported the long-term or follow-up efficacy of computer-based or iCBT self-help treatments for depression with minimal guidance of up to 10 min/wk. The search took place between 2015 and 2022 (October). Results: The search resulted in a total of 2809 study abstracts, of which 15 studies (with 17 samples) met all inclusion criteria and were included in the long-term analysis. The results showed that the depression outcomes of all follow-up time points together in the treatment conditions were favored over the control conditions with a medium effect size of 0.43 (n=1689 participants; 9 RCTs; standardized mean difference [SMD] –0.43, 95% CI –0.67 to –0.20; P<.001). The analysis of long-term efficacy within the iCBT treatment conditions showed that the follow-up outcomes of the treatment groups were favored over the posttreatment outcomes with a small effect size of 0.20 (n=2196 participants; 17 RCTs; SMD 0.20, 95% CI 0.07-0.49; P=.003). Findings for improving quality of life also showed that the iCBT conditions were favored over the control conditions with a small effect size of 0.19 (n=1345 participants; 3 RCTs; SMD 0.19, 95% CI 0.08-0.30; P<.001). Conclusions: This systematic review and meta-analysis found that iCBT self-help interventions had a superior long-term efficacy for individuals with depressive symptoms compared to control groups. The within-group analysis of iCBT treatment conditions also showed statistically significant improvements in reducing depressive symptoms at follow-up compared to posttreatment measurements. %M 37606990 %R 10.2196/46925 %U https://mental.jmir.org/2023/1/e46925 %U https://doi.org/10.2196/46925 %U http://www.ncbi.nlm.nih.gov/pubmed/37606990 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e44679 %T Health Economic Evaluation of Cognitive Control Training for Depression: Key Considerations %A Nève de Mévergnies,Constance %A Verhaeghe,Nick %A Koster,Ernst H W %A Baeken,Chris %A Vander Zwalmen,Yannick %A Hoorelbeke,Kristof %+ Department of Experimental Clinical and Health Psychology, Ghent University, Henri Dunantlaan 2, Ghent, 9000, Belgium, 32 9 264 64 74, kristof.hoorelbeke@Ugent.be %K health economic evaluation %K cost utility %K cognitive control training %K CCT %K depression recurrence %K health policies %D 2023 %7 18.8.2023 %9 Viewpoint %J JMIR Ment Health %G English %X Depression is a serious and burdensome psychiatric illness that contributes heavily to health expenditures. These costs are partly related to the observation that depression is often not limited to a single episode but can recur or follow a chronic pathway. In terms of risk factors, it is acknowledged that cognitive impairments play a crucial role in vulnerability to depression. Within this context, cognitive control training (CCT) has shown its effectiveness in reducing the risk for recurrence of depression. CCT is low cost intensive and can be provided as a web-based intervention, which makes it easy to disseminate. Despite increasing interest in the field, studies examining the cost-effectiveness of CCT in the context of depression are largely missing. Health economic evaluation (HEE) allows to inform decision makers with evidence-based insights about how to spend limited available (financial) resources in the most efficient way. HEE studies constitute a crucial step in the implementation of a new intervention in clinical practice. Approaching preventive measures for depression such as CCT from an HEE perspective is informative to health policy, fostering optimal use of health expenditures. The aim of this paper was to inform and guide researchers during the phase of designing HEE studies in the context of CCT for depression. A clear view of CCT’s cost-effectiveness is paramount for its clinical implementation. %M 37594847 %R 10.2196/44679 %U https://mental.jmir.org/2023/1/e44679 %U https://doi.org/10.2196/44679 %U http://www.ncbi.nlm.nih.gov/pubmed/37594847 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e46326 %T Effectiveness of an Internet-Based Self-Guided Program to Treat Depression in a Sample of Brazilian Users: Randomized Controlled Trial %A Lopes,Rodrigo T %A da Rocha,Gustavo Chapetta %A Svacina,Maria Adriana %A Meyer,Björn %A Šipka,Dajana %A Berger,Thomas %+ University of Bern, Fabrikstrasse, 8, Clinical Psychology and Psychotherapy Department, Bern, 3012, Switzerland, 41 0787574701, rodrigo.lopes@psy.unibe.ch %K depression %K internet-based interventions %K self-guided interventions %K cognitive behavioral therapy %D 2023 %7 17.8.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression is undertreated in Brazil. Deprexis is a self-guided internet-based program used to treat depressive symptoms based on empirically supported integrative and cognitive behavioral therapy. Evidence from a meta-analysis supports Deprexis’ efficacy in German-speaking countries and the United States, but no study has been conducted using this program in countries with low literacy rates and large social disparities. Furthermore, few studies have investigated whether internet-based interventions ameliorate the psychological processes that might underlie depressive symptomatology, such as low perceived self-efficacy. Objective: The main objective of this study was to replicate in Brazil previously reported effects of Deprexis on depressive symptom reduction. Therefore, the main research question was whether Deprexis is effective in reducing depressive symptoms and the general psychological state in Brazilian users with moderate and severe depression in comparison with a control group that does not receive access to Deprexis. A secondary research question was whether the use of Deprexis affects perceptions of self-efficacy. Methods: We interviewed 312 participants recruited over the internet and randomized 189 participants with moderate to severe depression (according to the Patient Health Questionnaire–9 and a semistructured interview) to an intervention condition (treatment as usual plus immediate access to Deprexis for 90 days, n=94) or to a control condition (treatment as usual and delayed access to Deprexis, after 8 weeks, n=95). Results: Participants from the immediate access group logged in at Deprexis an average of 14.81 (SD 12.16) times. The intention-to-treat analysis using a linear mixed model showed that participants who received Deprexis improved significantly more than participants assigned to the delayed access control group on the primary depression self-assessment measure (Patient Health Questionnaire–9; Cohen d=0.80; P<.001) and secondary outcomes, such as general psychological state measure (Clinical Outcome in Routine Evaluation–Outcome Measurement; Cohen d=0.82; P<.001) and the perceived self-efficacy measure (Cohen d=0.63; P<.001). The intention-to-treat analyses showed that 21% (20/94) of the participants achieved remission compared with 7% (7/95) in the control group (P<.001). The deterioration rates were lower in the immediate access control group. The dropout rate was high, but no differences in demographic and clinical variables were found. Participants reported a medium to high level of satisfaction with Deprexis. Conclusions: These results replicate previous findings by showing that Deprexis can facilitate symptomatic improvement over 3 months in depressed samples of Brazilian users. From a public health perspective, this is important information to expand the reach of internet-based interventions for those who really need them, especially in countries with less access to mental health care. This extends previous research by showing significant effects on perceived self-efficacy. Trial Registration: Registro Brasileiro de Ensaios Clíncos (ReBec) RBR-6kk3bx UTN U1111-1212-8998; https://ensaiosclinicos.gov.br/rg/RBR-6kk3bx/ International Registered Report Identifier (IRRID): RR2-10.1590/1516-4446-2019-0582 %M 37590052 %R 10.2196/46326 %U https://formative.jmir.org/2023/1/e46326 %U https://doi.org/10.2196/46326 %U http://www.ncbi.nlm.nih.gov/pubmed/37590052 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e42469 %T Association of Catastrophic Health Expenditure With the Risk of Depression in Chinese Adults: Population-Based Cohort Study %A Wang,Yaping %A Liang,Wannian %A Liu,Min %A Liu,Jue %+ Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No. 38 Xueyuan Road, Haidian District, Beijing, 100191, China, 86 10 8 2805146, liumin@bjmu.edu.cn %K catastrophic health expenditure %K depression %K universal health coverage %K economic burden %K socioeconomic status %D 2023 %7 15.8.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Depression is one of the most common mental illnesses, and it may have a lasting effect on one’s whole life. As a form of financial hardship, catastrophic health expenditure (CHE) may be associated with depression. However, current evidence about the relationship between CHE and the risk of depression is insufficient. Objective: This study aimed to explore the relationship between CHE and the risk of depression among Chinese adults. Methods: In this study, we used 3 waves of the China Family Panel Studies (CFPS) from 2012, 2016, and 2018. The CFPS are a nationally representative study covering 25 of 31 provinces in Chinese mainland and representing nearly 94.5% of the total population. We selected eligible household heads as participants, divided them into 2 groups by CHE events at baseline (exposed group: with CHE; unexposed group: without CHE), and followed them up. Households with CHE were defined as having out-of-pocket medical expenditures exceeding 40% of the total household nonfood expenditure, and people with depression were identified by the 8-item Centre for Epidemiological Studies Depression Scale (CES-D). We first described the baseline characteristics and used logistical regression to estimate their effects on CHE events. Then, we used Cox proportional hazard models to estimate adjusted hazard ratios and 95% CIs of depression among participants with CHE compared with those without CHE. Finally, we analyzed the subgroup difference in the association between CHE and depression. Results: Of a total of 13,315 households, 9629 were eligible for analysis. Among them, 6824 (70.9%) were men. The mean age was 50.15 (SD 12.84) years. Only 987 (10.3%) participants had no medical insurance. The prevalence of CHE at baseline was 12.9% (1393/9629). Participants with a higher family economic level (adjusted odds ratio [aOR] 1.15, 95% CI 1.02-1.31) and with the highest socioeconomic development level (aOR 1.18, 95% CI 1.04-1.34) had a higher prevalence of CHE than reference groups. During a median of 71 (IQR 69-72) person-months of follow-up, the depression incidence of participants with CHE (1.41 per 1000 person-months) was higher than those without CHE (0.73 per 1000 person-months). Multivariable models revealed that the adjusted hazard ratio for the incidence of depression in participants with CHE was 1.33 (95% CI 1.08-1.64), and this association appeared to be greater in participants without outpatient services (for interaction, P=.048). Conclusions: CHE was significantly associated with increased risk of depression among Chinese adults. Concentrated work should be done to monitor CHE, and more efforts to ensure financial protection need to be made to prevent depression, especially for people with high health care needs. %M 37581926 %R 10.2196/42469 %U https://publichealth.jmir.org/2023/1/e42469 %U https://doi.org/10.2196/42469 %U http://www.ncbi.nlm.nih.gov/pubmed/37581926 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e46061 %T Relationship Factors in Internet-Delivered Psychological Interventions for Veterans Experiencing Postpartum Depression: Qualitative Analysis %A Solness,Cara L %A Holdefer,Paul J %A Hsu,Ti %A Thomas,Emily B K %A O'Hara,Michael W %+ Department of Psychiatry, School of Medicine, University of Colorado, 1890 N Revere Court, Anschutz Medical Campus, Aurora, CO, 80045, United States, 1 319 331 3566, cara.solness@cuanschutz.edu %K internet-delivered treatment %K postpartum depression %K therapeutic alliance %K qualitative methodology %K veteran %D 2023 %7 15.8.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Internet-delivered psychological interventions (IPIs) have been shown to be effective for a variety of psychological concerns, including postpartum depression. Human-supported programs produce better adherence and larger effect sizes than unsupported programs; however, what it is about support that affects outcomes is not well understood. Therapeutic alliance is one possibility that has been found to contribute to outcomes; however, the specific mechanism is not well understood. Participant perspectives and qualitative methodology are nearly absent from the IPI alliance research and may help provide new directions. Objective: In this study, we aimed to provide participant perspectives on engagement with an IPI for postpartum depression to help inform alliance research, development of new IPIs, and inform resource allocation. Methods: A qualitative methodology was used to explore participant perspectives of veteran women’s engagement with the MomMoodBooster program, a human-supported internet-delivered intervention for postpartum depression. Participants were asked 4 open-ended questions with the 3-month postintervention survey, “In what ways did you find the MomMoodBooster most helpful?” “How do you think the MomMoodBooster could have been improved?” “In what ways did you find the personal coach calls to be helpful?” and “How do you think the personal coach calls could have been improved?” Results: Data were collected from 184 participants who responded to at least 1 of the open-ended questions. These were analyzed using thematic analysis and a process of reaching a consensus among coders. The results suggest that not only the engagement with the support person is perceived as a significant contributor to participant experiences while using the MomMoodBooster content but also the relationship factors are particularly meaningful. The results provide insights into the specific qualities of the support person that were perceived as most impactful, such as warmth, empathy and genuineness, and feeling normalized and supported. In addition, the results provide insight into the specific change processes that can be targeted through support interactions, such as encouraging self-reflection and self-care and challenging negative thinking. Conclusions: These data emphasize the importance of relationship factors between support persons and an IPI program for postpartum depression. The findings suggest that focusing on specific aspects of the alliance and the therapeutic relationship could yield fruitful directions for the training of support personnel and for future alliance-based research of internet-delivered treatments. %M 37581917 %R 10.2196/46061 %U https://mental.jmir.org/2023/1/e46061 %U https://doi.org/10.2196/46061 %U http://www.ncbi.nlm.nih.gov/pubmed/37581917 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45917 %T Feasibility and Effectiveness of an Intervention to Reduce Intimate Partner Violence and Psychological Distress Among Women in Nepal: Protocol for the Domestic Violence Intervention (DeVI) Cluster-Randomized Trial %A Shrestha,Rachana %A Sapkota,Diksha %A Mehra,Devika %A Ekström,Anna Mia %A Deuba,Keshab %+ Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18A, Widerströmska Huset, Stockholm, 171 77, Sweden, 977 9843064279, keshab.deuba@ki.se %K intimate partner violence %K intervention %K violence prevention %K mental health %K cluster-randomized trial %K depression %K anxiety %K posttraumatic stress disorder %K low-income country %K women %K Nepal %D 2023 %7 15.8.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Intimate partner violence (IPV) disproportionately affects people in low-and middle-income countries (LMICs), such as Nepal. Women experiencing IPV are at higher risk of developing depression, anxiety, and posttraumatic stress disorder. The shortage of trained frontline health care providers, coupled with stigma related to IPV and mental health disorders, fuels low service uptake among women experiencing IPV. The Domestic Violence Intervention (DeVI) combines the Problem Management Plus counseling program developed by the World Health Organization with a violence prevention component. Objective: This study aims to implement and evaluate the feasibility, acceptability, and effectiveness of DeVI in addressing psychological distress and enabling the secondary prevention of violence for women experiencing IPV. Methods: A parallel cluster-randomized trial will be conducted across 8 districts in Madhesh Province in Nepal, involving 24 health care facilities. The study will include women aged 18-49 years who are either nonpregnant or in their first trimester, have experienced IPV within the past 12 months, have a 12-item General Health Questionnaire (GHQ-12) score of 3 or more (indicating current mental health issues), and have lived with their husbands or in-laws for at least 6 months. A total sample size of 912 was estimated at 80% power and α<.05 statistical significance level to detect a 15% absolute risk reduction in the IPV frequency and a 50% reduction in the GHQ-12 score in the intervention arm. The health care facilities will be randomly assigned to either the intervention or the control arm in a 1:1 ratio. Women visiting the health care facilities in the intervention and control arms will be recruited into the respective arms. In total, 38 participants from each health care facility will be included in the trial to meet the desired sample size. Eligible participants allocated to either arm will be assessed at baseline and follow-up visits after 6, 17, and 52 weeks after baseline. Results: This study received funding in 2019. As of December 29, 2022, over 50% of eligible women had been recruited from both intervention and control sites. In total, 269 eligible women have been enrolled in the intervention arm and 309 eligible women in the control arm. The trial is currently in the recruitment phase. Data collection is expected to be completed by December 2023, after which data analysis will begin. Conclusions: If the intervention proves effective, it will provide evidence of how nonspecialist mental health care providers can address the harmful effects of IPV in resource-constrained settings with a high burden of IPV, such as Nepal. The study findings could also contribute evidence for integrating similar services into routine health programs in LMICs to prevent IPV and manage mental health problems among women experiencing IPV. Trial Registration: ClinicalTrials.gov NCT05426863; https://clinicaltrials.gov/ct2/show/NCT05426863 International Registered Report Identifier (IRRID): DERR1-10.2196/45917 %M 37581909 %R 10.2196/45917 %U https://www.researchprotocols.org/2023/1/e45917 %U https://doi.org/10.2196/45917 %U http://www.ncbi.nlm.nih.gov/pubmed/37581909 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45233 %T Challenges in Using mHealth Data From Smartphones and Wearable Devices to Predict Depression Symptom Severity: Retrospective Analysis %A Sun,Shaoxiong %A Folarin,Amos A %A Zhang,Yuezhou %A Cummins,Nicholas %A Garcia-Dias,Rafael %A Stewart,Callum %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Conde,Pauline %A Laiou,Petroula %A Sankesara,Heet %A Matcham,Faith %A Leightley,Daniel %A White,Katie M %A Oetzmann,Carolin %A Ivan,Alina %A Lamers,Femke %A Siddi,Sara %A Simblett,Sara %A Nica,Raluca %A Rintala,Aki %A Mohr,David C %A Myin-Germeys,Inez %A Wykes,Til %A Haro,Josep Maria %A Penninx,Brenda W J H %A Vairavan,Srinivasan %A Narayan,Vaibhav A %A Annas,Peter %A Hotopf,Matthew %A Dobson,Richard J B %A , %+ Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Social Genetic and Developmental Psychiatry Centre, Memory Lane, London, SE5 8AF, United Kingdom, 44 02078480951, shaoxiong.sun@kcl.ac.uk %K mobile health %K depression %K digital phenotypes %K behavioral patterns %K missing data %K smartphones %K wearable devices %K mobile phone %D 2023 %7 14.8.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Major depressive disorder (MDD) affects millions of people worldwide, but timely treatment is not often received owing in part to inaccurate subjective recall and variability in the symptom course. Objective and frequent MDD monitoring can improve subjective recall and help to guide treatment selection. Attempts have been made, with varying degrees of success, to explore the relationship between the measures of depression and passive digital phenotypes (features) extracted from smartphones and wearables devices to remotely and continuously monitor changes in symptomatology. However, a number of challenges exist for the analysis of these data. These include maintaining participant engagement over extended time periods and therefore understanding what constitutes an acceptable threshold of missing data; distinguishing between the cross-sectional and longitudinal relationships for different features to determine their utility in tracking within-individual longitudinal variation or screening individuals at high risk; and understanding the heterogeneity with which depression manifests itself in behavioral patterns quantified by the passive features. Objective: We aimed to address these 3 challenges to inform future work in stratified analyses. Methods: Using smartphone and wearable data collected from 479 participants with MDD, we extracted 21 features capturing mobility, sleep, and smartphone use. We investigated the impact of the number of days of available data on feature quality using the intraclass correlation coefficient and Bland-Altman analysis. We then examined the nature of the correlation between the 8-item Patient Health Questionnaire (PHQ-8) depression scale (measured every 14 days) and the features using the individual-mean correlation, repeated measures correlation, and linear mixed effects model. Furthermore, we stratified the participants based on their behavioral difference, quantified by the features, between periods of high (depression) and low (no depression) PHQ-8 scores using the Gaussian mixture model. Results: We demonstrated that at least 8 (range 2-12) days were needed for reliable calculation of most of the features in the 14-day time window. We observed that features such as sleep onset time correlated better with PHQ-8 scores cross-sectionally than longitudinally, whereas features such as wakefulness after sleep onset correlated well with PHQ-8 longitudinally but worse cross-sectionally. Finally, we found that participants could be separated into 3 distinct clusters according to their behavioral difference between periods of depression and periods of no depression. Conclusions: This work contributes to our understanding of how these mobile health–derived features are associated with depression symptom severity to inform future work in stratified analyses. %M 37578823 %R 10.2196/45233 %U https://www.jmir.org/2023/1/e45233 %U https://doi.org/10.2196/45233 %U http://www.ncbi.nlm.nih.gov/pubmed/37578823 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43727 %T Assessing Patient Adherence to and Engagement With Digital Interventions for Depression in Clinical Trials: Systematic Literature Review %A Forbes,Ainslie %A Keleher,Madeline Rose %A Venditto,Michael %A DiBiasi,Faith %+ Otsuka Pharmaceutical Development & Commercialization, Inc, 508 Carnegie Center Dr, Princeton, NJ, 08540, United States, 1 301 956 2702, ainslie.forbes@otsuka-us.com %K digital therapeutics %K digital interventions %K digital health %K mobile health %K mobile phone %K depression %K major depressive disorder %K engagement %K adherence %K systematic literature review %D 2023 %7 11.8.2023 %9 Review %J J Med Internet Res %G English %X Background: New approaches to the treatment of depression are necessary for patients who do not respond to current treatments or lack access to them because of barriers such as cost, stigma, and provider shortage. Digital interventions for depression are promising; however, low patient engagement could limit their effectiveness. Objective: This systematic literature review (SLR) assessed how participant adherence to and engagement with digital interventions for depression have been measured in the published literature, what levels of adherence and engagement have been reported, and whether higher adherence and increased engagement are linked to increased efficacy. Methods: We focused on a participant population of adults (aged ≥18 years) with depression or major depressive disorder as the primary diagnosis and included clinical trials, feasibility studies, and pilot studies of digital interventions for treating depression, such as digital therapeutics. We screened 756 unique records from Ovid MEDLINE, Embase, and Cochrane published between January 1, 2000, and April 15, 2022; extracted data from and appraised the 94 studies meeting the inclusion criteria; and performed a primarily descriptive analysis. Otsuka Pharmaceutical Development & Commercialization, Inc (Princeton, New Jersey, United States) funded this study. Results: This SLR encompassed results from 20,111 participants in studies using 47 unique web-based interventions (an additional 10 web-based interventions were not described by name), 15 mobile app interventions, 5 app-based interventions that are also accessible via the web, and 1 CD-ROM. Adherence was most often measured as the percentage of participants who completed all available modules. Less than half (44.2%) of the participants completed all the modules; however, the average dose received was 60.7% of the available modules. Although engagement with digital interventions was measured differently in different studies, it was most commonly measured as the number of modules completed, the mean of which was 6.4 (means ranged from 1.0 to 19.7) modules. The mean amount of time participants engaged with the interventions was 3.9 (means ranged from 0.7 to 8.4) hours. Most studies of web-based (34/45, 76%) and app-based (8/9, 89%) interventions found that the intervention group had substantially greater improvement for at least 1 outcome than the control group (eg, care as usual, waitlist, or active control). Of the 14 studies that investigated the relationship between engagement and efficacy, 9 (64%) found that increased engagement with digital interventions was significantly associated with improved participant outcomes. The limitations of this SLR include publication bias, which may overstate engagement and efficacy, and low participant diversity, which reduces the generalizability. Conclusions: Patient adherence to and engagement with digital interventions for depression have been reported in the literature using various metrics. Arriving at more standardized ways of reporting adherence and engagement would enable more effective comparisons across different digital interventions, studies, and populations. %M 37566447 %R 10.2196/43727 %U https://www.jmir.org/2023/1/e43727 %U https://doi.org/10.2196/43727 %U http://www.ncbi.nlm.nih.gov/pubmed/37566447 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45438 %T A Clinical Model for the Differentiation of Suicidality: Protocol for a Usability Study of the Proposed Model %A de Winter,Remco F P %A Meijer,Connie M %A Enterman,John H %A Kool-Goudzwaard,Nienke %A Gemen,Manuela %A van den Bos,Anne T %A Steentjes,Danielle %A van Son,Gabrielle E %A Hazewinkel,Mirjam C %A de Beurs,Derek P %A de Groot,Marieke H %+ Mental Health Institute Rivierduinen, Sandifortdreef 19, 2333 ZZ Leiden Postbox 405, Leiden, 2333 ZZ, Netherlands, 31 71 890 8888, bgd@rivierduinen.nl %K differentiation %K suicidality %K suicidal behavior %K subtype %K subcategory %K category %K categories %K categorize %K subcategories %K validation study %K mental health %K suicide %K suicidal %K differentiation %K classification %K psychiatry %K classify %K psychiatric %K suicide prevention %K suicidal ideation %K mental illness %K suicidal thought %K dying %K perceptual disintegration %K PD %K primary depressive cognition %K PDC %K psychosocial turmoil %K inadequate communication %K intraclass correlation coefficients %K ICC %D 2023 %7 11.8.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Even though various types of suicidality are observed in clinical practice, suicidality is still considered a uniform concept. To distinguish different types of suicidality and consequently improve detection and management of suicidality, we developed a clinical differentiation model for suicidality. We believe that the model allows for a more targeted assessment of suicidal conditions and improves the use of evidence-based treatment strategies. The differentiation model is based on the experience with suicidality that we have encountered in clinical practice. This model distinguishes 4 subtypes of entrapment leading to suicidality. The earliest description of this model and a proposal for usability research has been previously presented in a book chapter. Objective: In this study, we present the most recent version of the 4-type differentiation model of suicidality and a protocol for a study into the usability of the proposed model. Methods: The 4-type differentiation model of suicidality distinguishes the following subtypes: (1) perceptual disintegration, (2) primary depressive cognition, (3) psychosocial turmoil, and (4) inadequate coping or communication. We plan to test the usability of the 4 subtypes in a pilot study of 25 cases, and subsequently, we will include 75 cases in a follow-up study. We looked at the case notes of 100 anonymized patients with suicidality who presented to mental health care emergency service in The Hague International Center. The summary and conclusions of the letters sent to the patients’ general practitioners after suicide risk assessment will be independently rated by 3 psychiatrists and 3 nurse-scientists for absolute and dimensional scores. The Suicidality Differentiation version 2 (SUICIDI-II) instrument, developed for this study, is used for rating all the cases. Intraclass correlation coefficients for absolute and dimensional scores will be calculated to examine type agreement between raters to examine the usability of the model and the feasibility of the SUICIDI-II instrument. Results: We consider the model tentatively valid if the intraclass correlation coefficients are ≥0.70. Subsequently, if the model turns out to be valid, we plan to rate 75 other cases in a follow-up study, according to a similar or adjusted procedure. Study results are expected to be published by the end of 2023. Conclusions: The theoretical roots of the differentiation model stem from classic and contemporary theoretical models of suicidality and from our clinical practice experiences with suicidal behaviors. We believe that this model can be used to adjust the diagnosis, management, treatment, and research of suicidality, in addition to distinguishing different dynamics between practitioners and patients with suicidality and their families. International Registered Report Identifier (IRRID): DERR1-10.2196/45438 %M 37566444 %R 10.2196/45438 %U https://www.researchprotocols.org/2023/1/e45438 %U https://doi.org/10.2196/45438 %U http://www.ncbi.nlm.nih.gov/pubmed/37566444 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e11623 %T Examining Feasibility, Acceptability, and Preliminary Outcomes of a Culturally Adapted Evidence-Based Postpartum Depression Preventive Intervention for Women in Doha, Qatar: Protocol for a Randomized Controlled Trial %A Ahmed,Sawssan R %A Watt,Felice %A Mahfoud,Ziyad Riyad %A Korayem,Mona %A Buhmaid,Sara %A Alberry,Medhat %A Ibrahim,Ibrahim Mamoun %A Tandon,S Darius %+ Department of Psychology, California State University-Fullerton, 800 N. State College Blvd., Fullerton, CA, 92832, United States, 1 657 278 2173, saahmed@fullerton.edu %K postpartum depression %K intervention %K prevention %K cultural adaptation %K Arabic %D 2023 %7 11.8.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Postpartum depression and anxiety are the 2 most common perinatal mental health disorders, with prevalence rates higher among women living in the Middle East than in most Western countries. The negative outcomes associated with postpartum depression and anxiety are profound and include less responsive parenting and compromised infant and young child development. Although interventions exist to prevent postpartum depression and anxiety, to date, there have been no studies that have attempted to prevent postpartum depression or anxiety among Arabic-speaking women in the Middle East, including Qatar. Objective: The purpose of this study is to conduct a randomized controlled trial (RCT) of an evidence-based postpartum depression preventive intervention—Mothers and Babies (MB)—culturally adapted for use with Arabic-speaking women in Doha, Qatar. MB is guided by a cognitive behavioral therapy framework that focuses on increasing pleasant activities, promoting healthy thought patterns, and increasing the type and frequency of personal contacts. MB is tailored to specific needs and issues related to pregnancy and the postpartum period. Methods: A multidisciplinary and multiethnic investigator team adapted MB to promote cultural and contextual fit for Arabic-speaking women. Intervention concepts were reviewed to ensure core content would be understood by Arabic-speaking women in Qatar. Subsequently, images, activities, and examples in the intervention manuals were adapted, as needed, to make the content more relevant to Arab culture. To deliver the adapted intervention, 30 Arabic-speaking individuals with mental health backgrounds were trained. The adapted intervention was subsequently pilot-tested with 10 pregnant women receiving prenatal care at Sidra Hospital in Doha. We are now conducting an RCT to examine the effectiveness of the adapted intervention. We plan to enroll 210 pregnant individuals who are Arabic-speaking, with 1:1 randomization to the MB intervention or usual prenatal care. Among the enrolled participants, a stratified subsample of 40 pregnant women with diabetes is being recruited. Data collection will take place at baseline and a 6-month follow-up. The primary outcomes are depressive and anxiety symptoms and perceived stress. Diabetes self-care is the exploratory outcome for the subsample of individuals with diabetes. Intervention implementation will be assessed via client and provider surveys during and after intervention delivery. Power and sample size were calculated using a 2-sided 5% effort rate and assumed analyses on the individual level, accounting for attrition of 20%. Results: The cultural adaptation and pilot study of the adapted MB intervention are completed. A total of 157 women have been enrolled in the RCT as of March 31, 2023. Conclusions: This study is highly innovative, as it is the first study to our knowledge to examine the effectiveness of an evidence-based postpartum depression preventive intervention in the Middle East. Limitations include a single follow-up time point and a small subsample of individuals with diabetes. Trial Registration: ClinicalTrials.gov NCT04442529; https://www.clinicaltrials.gov/study/NCT04442529 International Registered Report Identifier (IRRID): DERR1-10.2196/11623 %M 37566449 %R 10.2196/11623 %U https://www.researchprotocols.org/2023/1/e11623 %U https://doi.org/10.2196/11623 %U http://www.ncbi.nlm.nih.gov/pubmed/37566449 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e47798 %T Assessing Vulnerability to Surges in Suicide-Related Tweets Using Japan Census Data: Case-Only Study %A Mitsuhashi,Toshiharu %+ Center for Innovative Clinical Medicine, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan, 81 86 235 6504, mitsuh-t@cc.okayama-u.ac.jp %K case-only approach %K mass media %K public health %K social media %K suicidal risk %K suicide prevention %K suicide %K suicide-related tweets %K Twitter %D 2023 %7 10.8.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: As the use of social media becomes more widespread, its impact on health cannot be ignored. However, limited research has been conducted on the relationship between social media and suicide. Little is known about individuals’ vulnerable to suicide, especially when social media suicide information is extremely prevalent. Objective: This study aims to identify the characteristics underlying individuals’ vulnerability to suicide brought about by an increase in suicide-related tweets, thereby contributing to public health. Methods: A case-only design was used to investigate vulnerability to suicide using individual data of people who died by suicide and tweet data from January 1, 2011, through December 31, 2014. Mortality data were obtained from Japanese government statistics, and tweet data were provided by a commercial service. Tweet data identified the days when suicide-related tweets surged, and the date-keyed merging was performed by considering 3 and 7 lag days. For the merged data set for analysis, the logistic regression model was fitted with one of the personal characteristics of interest as a dependent variable and the dichotomous exposure variable. This analysis was performed to estimate the interaction between the surges in suicide-related tweets and personal characteristics of the suicide victims as case-only odds ratios (ORs) with 95% CIs. For the sensitivity analysis, unexpected deaths other than suicide were considered. Results: During the study period, there were 159,490 suicides and 115,072 unexpected deaths, and the number of suicide-related tweets was 2,804,999. Following the 3-day lag of a highly tweeted day, there were significant interactions for those who were aged 40 years or younger (OR 1.09, 95% CI 1.03-1.15), male (OR 1.12, 95% CI 1.07-1.18), divorced (OR 1.11, 95% CI 1.03 1.19), unemployed (OR 1.12, 95% CI 1.02-1.22), and living in urban areas (OR 1.26, 95% CI 1.17 1.35). By contrast, widowed individuals had significantly lower interactions (OR 0.83, 95% CI 0.77-0.89). Except for unemployment, significant relationships were also observed for the 7-day lag. For the sensitivity analysis, no significant interactions were observed for other unexpected deaths in the 3-day lag, and only the widowed had a significantly larger interaction than those who were married (OR 1.08, 95% CI 1.02-1.15) in the 7-day lag. Conclusions: This study revealed the interactions of personal characteristics associated with susceptibility to suicide-related tweets. In addition, a few significant relationships were observed in the sensitivity analysis, suggesting that such an interaction is specific to suicide deaths. In other words, individuals with these characteristics, such as being young, male, unemployed, and divorced, may be vulnerable to surges in suicide-related tweets. Thus, minimizing public health strain by identifying people who are vulnerable and susceptible to a surge in suicide-related information on the internet is necessary. %M 37561553 %R 10.2196/47798 %U https://formative.jmir.org/2023/1/e47798 %U https://doi.org/10.2196/47798 %U http://www.ncbi.nlm.nih.gov/pubmed/37561553 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e28848 %T A Fast and Minimal System to Identify Depression Using Smartphones: Explainable Machine Learning–Based Approach %A Ahmed,Md Sabbir %A Ahmed,Nova %+ Design Inclusion and Access Lab, North South University, Plot #15, Block #B, Bashundhara, Dhaka, 1229, Bangladesh, 880 1781920068, msg2sabbir@gmail.com %K smartphone %K depression %K explainable machine learning %K low-resource settings %K real-time system %K students %D 2023 %7 10.8.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Existing robust, pervasive device-based systems developed in recent years to detect depression require data collected over a long period and may not be effective in cases where early detection is crucial. Additionally, due to the requirement of running systems in the background for prolonged periods, existing systems can be resource inefficient. As a result, these systems can be infeasible in low-resource settings. Objective: Our main objective was to develop a minimalistic system to identify depression using data retrieved in the fastest possible time. Another objective was to explain the machine learning (ML) models that were best for identifying depression. Methods: We developed a fast tool that retrieves the past 7 days’ app usage data in 1 second (mean 0.31, SD 1.10 seconds). A total of 100 students from Bangladesh participated in our study, and our tool collected their app usage data and responses to the Patient Health Questionnaire-9. To identify depressed and nondepressed students, we developed a diverse set of ML models: linear, tree-based, and neural network–based models. We selected important features using the stable approach, along with 3 main types of feature selection (FS) approaches: filter, wrapper, and embedded methods. We developed and validated the models using the nested cross-validation method. Additionally, we explained the best ML models through the Shapley additive explanations (SHAP) method. Results: Leveraging only the app usage data retrieved in 1 second, our light gradient boosting machine model used the important features selected by the stable FS approach and correctly identified 82.4% (n=42) of depressed students (precision=75%, F1-score=78.5%). Moreover, after comprehensive exploration, we presented a parsimonious stacking model where around 5 features selected by the all-relevant FS approach Boruta were used in each iteration of validation and showed a maximum precision of 77.4% (balanced accuracy=77.9%). Feature importance analysis suggested app usage behavioral markers containing diurnal usage patterns as being more important than aggregated data-based markers. In addition, a SHAP analysis of our best models presented behavioral markers that were related to depression. For instance, students who were not depressed spent more time on education apps on weekdays, whereas those who were depressed used a higher number of photo and video apps and also had a higher deviation in using photo and video apps over the morning, afternoon, evening, and night time periods of the weekend. Conclusions: Due to our system’s fast and minimalistic nature, it may make a worthwhile contribution to identifying depression in underdeveloped and developing regions. In addition, our detailed discussion about the implication of our findings can facilitate the development of less resource-intensive systems to better understand students who are depressed and take steps for intervention. %M 37561568 %R 10.2196/28848 %U https://formative.jmir.org/2023/1/e28848 %U https://doi.org/10.2196/28848 %U http://www.ncbi.nlm.nih.gov/pubmed/37561568 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e48709 %T Evaluating the Psychometric Properties and Clinical Utility of a Digital Psychosocial Self-Screening Tool (HEARTSMAP-U) for Postsecondary Students: Prospective Cohort Study %A Virk,Punit %A Arora,Ravia %A Burt,Heather %A Finnamore,Caitlin %A Gadermann,Anne %A Barbic,Skye %A Doan,Quynh %+ School of Population and Public Health, The University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada, 1 604 822 2772, punit.virk@ucalgary.ca %K mental health %K screening %K validity %K postsecondary students %K clinical utility %D 2023 %7 9.8.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Existing screening tools for mental health issues among postsecondary students have several challenges, including a lack of standardization and codevelopment by students. HEARTSMAP-U was adapted to address these issues. Objective: This study aimed to evaluate the suitability of HEARTSMAP-U as a self-screening tool for psychosocial issues among postsecondary students by evaluating its validity evidence and clinical utility. Methods: A prospective cohort study was conducted with University of British Columbia Vancouver students to evaluate HEARTSMAP-U’s predictive validity and convergent validity. Participating students completed baseline and 3-month follow-up assessments via HEARTSMAP-U and a clinician-administered interview. Results: In a diverse student sample (n=100), HEARTSMAP-U demonstrated high sensitivity (95%-100%) in identifying any psychiatric concerns that were flagged by a research clinician, with lower specificity (21%-25%). Strong convergent validity (r=0.54-0.68) was demonstrated when relevant domains and sections of HEARTSMAP-U were compared with those of other conceptually similar instruments. Conclusions: This preliminary evaluation suggests that HEARTSMAP-U may be suitable for screening in the postsecondary educational setting. However, a larger-scale evaluation is necessary to confirm and expand on these findings. %M 37556180 %R 10.2196/48709 %U https://mental.jmir.org/2023/1/e48709 %U https://doi.org/10.2196/48709 %U http://www.ncbi.nlm.nih.gov/pubmed/37556180 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45666 %T Referring Adolescent Primary Care Patients to Single-Session Interventions for Anxiety and Depression: Protocol for a Feasibility Study %A Eyllon,Mara %A Dalal,Michelle %A Jans,Laura %A Sotomayor,Ian %A Peloquin,Gabrielle %A Yon,James %A Fritz,Rochelle %A Schleider,Jessica %+ Practice Research Network, Reliant Medical Group, 5 Neponset Street, Worcester, MA, 01606, United States, 1 6178754554, mara.eyllon@reliantmedicalgroup.org %K adolescents %K behavioral health care %K mental health %K primary care %K single-session interventions %D 2023 %7 9.8.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Despite the growing prevalence of depression and anxiety among adolescents, fewer than half access appropriate mental health care. Single-session interventions (SSIs) for depression and anxiety offered in primary care are a promising approach to bridging the treatment gap. Objective: We aimed to implement a clinical workflow for primary care and behavioral health providers to refer patients aged 13 to 17 years with mild to moderate depression and anxiety symptoms to Project YES (Youth Empowerment and Support), an open-access SSI platform, in a large group medical practice with an integrated behavioral health department. Methods: Pediatric primary care and integrated behavioral health providers will be educated on the benefits of Project YES for adolescent anxiety and depression and trained in a workflow integrated within the electronic health record system, Epic, to refer patients during well-child visits and pediatric behavioral health visits. Patients with mild to moderate internalizing symptoms based on the 17-item Pediatric Symptom Checklist or youth Pediatric Symptom Checklist will be invited to try an SSI through Project YES. We will examine provider uptake and perceptions of acceptability, feasibility, and appropriateness over time. Results: The rollout will take place between November 2022 and May 2023, when outcomes will be evaluated. Data analysis and manuscript writing are anticipated to be completed during the summer of 2023. Conclusions: SSIs such as those available through Project YES have the potential to provide low-cost, evidence-based mental health treatment to adolescents with mild to moderate depression and anxiety. If deemed feasible and acceptable, providing SSIs in primary care settings could significantly improve access to mental health care without taxing pediatric primary care and behavioral health providers. International Registered Report Identifier (IRRID): DERR1-10.2196/45666 %M 37556202 %R 10.2196/45666 %U https://www.researchprotocols.org/2023/1/e45666 %U https://doi.org/10.2196/45666 %U http://www.ncbi.nlm.nih.gov/pubmed/37556202 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 10 %N %P e44388 %T Assessing Mood With the Identifying Depression Early in Adolescence Chatbot (IDEABot): Development and Implementation Study %A Viduani,Anna %A Cosenza,Victor %A Fisher,Helen L %A Buchweitz,Claudia %A Piccin,Jader %A Pereira,Rivka %A Kohrt,Brandon A %A Mondelli,Valeria %A van Heerden,Alastair %A Araújo,Ricardo Matsumura %A Kieling,Christian %+ Department of Psychiatry, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, Porto Alegre, 90035003, Brazil, 55 5133085624, ckieling@ufrgs.com %K depression %K adolescent %K ambulatory assessment %K chatbot %K smartphone %K digital mental health %K mobile phone %D 2023 %7 7.8.2023 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Mental health status assessment is mostly limited to clinical or research settings, but recent technological advances provide new opportunities for measurement using more ecological approaches. Leveraging apps already in use by individuals on their smartphones, such as chatbots, could be a useful approach to capture subjective reports of mood in the moment. Objective: This study aimed to describe the development and implementation of the Identifying Depression Early in Adolescence Chatbot (IDEABot), a WhatsApp-based tool designed for collecting intensive longitudinal data on adolescents’ mood. Methods: The IDEABot was developed to collect data from Brazilian adolescents via WhatsApp as part of the Identifying Depression Early in Adolescence Risk Stratified Cohort (IDEA-RiSCo) study. It supports the administration and collection of self-reported structured items or questionnaires and audio responses. The development explored WhatsApp’s default features, such as emojis and recorded audio messages, and focused on scripting relevant and acceptable conversations. The IDEABot supports 5 types of interactions: textual and audio questions, administration of a version of the Short Mood and Feelings Questionnaire, unprompted interactions, and a snooze function. Six adolescents (n=4, 67% male participants and n=2, 33% female participants) aged 16 to 18 years tested the initial version of the IDEABot and were engaged to codevelop the final version of the app. The IDEABot was subsequently used for data collection in the second- and third-year follow-ups of the IDEA-RiSCo study. Results: The adolescents assessed the initial version of the IDEABot as enjoyable and made suggestions for improvements that were subsequently implemented. The IDEABot’s final version follows a structured script with the choice of answer based on exact text matches throughout 15 days. The implementation of the IDEABot in 2 waves of the IDEA-RiSCo sample (140 and 132 eligible adolescents in the second- and third-year follow-ups, respectively) evidenced adequate engagement indicators, with good acceptance for using the tool (113/140, 80.7% and 122/132, 92.4% for second- and third-year follow-up use, respectively), low attrition (only 1/113, 0.9% and 1/122, 0.8%, respectively, failed to engage in the protocol after initial interaction), and high compliance in terms of the proportion of responses in relation to the total number of elicited prompts (12.8, SD 3.5; 91% out of 14 possible interactions and 10.57, SD 3.4; 76% out of 14 possible interactions, respectively). Conclusions: The IDEABot is a frugal app that leverages an existing app already in daily use by our target population. It follows a simple rule-based approach that can be easily tested and implemented in diverse settings and possibly diminishes the burden of intensive data collection for participants by repurposing WhatsApp. In this context, the IDEABot appears as an acceptable and potentially scalable tool for gathering momentary information that can enhance our understanding of mood fluctuations and development. %M 37548996 %R 10.2196/44388 %U https://humanfactors.jmir.org/2023/1/e44388 %U https://doi.org/10.2196/44388 %U http://www.ncbi.nlm.nih.gov/pubmed/37548996 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e48032 %T Depression as a Mediator and Social Participation as a Moderator in the Bidirectional Relationship Between Sleep Disorders and Pain: Dynamic Cohort Study %A Fan,Si %A Wang,Qianning %A Zheng,Feiyang %A Wu,Yuanyang %A Yu,Tiantian %A Wang,Yanting %A Zhang,Xinping %A Zhang,Dexing %+ School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Hangkong Road 13, Wuhan, Hubei, China, 86 18062643970, xpzhang602@hust.edu.cn %K depression %K dynamic cohort %K longitudinal mediation %K pain %K sleep disorders %K social participation %D 2023 %7 26.7.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Chronic pain, sleep disorders, and depression are major global health concerns. Recent studies have revealed a strong link between sleep disorders and pain, and each of them is bidirectionally correlated with depressive symptoms, suggesting a complex relationship between these conditions. Social participation has been identified as a potential moderator in this complex relationship, with implications for treatment. However, the complex interplay among sleep disorders, pain, depressive symptoms, and social participation in middle- and old-aged Asians remains unclear. Objective: This study aimed to examine the bidirectional relationship between sleep disorders and pain in middle- and old-aged Chinese and measure the role of depression as a mediator and social participation as a moderator in this bidirectional relationship through a dynamic cohort study. Methods: We used data from the China Health and Retirement Longitudinal Study across 5 years and included a total of 7998 middle- and old-aged people (≥45 years old) with complete data in 2011 (T1), 2015 (T2), and 2018 (T3). The cross-lag model was used to assess the interplay among sleep disorders, pain, depressive symptoms, and social participation. Depressive symptoms were assessed by the 10-item Centre for Epidemiological Studies Depression scale. Sleep disorders were assessed by a single-item sleep quality scale and nighttime sleep duration. The pain score was the sum of all pain locations reported. Social participation was measured using self-reported activity. Results: Our results showed significant cross-lagged effects of previous sleep disorders on subsequent pain at T2 (β=.141; P<.001) and T3 (β=.117; P<.001) and previous pain on subsequent poor sleep at T2 (β=.080; P<.001) and T3 (β=.093; P<.001). The indirect effects of previous sleep disorders on pain through depressive symptoms (β=.020; SE 0.004; P<.001; effect size 21.98%), as well as previous pain on sleep disorders through depressive symptoms (β=.012; SE 0.002; P<.001; effect size 20.69%), were significant across the 3 time intervals. Among participants with high levels of social participation, there were no statistically significant effects of previous sleep disorders on subsequent pain at T2 (β=.048; P=.15) and T3 (β=.085; P=.02), nor were there statistically significant effects of previous pain on subsequent sleep disorders at T2 (β=.037; P=.15) and T3 (β=.039; P=.24). Additionally, the mediating effects of depressive symptoms on the sleep disorders-to-pain pathway (P=.14) and the pain-to-sleep disorders pathway (P=.02) were no longer statistically significant. Conclusions: There is a bidirectional relationship between sleep disorders and pain in middle- and old-aged Asians; depression plays a longitudinal mediating role in the bidirectional relationship between them; and social participation moderates the bidirectional relationship between them directly and indirectly by affecting depression. Future interventions may consider the complex relationship between these conditions and adopt a comprehensive treatment regime. %M 37494109 %R 10.2196/48032 %U https://publichealth.jmir.org/2023/1/e48032 %U https://doi.org/10.2196/48032 %U http://www.ncbi.nlm.nih.gov/pubmed/37494109 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e42803 %T Intentional Self-Harm Among US Veterans With Traumatic Brain Injury or Posttraumatic Stress Disorder: Retrospective Cohort Study From 2008 to 2017 %A Rawat,Bhanu Pratap Singh %A Reisman,Joel %A Pogoda,Terri K %A Liu,Weisong %A Rongali,Subendhu %A Aseltine Jr,Robert H %A Chen,Kun %A Tsai,Jack %A Berlowitz,Dan %A Yu,Hong %A Carlson,Kathleen F %+ Manning College of Information and Computer Sciences, University of Massachusetts Amherst, 140 Governors Dr, Amherst, MA, 01002, United States, 1 4135452744, brawat@umass.edu %K self-harm %K suicide %K suicide attempt %K suicidal ideation %K veteran %K suicidal %K brain injury %K trauma %K posttraumatic stress disorder %K PTSD %K big data %K prevalence %K correlation %K risk factor %K traumatic brain injury %K TBI %D 2023 %7 24.7.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to veterans without TBI or PTSD. Objective: Using administrative data from the US Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm among US veterans who used VHA health care between 2008 and 2017. Methods: All veterans with encounters or hospitalizations for intentional self-harm were assigned “index dates” corresponding to the date of the first related visit; among those without intentional self-harm, we randomly selected a date from among the veteran’s health care encounters to match the distribution of case index dates over the 10-year period. We then examined the prevalence of TBI and PTSD diagnoses within the 5-year period prior to veterans’ index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by veterans’ average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by veterans’ prior TBI and PTSD diagnosis status (TBI only, PTSD only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs service-connection status, and Charlson Comorbidity Index scores. Results: About 6.7 million veterans with at least two VHA visits in the 5-year period before their index dates were included in the analyses; 86,644 had at least one intentional self-harm diagnosis during the study period. During the periods prior to veterans’ index dates, 93,866 were diagnosed with TBI only; 892,420 with PTSD only; and 102,549 with comorbid TBI/PTSD. Across all three VHA utilization strata, the prevalence of intentional self-harm diagnoses was higher among veterans diagnosed with TBI, PTSD, or TBI/PTSD than among veterans with neither diagnosis. The observed difference was most pronounced among veterans in the high VHA utilization stratum. The prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (6778/58,295, 11.63%) than among veterans with neither TBI nor PTSD (21,979/1,144,991, 1.92%). Adjusted odds ratios suggested that, after accounting for potential confounders, veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to veterans without these diagnoses. Among veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 (95% CI 4.15-4.38) times more likely to receive diagnoses for intentional self-harm than veterans with neither diagnosis. This pattern was similar for veterans with low and medium VHA utilization. Conclusions: Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among veterans who used VHA health care most frequently. These findings suggest a need for suicide prevention efforts targeted at veterans with these diagnoses. %M 37486751 %R 10.2196/42803 %U https://publichealth.jmir.org/2023/1/e42803 %U https://doi.org/10.2196/42803 %U http://www.ncbi.nlm.nih.gov/pubmed/37486751 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e46200 %T A Novel and Integrated Digitally Supported System of Care for Depression and Anxiety: Findings From an Open Trial %A Wolitzky-Taylor,Kate %A LeBeau,Richard %A Arnaudova,Inna %A Barnes-Horowitz,Nora %A Gong-Guy,Elizabeth %A Fears,Scott %A Congdon,Eliza %A Freimer,Nelson %A Craske,Michelle %+ Department of Psychiatry and Biobehavioral Sciences, University of California - Los Angeles, 760 Westwood Blvd., Los Angeles, CA, 90025, United States, 1 3102675339, kbtaylor@mednet.ucla.edu %K depression %K anxiety %K cognitive behavioral therapy %K digital mental health %K stratified models of care %K model of care %K care model %K depressive %K mental health %K CBT %K psychotherapy %K university %K postsecondary %K student %K college %K service delivery %K care system %K system of care %K mHealth %K eHealth %K online support %K student mental health %D 2023 %7 24.7.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: The global burden of anxiety and depression has created an urgent need for scalable approaches to increase access to evidence-based mental health care. The Screening and Treatment for Anxiety and Depression (STAND) system of care was developed to meet this need through the use of internet-connected devices for assessment and provision of treatment. STAND triages to level of care (monitoring only, digital therapy with coaches, digital therapy assisted by clinicians in training, and clinical care) and then continuously monitors symptoms to adapt level of care. Triaging and adaptation are based on symptom severity and suicide risk scores obtained from computerized adaptive testing administered remotely. Objective: This article discusses how the STAND system of care improves upon current clinical paradigms, and presents preliminary data on feasibility, acceptability, and effectiveness of STAND in a sample of US-based university students. Methods: US-based university students were recruited and enrolled in an open trial of the STAND system of care. Participants were triaged based on initial symptom severity derived from a computerized adaptive test and monitored over 40 weeks on anxiety, depression, and suicide risk to inform treatment adaptation and evaluate preliminary effectiveness. Results: Nearly 5000 students were screened and 516 received care. Depression and anxiety severity scores improved across all tiers (P<.001 in all cases). Suicide risk severity improved in the highest tier (ie, clinical care; P<.001). Acceptability and feasibility were demonstrated. Conclusions: STAND is a feasible and acceptable model of care that can reach large numbers of individuals. STAND showed preliminary effectiveness on all primary outcome measures. Current directions to improve STAND are described. %M 37486735 %R 10.2196/46200 %U https://mental.jmir.org/2023/1/e46200 %U https://doi.org/10.2196/46200 %U http://www.ncbi.nlm.nih.gov/pubmed/37486735 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e47084 %T Assessing Detection of Children With Suicide-Related Emergencies: Evaluation and Development of Computable Phenotyping Approaches %A Edgcomb,Juliet Beni %A Tseng,Chi-hong %A Pan,Mengtong %A Klomhaus,Alexandra %A Zima,Bonnie T %+ Mental Health Informatics and Data Science (MINDS) Hub, Center for Community Health, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, 760 Westwood Plaza, Los Angeles, CA, 90095, United States, 1 310 794 8278, jedgcomb@mednet.ucla.edu %K child mental health %K suicide %K self-harm %K machine learning %K phenotyping %D 2023 %7 21.7.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Although suicide is a leading cause of death among children, the optimal approach for using health care data sets to detect suicide-related emergencies among children is not known. Objective: This study aimed to assess the performance of suicide-related International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and suicide-related chief complaint in detecting self-injurious thoughts and behaviors (SITB) among children compared with clinician chart review. The study also aimed to examine variations in performance by child sociodemographics and type of self-injury, as well as develop machine learning models trained on codified health record data (features) and clinician chart review (gold standard) and test model detection performance. Methods: A gold standard classification of suicide-related emergencies was determined through clinician manual review of clinical notes from 600 emergency department visits between 2015 and 2019 by children aged 10 to 17 years. Visits classified with nonfatal suicide attempt or intentional self-harm using the Centers for Disease Control and Prevention surveillance case definition list of ICD-10-CM codes and suicide-related chief complaint were compared with the gold standard classification. Machine learning classifiers (least absolute shrinkage and selection operator–penalized logistic regression and random forest) were then trained and tested using codified health record data (eg, child sociodemographics, medications, disposition, and laboratory testing) and the gold standard classification. The accuracy, sensitivity, and specificity of each detection approach and relative importance of features were examined. Results: SITB accounted for 47.3% (284/600) of the visits. Suicide-related diagnostic codes missed nearly one-third (82/284, 28.9%) and suicide-related chief complaints missed more than half (153/284, 53.9%) of the children presenting to emergency departments with SITB. Sensitivity was significantly lower for male children than for female children (0.69, 95% CI 0.61-0.77 vs 0.84, 95% CI 0.78-0.90, respectively) and for preteens compared with adolescents (0.66, 95% CI 0.54-0.78 vs 0.86, 95% CI 0.80-0.92, respectively). Specificity was significantly lower for detecting preparatory acts (0.68, 95% CI 0.64-0.72) and attempts (0.67, 95% CI 0.63-0.71) than for detecting ideation (0.79, 95% CI 0.75-0.82). Machine learning–based models significantly improved the sensitivity of detection compared with suicide-related codes and chief complaint alone. Models considering all 84 features performed similarly to models considering only mental health–related ICD-10-CM codes and chief complaints (34 features) and models considering non–ICD-10-CM code indicators and mental health–related chief complaints (53 features). Conclusions: The capacity to detect children with SITB may be strengthened by applying a machine learning–based approach to codified health record data. To improve integration between clinical research informatics and child mental health care, future research is needed to evaluate the potential benefits of implementing detection approaches at the point of care and identifying precise targets for suicide prevention interventions in children. %M 37477974 %R 10.2196/47084 %U https://mental.jmir.org/2023/1/e47084 %U https://doi.org/10.2196/47084 %U http://www.ncbi.nlm.nih.gov/pubmed/37477974 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e46165 %T Privacy-Preserving Federated Model Predicting Bipolar Transition in Patients With Depression: Prediction Model Development Study %A Lee,Dong Yun %A Choi,Byungjin %A Kim,Chungsoo %A Fridgeirsson,Egill %A Reps,Jenna %A Kim,Myoungsuk %A Kim,Jihyeong %A Jang,Jae-Won %A Rhee,Sang Youl %A Seo,Won-Woo %A Lee,Seunghoon %A Son,Sang Joon %A Park,Rae Woong %+ Department of Biomedical Informatics, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, 16499, Republic of Korea, 82 2194471, rwpark99@gmail.com %K federated learning %K depression %K bipolar disorder %K data standardization %K differential privacy %D 2023 %7 20.7.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Mood disorder has emerged as a serious concern for public health; in particular, bipolar disorder has a less favorable prognosis than depression. Although prompt recognition of depression conversion to bipolar disorder is needed, early prediction is challenging due to overlapping symptoms. Recently, there have been attempts to develop a prediction model by using federated learning. Federated learning in medical fields is a method for training multi-institutional machine learning models without patient-level data sharing. Objective: This study aims to develop and validate a federated, differentially private multi-institutional bipolar transition prediction model. Methods: This retrospective study enrolled patients diagnosed with the first depressive episode at 5 tertiary hospitals in South Korea. We developed models for predicting bipolar transition by using data from 17,631 patients in 4 institutions. Further, we used data from 4541 patients for external validation from 1 institution. We created standardized pipelines to extract large-scale clinical features from the 4 institutions without any code modification. Moreover, we performed feature selection in a federated environment for computational efficiency and applied differential privacy to gradient updates. Finally, we compared the federated and the 4 local models developed with each hospital's data on internal and external validation data sets. Results: In the internal data set, 279 out of 17,631 patients showed bipolar disorder transition. In the external data set, 39 out of 4541 patients showed bipolar disorder transition. The average performance of the federated model in the internal test (area under the curve [AUC] 0.726) and external validation (AUC 0.719) data sets was higher than that of the other locally developed models (AUC 0.642-0.707 and AUC 0.642-0.699, respectively). In the federated model, classifications were driven by several predictors such as the Charlson index (low scores were associated with bipolar transition, which may be due to younger age), severe depression, anxiolytics, young age, and visiting months (the bipolar transition was associated with seasonality, especially during the spring and summer months). Conclusions: We developed and validated a differentially private federated model by using distributed multi-institutional psychiatric data with standardized pipelines in a real-world environment. The federated model performed better than models using local data only. %M 37471130 %R 10.2196/46165 %U https://www.jmir.org/2023/1/e46165 %U https://doi.org/10.2196/46165 %U http://www.ncbi.nlm.nih.gov/pubmed/37471130 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45766 %T Attitudes Toward Seeking Mental Health Services and Mobile Technology to Support the Management of Depression Among Black American Women: Cross-Sectional Survey Study %A McCall,Terika %A Foster,Meagan %A Schwartz,Todd A %+ Division of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College Street, New Haven, CT, 06510, United States, 1 203 737 7902, terika.mccall@yale.edu %K African American %K women %K depression %K telemedicine %K mobile health %K mHealth %K mobile apps %K digital health %K mental health %K gender minority %K mobile technology %K mobile phone %D 2023 %7 19.7.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is a common mental health condition among Black American women. Many factors may contribute to the development of depressive symptoms, such as gender and racial discrimination, financial strain, chronic health conditions, and caregiving responsibilities. Barriers such as the stigmatization of mental illness, less access to treatment, the lack of or inadequate health insurance, mistrust of providers, and limited health literacy prevent marginalized populations from seeking care. Previous literature has shown that mobile health interventions are effective and can increase access to mental health services and resources. Objective: We aimed to understand the attitudes and perceptions of Black women toward using mental health services and determine the acceptability and concerns of using mobile technology (ie, voice call, video call, SMS text messaging, and mobile app) to support the management of depression. Methods: We launched a self-administered web-based questionnaire in October 2019 and closed it in January 2020. Women (aged ≥18 years) who identify as Black or African American or multiracial (defined as Black or African American and another race) were eligible to participate. The survey consisted of approximately 70 questions and included topics such as attitudes toward seeking professional psychological help, the acceptability of using a mobile phone to receive mental health care, and screening for depression. Results: The findings (n=395) showed that younger Black women were more likely to have greater severity of depression than their older counterparts. The results also revealed that Black women have favorable views toward seeking mental health services. Respondents were the most comfortable with the use of voice calls or video calls to communicate with a professional to receive support for managing depression in comparison with SMS text messaging or mobile apps. The results revealed that higher help-seeking propensity increased the odds of indicating agreement with the use of voice calls and video calls to communicate with a professional to receive support for managing depression by 27% and 38%, respectively. However, no statistically significant odds ratios (all P>.05) were found between help-seeking propensity and respondents’ agreement to use mobile apps or SMS text messaging. Moderate to severe depression severity increased the odds of using mobile apps to communicate with a professional to receive support for managing depression by 43%; however, no statistically significant odds ratios existed for the other modalities. Privacy and confidentiality, communication issues (eg, misinterpreting text), and the impersonal feeling of communicating by mobile phone (eg, SMS text messaging) were the primary concerns. Conclusions: Black American women, in general, have favorable views toward seeking mental health services and are comfortable with the use of mobile technology to receive support for managing depression. Future work should address the issues of access and consider the preferences and cultural appropriateness of the resources provided. %M 37467027 %R 10.2196/45766 %U https://www.jmir.org/2023/1/e45766 %U https://doi.org/10.2196/45766 %U http://www.ncbi.nlm.nih.gov/pubmed/37467027 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e42377 %T Examining Predictors of Depression and Anxiety Symptom Change in Cognitive Behavioral Immersion: Observational Study %A Ezawa,Iony D %A Hollon,Steven D %A Robinson,Noah %+ Department of Psychology, University of Southern California, 3620 McClintock Ave, Los Angeles, CA, 90089, United States, 1 213 740 2203, ezawa@usc.edu %K Cognitive Behavioral Immersion %K virtual reality %K metaverse %K alliance %K social support %K cognitive behavioral %K depression %K anxiety %K mood %K mental health %K mobile phone %D 2023 %7 14.7.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depressive and anxiety disorders are the most common mental disorders, and there is a critical need for effective, affordable, and accessible interventions. Cognitive Behavioral Immersion (CBI) is a novel group-based cognitive behavioral skills training program delivered by lay coaches in the metaverse that can be accessed through various modalities including virtual reality (VR) head-mounted displays or flat-screen devices. Combining its ability to offer empirically supported therapy skills in a digital setting that can still facilitate interpersonal variables (eg, working alliance and sense of social support) with the aid of lay coaches, CBI has the potential to help fill this critical need. Objective: This study had 2 primary aims. First, we aimed to examine changes in depression and anxiety symptoms in a sample of individuals who participated in CBI. Second, we aimed to examine 2 interpersonal process variables (working alliance and web-based social support) as predictors of symptom changes. We predicted CBI participants would experience depression and anxiety symptom improvements and that such improvements would be associated with an increase in both interpersonal process variables. Methods: The study sample consists of 127 participants who endorsed clinical levels of depression or anxiety symptoms during their first CBI session and attended at least 2 sessions. Participants were asked to complete self-report measures of depression symptoms, anxiety symptoms, alliance, and web-based social support throughout their participation in CBI. Results: Repeated measures ANOVAs determined that depression and anxiety symptom scores differed significantly across sessions (Ps<.01). We also found participants’ web-based social support predicted improvement in depression symptoms (P=.01), but neither the alliance nor web-based social support predicted change in anxiety symptoms (Ps>.05). We also observed a significant difference in anxiety symptoms between participants who used a VR head-mounted display to access CBI and those who did not, such that participants who used VR head-mounted displays endorsed lower anxiety symptoms than those who did not at nearly every session (P=.04). Conclusions: Participation in CBI is associated with both depression and anxiety symptom improvement. Web-based social support may play an important role in fostering changes in depression symptoms. Future studies are encouraged to continue examining the process of change in CBI with special attention paid to methods that can elucidate causal mechanisms of change. %M 37450322 %R 10.2196/42377 %U https://mental.jmir.org/2023/1/e42377 %U https://doi.org/10.2196/42377 %U http://www.ncbi.nlm.nih.gov/pubmed/37450322 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e44529 %T Association of Depressive Symptom Trajectory With Physical Activity Collected by mHealth Devices in the Electronic Framingham Heart Study: Cohort Study %A Wang,Xuzhi %A Pathiravasan,Chathurangi H %A Zhang,Yuankai %A Trinquart,Ludovic %A Borrelli,Belinda %A Spartano,Nicole L %A Lin,Honghuang %A Nowak,Christopher %A Kheterpal,Vik %A Benjamin,Emelia J %A McManus,David D %A Murabito,Joanne M %A Liu,Chunyu %+ Department of Biostatistics, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, United States, 1 6176385104, liuc@bu.edu %K depression %K mobile health %K risk factors %K physical activity %K eCohort %K Framingham Heart Study %D 2023 %7 14.7.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Few studies have examined the association between depressive symptom trajectories and physical activity collected by mobile health (mHealth) devices. Objective: We aimed to investigate if antecedent depressive symptom trajectories predict subsequent physical activity among participants in the electronic Framingham Heart Study (eFHS). Methods: We performed group-based multi-trajectory modeling to construct depressive symptom trajectory groups using both depressive symptoms (Center for Epidemiological Studies-Depression [CES-D] scores) and antidepressant medication use in eFHS participants who attended 3 Framingham Heart Study research exams over 14 years. At the third exam, eFHS participants were instructed to use a smartphone app for submitting physical activity index (PAI) surveys. In addition, they were provided with a study smartwatch to track their daily step counts. We performed linear mixed models to examine the association between depressive symptom trajectories and physical activity including app-based PAI and smartwatch-collected step counts over a 1-year follow-up adjusting for age, sex, wear hour, BMI, smoking status, and other health variables. Results: We identified 3 depressive symptom trajectory groups from 722 eFHS participants (mean age 53, SD 8.5 years; n=432, 60% women). The low symptom group (n=570; mean follow-up 287, SD 109 days) consisted of participants with consistently low CES-D scores, and a small proportion reported antidepressant use. The moderate symptom group (n=71; mean follow-up 280, SD 118 days) included participants with intermediate CES-D scores, who showed the highest and increasing likelihood of reporting antidepressant use across 3 exams. The high symptom group (n=81; mean follow-up 252, SD 116 days) comprised participants with the highest CES-D scores, and the proportion of antidepressant use fell between the other 2 groups. Compared to the low symptom group, the high symptom group had decreased PAI (mean difference –1.09, 95% CI –2.16 to –0.01) and the moderate symptom group walked fewer daily steps (823 fewer, 95% CI –1421 to –226) during the 1-year follow-up. Conclusions: Antecedent depressive symptoms or antidepressant medication use was associated with lower subsequent physical activity collected by mHealth devices in eFHS. Future investigation of interventions to improve mood including via mHealth technologies to help promote people’s daily physical activity is needed. %M 37450333 %R 10.2196/44529 %U https://mental.jmir.org/2023/1/e44529 %U https://doi.org/10.2196/44529 %U http://www.ncbi.nlm.nih.gov/pubmed/37450333 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 11 %N %P e41815 %T Trajectories of Symptoms in Digital Interventions for Depression and Anxiety Using Routine Outcome Monitoring Data: Secondary Analysis Study %A Cumpanasoiu,Diana Catalina %A Enrique,Angel %A Palacios,Jorge E %A Duffy,Daniel %A McNamara,Scott %A Richards,Derek %+ SilverCloud Science, SilverCloud Health, One Stephen Street Upper, Dublin, D08 DR9P, Ireland, 353 6467031051, catalina.cumpanasoiu@amwell.com %K internet-delivered cognitive behavioral therapy %K iCBT %K depression %K anxiety %K trajectory of symptom change %K routine outcome monitoring data %D 2023 %7 12.7.2023 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Research suggests there is heterogeneity in treatment response for internet-delivered cognitive behavioral therapy (iCBT) users, but few studies have investigated the trajectory of individual symptom change across iCBT treatment. Large patient data sets using routine outcome measures allows the investigation of treatment effects over time as well as the relationship between outcomes and platform use. Understanding trajectories of symptom change, as well as associated characteristics, may prove important for tailoring interventions or identifying patients who may not benefit from the intervention. Objective: We aimed to identify latent trajectories of symptom change during the iCBT treatment course for depression and anxiety and to investigate the patients’ characteristics and platform use for each of these classes. Methods: This is a secondary analysis of data from a randomized controlled trial designed to examine the effectiveness of guided iCBT for anxiety and depression in the UK Improving Access to Psychological Therapies (IAPT) program. This study included patients from the intervention group (N=256) and followed a longitudinal retrospective design. As part of the IAPT’s routine outcome monitoring system, patients were prompted to complete the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) after each supporter review during the treatment period. Latent class growth analysis was used to identify the underlying trajectories of symptom change across the treatment period for both depression and anxiety. Differences in patient characteristics were then evaluated between these trajectory classes, and the presence of a time-varying relationship between platform use and trajectory classes was investigated. Results: Five-class models were identified as optimal for both PHQ-9 and GAD-7. Around two-thirds (PHQ-9: 155/221, 70.1%; GAD-7: 156/221, 70.6%) of the sample formed various trajectories of improvement classes that differed in baseline score, the pace of symptom change, and final clinical outcome score. The remaining patients were in 2 smaller groups: one that saw minimal to no gains and another with consistently high scores across the treatment journey. Baseline severity, medication status, and program assigned were significantly associated (P<.001) with different trajectories. Although we did not find a time-varying relationship between use and trajectory classes, we found an overall effect of time on platform use, suggesting that all participants used the intervention significantly more in the first 4 weeks (P<.001). Conclusions: Most patients benefit from treatment, and the various patterns of improvement have implications for how the iCBT intervention is delivered. Identifying predictors of nonresponse or early response might inform the level of support and monitoring required for different types of patients. Further work is necessary to explore the differences between these trajectories to understand what works best for whom and to identify early on those patients who are less likely to benefit from treatment. %M 37436812 %R 10.2196/41815 %U https://mhealth.jmir.org/2023/1/e41815 %U https://doi.org/10.2196/41815 %U http://www.ncbi.nlm.nih.gov/pubmed/37436812 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e46867 %T Investigating COVID-19’s Impact on Mental Health: Trend and Thematic Analysis of Reddit Users’ Discourse %A Zhu,Jianfeng %A Yalamanchi,Neha %A Jin,Ruoming %A Kenne,Deric R %A Phan,NhatHai %+ Department of Computer Science, Kent State University, 800 E Summit St, Kent, OH, 44240, United States, 1 2348639445, jzhu10@kent.edu %K COVID-19 %K Reddit %K r/Depression %K r/Anxiety %K pandemic %K mental health %K trend analysis %K thematic analysis %K natural language processing (NLP) %K Word2Vec %D 2023 %7 12.7.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has resulted in heightened levels of depression, anxiety, and other mental health issues due to sudden changes in daily life, such as economic stress, social isolation, and educational irregularity. Accurately assessing emotional and behavioral changes in response to the pandemic can be challenging, but it is essential to understand the evolving emotions, themes, and discussions surrounding the impact of COVID-19 on mental health. Objective: This study aims to understand the evolving emotions and themes associated with the impact of COVID-19 on mental health support groups (eg, r/Depression and r/Anxiety) on Reddit (Reddit Inc) during the initial phase and after the peak of the pandemic using natural language processing techniques and statistical methods. Methods: This study used data from the r/Depression and r/Anxiety Reddit communities, which consisted of posts contributed by 351,409 distinct users over a period spanning from 2019 to 2022. Topic modeling and Word2Vec embedding models were used to identify key terms associated with the targeted themes within the data set. A range of trend and thematic analysis techniques, including time-to-event analysis, heat map analysis, factor analysis, regression analysis, and k-means clustering analysis, were used to analyze the data. Results: The time-to-event analysis revealed that the first 28 days following a major event could be considered a critical window for mental health concerns to become more prominent. The theme trend analysis revealed key themes such as economic stress, social stress, suicide, and substance use, with varying trends and impacts in each community. The factor analysis highlighted pandemic-related stress, economic concerns, and social factors as primary themes during the analyzed period. Regression analysis showed that economic stress consistently demonstrated the strongest association with the suicide theme, whereas the substance theme had a notable association in both data sets. Finally, the k-means clustering analysis showed that in r/Depression, the number of posts related to the “depression, anxiety, and medication” cluster decreased after 2020, whereas the “social relationships and friendship” cluster showed a steady decrease. In r/Anxiety, the “general anxiety and feelings of unease” cluster peaked in April 2020 and remained high, whereas the “physical symptoms of anxiety” cluster showed a slight increase. Conclusions: This study sheds light on the impact of COVID-19 on mental health and the related themes discussed in 2 web-based communities during the pandemic. The results offer valuable insights for developing targeted interventions and policies to support individuals and communities in similar crises. %M 37436793 %R 10.2196/46867 %U https://www.jmir.org/2023/1/e46867 %U https://doi.org/10.2196/46867 %U http://www.ncbi.nlm.nih.gov/pubmed/37436793 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 11 %N %P e45186 %T Testing Mechanisms of Change for Text Message–Delivered Cognitive Behavioral Therapy: Randomized Clinical Trial for Young Adult Depression %A Mason,Michael J %A Coatsworth,J Douglas %A Zaharakis,Nikola %A Russell,Michael %A Brown,Aaron %A McKinstry,Sydney %+ Center for Behavioral Health Research, College of Social Work, University of Tennessee, Center for Behavioral Health Research, 202 Henson Hall, Knoxville, TN, 37996, United States, 1 18659749148, mmason29@utk.edu %K young adults %K depression %K SMS text message–delivered treatment %K cognitive behavioral therapy %K randomized clinical trial %K mobile health treatment %K mHealth treatment %K mobile phone %D 2023 %7 11.7.2023 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Current psychiatric epidemiological evidence estimates that 17% of young adults (aged 18-25 years) experienced a major depressive episode in 2020, relative to 8.4% of all adults aged ≥26 years. Young adults with a major depressive episode in the past year are the least likely to receive treatment for depression compared with other age groups. Objective: We conducted a randomized clinical trial following our initial 4-week SMS text message–delivered cognitive behavioral therapy (CBT-txt) for depression in young adults. We sought to test mechanisms of change for CBT-txt. Methods: Based on participant feedback, outcome data, and the empirical literature, we increased the treatment dosage from 4-8 weeks and tested 3 mechanisms of change with 103 young adults in the United States. Participants were from 34 states, recruited from Facebook and Instagram and presenting with at least moderate depressive symptomatology. Web-based assessments occurred at baseline prior to randomization and at 1, 2, and 3 months after enrollment. The primary outcome, the severity of depressive symptoms, was assessed using the Beck Depression Inventory II. Behavioral activation, perseverative thinking, and cognitive distortions were measured as mechanisms of change. Participants were randomized to CBT-txt or a waitlist control condition. Those assigned to the CBT-txt intervention condition received 474 fully automated SMS text messages, delivered every other day over a 64-day period and averaging 14.8 (SD 2.4) SMS text messages per treatment day. Intervention texts are delivered via TextIt, a web-based automated SMS text messaging platform. Results: Across all 3 months of the study, participants in the CBT-txt group showed significantly larger decreases in depressive symptoms than those in the control group (P<.001 at each follow-up), producing a medium-to-large effect size (Cohen d=0.76). Over half (25/47, 53%) of the treatment group moved into the “high-end functioning” category, representing no or minimal clinically significant depressive symptoms, compared with 15% (8/53) of the control condition. Mediation analysis showed that CBT-txt appeared to lead to greater increases in behavioral activation and greater decreases in cognitive distortions and perseverative thinking across the 3-month follow-up period, which were then associated with larger baseline to 3-month decreases in depression. The size of the indirect effects was substantial: 57%, 41%, and 50% of the CBT-txt effect on changes in depression were mediated by changes in behavioral activation, cognitive distortions, and perseverative thinking, respectively. Models including all 3 mediators simultaneously showed that 63% of the CBT-txt effect was mediated by the combined indirect effects. Conclusions: Results provide evidence for the efficacy of CBT-txt to reduce young adult depressive symptoms through hypothesized mechanisms. To the best of our knowledge, CBT-txt is unique in its SMS text message–delivered modality, the strong clinical evidence supporting efficacy and mechanisms of change. Trial Registration: ClinicalTrials.gov NCT05551702; https://clinicaltrials.gov/study/NCT05551702 %M 37432723 %R 10.2196/45186 %U https://mhealth.jmir.org/2023/1/e45186 %U https://doi.org/10.2196/45186 %U http://www.ncbi.nlm.nih.gov/pubmed/37432723 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e46781 %T Effects of an Artificial Intelligence Platform for Behavioral Interventions on Depression and Anxiety Symptoms: Randomized Clinical Trial %A Sadeh-Sharvit,Shiri %A Camp,T Del %A Horton,Sarah E %A Hefner,Jacob D %A Berry,Jennifer M %A Grossman,Eyal %A Hollon,Steven D %+ Eleos Health, 260 Charles St, Waltham, MA, 02453, United States, 1 5109848132, ssharvit@paloaltou.edu %K augmentation %K anxiety %K artificial intelligence %K cognitive-behavioral therapy %K community-based center %K depression %K evidence-based practices %K health force burnout %K depressive %D 2023 %7 10.7.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: The need for scalable delivery of mental health care services that are efficient and effective is now a major public health priority. Artificial intelligence (AI) tools have the potential to improve behavioral health care services by helping clinicians collect objective data on patients’ progress, streamline their workflow, and automate administrative tasks. Objective: The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of an AI platform for behavioral health in facilitating better clinical outcomes for patients receiving outpatient therapy. Methods: The study was conducted at a community-based clinic in the United States. Participants were 47 adults referred for outpatient, individual cognitive behavioral therapy for a main diagnosis of a depressive or anxiety disorder. The platform provided by Eleos Health was compared to a treatment-as-usual (TAU) approach during the first 2 months of therapy. This AI platform summarizes and transcribes the therapy session, provides feedback to therapists on the use of evidence-based practices, and integrates these data with routine standardized questionnaires completed by patients. The information is also used to draft the session’s progress note. Patients were randomized to receive either therapy provided with the support of an AI platform developed by Eleos Health or TAU at the same clinic. Data analysis was carried out based on an intention-to-treat approach from December 2022 to January 2023. The primary outcomes included the feasibility and acceptability of the AI platform. Secondary outcomes included changes in depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7) scores as well as treatment attendance, satisfaction, and perceived helpfulness. Results: A total of 72 patients were approached, of whom 47 (67%) agreed to participate. Participants were adults (34/47, 72% women and 13/47, 28% men; mean age 30.64, SD 11.02 years), with 23 randomized to the AI platform group, and 24 to TAU. Participants in the AI group attended, on average, 67% (mean 5.24, SD 2.31) more sessions compared to those in TAU (mean 3.14, SD 1.99). Depression and anxiety symptoms were reduced by 34% and 29% in the AI platform group versus 20% and 8% for TAU, respectively, with large effect sizes for the therapy delivered with the support of the AI platform. No group difference was found in 2-month treatment satisfaction and perceived helpfulness. Further, therapists using the AI platform submitted their progress notes, on average, 55 hours earlier than therapists in the TAU group (t=–0.73; P<.001). Conclusions: In this randomized controlled trial, therapy provided with the support of Eleos Health demonstrated superior depression and anxiety outcomes as well as patient retention, compared with TAU. These findings suggest that complementing the mental health services provided in community-based clinics with an AI platform specializing in behavioral treatment was more effective in reducing key symptoms than standard therapy. Trial Registration: ClinicalTrials.gov NCT05745103; https://classic.clinicaltrials.gov/ct2/show/NCT05745103 %M 37428547 %R 10.2196/46781 %U https://www.jmir.org/2023/1/e46781 %U https://doi.org/10.2196/46781 %U http://www.ncbi.nlm.nih.gov/pubmed/37428547 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e47058 %T Effects of Tobacco Versus Electronic Cigarette Usage on Nonsuicidal Self-Injury and Suicidality Among Chinese Youth: Cross-Sectional Self-Report Survey Study %A Wang,Yinzhe %A Xu,Shicun %A Zhang,Xiaoqian %A Zhang,Yanwen %A Feng,Yi %A Wang,Yuanyuan %A Chen,Runsen %+ China Center for Aging Studies and Social-Economic Development, Jilin University, Kuang Yaming Bldg, 6th Fl, Changchun, Jilin, China, 86 43185166393, xushicun@jlu.edu.cn %K electronic cigarettes %K tobacco %K conventional cigarettes %K SGM %K nonsuicidal self-injury %K suicidality %K suicidal %K cigarette %K cigarettes %K suicide %K self-harm %K mental health %K sexual minority %K gender minority %K sexual and gender minority %K transgender %K youth %K cross-sectional %K survey %K smoker %K smoking %D 2023 %7 7.7.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The increase in tobacco/conventional cigarette (CC) and electronic cigarette (EC) usage among Chinese youth has become a growing public health concern. This is the first large-scale study to compare the impact of CC and EC usage on risk for nonsuicidal self-injury (NSSI) and suicidality in cis-heterosexual and sexual and gender minority (SGM) youth populations in China. Objective: This study examines the CC and EC risks for NSSI and suicidality among Chinese youth and compares the extent to which SGM and cis-heterosexual youth’s risks for NSSI and suicidality are influenced by their CC and EC usage and dependence. Methods: A total of 89,342 Chinese participants completed a cross-sectional self-report survey in 2021. Sociodemographic information, sexual orientations, gender identities, CC and EC usage, CC and EC dependence, and risks for suicidality and NSSI were assessed. The Mann-Whitney U test and chi-square test were performed for nonnormally distributed continuous variables and categorical variables, respectively. The multivariable linear regression model was used to examine both the influence of CC and EC usage and CC and EC dependence on NSSI and suicidality as well as the interaction effects of CC and EC usage and CC and EC dependence on NSSI and suicidality by group. Results: The prevalence of CC usage (P<.001) and dependence (P<.001) among SGM participants was lower than that among their cis-heterosexual counterparts. However, the prevalence of EC usage (P=.03) and EC dependence (P<.001) among SGM participants was higher than that among their cis-heterosexual counterparts. The multivariable linear regression model showed that CC dependence and EC dependence had a unique effect on NSSI and suicidality (CCs: B=0.02, P<.001; B=0.09, P<.001; ECs: B=0.05, P<.001; B=0.14, P<.001, respectively). The interaction effects of (1) CC usage and group type on NSSI and suicidality (B=0.34, P<.001; B=0.24, P=.03, respectively) and dual usage and group type on NSSI and suicidality (B=0.54, P<.001; B=0.84, P<.001, respectively) were significant, (2) CC dependence and group type on NSSI were significant (B=0.07, P<.001), and (3) EC dependence and group type on NSSI and suicidality were significant (B=0.04, P<.001; B=0.09, P<.001, respectively). No significant interaction effect was observed between EC usage and group type on NSSI and suicidality (B=0.15, P=.12; B=0.33, P=.32, respectively) and between CC dependence and group type on suicidality (B=–0.01, P=.72). Conclusions: Our study shows evidence of intergroup differences in NSSI and suicidality risks between SGM and cis-heterosexual youth related to CC and EC usage. These findings contribute to the growing literature on CC and EC in cis-heterosexual and SGM populations. Concerted efforts are necessary at a societal level to curb the aggressive marketing strategies of the EC industry and media coverage and to maximize the impact of educational campaigns on EC prevention and intervention among the youth population. %M 37418293 %R 10.2196/47058 %U https://publichealth.jmir.org/2023/1/e47058 %U https://doi.org/10.2196/47058 %U http://www.ncbi.nlm.nih.gov/pubmed/37418293 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e46289 %T Association Between Comorbid Anxiety and Depression and Health Risk Behaviors Among Chinese Adolescents: Cross-Sectional Questionnaire Study %A Wang,Meng %A Mou,Xingyue %A Li,Tingting %A Zhang,Yi %A Xie,Yang %A Tao,Shuman %A Wan,Yuhui %A Tao,Fangbiao %A Wu,Xiaoyan %+ Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81, Meishan Road, Shushan District, Hefei, 230032, China, 86 551 65161168, xywu@ahmu.edu.cn %K health risk behaviors %K anxiety %K depression %K comorbidity %K adolescent %K mental health %K children %K intervention %K lifestyle behavior %K mental disorder %K public health %K cross-sectional study %D 2023 %7 5.7.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Comorbidity of psychiatric disorders such as depression and anxiety is very common among children and adolescents. Few studies have examined how comorbid anxiety and depression are associated with health risk behaviors (HRBs) in adolescents, which could inform preventative approaches for mental health. Objective: We evaluated the association between HRBs and comorbid anxiety and depression in a large adolescent cohort. Methods: We used data from 22,868 adolescents in the National Youth Cohort (China). Anxiety and depression symptoms were assessed using the 9-item Patient Health Questionnaire scale and the 7-item Generalized Anxiety Disorder scale, respectively. Comorbidity was determined by the coexistence of anxiety and depression. HRBs including poor diet, smoking, physical inactivity, and poor sleep, as well as the above HRB scores, were added to obtain the total HRB score (HRB risk index). Based on single and total HRB scores, we divided participants into low-, medium-, and high-risk groups. Potential confounders included gender, presence of siblings, regional economic level, educational status, self-rated health, parental education level, self-reported family income, number of friends, learning burden, and family history of psychosis. Correlation analysis was used to explore associations between single risk behaviors. Binary logistic regression estimated the association between HRBs and anxiety-depression comorbidity before and after adjusting for potential confounders. Results: The comorbidity rate of anxiety and depression among Chinese adolescents was 31.6% (7236/22,868). There was a statistically significant association between each HRB (P<.05), and HRBs were positively associated with comorbid anxiety and depression in the above population. For single HRBs, adolescents with poor diet, smoking, and poor sleep (medium-risk) were more prone to anxiety-depression comorbidity after adjusting for confounders compared to low-risk adolescents. However, adolescents with all high-risk HRBs were more likely to have comorbid anxiety and depression after adjusting for confounders (poor diet odds ratio [OR] 1.50, 95% CI 1.39-1.62; smoking OR 2.17, 95% CI 1.67-2.81; physical inactivity OR 1.16, 95% CI 1.06-1.28; poor sleep OR 1.84, 95% CI 1.70-2.01). Moreover, in both unadjusted (medium risk OR 1.79, 95% CI 1.56-2.05; high risk OR 3.09, 95% CI 2.72-3.52) and adjusted (medium risk OR 1.57, 95% CI 1.37-1.80; high risk OR 2.33, 95% CI 2.03-2.68) models, HRB risk index, like clustered HRBs, was positively associated with anxiety-depression comorbidity, and the strength of the association was stronger than for any single HRB. In addition, we found that compared to girls, the association between clustered HRBs and anxiety-depression comorbidity was stronger in boys after adjustment. Conclusions: We provide evidence that HRBs are related to comorbid anxiety and depression. Interventions that decrease HRBs may support mental health development in adolescence, with the potential to improve health and well-being through to adulthood. %M 37405826 %R 10.2196/46289 %U https://publichealth.jmir.org/2023/1/e46289 %U https://doi.org/10.2196/46289 %U http://www.ncbi.nlm.nih.gov/pubmed/37405826 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e44790 %T Psychiatric Treatment Conducted via Telemedicine Versus In-Person Modality in Posttraumatic Stress Disorder, Mood Disorders, and Anxiety Disorders: Systematic Review and Meta-Analysis %A Shaker,Ali Abbas %A Austin,Stephen F %A Storebø,Ole Jakob %A Schaug,Julie Perrine %A Ayad,Alaa %A Sørensen,John Aasted %A Tarp,Kristine %A Bechmann,Henrik %A Simonsen,Erik %+ Psychiatric Department, Region Zealand Psychiatry, Psychiatric Research Unit, Fælledvej 6, Slagelse, 4200, Denmark, 45 58536070, ashak@regionsjaelland.dk %K telemedicine %K telepsychiatry %K video consultation %K mobile health %K mHealth %K eHealth %K COVID-19 %K synchronous technology %K anxiety %K psychiatry %K patient satisfaction %K depression %K posttraumatic stress disorder %K PTSD %D 2023 %7 5.7.2023 %9 Review %J JMIR Ment Health %G English %X Background: Telemedicine has played a vital role in providing psychiatric treatment to patients during the rapid transition of services during the COVID-19 pandemic. Furthermore, the use of telemedicine is expected to expand within the psychiatric field. The efficacy of telemedicine is well described in scientific literature. However, there is a need for a comprehensive quantitative review that analyzes and considers the different clinical outcomes and psychiatric diagnoses. Objective: This paper aimed to assess whether individual psychiatric outpatient treatment for posttraumatic stress disorder, mood disorders, and anxiety disorders in adults using telemedicine is equivalent to in-person treatment. Methods: A systematic search of randomized controlled trials was conducted using recognized databases for this review. Overall, 4 outcomes were assessed: treatment efficacy, levels of patient satisfaction, working alliance, and attrition rate. The inverse-variance method was used to summarize the effect size for each outcome. Results: A total of 7414 records were identified, and 20 trials were included in the systematic review and meta-analysis. The trials included posttraumatic stress disorder (9 trials), depressive disorder (6 trials), a mix of different disorders (4 trials), and general anxiety disorder (1 trial). Overall, the analyses yielded evidence that telemedicine is comparable with in-person treatment regarding treatment efficacy (standardized mean difference −0.01, 95% CI −0.12 to 0.09; P=.84; I2=19%, 17 trials, n=1814), patient satisfaction mean difference (−0.66, 95% CI −1.60 to 0.28; P=.17; I2=44%, 6 trials, n=591), and attrition rates (risk ratio 1.07, 95% CI 0.94-1.21; P=.32; I2=0%, 20 trials, n=2804). The results also indicated that the working alliance between telemedicine and in-person modalities was comparable, but the heterogeneity was substantial to considerable (mean difference 0.95, 95% CI −0.47 to 2.38; P=.19; I2=75%, 6 trials, n=539). Conclusions: This meta-analysis provided new knowledge on individual telemedicine interventions that were considered equivalent to in-person treatment regarding efficacy, patient satisfaction, working alliance, and attrition rates across diagnoses. The certainty of the evidence regarding efficacy was rated as moderate. Furthermore, high-quality randomized controlled trials are needed to strengthen the evidence base for treatment provided via telemedicine in psychiatry, particularly for personality disorders and a range of anxiety disorders where there is a lack of studies. Individual patient data meta-analysis is suggested for future studies to personalize telemedicine. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021256357; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=256357 %M 37277113 %R 10.2196/44790 %U https://mental.jmir.org/2023/1/e44790 %U https://doi.org/10.2196/44790 %U http://www.ncbi.nlm.nih.gov/pubmed/37277113 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e48913 %T Designing High-Fidelity Mobile Health for Depression in Indonesian Adolescents Using Design Science Research: Mixed Method Approaches %A Shania,Mila %A Handayani,Putu Wuri %A Asih,Sali %+ Faculty of Psychology, University of Indonesia, Jl Kampus UI, Depok, 16424, Indonesia, 62 217863419, Putu.wuri@cs.ui.ac.id %K mobile health %K mental health %K user interface %K design science research %K Indonesia %K digital app %K mHealth %K depression %K pandemic %K adolescents %D 2023 %7 3.7.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: COVID-19 mitigation protocols, enacted to control the pandemic, have also been shown to have a negative impact on mental health, including the mental health of adolescents. The threat of being infected by SARS-CoV-2 and substantial changes in lifestyle, including limited social interaction due to stay-at-home orders, led to loneliness as well as depressive symptoms. However, offline psychological assistance is restricted, as psychologists are bounded by mitigation protocols. Further, not all adolescents’ guardians are open to their children attending or have the means to pay for psychological service; thus, adolescents remain untreated. Having a mobile health (mHealth) app for mental health that uses monitoring, provides social networks, and delivers psychoeducation may provide a solution, especially in countries that have limited health facilities and mental health workers. Objective: This study aimed to design an mHealth app to help prevent and monitor depression in adolescents. The design of this mHealth app was carried out as a high-fidelity prototype. Methods: We used a design science research (DSR) methodology with 3 iterations and 8 golden rule guidelines. The first iteration used interviews, and the second and third iterations used mixed method approaches. The DSR stages include the following: (1) identify the problem; (2) define the solution; (3) define the solution objective; (4) develop, demonstrate, and evaluate the solution; and (5) communicate the solution. This study involved students and medical experts. Results: The first iteration resulted in a wireframe and prototype for the next iteration. The second iteration resulted in a System Usability Scale score of 67.27, indicating a good fit. In the third iteration, the system usefulness, information quality, interface quality, and overall values were 2.416, 2.341, 2.597, and 2.261, respectively, indicating a good design. Key features of this mHealth app include a mood tracker, community, activity target, and meditation, and supporting features that complement the design include education articles and early detection features. Conclusions: Our findings provide guidance for health facilities and to design and implement future mHealth apps to help treat adolescent depression. %M 37399059 %R 10.2196/48913 %U https://formative.jmir.org/2023/1/e48913 %U https://doi.org/10.2196/48913 %U http://www.ncbi.nlm.nih.gov/pubmed/37399059 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e46052 %T Comparing Message-Based Psychotherapy to Once-Weekly, Video-Based Psychotherapy for Moderate Depression: Randomized Controlled Trial %A Song,Jiyoung %A Litvin,Boris %A Allred,Ryan %A Chen,Shiyu %A Hull,Thomas D %A Areán,Patricia A %+ Department of Psychology, University of California, Berkeley, 2121 Berkeley Way, Berkeley, CA, 94720, United States, 1 9493794232, jiyoungsong@berkeley.edu %K randomized controlled trial %K message-based psychotherapy %K video-based psychotherapy %K telemedicine %K depression %K anxiety %K functional impairment, credibility, alliance, engagement %K mental health %K text mining %K message therapy %K Burden of Disease %K telehealth %K intervention %D 2023 %7 29.6.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite the high prevalence of major depressive disorder and the related societal burden, access to effective traditional face-to-face or video-based psychotherapy is a challenge. An alternative that offers mental health care in a flexible setting is asynchronous messaging therapy. To date, no study has evaluated its efficacy and acceptability in a randomized controlled trial for depression. Objective: The aim of this study was to compare the efficacy and acceptability of message-based psychotherapy for depression to once-weekly video-based psychotherapy. Methods: In this 2-armed randomized controlled trial, individuals (N=83) with depressive symptomatology (Patient Health Questionnaire-9 ≥10) were recruited on the internet and randomly assigned to either a message-based intervention group (n=46) or a once-weekly video-based intervention group (n=37). Patients in the message-based treatment condition exchanged asynchronous messages with their therapist following an agreed-upon schedule. Patients in the video-based treatment condition met with their therapist once each week for a 45-minute video teletherapy session. Self-report data for depression, anxiety, and functional impairment were collected at pretreatment, weekly during treatment, at posttreatment, and at a 6-month follow-up. Self-reported treatment expectancy and credibility for the assigned intervention were assessed at pretreatment and therapeutic alliance at posttreatment. Results: Findings from multilevel modeling indicated significant, medium-to-large improvements in depression (d=1.04; 95% CI 0.60-1.46), anxiety (d=0.61; 95% CI 0.22-0.99), and functional impairment (d=0.66; 95% CI 0.27-1.05) for patients in the message-based treatment condition. Changes in depression (d=0.11; 95% CI –0.43 to 0.66), anxiety (d=–0.01; 95% CI –0.56 to 0.53), and functional impairment (d=0.25; 95% CI –0.30 to 0.80) in the message-based treatment condition were noninferior to those in the video-based treatment condition. There were no significant differences in treatment credibility (d=–0.09; 95% CI –0.64 to 0.45), therapeutic alliance (d=–0.15; 95% CI –0.75 to 0.44), or engagement (d=0.24; 95% CI –0.20 to 0.67) between the 2 treatment conditions. Conclusions: Message-based psychotherapy could present an effective and accessible alternative treatment modality for patients who might not be able to engage in traditional scheduled services such as face-to-face or video-based psychotherapy. Trial Registration: ClinicalTrials.gov NCT05467787; https://www.clinicaltrials.gov/ct2/show/NCT05467787 %M 37384392 %R 10.2196/46052 %U https://www.jmir.org/2023/1/e46052 %U https://doi.org/10.2196/46052 %U http://www.ncbi.nlm.nih.gov/pubmed/37384392 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e46771 %T The Effects of Internet-Based Cognitive Behavioral Therapy for Suicidal Ideation or Behaviors on Depression, Anxiety, and Hopelessness in Individuals With Suicidal Ideation: Systematic Review and Meta-Analysis of Individual Participant Data %A Sander,Lasse B %A Beisemann,Marie %A Doebler,Philipp %A Micklitz,Hannah Moon %A Kerkhof,Ad %A Cuijpers,Pim %A Batterham,Philip %A Calear,Alison %A Christensen,Helen %A De Jaegere,Eva %A Domhardt,Matthias %A Erlangsen,Annette %A Eylem-van Bergeijk,Ozlem %A Hill,Ryan %A Mühlmann,Charlotte %A Österle,Marie %A Pettit,Jeremy %A Portzky,Gwendolyn %A Steubl,Lena %A van Spijker,Bregje %A Tighe,Joseph %A Werner-Seidler,Aliza %A Büscher,Rebekka %+ Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Hebelstraße 29, Freiburg, 79104, Germany, 49 761 203 5519, Lasse.Sander@mps.uni-freiburg.de %K meta-analysis %K internet-based cognitive behavioral therapy %K suicidal ideation %K anxiety %K depression %K hopelessness %K depressive %K mental health %K systematic review %K review method %K suicide %K suicidal %K psychotherapy %K CBT %K cognitive behavioral therapy %D 2023 %7 26.6.2023 %9 Review %J J Med Internet Res %G English %X Background: Suicide is a global public health problem. Digital interventions are considered a low-threshold treatment option for people with suicidal ideation or behaviors. Internet-based cognitive behavioral therapy (iCBT) targeting suicidal ideation has demonstrated effectiveness in reducing suicidal ideation. However, suicidal ideation often is related to additional mental health problems, which should be addressed for optimal care. Yet, the effects of iCBT on related symptoms, such as depression, anxiety, and hopelessness, remain unclear. Objective: We aimed to analyze whether digital interventions targeting suicidal ideation had an effect on related mental health symptoms (depression, anxiety, and hopelessness). Methods: We systematically searched CENTRAL, PsycInfo, Embase, and PubMed for randomized controlled trials that investigated guided or unguided iCBT for suicidal ideation or behaviors. Participants reporting baseline suicidal ideation were eligible. Individual participant data (IPD) were collected from eligible trials. We conducted a 1-stage IPD meta-analysis on the effects on depression, anxiety, and hopelessness—analyzed as 2 indices: symptom severity and treatment response. Results: We included IPD from 8 out of 9 eligible trials comprising 1980 participants with suicidal ideation. iCBT was associated with significant reductions in depression severity (b=−0.17; 95% CI −0.25 to −0.09; P<.001) and higher treatment response (ie, 50% reduction of depressive symptoms; b=0.36; 95% CI 0.12-0.60; P=.008) after treatment. We did not find significant effects on anxiety and hopelessness. Conclusions: iCBT for people with suicidal ideation revealed significant effects on depression outcomes but only minor or no effects on anxiety and hopelessness. Therefore, individuals with comorbid symptoms of anxiety or hopelessness may require additional treatment components to optimize care. Studies that monitor symptoms with higher temporal resolution and consider a broader spectrum of factors influencing suicidal ideation are needed to understand the complex interaction of suicidality and related mental health symptoms. %M 37358893 %R 10.2196/46771 %U https://www.jmir.org/2023/1/e46771 %U https://doi.org/10.2196/46771 %U http://www.ncbi.nlm.nih.gov/pubmed/37358893 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 11 %N %P e46286 %T The Effectiveness of a Mobile Phone–Based Physical Activity Program for Treating Depression, Stress, Psychological Well-Being, and Quality of Life Among Adults: Quantitative Study %A Kim,Hyungsook %A Lee,Kikwang %A Lee,Ye Hoon %A Park,Yoonjung %A Park,Yonghyun %A Yu,Yeonwoo %A Park,Jaeyoung %A Noh,Sihyeon %+ Division of Global Sport Industry, Hankuk University of Foreign Studies, 81, Oedae-ro, Mohyeon-eup, Cheoin-gu, Gyeonggi-do, 17035, Republic of Korea, 82 31 330 4986, leeye22@o365.hufs.ac.kr %K depressive symptoms %K mobile intervention %K exercise %K internet-based fitness %K mental health %D 2023 %7 26.6.2023 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depression is a substantial global health problem, affecting >300 million people and resulting in 12.7% of all deaths. Depression causes various physical and cognitive problems, leading to a 5-year to 10-year decrease in life expectancy compared with the general population. Physical activity is known to be an effective, evidence-based treatment for depression. However, people generally have difficulties with participating in physical activity owing to limitations in time and accessibility. Objective: To address this issue, this study aimed to contribute to the development of alternative and innovative intervention methods for depression and stress management in adults. More specifically, we attempted to investigate the effectiveness of a mobile phone–based physical activity program on depression, perceived stress, psychological well-being, and quality of life among adults in South Korea. Methods: Participants were recruited and randomly assigned to the mobile phone intervention or waitlist group. Self-report questionnaires were used to assess variables before and after treatment. The treatment group used the program around 3 times per week at home for 4 weeks, with each session lasting about 30 minutes. To evaluate the program’s impact, a 2 (condition) × 2 (time) repeated-measures ANOVA was conducted, considering pretreatment and posttreatment measures along with group as independent variables. For a more detailed analysis, paired-samples 2-tailed t tests were used to compare pretreatment and posttreatment measurements within each group. Independent-samples 2-tailed t tests were conducted to assess intergroup differences in pretreatment measurements. Results: The study included a total of 68 adults aged between 18 and 65 years, who were recruited both through web-based and offline methods. Of these 68 individuals, 41 (60%) were randomly assigned to the treatment group and 27 (40%) to the waitlist group. The attrition rate was 10.2% after 4 weeks. The findings indicated that there is a significant main effect of time (F1,60=15.63; P=.003; ηp2=0.21) in participants’ depression scores, indicating that there were changes in depression level across time. No significant changes were observed in perceived stress (P=.25), psychological well-being (P=.35), or quality of life (P=.07). Furthermore, depression scores significantly decreased in the treatment group (from 7.08 to 4.64; P=.03; Cohen d=0.50) but not in the waitlist group (from 6.72 to 5.08; P=.20; Cohen d=0.36). Perceived stress score of the treatment group also significantly decreased (from 2.95 to 2.72; P=.04; Cohen d=0.46) but not in the waitlist group (from 2.82 to 2.74; P=.55; Cohen d=0.15). Conclusions: This study provided experimental evidence that mobile phone–based physical activity program affects depression significantly. By exploring the potential of mobile phone–based physical activity programs as a treatment option, this study sought to improve accessibility and encourage participation in physical activity, ultimately promoting better mental health outcomes for individuals with depression and stress. %M 37358905 %R 10.2196/46286 %U https://mhealth.jmir.org/2023/1/e46286 %U https://doi.org/10.2196/46286 %U http://www.ncbi.nlm.nih.gov/pubmed/37358905 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e46464 %T Real-Time Real-World Digital Monitoring of Adolescent Suicide Risk During the Six Months Following Emergency Department Discharge: Protocol for an Intensive Longitudinal Study %A Barzilay,Shira %A Fine,Shai %A Akhavan,Shannel %A Haruvi-Catalan,Liat %A Apter,Alan %A Brunstein-Klomek,Anat %A Carmi,Lior %A Zohar,Mishael %A Kinarty,Inbar %A Friedman,Talia %A Fennig,Silvana %+ Department of Community Mental Health, University of Haifa, Abba Khoushy Ave 199, Haifa, 3498838, Israel, 972 545309759, shirabarzilay@univ.haifa.ac.il %K suicide %K suicide ideation %K suicide prevention %K adolescents %K real-time assessment %K digital phenotyping %K risk assessment %K mobile phone %D 2023 %7 26.6.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is the second leading cause of death in adolescents, and self-harm is one of the strongest predictors of death by suicide. The rates of adolescents presenting to emergency departments (EDs) for suicidal thoughts and behaviors (STBs) have increased. Still, existing follow-up after ED discharge is inadequate, leaving a high-risk period for reattempts and suicide. There is a need for innovative evaluation of imminent suicide risk factors in these patients, focusing on continuous real-time evaluations with low assessment burden and minimal reliance on patient disclosure of suicidal intent. Objective: This study examines prospective longitudinal associations between observed real-time mobile passive sensing, including communication and activity patterns, and clinical and self-reported assessments of STB over 6 months. Methods: This study will include 90 adolescents recruited on their first outpatient clinic visit following their discharge from the ED due to a recent STB. Participants will complete brief weekly assessments and be monitored continuously for their mobile app usage, including mobility, activity, and communication patterns, over 6 months using the iFeel research app. Participants will complete 4 in-person visits for clinical assessment at baseline and at the 1-, 3-, and 6-month follow-ups. The digital data will be processed, involving feature extraction, scaling, selection, and dimensionality reduction. Passive monitoring data will be analyzed using both classical machine learning models and deep learning models to identify proximal associations between real-time observed communication, activity patterns, and STB. The data will be split into a training and validation data set, and predictions will be matched against the clinical evaluations and self-reported STB events (ie, labels). To use both labeled and unlabeled digital data (ie, passively collected), we will use semisupervised methods in conjunction with a novel method that is based on anomaly detection notions. Results: Participant recruitment and follow-up started in February 2021 and are expected to be completed by 2024. We expect to find prospective proximal associations between mobile sensor communication, activity data, and STB outcomes. We will test predictive models for suicidal behaviors among high-risk adolescents. Conclusions: Developing digital markers of STB in a real-world sample of high-risk adolescents presenting to ED can inform different interventions and provide an objective means to assess the risk of suicidal behaviors. The results of this study will be the first step toward large-scale validation that may lead to suicide risk measures that aid psychiatric follow-up, decision-making, and targeted treatments. This novel assessment could facilitate timely identification and intervention to save young people’s lives. International Registered Report Identifier (IRRID): DERR1-10.2196/46464 %M 37358906 %R 10.2196/46464 %U https://www.researchprotocols.org/2023/1/e46464 %U https://doi.org/10.2196/46464 %U http://www.ncbi.nlm.nih.gov/pubmed/37358906 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e43788 %T Design and Implementation of a Digitally Enabled Care Pathway to Improve Management of Depression in a Large Health Care System: Protocol for the Implementation of a Patient Care Platform %A Khatib,Rasha %A McCue,Maggie %A Blair,Chris %A Roy,Anit %A Franco,John %A Fehnert,Ben %A King,James %A Sarkey,Sara %A Chrones,Lambros %A Martin,Michael %A Kabir,Christopher %A Kemp,David E %+ Takeda Pharmaceuticals U.S.A., Inc., 95 Hayden Ave, Lexington, MA, 02421, United States, 1 781 482 0426, chris.blair@takeda.com %K mental health %K depression %K depressive %K major depressive disorder %K depression management %K primary care %K patient engagement %K measurement-based care %K shared decision-making %K user-centered design %K mobile app %K digital platform %K mobile phone %K mobile health %K adherence %D 2023 %7 23.6.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Major depressive disorder (MDD) is a serious public health concern worldwide. A treatment approach that incorporates measurement-based care (MBC) and shared decision-making between patients with MDD and their providers may foster patient engagement and improve clinical outcomes. While digital tools such as mobile apps show promise for expanding health interventions, these apps are rarely integrated into clinical practice. Objective: The primary objective of this ongoing study is to determine whether implementation of a digital tool—the Pathway Platform—in primary care improves adherence to MBC practices; here, we present the study methods. Methods: This large-scale, real-world implementation study is based on a pilot study of an earlier iteration of a mobile app (the Pathway app) that confirmed the feasibility of using the app in patients with MDD and showed a positive trend in patient engagement in the app arm. In addition, a user-centered design approach that included qualitative assessments from patients and providers was used to improve understanding of the patient journey and care team workflows. User feedback highlighted the need for enhanced features, education modules, and real-time data sharing via integration with the electronic health record. The current iteration of the Platform includes the newest version of the Pathway app, education modules for both patients and providers, and real-time patient-level data sharing with the electronic health record. The study takes place in primary care sites within the Advocate Aurora Health system in Illinois and includes adult patients with MDD who were recently prescribed monotherapy antidepressant medication (defined as a new start, medication switch, or dose change in the past 3 months). Clinical performance and selected patient outcomes will be compared before and after the implementation of the Platform. Results: Patient recruitment was completed in July 2022, with initial results expected in mid-2023. Conclusions: This study will provide useful insights into real-world integration of a digital platform within a large health system. The methods presented here highlight the unique user-centric development of the Pathway Platform, which has resulted in an enhanced digital tool with the potential to foster MBC and shared decision-making, improve patient-provider communication, and ultimately lead to optimized treatment outcomes for patients with MDD. Trial Registration: ClinicalTrials.gov NCT04891224; https://clinicaltrials.gov/ct2/show/NCT04891224 International Registered Report Identifier (IRRID): DERR1-10.2196/43788 %M 37351941 %R 10.2196/43788 %U https://www.researchprotocols.org/2023/1/e43788 %U https://doi.org/10.2196/43788 %U http://www.ncbi.nlm.nih.gov/pubmed/37351941 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45334 %T Graded Response Model Analysis and Computer Adaptive Test Simulation of the Depression Anxiety Stress Scale 21: Evaluation and Validation Study %A Kraska,Jake %A Bell,Karen %A Costello,Shane %+ School of Educational Psychology and Counselling, Faculty of Education, Monash University, 19 Ancora Imparo Way, Clayton, 3800, Australia, 61 399052896, jake.kraska@gmail.com %K graded response model %K DASS-21 %K CAT %K computer adaptive testing %K simulation %K psychological distress %K depression %K anxiety %K stress %K simulation %K mental health %K screening tool %K tool %K reliability %K development %K model %D 2023 %7 22.6.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: The Depression Anxiety Stress Scale 21 (DASS-21) is a mental health screening tool with conflicting studies regarding its factor structure. No studies have yet attempted to develop a computer adaptive test (CAT) version of it. Objective: This study calibrated items for, and simulated, a DASS-21 CAT using a nonclinical sample. Methods: An evaluation sample (n=580) was used to evaluate the DASS-21 scales via confirmatory factor analysis, Mokken analysis, and graded response modeling. A CAT was simulated with a validation sample (n=248) and a simulated sample (n=10,000) to confirm the generalizability of the model developed. Results: A bifactor model, also known as the “quadripartite” model (1 general factor with 3 specific factors) in the context of the DASS-21, displayed good fit. All scales displayed acceptable fit with the graded response model. Simulation of 3 unidimensional (depression, anxiety, and stress) CATs resulted in an average 17% to 48% reduction in items administered when a reliability of 0.80 was acceptable. Conclusions: This study clarifies previous conflicting findings regarding the DASS-21 factor structure and suggests that the quadripartite model for the DASS-21 items fits best. Item response theory modeling suggests that the items measure their respective constructs best between 0θ and 3θ (mild to moderate severity). %M 37347530 %R 10.2196/45334 %U https://www.jmir.org/2023/1/e45334 %U https://doi.org/10.2196/45334 %U http://www.ncbi.nlm.nih.gov/pubmed/37347530 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e47627 %T Culturally Adapting a Digital Intervention to Reduce Suicidal Ideation for Syrian Asylum Seekers and Refugees in the United Kingdom: Protocol for a Qualitative Study %A Beuthin,Oliver %A Bhui,Kamaldeep %A Yu,Ly-Mee %A Shahid,Sadiya %A Almidani,Louay %A Bilalaga,Mariah Malak %A Hussein,Roshan %A Harba,Alnarjes %A Nasser,Yasmine %+ Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Ln, Headington, Oxford, OX3 7JX, United Kingdom, 44 1865 618200, oliver.beuthin@linacre.ox.ac.uk %K cultural adaptation %K digital mental health %K suicidal ideation %K refugee mental health %K Syrian refugee %K experience-based co-design %K mental health %K suicide %K suicidal %K refugee %K immigrant %K ethnic minority %K asylum %K user experience %K cultural %K Syria %K Syrian %K refugees %D 2023 %7 22.6.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: The conflict in Syria has produced the largest forced displacement crisis since the Second World War. As a result, Syrians have experienced various stressors across the migratory process, putting them at an increased risk of developing mental health issues, including, crucially, suicidal ideation (SI). Despite their high rates of SI across Europe, there remain various barriers to accessing treatment. One way to increase access is the use of culturally adapted digital interventions, which have already shown potential for other minority populations. To culturally adapt the intervention, further research is needed to better understand Syrian asylum seekers’ and refugees’ cultural conceptualizations, coping strategies, and help-seeking behavior for SI. To do so, this study will use a unique cultural adaptation framework to intervene at points of lived experience with the migratory process where Syrian culture and signs of psychopathology converge. Likewise, co-design events will be used to adapt points of experience with the intervention where Syrian culture and the intervention conflict. As the first cultural adaption of a digital SI intervention for Syrian asylum seekers and refugees, this study will hopefully encourage further development of culturally sensitive interventions for the largest refugee population in the United Kingdom and the world. Objective: The objective of the study is to increase access to mental health treatment for Syrian asylum seekers and refugees in the United Kingdom by culturally adapting a digital intervention to reduce SI. Methods: The study will use experience-based co-design, an action research method, to culturally adapt a digital intervention to reduce SI for Syrian asylum seekers and refugees in the United Kingdom. This will involve conducting 20-30 interviews to understand their lived experiences with the migratory process, cultural conceptualizations of mental health and SI, coping strategies, mental health help-seeking behavior, and perceptions of digital mental health interventions. In addition, 3 co-design events with 6 participants in each will be held to collaboratively adapt the intervention. Touchpoints and themes extracted from each phase will be prioritized by a community panel before adapting the intervention. Results: The study began in November 2022 and will continue until the last co-design event in August 2023. The results of the study will then be published by December 2023. Conclusions: Access to treatment for some of the most severe mental health issues is still limited for Syrian asylum seekers and refugees in the United Kingdom. Cultural adaptations of digital interventions developed for general populations have the potential to increase access to treatment for this population. Specifically, adapting the intervention for Syrian asylum seekers’ and refugees’ experiences with SI in relation to their lived experience with the migratory process may enable greater recruitment and adherence for users of various cultural and ethnic subgroups and levels of SI. International Registered Report Identifier (IRRID): DERR1-10.2196/47627 %M 37347522 %R 10.2196/47627 %U https://www.researchprotocols.org/2023/1/e47627 %U https://doi.org/10.2196/47627 %U http://www.ncbi.nlm.nih.gov/pubmed/37347522 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e46062 %T Understanding Users’ Experiences of a Novel Web-Based Cognitive Behavioral Therapy Platform for Depression and Anxiety: Qualitative Interviews From Pilot Trial Participants %A Shkel,Jane %A Green,Gavin %A Le,Stacey %A Kaveladze,Benjamin %A Marcotte,Veronique %A Rushton,Kevin %A Nguyen,Theresa %A Schueller,Stephen M %+ Department of Psychological Science, University of California, Irvine, 4341 Social and Behavioral Sciences Gateway, Irvine, CA, 92697, United States, 1 949 824 3850, s.schueller@uci.edu %K anxiety %K depression %K cognitive behavioral therapy %K clinical trial %K intervention %K qualitative research %K digital mental health intervention %D 2023 %7 20.6.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital mental health interventions (DMHIs) can help bridge the gap between the demand for mental health care and availability of treatment resources. The affordances of DMHIs have been proposed to overcome barriers to care such as accessibility, cost, and stigma. Despite these proposals, most evaluations of the DMHI focus on clinical effectiveness, with less consideration of users’ perspectives and experiences. Objective: We conducted a pilot randomized controlled trial of “Overcoming Thoughts,” a web-based platform that uses cognitive and behavioral principles to address depression and anxiety. The “Overcoming Thoughts” platform included 2 brief interventions—cognitive restructuring and behavioral experimentation. Users accessed either a version that included asynchronous interactions with other users (“crowdsourced” platform) or a completely self-guided version (control condition). We aimed to understand the users’ perspectives and experiences by conducting a subset of interviews during the follow-up period of the trial. Methods: We used purposive sampling to select a subset of trial participants based on group assignment (treatment and control) and symptom improvement (those who improved and those who did not on primary outcomes). We conducted semistructured interviews with 23 participants during the follow-up period that addressed acceptability, usability, and impact. We conducted a thematic analysis of the interviews until saturation was reached. Results: A total of 8 major themes were identified: possible opportunities to expand the platform; improvements in mental health because of using the platform; increased self-reflection skills; platform being more helpful for certain situations or domains; implementation of skills into users’ lives, even without direct platform use; increased coping skills because of using the platform; repetitiveness of platform exercises; and use pattern. Although no differences in themes were found among groups based on improvement status (all P values >.05, ranging from .12 to .86), there were 4 themes that differed based on conditions (P values from .01 to .046): helpfulness of self-reflection supported by an exercise summary (greater in control); aiding in slowing thoughts and feeling calmer (greater in control); overcoming patterns of avoidance (greater in control); and repetitiveness of content (greater in the intervention). Conclusions: We identified the different benefits that users perceived from a novel DMHI and opportunities to improve the platform. Interestingly, we did not note any differences in themes between those who improved and those who did not, but we did find some differences between those who received the control and intervention versions of the platform. Future research should continue to investigate users’ experiences with DMHIs to better understand the complex dynamics of their use and outcomes. %M 37338967 %R 10.2196/46062 %U https://formative.jmir.org/2023/1/e46062 %U https://doi.org/10.2196/46062 %U http://www.ncbi.nlm.nih.gov/pubmed/37338967 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e42573 %T Computerized Cognitive Behavioral Therapy for Anxiety and Depression in Farming Communities: Mixed Methods Feasibility Study of Participant Use and Acceptability %A Bowyer,Harriet L %A Pegler,Ruth %A Williams,Christopher %+ Department of Psychology, Glasgow Caledonian University, Cowcaddens Rd, Glasgow, G4 0BA, United Kingdom, 44 1413318630, harriet.bowyer@gcu.ac.uk %K computerized cognitive behavioral therapy %K cCBT %K cognitive behavioral therapy %K CBT %K farmer %K depression %D 2023 %7 19.6.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Farmers have higher rates of depression than nonfarmers and higher rates of suicide than the general population. Several barriers to help seeking have been identified in farmers, which may be overcome by offering web-based mental health support. Computerized cognitive behavioral therapy (cCBT) is an effective intervention used to prevent and treat mild to moderate depression but has not been evaluated in the farming community. Objective: This study explored the feasibility of delivering a cCBT course tailored to farmers using a mixed methods approach. Methods: Farmers (aged ≥18 years) with no, minimal, or moderately severe depressive symptoms (Patient Health Questionnaire–9 [PHQ-9] score <20) were recruited using web-based and offline advertisements and given access to a cCBT course consisting of 5 core modules and automated and personalized email support. Depression (PHQ-9), anxiety (General Anxiety Disorder–7), and social functioning (Work and Social Adjustment Scale) were measured at baseline and the 8-week follow-up. Wilcoxon signed rank tests assessed changes in scores for all outcome measures over time. Telephone interviews focusing on participant use and satisfaction with the course were analyzed using thematic analysis. Results: Overall, 56 participants were recruited; 27 (48%) through social media. Overall, 62% (35/56) of participants logged into the course. At baseline, almost half of the participants reported experiencing minimal depressive symptoms (25/56, 45%) and mild anxiety (25/56, 45%), and just over half (30/56, 54%) reported mild to moderate functional impairment. Posttreatment data were available for 27% (15/56) of participants (41/56, 73% attrition rate). On average, participants experienced fewer depressive symptoms (P=.38) and less functional impairment (P=.26) at the 8-week follow-up; these results were not statistically significant. Participants experienced significantly fewer symptoms of anxiety at the 8-week follow-up (P=.02). Most participants (13/14, 93%) found the course helpful and easy to access (10/13, 77%) and the email support helpful (12/14, 86%). Qualitative interviews identified heavy workloads and mental health stigma within the farming community as barriers to help seeking. Participants thought that web-based support would be helpful, being convenient and anonymous. There were concerns that older farmers and those with limited internet connections may have difficulty accessing the course. Improvements regarding the layout and content of the course were suggested. Dedicated support from someone with farming knowledge was recommended to improve retention. Conclusions: cCBT may be a convenient way of supporting mental health within farming communities. However, challenges in recruiting and retaining farmers may indicate that cCBT supported only by email may not be an acceptable mode of mental health care delivery for many; however, it was valued by respondents. Involving farming organizations in planning, recruitment, and support may address these issues. Mental health awareness campaigns targeting farming communities may also help reduce stigma and improve recruitment and retention. %M 37335597 %R 10.2196/42573 %U https://formative.jmir.org/2023/1/e42573 %U https://doi.org/10.2196/42573 %U http://www.ncbi.nlm.nih.gov/pubmed/37335597 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e41590 %T Feasibility and Preliminary Efficacy of Digital Interventions for Depressive Symptoms in Working Adults: Multiarm Randomized Controlled Trial %A Taylor,Rachael Wallis %A Male,Rhian %A Economides,Marcos %A Bolton,Heather %A Cavanagh,Kate %+ Unmind Ltd, 180 Borough High Street, London, SE1 1LB, United Kingdom, 44 7814522979, rachaelwtaylor@gmail.com %K depression %K digital intervention %K randomized controlled trial %K RCT %K cognitive behavioral therapy %K CBT %K acceptance and commitment therapy %K ACT %K behavioral activation %K BA %K mobile phone %D 2023 %7 16.6.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Depressive symptoms are highly prevalent and have broad-ranging negative implications. Digital interventions are increasingly available in the workplace context, but supporting evidence is limited. Objective: This study aimed to evaluate the feasibility, acceptability, and preliminary efficacy of 3 digital interventions for depressive symptoms in a sample of UK-based working adults experiencing mild to moderate symptoms. Methods: This was a parallel, multiarm, pilot randomized controlled trial. Participants were allocated to 1 of 3 digital interventions or a waitlist control group and had 3 weeks to complete 6 to 8 short self-guided sessions. The 3 interventions are available on the Unmind mental health app for working adults and draw on behavioral activation, cognitive behavioral therapy, and acceptance and commitment therapy. Web-based assessments were conducted at baseline, postintervention (week 3), and at 1-month follow-up (week 7). Participants were recruited via Prolific, a web-based recruitment platform, and the study was conducted entirely on the web. Feasibility and acceptability were assessed using objective engagement data and self-reported feedback. Efficacy outcomes were assessed using validated self-report measures of mental health and functioning and linear mixed models with intention-to-treat principles. Results: In total, 2003 individuals were screened for participation, of which 20.22% (405/2003) were randomized. A total of 92% (373/405) of the participants were retained in the study, 97.4% (295/303) initiated their allocated intervention, and 66.3% (201/303) completed all sessions. Moreover, 80.6% (229/284) of the participants rated the quality of their allocated intervention as excellent or good, and 79.6% (226/284) of the participants were satisfied or very satisfied with their intervention. All active groups showed improvements in well-being, functioning, and depressive and anxiety symptoms compared with the control group, which were maintained at 4 weeks. Hedges g effect sizes for depressive symptoms ranged from −0.53 (95% CI −0.25 to −0.81) to −0.74 (95% CI −0.45 to −1.03). Conclusions: All interventions were feasible and acceptable, and the preliminary efficacy findings indicated that their use may improve depressive symptoms, well-being, and functioning. The predefined criteria for a definitive trial were met. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) ISRCTN13067492; https://www.isrctn.com/ISRCTN13067492 %M 37327027 %R 10.2196/41590 %U https://formative.jmir.org/2023/1/e41590 %U https://doi.org/10.2196/41590 %U http://www.ncbi.nlm.nih.gov/pubmed/37327027 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45100 %T Positive Psychological Intervention Delivered Using Virtual Reality in Patients on Hemodialysis With Comorbid Depression: Protocol and Design for the Joviality Randomized Controlled Trial %A Hernandez,Rosalba %A Wilund,Ken %A Solai,Killivalavan %A Tamayo,David %A Fast,Drew %A Venkatesan,Prasakthi %A Lash,James P %A Lora,Claudia M %A Martinez,Lizet %A Martin Alemañy,Geovana %A Martinez,Angela %A Kwon,Soonhyung %A Romero,Dana %A Browning,Matthew H E M %A Moskowitz,Judith T %+ Department of Population Health Nursing Science, College of Nursing, University of Illinois Chicago, 845 S Damen Ave, MC 802, Chicago, IL, 60612, United States, 1 3129965706, rherna17@uic.edu %K virtual reality %K hemodialysis %K positive psychology %K emotional well-being %K mindfulness %K depression %K comorbid depression %D 2023 %7 16.6.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is highly prevalent in individuals on hemodialysis, but it is infrequently identified and remains undertreated. In this paper, we present details of the methodology of a randomized controlled trial (RCT) aimed at testing the feasibility and preliminary efficacy of a 5-week positive psychological intervention in individuals on hemodialysis with comorbid depression delivered using immersive virtual reality (VR) technology. Objective: We aim to describe the protocol and design of the Joviality trial whose main objectives are 2-fold: determine the feasibility of the Joviality VR software through metrics capturing rates of recruitment, refusal, retention, noncompliance, and adherence, as well as end-user feedback; and assess preliminary efficacy for outcomes measures of depressive symptoms, psychological well-being and distress, quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalizations. Methods: This 2-arm RCT is scheduled to enroll 84 individuals on hemodialysis with comorbid depression from multiple outpatient centers in Chicago, Illinois, United States. Enrollees will be randomized to the following groups: VR-based Joviality positive psychological intervention or sham VR (2D wildlife footage and nature-based settings with inert music presented using a head-mounted display). To be eligible, individuals must be on hemodialysis for at least 3 months, have Beck Depression Inventory-II scores of ≥11 (ie, indicative of mild-to-severe depressive symptoms), be aged ≥21 years, and be fluent in English or Spanish. The Joviality VR software was built using agile design principles and incorporates fully immersive content, digital avatars, and multiplex features of interactability. Targeted skills of the intervention include noticing positive events, positive reappraisal, gratitude, acts of kindness, and mindful or nonjudgmental awareness. The primary outcomes include metrics of feasibility and acceptability, along with preliminary efficacy focused on decreasing symptoms of depression. The secondary and tertiary outcomes include quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalization rates. There are 4 assessment time points: baseline, immediately after the intervention, 3 months after the intervention, and 6 months after the intervention. We hypothesize that depressive symptoms and hemodialysis-related markers of disease will substantially improve in participants randomized to the VR-based Joviality positive psychology treatment arm compared with those in the attention control condition. Results: This RCT is funded by the National Institute of Diabetes and Digestive and Kidney Diseases and is scheduled to commence participant recruitment in June 2023. Conclusions: This trial will be the first to test custom-built VR software to deliver a positive psychological intervention, chairside, in individuals on hemodialysis to reduce symptoms of depression. Within the context of an RCT using an active control arm, if proven effective, VR technology may become a potent tool to deliver mental health programming in clinical populations during their outpatient treatment sessions. Trial Registration: ClinicalTrials.gov NCT05642364; https://clinicaltrials.gov/ct2/show/NCT05642364 International Registered Report Identifier (IRRID): PRR1-10.2196/45100 %M 37327026 %R 10.2196/45100 %U https://www.researchprotocols.org/2023/1/e45100 %U https://doi.org/10.2196/45100 %U http://www.ncbi.nlm.nih.gov/pubmed/37327026 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e46244 %T The Detection of Acute Risk of Self-injury Project: Protocol for an Ecological Momentary Assessment Study Among Individuals Seeking Treatment %A Kiekens,Glenn %A Claes,Laurence %A Schoefs,Steffie %A Kemme,Nian D F %A Luyckx,Koen %A Kleiman,Evan M %A Nock,Matthew K %A Myin-Germeys,Inez %+ Faculty of Psychology and Educational Sciences, KU Leuven, Tiensestraat 102, box 3720, Leuven, 3000, Belgium, 32 16372852, glenn.kiekens@kuleuven.be %K nonsuicidal self-injury %K suicidal thoughts and behaviors %K real-time %K experience sampling %K ecological momentary assessment %K digital interventions %K mobile phone %D 2023 %7 15.6.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Nonsuicidal self-injury (NSSI) is a major mental health concern. Despite increased research efforts on establishing the prevalence and correlates of the presence and severity of NSSI, we still lack basic knowledge of the course, predictors, and relationship of NSSI with other self-damaging behaviors in daily life. Such information will be helpful for better informing mental health professionals and allocating treatment resources. The DAILY (Detection of Acute rIsk of seLf-injurY) project will address these gaps among individuals seeking treatment. Objective: This protocol paper presents the DAILY project’s aims, design, and materials used. The primary objectives are to advance understanding of (1) the short-term course and contexts of elevated risk for NSSI thoughts, urges, and behavior; (2) the transition from NSSI thoughts and urges to NSSI behavior; and (3) the association of NSSI with disordered eating, substance use, and suicidal thoughts and behaviors. A secondary aim is to evaluate the perspectives of individuals seeking treatment and mental health professionals regarding the feasibility, scope, and utility of digital self-monitoring and interventions that target NSSI in daily life. Methods: The DAILY project is funded by the Research Foundation Flanders (Belgium). Data collection involves 3 phases: a baseline assessment (phase 1), 28 days of ecological momentary assessment (EMA) followed by a clinical session and feedback survey (phase 2), and 2 follow-up surveys and an optional interview (phase 3). The EMA protocol consists of regular EMA surveys (6 times per day), additional burst EMA surveys spaced at a higher frequency when experiencing intense NSSI urges (3 surveys within 30 minutes), and event registrations of NSSI behavior. The primary outcomes are NSSI thoughts, NSSI urges, self-efficacy to resist NSSI, and NSSI behavior, with disordered eating (restrictive eating, binge eating, and purging), substance use (binge drinking and smoking cannabis), and suicidal thoughts and behaviors surveyed as secondary outcomes. The assessed predictors include emotions, cognitions, contextual information, and social appraisals. Results: We will recruit approximately 120 individuals seeking treatment aged 15 to 39 years from mental health services across the Flanders region of Belgium. Recruitment began in June 2021 and data collection is anticipated to conclude in August 2023. Conclusions: The findings of the DAILY project will provide a detailed characterization of the short-term course and patterns of risk for NSSI and advance understanding of how, why, and when NSSI and other self-damaging behaviors unfold among individuals seeking treatment. This will inform clinical practice and provide the scientific building blocks for novel intervention approaches outside of the therapy room that support people who self-injure in real time. International Registered Report Identifier (IRRID): DERR1-10.2196/46244 %M 37318839 %R 10.2196/46244 %U https://www.researchprotocols.org/2023/1/e46244 %U https://doi.org/10.2196/46244 %U http://www.ncbi.nlm.nih.gov/pubmed/37318839 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45135 %T Efficacy of a Digital Mental Health Biopsychosocial Transdiagnostic Intervention With or Without Therapist Assistance for Adults With Anxiety and Depression: Adaptive Randomized Controlled Trial %A Andrews,Brooke %A Klein,Britt %A Van Nguyen,Huy %A Corboy,Denise %A McLaren,Suzanne %A Watson,Shaun %+ Health Innovation & Transformation Centre, Federation University Australia, University Drive, Mt Helen Victoria, Ballarat, 3350, Australia, 61 53279623 ext 9623, b.andrews@federation.edu.au %K video chat therapy %K therapist assistance %K self-help %K transdiagnostic %K digital intervention %K anxiety %K depression %K comorbidity %D 2023 %7 12.6.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital mental health (DMH) interventions incorporating elements that adapt to the evolving needs of consumers have the potential to further our understanding of the optimal intensity of therapist assistance and inform stepped-care models. Objective: The primary objective was to compare the efficacy of a transdiagnostic biopsychosocial DMH program, with or without therapist assistance for adults with subthreshold symptoms or a diagnosis of anxiety or depression. Methods: In a randomized adaptive clinical trial design, all participants had access to the DMH program, with eligibility to have their program augmented with therapist assistance determined by program engagement or symptom severity. Participants who met stepped-care criteria were randomized to have their treatment program augmented with either low-intensity (10 min/week of video chat support for 7 weeks) or high-intensity (50 min/week of video chat support for 7 weeks) therapist assistance. A total of 103 participants (mean age 34.17, SD 10.50 years) were assessed before (week 0), during (weeks 3 and 6), and after the intervention (week 9) and at the 3-month follow-up (week 21). The effects of 3 treatment conditions (DMH program only, DMH program+low-intensity therapist assistance, and DMH program+high-intensity therapist assistance) on changes in the 2 primary outcomes of anxiety (7-item Generalized Anxiety Disorder Scale [GAD-7]) and depression (9-item Patient Health Questionnaire [PHQ-9]) were assessed using the Cohen d, reliable change index, and mixed-effects linear regression analyses. Results: There were no substantial differences in the outcome measures among intervention conditions. However, there were significant time effect changes in most outcomes over time. All 3 intervention conditions demonstrated strong and significant treatment effect changes in GAD-7 and PHQ-9 scores, with absolute Cohen d values ranging from 0.82 to 1.79 (all P<.05). The mixed-effects models revealed that, in the Life Flex program–only condition at week 3, mean GAD-7 and PHQ-9 scores significantly decreased from baseline by 3.54 and 4.38 (all P<.001), respectively. At weeks 6, 9, and 21, GAD-7 and PHQ-9 scores significantly decreased from baseline by at least 6 and 7 points (all P<.001), respectively. Nonresponders at week 3 who were stepped up to therapist assistance increased program engagement and treatment response. At the postintervention time point and 3-month follow-up, 67% (44/65) and 69% (34/49) of the participants, respectively, no longer met diagnostic criteria for anxiety or depression. Conclusions: The findings highlight that early detection of low engagement and non–treatment response presents an opportunity to effectively intervene by incorporating an adaptive design. Although the study findings indicate that therapist assistance was no more effective than the DMH intervention program alone for reducing symptoms of anxiety or depression, the data highlight the potential influence of participant selection bias and participant preferences within stepped-care treatment models. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620000422921; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378317&isReview=true International Registered Report Identifier (IRRID): RR2-10.2196/45040 %M 37307046 %R 10.2196/45135 %U https://www.jmir.org/2023/1/e45135 %U https://doi.org/10.2196/45135 %U http://www.ncbi.nlm.nih.gov/pubmed/37307046 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e45234 %T Promoting Engagement With Smartphone Apps for Suicidal Ideation in Young People: Development of an Adjunctive Strategy Using a Lived Experience Participatory Design Approach %A Gan,Daniel Z Q %A McGillivray,Lauren %A Larsen,Mark Erik %A Bloomfield,Taylor %A Torok,Michelle %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney, NSW 2031, Australia, 61 423828945, danielzqgan@gmail.com %K eHealth %K digital mental health %K smartphone app %K engagement %K youth suicide prevention %K qualitative methods %K suicide %K development %K youth %K mental health %K support %K user-centered %K design %K survey %K interview %K prototype %K prevention %K participatory design %K mobile phone %D 2023 %7 6.6.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Suicide among young people is a worrying public health concern. Despite this, there is a lack of suitable interventions aligned with the needs of this priority population. Emerging evidence supports the effectiveness of digital interventions in alleviating the severity of suicidal thoughts. However, their efficacy may be undermined by poor engagement. Technology-supported strategies (eg, electronic prompts and reminders) have been deployed alongside digital interventions to increase engagement with the latter. However, evidence of their efficacy is inconclusive. User-centered design approaches may be key to developing feasible and effective engagement strategies. Currently, no study has been published on how such an approach might be expressly applied toward developing strategies for promoting engagement with digital interventions. Objective: This study aimed to detail the processes and activities involved in developing an adjunctive strategy for promoting engagement with LifeBuoy—a smartphone app that helps young people manage suicidal thoughts. Methods: Development of the engagement strategy took place in 2 phases. The discovery phase aimed to create an initial prototype by synthesizing earlier findings—from 2 systematic reviews and a cross-sectional survey of the broader mental health app user population—with qualitative insights from LifeBuoy users. A total of 16 web-based interviews were conducted with young people who participated in the LifeBuoy trial. Following the discovery phase, 3 interviewees were invited by the research team to take part in the workshops in the design phase, which sought to create a final prototype by making iterative improvements to the initial prototype. These improvements were conducted over 2 workshops. Thematic analysis was used to analyze the qualitative data obtained from the interviews and workshops. Results: Main themes from the interviews centered around the characteristics of the strategy, timing of notifications, and suitability of social media platforms. Subsequently, themes that emerged from the design workshops emphasized having a wider variety of content, greater visual consistency with LifeBuoy, and a component with more detailed information to cater to users with greater informational needs. Thus, refinements to the prototype were focused on (1) improving the succinctness, variety, and practical value of Instagram content, (2) creating a blog containing articles contributed by mental health professionals and young people with lived experience of suicide, and (3) standardizing the use of marine-themed color palettes across the Instagram and blog components. Conclusions: This is the first study to describe the development of a technology-supported adjunctive strategy for promoting engagement with a digital intervention. It was developed by integrating perspectives from end users with lived experience of suicide with evidence from the existing literature. The development process documented in this study may be useful for guiding similar projects aimed at supporting the use of digital interventions for suicide prevention or mental health. %M 37279058 %R 10.2196/45234 %U https://formative.jmir.org/2023/1/e45234 %U https://doi.org/10.2196/45234 %U http://www.ncbi.nlm.nih.gov/pubmed/37279058 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e47225 %T Public Surveillance of Social Media for Suicide Using Advanced Deep Learning Models in Japan: Time Series Study From 2012 to 2022 %A Wang,Siqin %A Ning,Huan %A Huang,Xiao %A Xiao,Yunyu %A Zhang,Mengxi %A Yang,Ellie Fan %A Sadahiro,Yukio %A Liu,Yan %A Li,Zhenlong %A Hu,Tao %A Fu,Xiaokang %A Li,Zi %A Zeng,Ye %+ Graduate School of Interdisciplinary Information Studies, University of Tokyo, 7 Chome-3 Hongo, Bunkyo City, Tokyo, 113-0033, Japan, 81 358415938, sisiplanner@gmail.com %K suicide %K suicidal ideation %K suicide-risk identification %K natural language processing %K social media %K Japan %D 2023 %7 2.6.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Social media platforms have been increasingly used to express suicidal thoughts, feelings, and acts, raising public concerns over time. A large body of literature has explored the suicide risks identified by people’s expressions on social media. However, there is not enough evidence to conclude that social media provides public surveillance for suicide without aligning suicide risks detected on social media with actual suicidal behaviors. Corroborating this alignment is a crucial foundation for suicide prevention and intervention through social media and for estimating and predicting suicide in countries with no reliable suicide statistics. Objective: This study aimed to corroborate whether the suicide risks identified on social media align with actual suicidal behaviors. This aim was achieved by tracking suicide risks detected by 62 million tweets posted in Japan over a 10-year period and assessing the locational and temporal alignment of such suicide risks with actual suicide behaviors recorded in national suicide statistics. Methods: This study used a human-in-the-loop approach to identify suicide-risk tweets posted in Japan from January 2013 to December 2022. This approach involved keyword-filtered data mining, data scanning by human efforts, and data refinement via an advanced natural language processing model termed Bidirectional Encoder Representations from Transformers. The tweet-identified suicide risks were then compared with actual suicide records in both temporal and spatial dimensions to validate if they were statistically correlated. Results: Twitter-identified suicide risks and actual suicide records were temporally correlated by month in the 10 years from 2013 to 2022 (correlation coefficient=0.533; P<.001); this correlation coefficient is higher at 0.652 when we advanced the Twitter-identified suicide risks 1 month earlier to compare with the actual suicide records. These 2 indicators were also spatially correlated by city with a correlation coefficient of 0.699 (P<.001) for the 10-year period. Among the 267 cities with the top quintile of suicide risks identified from both tweets and actual suicide records, 73.5% (n=196) of cities overlapped. In addition, Twitter-identified suicide risks were at a relatively lower level after midnight compared to a higher level in the afternoon, as well as a higher level on Sundays and Saturdays compared to weekdays. Conclusions: Social media platforms provide an anonymous space where people express their suicidal thoughts, ideation, and acts. Such expressions can serve as an alternative source to estimating and predicting suicide in countries without reliable suicide statistics. It can also provide real-time tracking of suicide risks, serving as an early warning for suicide. The identification of areas where suicide risks are highly concentrated is crucial for location-based mental health planning, enabling suicide prevention and intervention through social media in a spatially and temporally explicit manner. %M 37267022 %R 10.2196/47225 %U https://www.jmir.org/2023/1/e47225 %U https://doi.org/10.2196/47225 %U http://www.ncbi.nlm.nih.gov/pubmed/37267022 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44673 %T Skill Enactment and Knowledge Acquisition in Digital Cognitive Behavioral Therapy for Depression and Anxiety: Systematic Review of Randomized Controlled Trials %A Jackson,Hayley M %A Calear,Alison L %A Batterham,Philip J %A Ohan,Jeneva L %A Farmer,Glenda M %A Farrer,Louise M %+ Centre for Mental Health Research, National Centre for Epidemiology and Population Health, The Australian National University, 63 Eggleston Road, Acton ACT, 2601, Australia, 61 416913323, hayley.jackson@anu.edu.au %K cognitive behavioral therapy %K technology %K engagement %K skill enactment %K knowledge acquisition %K depression %K anxiety %K adults %K young people %K systematic review %K mobile phone %D 2023 %7 31.5.2023 %9 Review %J J Med Internet Res %G English %X Background: Digital cognitive behavioral therapy (CBT) interventions can effectively prevent and treat depression and anxiety, but engagement with these programs is often low. Although extensive research has evaluated program use as a proxy for engagement, the extent to which users acquire knowledge and enact skills from these programs has been largely overlooked. Objective: This study aimed to investigate how skill enactment and knowledge acquisition have been measured, evaluate postintervention changes in skill enactment and knowledge acquisition, examine whether mental health outcomes are associated with skill enactment or knowledge acquisition, and evaluate predictors of skill enactment and knowledge acquisition. Methods: PubMed, PsycINFO, and Cochrane CENTRAL were searched for randomized controlled trials (RCTs) published between January 2000 and July 2022. We included RCTs comparing digital CBT with any comparison group in adolescents or adults (aged ≥12 years) for anxiety or depression. Eligible studies reported quantitative measures of skill enactment or knowledge acquisition. The methodological quality of the studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for RCTs. Narrative synthesis was used to address the review questions. Results: In total, 43 papers were included, of which 29 (67%) reported a skill enactment measure and 15 (35%) reported a knowledge acquisition measure. Skill enactment was typically operationalized as the frequency of enacting skills using the completion of in-program activities (ie, formal skill enactment; 13/29, 45%) and intervention-specific (9/29, 31%) or standardized (8/29, 28%) questionnaires. Knowledge measures included tests of CBT knowledge (6/15, 40%) or mental health literacy (5/15, 33%) and self-report questionnaires (6/15, 40%). In total, 17 studies evaluated postintervention changes in skill enactment or knowledge acquisition, and findings were mostly significant for skill enactment (6/8, 75% of the studies), CBT knowledge (6/6, 100%), and mental health literacy (4/5, 80%). Of the 12 studies that evaluated the association between skill enactment and postintervention mental health outcomes, most reported ≥1 significant positive finding on standardized questionnaires (4/4, 100%), formal skill enactment indicators (5/7, 71%), or intervention-specific questionnaires (1/1, 100%). None of the 4 studies that evaluated the association between knowledge acquisition and primary mental health outcomes reported significant results. A total of 13 studies investigated predictors of skill enactment; only type of guidance and improvements in psychological variables were associated with increased skill enactment in ≥2 analyses. Predictors of knowledge acquisition were evaluated in 2 studies. Conclusions: Digital CBT for depression and anxiety can improve skill enactment and knowledge acquisition. However, only skill enactment appears to be associated with mental health outcomes, which may depend on the type of measure examined. Additional research is needed to understand what types and levels of skill enactment and knowledge acquisition are most relevant for outcomes and identify predictors of these constructs. Trial Registration: PROSPERO CRD42021275270; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=275270 %M 37256673 %R 10.2196/44673 %U https://www.jmir.org/2023/1/e44673 %U https://doi.org/10.2196/44673 %U http://www.ncbi.nlm.nih.gov/pubmed/37256673 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e43385 %T A Fully Automated Self-help Biopsychosocial Transdiagnostic Digital Intervention to Reduce Anxiety and/or Depression and Improve Emotional Regulation and Well-being: Pre–Follow-up Single-Arm Feasibility Trial %A Klein,Britt %A Nguyen,Huy %A McLaren,Suzanne %A Andrews,Brooke %A Shandley,Kerrie %+ Health Innovation & Transformation Centre, Federation University Australia, PO Box 663, Ballarat, 3353, Australia, 61 353276717, b.klein@federation.edu.au %K anxiety %K depression %K fully automated %K self-help %K digital intervention %K transdiagnostic %K biopsychosocial %K emotion regulation %K allostatic load %K brain plasticity %K positive affect %K comorbidity %D 2023 %7 30.5.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Anxiety disorders and depression are prevalent disorders with high comorbidity, leading to greater chronicity and severity of symptoms. Given the accessibility to treatment issues, more evaluation is needed to assess the potential benefits of fully automated self-help transdiagnostic digital interventions. Innovating beyond the current transdiagnostic one-size-fits-all shared mechanistic approach may also lead to further improvements. Objective: The primary objective of this study was to explore the preliminary effectiveness and acceptability of a new fully automated self-help biopsychosocial transdiagnostic digital intervention (Life Flex) aimed at treating anxiety and/or depression, as well as improving emotional regulation; emotional, social, and psychological well-being; optimism; and health-related quality of life. Methods: This was a real-world pre-during-post-follow-up feasibility trial design evaluation of Life Flex. Participants were assessed at the preintervention time point (week 0), during intervention (weeks 3 and 5), at the postintervention time point (week 8), and at 1- and 3-month follow-ups (weeks 12 and 20, respectively). Results: The results provided early support for the Life Flex program in reducing anxiety (Generalized Anxiety Disorder 7), depression (Patient Health Questionnaire 9), psychological distress (Kessler 6), and emotional dysregulation (Difficulties in Emotional Regulation 36) and increasing emotional, social, and psychological well-being (Mental Health Continuum—Short Form); optimism (Revised Life Orientation Test); and health-related quality of life (EQ-5D-3L Utility Index and Health Rating; all false discovery rate [FDR]<.001). Large within-group treatment effect sizes (range |d|=0.82 to 1.33) were found for most variables from pre- to postintervention assessments and at the 1- and 3-month follow-up. The exceptions were medium treatment effect sizes for EQ-5D-3L Utility Index (range Cohen d=−0.50 to −0.63) and optimism (range Cohen d=−0.72 to −0.79) and small-to-medium treatment effect size change for EQ-5D-3L Health Rating (range Cohen d=−0.34 to −0.58). Changes across all outcome variables were generally strongest for participants with preintervention clinical comorbid anxiety and depression presentations (range |d|=0.58 to 2.01) and weakest for participants presenting with nonclinical anxiety and/or depressive symptoms (|d|=0.05 to 0.84). Life Flex was rated as acceptable at the postintervention time point, and participants indicated that they enjoyed the transdiagnostic program and biological, wellness, and lifestyle-focused content and strategies. Conclusions: Given the paucity of evidence on fully automated self-help transdiagnostic digital interventions for anxiety and/or depressive symptomatology and general treatment accessibility issues, this study provides preliminary support for biopsychosocial transdiagnostic interventions, such as Life Flex, as a promising future mental health service delivery gap filler. Following large-scale, randomized controlled trials, the potential benefits of fully automated self-help digital health programs, such as Life Flex, could be considerable. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12615000480583; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368007 %M 37252790 %R 10.2196/43385 %U https://formative.jmir.org/2023/1/e43385 %U https://doi.org/10.2196/43385 %U http://www.ncbi.nlm.nih.gov/pubmed/37252790 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e40163 %T The Use of Photoplethysmography in the Assessment of Mental Health: Scoping Review %A Lyzwinski,Lynnette Nathalie %A Elgendi,Mohamed %A Menon,Carlo %+ Biomedical and Mobile Health Technology Lab, Department of Health Sciences and Technology, ETH Zurich, Lengghalde 5, Zurich, 8008, Switzerland, 41 44 510 72 2, carlo.menon@hest.ethz.ch %K photoplethysmography %K PPG %K mental health %K depression %K anxiety %K suicide %K mobile phone %D 2023 %7 29.5.2023 %9 Review %J JMIR Ment Health %G English %X Background: With the rise in mental health problems globally, mobile health provides opportunities for timely medical care and accessibility. One emerging area of mobile health involves the use of photoplethysmography (PPG) to assess and monitor mental health. Objective: In recent years, there has been an increase in the use of PPG-based technology for mental health. Therefore, we conducted a review to understand how PPG has been evaluated to assess a range of mental health and psychological problems, including stress, depression, and anxiety. Methods: A scoping review was performed using PubMed and Google Scholar databases. Results: A total of 24 papers met the inclusion criteria and were included in this review. We identified studies that assessed mental health via PPG using finger- and face-based methods as well as smartphone-based methods. There was variation in study quality. PPG holds promise as a potential complementary technology for detecting changes in mental health, including depression and anxiety. However, rigorous validation is needed in diverse clinical populations to advance PPG technology in tackling mental health problems. Conclusions: PPG holds promise for assessing mental health problems; however, more research is required before it can be widely recommended for clinical use. %M 37247209 %R 10.2196/40163 %U https://mental.jmir.org/2023/1/e40163 %U https://doi.org/10.2196/40163 %U http://www.ncbi.nlm.nih.gov/pubmed/37247209 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e41643 %T Internet-Based Behavioral Activation for Depression: Systematic Review and Meta-Analysis %A Alber,Carolin Sophie %A Krämer,Lena Violetta %A Rosar,Sophia Marie %A Mueller-Weinitschke,Claudia %+ Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Engelbergerstraße 41, Freiburg, 79085, Germany, 49 (0)761 203 9439, claudia.mueller-weinitschke@psychologie.uni-freiburg.de %K behavioral activation %K depression %K systematic review %K meta-analysis %K internet- and mobile-based intervention %D 2023 %7 25.5.2023 %9 Review %J J Med Internet Res %G English %X Background: Behavioral activation is an effective treatment for reducing depression. As depressive disorders affect many people worldwide, internet-based behavioral activation (iBA) could provide enhanced treatment access. Objective: This study aimed to investigate whether iBA is effective in reducing depressive symptoms and to assess the impact on secondary outcomes. Methods: We systematically searched MEDLINE, PsycINFO, PSYNDEX, and CENTRAL up to December 2021 for eligible randomized controlled trials. In addition, a reference search was conducted. Title and abstract screening, as well as a full-text screening, was conducted by 2 independent reviewers. Randomized controlled trials that investigated the effectiveness of iBA for depression as a treatment or main component were included. Randomized controlled trials had to report depressive symptoms, with a quantitative outcome measure and assess an adult population with depressive symptoms above cutoff. Two independent reviewers performed the data extraction and risk of bias assessment. Data were pooled in random-effects meta-analyses. The primary outcome was self-reported depressive symptoms posttreatment. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Results: A total of 12 randomized controlled trials, with 3274 participants (88% female, 43.61 years) were included. iBA was more effective in reducing depressive symptom severity posttreatment than inactive control groups (standardized mean difference −0.49; 95% CI −0.63 to −0.34; P<.001). The overall level of heterogeneity was moderate to substantial (I2=53%). No significant effect of iBA on depressive symptoms could be found at 6-month follow-up. Participants assigned to iBA also experienced a significant reduction of anxiety and a significant increase in quality of life and activation compared to the inactive control groups. The results remained robust in multiple sensitivity analyses. The risk of bias assessment revealed at least some concerns for all studies, and there was evidence of slight publication bias. Conclusions: This systematic review and meta-analysis implies that iBA is effective in reducing depressive symptoms. It represents a promising treatment option, providing treatment access where no treatment is available yet. Trial Registration: International Prospective Register of Systematic Reviews CRD42021236822; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=236822 %M 37227760 %R 10.2196/41643 %U https://www.jmir.org/2023/1/e41643 %U https://doi.org/10.2196/41643 %U http://www.ncbi.nlm.nih.gov/pubmed/37227760 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e45991 %T Prediction of Diagnosis and Treatment Response in Adolescents With Depression by Using a Smartphone App and Deep Learning Approaches: Usability Study %A Kim,Jae Sung %A Wang,Bohyun %A Kim,Meelim %A Lee,Jung %A Kim,Hyungjun %A Roh,Danyeul %A Lee,Kyung Hwa %A Hong,Soon-Beom %A Lim,Joon Shik %A Kim,Jae-Won %A Ryan,Neal %+ Division of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea, 82 2 2072 3648, kimjw412@snu.ac.kr %K major depressive disorder %K adolescent %K deep learning %K smart health care %K suicide %K risk factor %K antidepressant treatment %K depression %K machine learning %K smartphone %K mobile health %K mHealth %D 2023 %7 24.5.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Lack of quantifiable biomarkers is a major obstacle in diagnosing and treating depression. In adolescents, increasing suicidality during antidepressant treatment further complicates the problem. Objective: We sought to evaluate digital biomarkers for the diagnosis and treatment response of depression in adolescents through a newly developed smartphone app. Methods: We developed the Smart Healthcare System for Teens At Risk for Depression and Suicide app for Android-based smartphones. This app passively collected data reflecting the social and behavioral activities of adolescents, such as their smartphone usage time, physical movement distance, and the number of phone calls and text messages during the study period. Our study consisted of 24 adolescents (mean age 15.4 [SD 1.4] years, 17 girls) with major depressive disorder (MDD) diagnosed with Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version and 10 healthy controls (mean age 13.8 [SD 0.6] years, 5 girls). After 1 week’s baseline data collection, adolescents with MDD were treated with escitalopram in an 8-week, open-label trial. Participants were monitored for 5 weeks, including the baseline data collection period. Their psychiatric status was measured every week. Depression severity was measured using the Children’s Depression Rating Scale-Revised and Clinical Global Impressions-Severity. The Columbia Suicide Severity Rating Scale was administered in order to assess suicide severity. We applied the deep learning approach for the analysis of the data. Deep neural network was employed for diagnosis classification, and neural network with weighted fuzzy membership functions was used for feature selection. Results: We could predict the diagnosis of depression with training accuracy of 96.3% and 3-fold validation accuracy of 77%. Of the 24 adolescents with MDD, 10 responded to antidepressant treatments. We predicted the treatment response of adolescents with MDD with training accuracy of 94.2% and 3-fold validation accuracy of 76%. Adolescents with MDD tended to move longer distances and use smartphones for longer periods of time compared to controls. The deep learning analysis showed that smartphone usage time was the most important feature in distinguishing adolescents with MDD from controls. Prominent differences were not observed in the pattern of each feature between the treatment responders and nonresponders. The deep learning analysis revealed that the total length of calls received as the most important feature predicting antidepressant response in adolescents with MDD. Conclusions: Our smartphone app demonstrated preliminary evidence of predicting diagnosis and treatment response in depressed adolescents. This is the first study to predict the treatment response of adolescents with MDD by examining smartphone-based objective data with deep learning approaches. %M 37223978 %R 10.2196/45991 %U https://formative.jmir.org/2023/1/e45991 %U https://doi.org/10.2196/45991 %U http://www.ncbi.nlm.nih.gov/pubmed/37223978 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e45543 %T Evaluating the Modified Patient Health Questionnaire-2 and Insomnia Severity Index-2 for Daily Digital Screening of Depression and Insomnia: Validation Study %A Oh,Jae Won %A Kim,Sun Mi %A Lee,Deokjong %A Son,Nak-Hoon %A Uh,Jinsun %A Yoon,Ju Hong %A Choi,Yukyung %A Lee,San %+ Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, 363 Dongbaekjukjeondaero, Jung-dong, Giheung-gu, Yongin, 16995, Republic of Korea, 82 031 5189 8531, sanlee@yonsei.ac.kr %K Patient Health Questionnaire-2 %K PHQ-2 %K Insomnia Severity Index %K ISI-2 %K depression %K insomnia %K mobile health %K mobile phone %D 2023 %7 22.5.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: The Patient Health Questionnaire-2 (PHQ-2) and Insomnia Severity Index-2 (ISI-2) are screening assessments that reflect the past 2-week experience of depression and insomnia, respectively. Retrospective assessment has been associated with reduced accuracy owing to recall bias. Objective: This study aimed to increase the reliability of responses by validating the use of the PHQ-2 and ISI-2 for daily screening. Methods: A total of 167 outpatients from the psychiatric department at the Yongin Severance Hospital participated in this study, of which 63 (37.7%) were male and 104 (62.3%) were female with a mean age of 35.1 (SD 12.1) years. Participants used a mobile app (“Mental Protector”) for 4 weeks and rated their depressive and insomnia symptoms daily on the modified PHQ-2 and ISI-2 scales. The validation assessments were conducted in 2 blocks, each with a fortnight response from the participants. The modified version of the PHQ-2 was evaluated against the conventional scales of the Patient Health Questionnaire-9 and the Korean version of the Center for Epidemiologic Studies Depression Scale–Revised. Results: According to the sensitivity and specificity analyses, an average score of 3.29 on the modified PHQ-2 was considered valid for screening for depressive symptoms. Similarly, the ISI-2 was evaluated against the conventional scale, Insomnia Severity Index, and a mean score of 3.50 was determined to be a valid threshold for insomnia symptoms when rated daily. Conclusions: This study is one of the first to propose a daily digital screening measure for depression and insomnia delivered through a mobile app. The modified PHQ-2 and ISI-2 were strong candidates for daily screening of depression and insomnia, respectively. %M 37213186 %R 10.2196/45543 %U https://mental.jmir.org/2023/1/e45543 %U https://doi.org/10.2196/45543 %U http://www.ncbi.nlm.nih.gov/pubmed/37213186 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 10 %N %P e44535 %T Acceptability and Potential Impact of the #chatsafe Suicide Postvention Response Among Young People Who Have Been Exposed to Suicide: Pilot Study %A La Sala,Louise %A Pirkis,Jane %A Cooper,Charlie %A Hill,Nicole T M %A Lamblin,Michelle %A Rajaram,Gowri %A Rice,Simon %A Teh,Zoe %A Thorn,Pinar %A Zahan,Rifat %A Robinson,Jo %+ Orygen, Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, 3052, Australia, 61 3 9966 9512, louise.lasala@orygen.org.au %K youth %K suicide %K social media %K suicide postvention %K suicide prevention %K contagion %K postvention %D 2023 %7 19.5.2023 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Young people are more likely to be affected by suicide contagion, and there are concerns about the role social media plays in the development and maintenance of suicide clusters or in facilitating imitative suicidal behavior. However, social media also presents an opportunity to provide real-time and age-appropriate suicide prevention information, which could be an important component of suicide postvention activities. Objective: This study aimed to test an intervention designed to equip young people to communicate safely online about suicide (#chatsafe) with a sample of young people who had recently been exposed to a suicide or suicide attempt, with a view to determining the role social media can play as part of a postvention response. Methods: A sample of 266 young people from Australia, aged 16 to 25 years, were recruited to participate in the study. They were eligible if they had been exposed to a suicide or knew of a suicide attempt in the past 2 years. All participants received the #chatsafe intervention, which comprised 6 pieces of social media content that were sent to them weekly via direct message through Instagram, Facebook, or Snapchat. Participants were assessed on a range of outcome measures (social media use, willingness to intervene against suicide, internet self-efficacy, confidence, and safety when communicating about suicide on social media platforms) at baseline, immediately after the intervention, and at 4-week follow-up. Results: After the 6-week #chatsafe intervention, participants reported substantial improvements in their willingness to intervene against suicide online, their internet self-efficacy, and their perceived confidence and safety when communicating about suicide online. Overall, the participants reported that it was appropriate to receive the #chatsafe intervention via social media, and no iatrogenic effects were recorded. Conclusions: The findings suggest that it is safe and acceptable to disseminate suicide prevention information entirely via social media among young people who have recently been exposed to a suicide or suicide attempt. Interventions such as #chatsafe could potentially mitigate the risk of distress and future suicidal behavior in young people by improving the quality and safety of online communication about suicide and, as such, can be an important component of delivering a postvention response to young people. %M 37204854 %R 10.2196/44535 %U https://humanfactors.jmir.org/2023/1/e44535 %U https://doi.org/10.2196/44535 %U http://www.ncbi.nlm.nih.gov/pubmed/37204854 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e46157 %T Evaluating the Efficacy of Web-Based Cognitive Behavioral Therapy for the Treatment of Patients With Bipolar II Disorder and Residual Depressive Symptoms: Protocol for a Randomized Controlled Trial %A Gutierrez,Gilmar %A Stephenson,Callum %A Eadie,Jazmin %A Moghimi,Elnaz %A Omrani,Mohsen %A Groll,Dianne %A Soares,Claudio N %A Milev,Roumen %A Vazquez,Gustavo %A Yang,Megan %A Alavi,Nazanin %+ Department of Psychiatry, Queen's University, 166 Brock St, Kingston, ON, K7L5G2, Canada, 1 6135443310, nazanin.alavitabari@kingstonhsc.ca %K bipolar disorder %K cognitive behavioral therapy %K depression %K eHealth %K electronic care %K internet %K mental health %K psychotherapy %K treatment %K web-based therapy %D 2023 %7 19.5.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Bipolar disorder (BD) is a highly prevalent psychiatric condition that can significantly impact every aspect of a person’s life if left untreated. A subtype of BD, bipolar disorder type II (BD-II), is characterized by long depressive episodes and residual depression symptoms, with short-lived hypomanic episodes. Medication and psychotherapy, such as cognitive behavioral therapy (CBT), are the main treatment options for BD-II. CBT specific for BD-II involves the recognition of warning signs, potentially triggering stimuli, and the development of coping skills to increase euthymic periods and improve global functioning. However, access to in-person CBT may be limited by several barriers, including low availability, high costs, and geographical limitations. Thus, web-based adaptations of CBT (e-CBT) have become a promising solution to address these treatment barriers. Nevertheless, e-CBT for the treatment of BD-II remains understudied. Objective: The proposed study aims to establish the first e-CBT program specific for the treatment of BD-II with residual depressive symptoms. The primary objective of this study will be to determine the effect of e-CBT in managing BD symptomatology. The secondary objective will be to assess the effects of this e-CBT program on quality of life and resilience. The tertiary objective will involve gathering user feedback using a posttreatment survey to support the continuous improvement and optimization of the proposed program. Methods: Adult participants (N=170) with a confirmed diagnosis of BD-II experiencing residual depressive symptoms will be randomly assigned to either the e-CBT and treatment as usual (TAU; n=85) group or the TAU (n=85) control group. Participants in the control group will be able to participate in the web-based program after the first 13 weeks. The e-CBT program will consist of 13 weekly web-based modules designed following a validated CBT framework. Participants will complete module-related homework and receive asynchronous personalized feedback from a therapist. TAU will consist of standard treatment services conducted outside of this research study. Depression and manic symptoms, quality of life, and resiliency will be assessed using clinically validated symptomatology questionnaires at baseline, week 6, and week 13. Results: The study received ethics approval in March 2020, and participant recruitment is expected to begin in February 2023 through targeted advertisements and physician referrals. Data collection and analysis are expected to conclude by December 2024. Linear and binomial regression (continuous and categorical outcomes, respectively) will be conducted along with qualitative interpretive methods. Conclusions: The findings will be the first on the effectiveness of delivering e-CBT for patients with BD-II with residual depressive symptoms. This approach can provide an innovative method to address barriers to in-person psychotherapy by increasing accessibility and decreasing costs. Trial Registration: ClinicalTrials.gov NCT04664257; https://clinicaltrials.gov/ct2/show/NCT04664257 International Registered Report Identifier (IRRID): PRR1-10.2196/46157 %M 37140460 %R 10.2196/46157 %U https://www.researchprotocols.org/2023/1/e46157 %U https://doi.org/10.2196/46157 %U http://www.ncbi.nlm.nih.gov/pubmed/37140460 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e44986 %T Associations Between Smartphone Keystroke Metadata and Mental Health Symptoms in Adolescents: Findings From the Future Proofing Study %A Braund,Taylor A %A O’Dea,Bridianne %A Bal,Debopriyo %A Maston,Kate %A Larsen,Mark %A Werner-Seidler,Aliza %A Tillman,Gabriel %A Christensen,Helen %+ Faculty of Medicine and Health, University of New South Wales, High St, Kensington, 2052, Australia, 61 290659255, t.braund@blackdog.org.au %K adolescents %K anxiety %K depression %K digital phenotype %K keystroke dynamics %K keystroke metadata %K smartphone %K students %D 2023 %7 15.5.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental disorders are prevalent during adolescence. Among the digital phenotypes currently being developed to monitor mental health symptoms, typing behavior is one promising candidate. However, few studies have directly assessed associations between typing behavior and mental health symptom severity, and whether these relationships differs between genders. Objective: In a cross-sectional analysis of a large cohort, we tested whether various features of typing behavior derived from keystroke metadata were associated with mental health symptoms and whether these relationships differed between genders. Methods: A total of 934 adolescents from the Future Proofing study undertook 2 typing tasks on their smartphones through the Future Proofing app. Common keystroke timing and frequency features were extracted across tasks. Mental health symptoms were assessed using the Patient Health Questionnaire-Adolescent version, the Children’s Anxiety Scale-Short Form, the Distress Questionnaire 5, and the Insomnia Severity Index. Bivariate correlations were used to test whether keystroke features were associated with mental health symptoms. The false discovery rates of P values were adjusted to q values. Machine learning models were trained and tested using independent samples (ie, 80% train 20% test) to identify whether keystroke features could be combined to predict mental health symptoms. Results: Keystroke timing features showed a weak negative association with mental health symptoms across participants. When split by gender, females showed weak negative relationships between keystroke timing features and mental health symptoms, and weak positive relationships between keystroke frequency features and mental health symptoms. The opposite relationships were found for males (except for dwell). Machine learning models using keystroke features alone did not predict mental health symptoms. Conclusions: Increased mental health symptoms are weakly associated with faster typing, with important gender differences. Keystroke metadata should be collected longitudinally and combined with other digital phenotypes to enhance their clinical relevance. Trial Registration: Australian and New Zealand Clinical Trial Registry, ACTRN12619000855123; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377664&isReview=true %M 37184904 %R 10.2196/44986 %U https://mental.jmir.org/2023/1/e44986 %U https://doi.org/10.2196/44986 %U http://www.ncbi.nlm.nih.gov/pubmed/37184904 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e43065 %T Mobile Acceptance and Commitment Therapy With Distressed First-Generation College Students: Microrandomized Trial %A Thomas,Emily Brenny Kroska %A Sagorac Gruichich,Tijana %A Maronge,Jacob M %A Hoel,Sydney %A Victory,Amanda %A Stowe,Zachary N %A Cochran,Amy %+ Department of Psychological and Brain Sciences, University of Iowa, 340 Iowa Avenue, G60 PBSB, Iowa City, IA, 52242, United States, 1 319 467 1691, emily-kroska@uiowa.edu %K acceptance and commitment therapy %K randomized controlled trials %K mobile health %K mHealth %K first-generation college students %K psychological flexibility %K distress %K depression %D 2023 %7 15.5.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Extant gaps in mental health services are intensified among first-generation college students. Improving access to empirically based interventions is critical, and mobile health (mHealth) interventions are growing in support. Acceptance and commitment therapy (ACT) is an empirically supported intervention that has been applied to college students, via mobile app, and in brief intervals. Objective: This study evaluated the safety, feasibility, and effectiveness of an ACT-based mHealth intervention using a microrandomized trial (MRT) design. Methods: Participants (N=34) were 18- to 19-year-old first-generation college students reporting distress, who participated in a 6-week intervention period of twice-daily assessments and randomization to intervention. Participants logged symptoms, moods, and behaviors on the mobile app Lorevimo. After the assessment, participants were randomized to an ACT-based intervention or no intervention. Analyses examined proximal change after randomization using a weighted and centered least squares approach. Outcomes included values-based and avoidance behavior, as well as depressive symptoms and perceived stress. Results: The findings indicated the intervention was safe and feasible. The intervention increased values-based behavior but did not decrease avoidance behavior. The intervention reduced depressive symptoms but not perceived stress. Conclusions: An MRT of an mHealth ACT-based intervention among distressed first-generation college students suggests that a larger MRT is warranted. Future investigations may tailor interventions to contexts where intervention is most impactful. Trial Registration: ClinicalTrials.gov NCT04081662; https://clinicaltrials.gov/show/NCT04081662 International Registered Report Identifier (IRRID): RR2-10.2196/17086 %M 37184896 %R 10.2196/43065 %U https://mental.jmir.org/2023/1/e43065 %U https://doi.org/10.2196/43065 %U http://www.ncbi.nlm.nih.gov/pubmed/37184896 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e41638 %T Gamifying Cognitive Behavioral Therapy Techniques on Smartphones for Bangkok’s Millennials With Depressive Symptoms: Interdisciplinary Game Development %A Sriwatanathamma,Poe %A Sirivesmas,Veerawat %A Simatrang,Sone %A Bhowmik,Nobonita Himani %+ Doctor of Philosophy Program in Design Arts (International Program), Faculty of Decorative Arts, Silpakorn University, 22 Borommaratchachonnani Rd, Khwaeng Taling Chan, Khet Taling Chan, Bangkok, 10170, Thailand, 66 917655317, poesriwatana@gmail.com %K cognitive behavioral therapy %K gamification %K Bangkok’s millennials %K depressive symptoms %K mobile phone %D 2023 %7 12.5.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: There is serious concern over the annual increase in depressive symptoms among millennials in Bangkok, Thailand. Their daily routine revolves around the use of their smartphones for work and leisure. Although accessibility to mental health care is expanding, it cannot keep up with the demand for mental health treatment. Outside Thailand, multiple projects and studies have attempted to merge gamification mechanisms and cognitive behavioral therapy (CBT) to create mobile health intervention apps and serious games with positive feedback. This presents an opportunity to explore the same approach in Thailand. Objective: This study investigated the development process of gamifying CBT techniques to support game mechanics in a visual narrative serious game, BlueLine. The primary target of this research is Bangkok’s millennials. In the game, players play as Blue, a Bangkok millennial who struggles to live through societal norms that influence his digital life and relationships. Through in-game scenarios, players will learn and understand how to lessen the impact of depressive symptoms via gamified interactions on their smartphones. Methods: First, this paper follows each development step of solidifying BlueLine’s game structure by integrating the Activating Events, Beliefs, Consequences, Disputation of Beliefs and Effective New Approaches (ABCDE) model and narrative in games. Second, the approach to select CBT and related therapeutic elements for gamification is based on suitability to the game structure. Throughout the process, CBT experts in Thailand have reviewed these scenarios. The approach forms the base of the player’s interactions throughout the scenarios in BlueLine, broken down into 4 types of gamified mechanisms: narrative, verbal interactions, physical interactions, and social media interactions. Results: With the game structure based on the ABCDE model, BlueLine scenarios implement gamified mechanisms in conjunction with the following CBT and related therapeutic elements: behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. In each scenario, players guide Blue to overcome his triggered dysfunctional beliefs. During this process, players can learn and understand how to lessen the impact of depressive symptoms through gamified interactions. Conclusions: This paper presents the development process of gamifying CBT and related therapeutic techniques in BlueLine game scenarios. A scenario can harbor multiple techniques, including behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. BlueLine’s game structure does not limit the fact that the same combination of CBT elements ties each gamified mechanism. %M 37171845 %R 10.2196/41638 %U https://games.jmir.org/2023/1/e41638 %U https://doi.org/10.2196/41638 %U http://www.ncbi.nlm.nih.gov/pubmed/37171845 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e45776 %T Association Between Joint Physical Activity and Dietary Quality and Lower Risk of Depression Symptoms in US Adults: Cross-sectional NHANES Study %A Liang,Jinghong %A Huang,Shan %A Jiang,Nan %A Kakaer,Aerziguli %A Chen,Yican %A Liu,Meiling %A Pu,Yingqi %A Huang,Shaoyi %A Pu,Xueya %A Zhao,Yu %A Chen,Yajun %+ Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, No.74 Zhongshan 2nd Road, Yuexiu District, Guangzhou, 510080, China, 86 17372110875, chenyj68@mail.sysu.edu.cn %K physical activity %K dietary quality %K depression symptom %K adults %K NHANES %D 2023 %7 10.5.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Depression escalating public health concern and the modest efficacy of currently available treatments have prompted efforts to identify modifiable risk factors associated with depression symptoms. Physical inactivity, poor nutrition, or other lifestyle behaviors are among the potentially modifiable risk factors most consistently linked with depression. Past evidence regarding the single effect of physical activity (PA) or dietary quality (DQ) on reducing the risk of depression symptoms has been well-documented. However, the association of the joint effect of PA and DQ on depression symptoms has never been investigated in a representative sample of adults. Objective: This study investigates the association between PA and depression symptoms and between DQ and depression symptoms, and their combined effects on US adults. Methods: Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2007 to 2018 cycles. The primary exposures were DQ and PA, measured using the Healthy Eating Index (HEI)-2015 and the metabolic equivalent (MET) minutes per week reported in questionnaires, respectively. Depression symptoms were defined as a 9-item Patient Health Questionnaire (PHQ-9) score of ≥10. We created 4 lifestyle categories: healthy diet and active individuals, unhealthy diet but active individuals, healthy diet but inactive individuals, and unhealthy diet and inactive individuals. Participants were considered to have a healthy diet if they fell within the 60th percentile of the HEI-2015 or to be active if they met the current guidelines for PA. A survey-multivariable logistic regression approach was used to model adjust the variables relevant to the associations, and an age-adjusted prevalence for depression symptoms was calculated following the NHANES guidelines. Results: In total, 19,295 participants represented a weighted number of 932.5 million adults aged 20 to 80 years in the noninstitutionalized US population. The total age-adjusted prevalence of depression symptoms among all respondents was 7.08% (1507/19,295). Of the respondents, 81.97% (15,816/19,295) met the PA recommendation and 26.79% (5170/19,295) scored at or above the 60th percentile on the HEI-2015. Depression symptoms were inversely associated with a higher level of PA (adjusted odds ratio [AOR] 0.819, 95% CI 0.716-0.938) and healthy DQ (AOR 0.809, 95% CI 0.701-0.931), respectively. A healthy diet combined with recommended PA was associated with a significantly lower risk of depression symptoms (AOR 0.658, 95% CI 0.538-0.803) than those who consumed an unhealthy diet but were physically active (AOR 0.890, 95% CI 0.765-1.038) or consumed a healthy diet but were physically inactive (AOR 1.077, 95% CI 0.817-1.406). Conclusions: Our findings indicate that people with a healthy diet and recommended PA have a lower risk of depression symptoms than those with an unhealthy diet and a low level of PA. A healthy dietary habit and regular PA are potential precautions against depression. %M 37163324 %R 10.2196/45776 %U https://publichealth.jmir.org/2023/1/e45776 %U https://doi.org/10.2196/45776 %U http://www.ncbi.nlm.nih.gov/pubmed/37163324 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e42420 %T Prediction of Mental Health Problem Using Annual Student Health Survey: Machine Learning Approach %A Baba,Ayako %A Bunji,Kyosuke %+ Health Service Center, Kanazawa University, Kakuma-machi, Kanazawa-city, Ishikawa, 9201192, Japan, 81 762645254, a_baba@staff.kanazawa-u.ac.jp %K student counseling %K health survey %K machine learning %K mental health problem %K response time %D 2023 %7 10.5.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: One of the reasons why students go to counseling is being called on based on self-reported health survey results. However, there is no concordant standard for such calls. Objective: This study aims to develop a machine learning (ML) model to predict students’ mental health problems in 1 year and the following year using the health survey’s content and answering time (response time, response time stamp, and answer date). Methods: Data were obtained from the responses of 3561 (62.58%) of 5690 undergraduate students from University A in Japan (a national university) who completed the health survey in 2020 and 2021. We performed 2 analyses; in analysis 1, a mental health problem in 2020 was predicted from demographics, answers for the health survey, and answering time in the same year, and in analysis 2, a mental health problem in 2021 was predicted from the same input variables as in analysis 1. We compared the results from different ML models, such as logistic regression, elastic net, random forest, XGBoost, and LightGBM. The results with and without answering time conditions were compared using the adopted model. Results: On the basis of the comparison of the models, we adopted the LightGBM model. In this model, both analyses and conditions achieved adequate performance (eg, Matthews correlation coefficient [MCC] of with answering time condition in analysis 1 was 0.970 and MCC of without answering time condition in analysis 1 was 0.976; MCC of with answering time condition in analysis 2 was 0.986 and that of without answering time condition in analysis 2 was 0.971). In both analyses and in both conditions, the response to the questions about campus life (eg, anxiety and future) had the highest impact (Gain 0.131-0.216; Shapley additive explanations 0.018-0.028). Shapley additive explanations of 5 to 6 input variables from questions about campus life were included in the top 10. In contrast to our expectation, the inclusion of answering time–related variables did not exhibit substantial improvement in the prediction of students’ mental health problems. However, certain variables generated based on the answering time are apparently helpful in improving the prediction and affecting the prediction probability. Conclusions: These results demonstrate the possibility of predicting mental health across years using health survey data. Demographic and behavioral data, including answering time, were effective as well as self-rating items. This model demonstrates the possibility of synergistically using the characteristics of health surveys and advantages of ML. These findings can improve health survey items and calling criteria. %M 37163323 %R 10.2196/42420 %U https://mental.jmir.org/2023/1/e42420 %U https://doi.org/10.2196/42420 %U http://www.ncbi.nlm.nih.gov/pubmed/37163323 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e45136 %T Preliminary Evaluation of Translated and Culturally Adapted Internet-Delivered Cognitive Therapy for Social Anxiety Disorder: Multicenter, Single-Arm Trial in Japan %A Yoshinaga,Naoki %A Thew,Graham R %A Hayashi,Yuta %A Matsuoka,Jun %A Tanoue,Hiroki %A Takanashi,Rieko %A Araki,Mutsumi %A Kanai,Yoshihiro %A Smith,Alisha %A Grant,Sophie H L %A Clark,David M %+ School of Nursing, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan, 81 985 85 9784, naoki-y@med.miyazaki-u.ac.jp %K benchmarking %K anxiety %K social anxiety %K social phobia %K cognitive behavioral therapy %K cognitive therapy %K cross-cultural comparison %K Japan %K mental disorders %K internet-based intervention %K mobile phone %D 2023 %7 5.5.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Internet-delivered cognitive therapy for social anxiety disorder (iCT-SAD), which is a therapist-guided modular web-based treatment, has shown strong efficacy and acceptability in English-language randomized controlled trials in the United Kingdom and Hong Kong. However, it is not yet known whether iCT-SAD can retain its efficacy following linguistic translation and cultural adaptation of treatment contents and implementation in other countries such as Japan. Objective: This study aimed to examine the preliminary efficacy and acceptability of the translated and culturally adapted iCT-SAD in Japanese clinical settings. Methods: This multicenter, single-arm trial recruited 15 participants with social anxiety disorder. At the time of recruitment, participants were receiving usual psychiatric care but had not shown improvement in their social anxiety and required additional treatment. iCT-SAD was provided in combination with usual psychiatric care for 14 weeks (treatment phase) and for a subsequent 3-month follow-up phase that included up to 3 booster sessions. The primary outcome measure was the self-report version of the Liebowitz Social Anxiety Scale. The secondary outcome measures examined social anxiety–related psychological processes, taijin kyofusho (the fear of offending others), depression, generalized anxiety, and general functioning. The assessment points for the outcome measures were baseline (week 0), midtreatment (week 8), posttreatment (week 15; primary assessment point), and follow-up (week 26). Acceptability was measured using the dropout rate from the treatment, the level of engagement with the program (the rate of module completion), and participants’ feedback about their experience with the iCT-SAD. Results: Evaluation of the outcome measures data showed that iCT-SAD led to significant improvements in social anxiety symptoms during the treatment phase (P<.001; Cohen d=3.66), and these improvements were maintained during the follow-up phase. Similar results were observed for the secondary outcome measures. At the end of the treatment phase, 80% (12/15) of participants demonstrated reliable improvement, and 60% (9/15) of participants demonstrated remission from social anxiety. Moreover, 7% (1/15) of participants dropped out during treatment, and 7% (1/15) of participants declined to undergo the follow-up phase after completing the treatment. No serious adverse events occurred. On average, participants completed 94% of the modules released to them. Participant feedback was positive and highlighted areas of strength in treatment, and it included further suggestions to improve suitability for Japanese settings. Conclusions: Translated and culturally adapted iCT-SAD demonstrated promising initial efficacy and acceptability for Japanese clients with social anxiety disorder. A randomized controlled trial is required to examine this more robustly. %M 37145850 %R 10.2196/45136 %U https://formative.jmir.org/2023/1/e45136 %U https://doi.org/10.2196/45136 %U http://www.ncbi.nlm.nih.gov/pubmed/37145850 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e37105 %T Serious Games Based on Cognitive Bias Modification and Learned Helplessness Paradigms for the Treatment of Depression: Design and Acceptability Study %A Ghosh,Arka %A Agnihotri,Jagriti %A Bhalotia,Sradha %A Sati,Bharat Kumar %A Agarwal,Latika %A A,Akash %A Tandon,Swastika %A Meena,Komal %A Raj,Shreyash %A Azad,Yatin %A Gupta,Silky %A Gupta,Nitin %+ Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kalyanpur, Kanpur, 208016, India, 91 5122594384, guptan@iitk.ac.in %K serious games %K cognitive bias modification %K learned helplessness %K depression %K digital intervention %K mobile phone %D 2023 %7 3.5.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a debilitating mental health disorder, with a large treatment gap. Recent years have seen a surge in digital interventions to bridge this treatment gap. Most of these interventions are based on computerized cognitive behavioral therapy. Despite the efficacy of computerized cognitive behavioral therapy–based interventions, their uptake is low and dropout rates are high. Cognitive bias modification (CBM) paradigms provide a complementary approach to digital interventions for depression. However, interventions based on CBM paradigms have been reported to be repetitive and boring. Objective: In this paper, we described the conceptualization, design, and acceptability of serious games based on CBM paradigms and the learned helplessness paradigm. Methods: We searched the literature for CBM paradigms that were shown to be effective in reducing depressive symptoms. For each of the CBM paradigms, we ideated how to create a game so that the gameplay was engaging while the active therapeutic component remained unchanged. Results: We developed 5 serious games based on the CBM paradigms and the learned helplessness paradigm. The games include various core elements of gamification, such as goals, challenges, feedback, rewards, progress, and fun. Overall, the games received positive acceptability ratings from 15 users. Conclusions: These games may help improve the effectiveness and engagement levels of computerized interventions for depression. %M 37133923 %R 10.2196/37105 %U https://games.jmir.org/2023/1/e37105 %U https://doi.org/10.2196/37105 %U http://www.ncbi.nlm.nih.gov/pubmed/37133923 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43862 %T Conversational Agent Interventions for Mental Health Problems: Systematic Review and Meta-analysis of Randomized Controlled Trials %A He,Yuhao %A Yang,Li %A Qian,Chunlian %A Li,Tong %A Su,Zhengyuan %A Zhang,Qiang %A Hou,Xiangqing %+ Institute of Applied Psychology, College of Education, Tianjin University, 135 Yaguan Road, Jinnan District, Tianjin, 300354, China, 86 15034071215, 2020212056@tju.edu.cn %K chatbot and conversational agent %K mental health %K meta-analysis %K depression %K anxiety %K quality of life %K stress %K mobile health %K mHealth %K digital medicine %K meta-regression %K mobile phone %D 2023 %7 28.4.2023 %9 Review %J J Med Internet Res %G English %X Background: Mental health problems are a crucial global public health concern. Owing to their cost-effectiveness and accessibility, conversational agent interventions (CAIs) are promising in the field of mental health care. Objective: This study aims to present a thorough summary of the traits of CAIs available for a range of mental health problems, find evidence of efficacy, and analyze the statistically significant moderators of efficacy via a meta-analysis of randomized controlled trial. Methods: Web-based databases (Embase, MEDLINE, PsycINFO, CINAHL, Web of Science, and Cochrane) were systematically searched dated from the establishment of the database to October 30, 2021, and updated to May 1, 2022. Randomized controlled trials comparing CAIs with any other type of control condition in improving depressive symptoms, generalized anxiety symptoms, specific anxiety symptoms, quality of life or well-being, general distress, stress, mental disorder symptoms, psychosomatic disease symptoms, and positive and negative affect were considered eligible. This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data were extracted by 2 independent reviewers, checked by a third reviewer, and pooled using both random effect models and fixed effects models. Hedges g was chosen as the effect size. Results: Of the 6900 identified records, a total of 32 studies were included, involving 6089 participants. CAIs showed statistically significant short-term effects compared with control conditions in improving depressive symptoms (g=0.29, 95% CI 0.20-0.38), generalized anxiety symptoms (g=0.29, 95% CI 0.21-0.36), specific anxiety symptoms (g=0.47, 95% CI 0.07-0.86), quality of life or well-being (g=0.27, 95% CI 0.16-0.39), general distress (g=0.33, 95% CI 0.20-0.45), stress (g=0.24, 95% CI 0.08-0.41), mental disorder symptoms (g=0.36, 95% CI 0.17-0.54), psychosomatic disease symptoms (g=0.62, 95% CI 0.14-1.11), and negative affect (g=0.28, 95% CI 0.05-0.51). However, the long-term effects of CAIs for the most mental health outcomes were not statistically significant (g=−0.04 to 0.39). Personalization and empathic response were 2 critical facilitators of efficacy. The longer duration of interaction with conversational agents was associated with the larger pooled effect sizes. Conclusions: The findings show that CAIs are research-proven interventions that ought to be implemented more widely in mental health care. CAIs are effective and easily acceptable for those with mental health problems. The clinical application of this novel digital technology will conserve human health resources and optimize the allocation of mental health services. Trial Registration: PROSPERO CRD42022350130; https://tinyurl.com/mvhk6w9p %M 37115595 %R 10.2196/43862 %U https://www.jmir.org/2023/1/e43862 %U https://doi.org/10.2196/43862 %U http://www.ncbi.nlm.nih.gov/pubmed/37115595 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e42024 %T Intervening on Social Comparisons on Social Media: Electronic Daily Diary Pilot Study %A Andrade,Fernanda C %A Erwin,Savannah %A Burnell,Kaitlyn %A Jackson,Jalisa %A Storch,Marley %A Nicholas,Julia %A Zucker,Nancy %+ Department of Psychology & Neuroscience, Duke University, 417 Chapel Drive, Campus Box 90086, Durham, NC, 27708, United States, 1 (919) 660 5640, fernanda.andrade@duke.edu %K social media %K social comparison %K young adults %K social savoring %K intervention %K self-esteem %K depression %D 2023 %7 28.4.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Literature has underscored the dark aspects of social media use, including associations with depressive symptoms, feelings of social isolation, and diminished self-esteem. Social comparison, the process of evaluating oneself relative to another person, is thought to contribute to these negative experiences such that people with a stronger tendency to compare themselves with others are particularly susceptible to the detrimental effects of social media. Social media as a form of social connection and communication is nevertheless an inevitable—and arguably integral—part of life, particularly for young adults. Therefore, there is a need to investigate strategies that could alter the manner in which people interact with social media to minimize its detrimental effects and maximize the feelings of affiliation and connection. Objective: This pilot study examined the feasibility, acceptability, and effectiveness of a brief web-based intervention designed to alter engagement with social media and promote psychological well-being by encouraging social savoring as an alternative to social comparison. Social savoring was operationalized as experiencing joyful emotions related to the happiness of someone else’s experiences (ie, feeling happy for someone else). Methods: Following an intensive longitudinal design, 55 college students (mean age 19.29, SD 0.93 years; n=43, 78% women and n=23, 42% White) completed baseline measures (individual differences, psychological well-being, connectedness, and social media use) and then 14 days of daily surveys on their social media activity and well-being. On day 8, the group that was randomized to receive the intervention watched a video instructing them on the skill of social savoring and was asked to practice this skill during days 8 to 14. Results: Overall, participants reported positive perceptions of the intervention. Participants who watched the intervention video reported significantly higher performance self-esteem (P=.02) at posttest than those in the control condition, after controlling for baseline levels. Participants also reported significantly higher state self-esteem (P=.01) on days in which they engaged in more social savoring while using social media, and the use of social savoring increased significantly (P=.01) over time, suggesting that participants found it helpful. Participants in both conditions reported significantly lower levels of social comparison (control: P=.01; intervention: P=.002) and higher levels of connectedness (control: P<.001; intervention: P=.001) at posttest than at baseline. Conclusions: Initial evidence from this pilot study suggests that a web-based social savoring intervention may help minimize the potentially harmful consequences of social media use, at least in some domains. Future work is needed to examine the effectiveness and acceptance of this intervention in different age groups and in clinical samples that are in part characterized by higher levels of comparison with others (eg, people with eating disorders). %M 37115607 %R 10.2196/42024 %U https://mental.jmir.org/2023/1/e42024 %U https://doi.org/10.2196/42024 %U http://www.ncbi.nlm.nih.gov/pubmed/37115607 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45040 %T Evaluation of Various Support Intensities of Digital Mental Health Treatment for Reducing Anxiety and Depression in Adults: Protocol for a Mixed Methods, Adaptive, Randomized Clinical Trial %A Andrews,Brooke %A Klein,Britt %A McLaren,Suzanne %A Watson,Shaun %A Corboy,Denise %+ Health Innovation & Transformation Centre, Federation University Australia, PO BOX 663, Ballarat, 3353, Australia, 61 53279623 ext 9623, b.andrews@federation.edu.au %K video chat therapy %K therapist assistance %K self-help %K transdiagnostic %K digital intervention %K anxiety %K depression %K comorbidity %D 2023 %7 28.4.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Anxiety and depression are leading causes of disease worldwide, requiring timely access to evidence-based treatment. Digital mental health (dMH) interventions increase accessibility to evidence-based psychological services delivered in a variety of web-based formats (eg, self-help and therapist-assisted interventions). Robust and rigorous studies of adaptive web-based intervention designs are scarce. No identified randomized clinical trial has investigated the efficacy of a 2-stage adaptive design, whereby the program-only condition or no support dMH treatment program is augmented by either low or high therapist assistance, if a participant does not improve or engage in the program-only condition. Objective: The primary objective is to assess whether low or high therapist-assisted support delivered via video chat is more effective in reducing anxiety and depressive symptoms compared with a dMH program–only condition. The secondary objective is to evaluate the role of motivation; self-efficacy; and preferences in participant engagement, adherence, and clinical outcomes (anxiety and depression symptoms) among the 3 treatment conditions (program only, low-intensity therapist assistance, and high-intensity therapist assistance). A mixed methods analysis of factors affecting participant attrition, participant reasons for nonengagement and withdrawal, and therapist training and implementation of dMH interventions will be completed. Qualitative data regarding participant and therapist experiences and satisfaction with video chat assessment and treatment will also be analyzed. Methods: Australian adults (N=137) with symptoms or a diagnosis of anxiety or depression will be screened for eligibility and given access to the 8-module Life Flex dMH treatment program. On day 15, participants who meet the augmentation criteria will be stepped up via block randomization to receive therapist assistance delivered via video chat for either 10 minutes (low intensity) or 50 minutes (high intensity) per week. This adaptive trial will implement a mixed methods design, with outcomes assessed before the intervention (week 0), during the intervention (weeks 3 and 6), after the intervention (week 9), and at the 3-month follow-up (week 21). Results: The primary outcome measures are for anxiety (Generalized Anxiety Disorder–7) and depression severity (Patient Health Questionnaire–9). Measures of working alliance, health status, health resources, preferences, self-efficacy, and motivation will be used for secondary outcomes. Qualitative methods will be used to explore participant and therapist experiences of video chat assessment and treatment, participant reasons for withdrawal and nonengagement, and therapist training and implementation experiences. Data collection commenced in November 2020 and was completed at the end of March 2022. Conclusions: This is the first mixed methods adaptive trial to explore the comparative efficacy of different intensity levels of self-help and a therapist-assisted dMH intervention program delivered via video chat for adults with anxiety or depression. Anticipated results may have implications for the implementation of dMH interventions. Trial Registration: Australian and New Zealand Clinical Trials Registry 12620000422921; https://tinyurl.com/t9cyu372 International Registered Report Identifier (IRRID): RR1-10.2196/45040 %M 37115623 %R 10.2196/45040 %U https://www.researchprotocols.org/2023/1/e45040 %U https://doi.org/10.2196/45040 %U http://www.ncbi.nlm.nih.gov/pubmed/37115623 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e41005 %T An Unguided, Computerized Cognitive Behavioral Therapy Intervention (TreadWill) in a Lower Middle-Income Country: Pragmatic Randomized Controlled Trial %A Ghosh,Arka %A Cherian,Rithwik J %A Wagle,Surbhit %A Sharma,Parth %A Kannan,Karthikeyan R %A Bajpai,Alok %A Gupta,Nitin %+ Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, IIT Campus, Kanpur, 208016, India, 91 5122594384, guptan@iitk.ac.in %K computerized cognitive behavioral therapy %K cCBT %K depression %K digital intervention %K mobile phone %D 2023 %7 26.4.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Globally, most individuals who are susceptible to depression do not receive adequate or timely treatment. Unguided computerized cognitive behavioral therapy (cCBT) has the potential to bridge this treatment gap. However, the real-world effectiveness of unguided cCBT interventions, particularly in low- and middle-income countries (LMICs), remains inconclusive. Objective: In this study, we aimed to report the design and development of a new unguided cCBT–based multicomponent intervention, TreadWill, and its pragmatic evaluation. TreadWill was designed to be fully automated, engaging, easy to use, and accessible to LMICs. Methods: To evaluate the effectiveness of TreadWill and the engagement level, we performed a double-blind, fully remote, and randomized controlled trial with 598 participants in India and analyzed the data using a completer’s analysis. Results: The users who completed at least half of the modules in TreadWill showed significant reduction in depression-related (P=.04) and anxiety-related (P=.02) symptoms compared with the waitlist control. Compared with a plain-text version with the same therapeutic content, the full-featured version of TreadWill showed significantly higher engagement (P=.01). Conclusions: Our study provides a new resource and evidence for the use of unguided cCBT as a scalable intervention in LMICs. Trial Registration: ClinicalTrials.gov NCT03445598; https://clinicaltrials.gov/ct2/show/NCT03445598 %M 37099376 %R 10.2196/41005 %U https://www.jmir.org/2023/1/e41005 %U https://doi.org/10.2196/41005 %U http://www.ncbi.nlm.nih.gov/pubmed/37099376 %0 Journal Article %@ 2817-092X %I JMIR Publications %V 2 %N %P e41439 %T Clinical Perspectives on Using Remote Measurement Technology in Assessing Epilepsy, Multiple Sclerosis, and Depression: Delphi Study %A Andrews,Jacob A %A Craven,Michael P %A Guo,Boliang %A Weyer,Janice %A Lees,Simon %A Zormpas,Spyridon I %A Thorpe,Sarah E %A Devonshire,Julie %A San Antonio-Arce,Victoria %A Whitehouse,William P %A Julie,Jessica %A Malins,Sam %A Hammers,Alexander %A Reif,Andreas %A Ruhe,Henricus G %A Durbano,Federico %A Barlati,Stefano %A Sen,Arjune %A Frederiksen,Jette L %A Martinelli,Alessandra %A Callen,Antonio %A Torras-Borrell,Joan %A Berrocal-Izquierdo,Nuria %A Zabalza,Ana %A Morriss,Richard %A Hollis,Chris %A , %+ National Institute for Health and Care Research MindTech MedTech Co-operative, University of Nottingham, Institute of Mental Health, Triumph Road, Nottingham, NG7 2TU, United Kingdom, 44 01157484 218, jacob.andrews@nottingham.ac.uk %K mobile health %K mHealth %K wearable %K wearable technology %K smartphone %K use case %K implementation %K epilepsy %K multiple sclerosis %K MS %K depression %K depressive disorder %K Delphi %K remote measurement technology %K RMT %K central nervous system %K nervous system disorder %K neurology %K neurological disorder %K expert panel %K expert opinion %K perspective %K mobile phone %D 2023 %7 25.4.2023 %9 Original Paper %J JMIR Neurotech %G English %X Background: Multiple sclerosis (MS), epilepsy, and depression are chronic central nervous system conditions in which remote measurement technology (RMT) may offer benefits compared with usual assessment. We previously worked with clinicians, patients, and researchers to develop 13 use cases for RMT: 5 in epilepsy (seizure alert, seizure counting, risk scoring, triage support, and trend analysis), 3 in MS (detecting silent progression, detecting depression in MS, and donating data to a biobank), and 5 in depression (detecting trends, reviewing treatment, self-management, comorbid monitoring, and carer alert). Objective: In this study, we aimed to evaluate the use cases and related implementation issues with an expert panel of clinicians external to our project consortium. Methods: We used a Delphi exercise to validate the use cases and suggest a prioritization among them and to ascertain the importance of a variety of implementation issues related to RMT. The expert panel included clinicians from across Europe who were external to the project consortium. The study had 2 survey rounds (n=23 and n=17) and a follow-up interview round (n=9). Data were analyzed for consensus between participants and for stability between survey rounds. The interviews explored the reasons for answers given in the survey. Results: The findings showed high stability between rounds on questions related to specific use cases but lower stability on questions relating to wider issues around the implementation of RMT. Overall, questions on wider issues also had less consensus. All 5 use cases for epilepsy (seizure alert, seizure counting, risk scoring, triage support, and trend analysis) were considered beneficial, with consensus among participants above the a priori threshold for most questions, although use case 3 (risk scoring) was considered less likely to facilitate or catalyze care. There was very little consensus on the benefits of the use cases in MS, although this may have resulted from a higher dropout rate of MS clinicians (50%). Participants agreed that there would be benefits for all 5 of the depression use cases, although fewer questions on use case 4 (triage support) reached consensus agreement than for depression use cases 1 (detecting trends), 2 (reviewing treatment), 3 (self-management), and 5 (carer alert). The qualitative analysis revealed further insights into each use case and generated 8 themes on practical issues related to implementation. Conclusions: Overall, these findings inform the prioritization of use cases for RMT that could be developed in future work, which may include clinical trials, cost-effectiveness studies, and the commercial development of RMT products and services. Priorities for further development include the use of RMT to provide more accurate records of symptoms and treatment response than is currently possible and to provide data that could help inform patient triage and generate timely alerts for patients and carers. %R 10.2196/41439 %U https://neuro.jmir.org/2023/1/e41439 %U https://doi.org/10.2196/41439 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e47898 %T Focusing on Digital Research Priorities for Advancing the Access and Quality of Mental Health %A Torous,John %A Benson,Nicole M %A Myrick,Keris %A Eysenbach,Gunther %+ Beth Israel Deaoness Medical Center, 330 Brookline Ave, Boston, MA, 02446, United States, 1 6176676700, jtorous@gmail.com %K digital phenotyping %K mental health %K depression %K anxiety %K smartphone %D 2023 %7 24.4.2023 %9 Editorial %J JMIR Ment Health %G English %X Digital mental health solutions are now well recognized as critical to solving the global mental health crisis. As research accelerates, it is now clear that solutions ranging from computer-based therapy programs to virtual reality headsets and smartphone apps to large language model chatbots are of interest, feasible, and hold exciting potential to improve mental health. This research should now consider the next generation of scientific and clinical questions regarding if these new approaches are equitable, valid, effective, implementable, efficacious, and even cost-effective. This paper outlines several of the new frontiers for the next generation of research and introduces JMIR Publications’ partnership with the Society of Digital Psychiatry to further advance these aims. %M 37093624 %R 10.2196/47898 %U https://mental.jmir.org/2023/1/e47898 %U https://doi.org/10.2196/47898 %U http://www.ncbi.nlm.nih.gov/pubmed/37093624 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e41078 %T Breaking Down Barriers to a Suicide Prevention Helpline: Protocol for a Web-Based Randomized Controlled Trial %A van der Burgt,Margot C A %A Mérelle,Saskia %A Brinkman,Willem-Paul %A Beekman,Aartjan T F %A Gilissen,Renske %+ Department of Research, 113 Suicide Prevention, Paasheuvelweg 25, Amsterdam, 1105 BP, Netherlands, 31 203113883, m.vanderburgt@113.nl %K barrier reduction intervention %K suicidal ideation %K self-help %K suicide prevention helpline %K randomized controlled trial %K help-seeking %D 2023 %7 24.4.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Globally, suicide is among the leading causes of death, with men being more at risk to die from suicide than women. Research suggests that people with suicidal ideation often struggle to find adequate help. Every month, around 4000 people fill in the anonymous self-test for suicidal thoughts on the website of the Dutch suicide prevention helpline. This self-test includes the Suicidal Ideation Attributes Scale (SIDAS), which educates users about the severity of their suicidal thoughts. The vast majority (70%) of people who complete the self-test score higher than the cutoff point (≥21) for severe suicidal thoughts. Unfortunately, despite this, less than 10% of test-takers navigate to the web page about contacting the helpline. Objective: This protocol presents the design of a web-based randomized controlled trial that aims to reduce barriers to contacting the suicide prevention helpline. The aim of this study is 2-fold: (1) to measure the effectiveness of a brief barrier reduction intervention (BRI) provided in the self-test motivating people with severe suicidal thoughts to contact the Dutch suicide prevention helpline and (2) to specifically evaluate the effectiveness of the BRI in increasing service use by high-risk groups for suicide such as men and middle-aged people. Methods: People visiting the self-test for suicidal thoughts on the website of the suicide prevention helpline will be asked to participate in a study to improve the self-test. Individuals with severe suicidal thoughts and little motivation to contact the helpline will be randomly allocated either to a brief BRI, in which they will receive a short tailored message based on their self-reported barrier to the helpline (n=388) or care as usual (general advisory text, n=388). The primary outcome measure is the use of a direct link to contact the helpline after receiving the intervention or control condition. Secondary outcomes are the self-reported likelihood of contacting the helpline (on a 5-point scale) and satisfaction with the self-test. In the BRI, participants receive tailored information to address underlying concerns and misconceptions of barriers to the helpline. A pilot study was conducted among current test-takers to identify these specific barriers. Results: The pilot study (N=1083) revealed multiple barriers to contacting the helpline. The most prominent were the belief that a conversation with a counselor would not be effective, fear of the conversation itself, and emotional concerns about talking about suicidal thoughts. Conclusions: Our study will provide insight into the effectiveness of a brief BRI designed to increase the use of a suicide prevention helpline provided in a self-test on suicidal thoughts. If successful, this intervention has the potential to be a low-cost, easily scalable, and feasible method to increase service use for helplines across the world. Trial Registration: ClinicalTrials.gov NCT05458830; https://clinicaltrials.gov/ct2/show/NCT05458830 International Registered Report Identifier (IRRID): PRR1-10.2196/41078 %M 37093641 %R 10.2196/41078 %U https://www.researchprotocols.org/2023/1/e41078 %U https://doi.org/10.2196/41078 %U http://www.ncbi.nlm.nih.gov/pubmed/37093641 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e45796 %T Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and Other Minoritized Gender and Sexual Identities–Adapted Telehealth Intensive Outpatient Program for Youth and Young Adults: Subgroup Analysis of Acuity and Improvement Following Treatment %A Berry,Katie R %A Gliske,Kate %A Schmidt,Clare %A Cray,Ley David Elliette %A Killian,Michael %A Fenkel,Caroline %+ Charlie Health, Inc, 233 E Main St, Ste. 401, Bozeman, MT, 59715, United States, 1 9545527671, krberry@fsu.edu %K lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other minoritized gender and sexual identities %K LGBTQIA+ %K youth %K mental health %K affirming health care %K suicidal ideation %K depression %K nonsuicidal self-harm %K NSSI %D 2023 %7 21.4.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other minoritized gender and sexual identities (LGBTQIA+) youth have disproportionately high levels of depression, self-harm, and suicidal thoughts and behaviors. In addition, LGBTQIA+ youth frequently report lower levels of satisfaction or comfort with their health care providers because of stigmatization, which may prevent continuation of care, yet there is a lack of mental health treatment and outcome research addressing these disparities. However, there is some indication that LGBTQIA+ individuals feel more comfortable with web-based formats, indicating that telehealth services may be beneficial for this population. Objective: This program evaluation explored the effectiveness of a remote intensive outpatient program with a curriculum tailored specifically to LGBTQIA+ youth with high-acuity depression, anxiety, and suicidality. This study sought to understand baseline acuity differences between LGBTQIA+ and non-LGBTQIA+ youth and young adult patients and to determine if there were differences in clinically significant improvement by subtypes within the LGBTQIA+ population following participation in LGBTQIA+-specific programming. Methods: Data were collected from intake and discharge outcome surveys measuring depression, suicidality, and nonsuicidal self-injury (NSSI) in 878 patients who attended at least six sessions of a remote intensive outpatient program for youth and young adults. Of these 878 clients, 551 (62.8%) were identified as having at least one LGBTQIA+ identity; they participated in an LGBTQIA+-adapted program of the general curriculum. Results: LGBTQIA+ patients had more clinically severe intake for depression, NSSI, and suicidal ideation. Nonbinary clients had greater NSSI within the LGBTQIA+ sample at intake than their binary counterparts, and transgender clients had significantly higher depressive scores at intake than their nontransgender counterparts. LGBTQIA+ patients demonstrated improvements in all outcomes from intake to discharge. The Patient Health Questionnaire for Adolescents depression scores improved from 18.15 at intake to 10.83 at discharge, representing a 41.5% reduction in depressive symptoms. Overall, 50.5% (149/295) of the LGBTQIA+ youth who endorsed passive suicidal ideation at intake no longer reported it at discharge, 72.1% (160/222) who endorsed active suicidal ideation at intake no longer reported it at discharge, and 55.1% (109/198) of patients who met the criteria for clinical NSSI no longer met the criteria at discharge. In the subgroup analysis, transgender patients were still 2 times more likely to report clinical NSSI at discharge. Conclusions: This program evaluation found substantial differences in rates of depression, NSSI, and suicidal ideation between LGBTQIA+ clients compared with their non-LGBTQIA+ counterparts. In addition, this evaluation showed a considerable decrease in symptoms when clients attended LGBTQIA+-affirming care. The findings provide support for the role of LGBTQIA+-specific programming to meet the elevated mental health needs of these youth and that more research is needed to understand barriers that may negatively affect transgender clients, specifically. %M 37083637 %R 10.2196/45796 %U https://formative.jmir.org/2023/1/e45796 %U https://doi.org/10.2196/45796 %U http://www.ncbi.nlm.nih.gov/pubmed/37083637 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e46254 %T Association Between Internet Searches Related to Suicide/Self-harm and Adolescent Suicide Death in South Korea in 2016-2020: Secondary Data Analysis %A Choi,Won-Seok %A Han,Junhee %A Hong,Hyun Ju %+ Department of Psychiatry, Hallym University Sacred Heart Hospital, College of Medicine, Hallym Univerisity, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Gyeonggi-do, Anyang, 14068, Republic of Korea, 82 010 8880 8769, honghj88@gmail.com %K adolescent %K suicide %K self-mutilation %K internet %K search engine %K Korea %K suicide death %K surveillance %K monitoring %K internet search %D 2023 %7 20.4.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Previous studies have investigated the association between suicide and internet search volumes of terms related to suicide or self-harm. However, the results varied by people’s age, period, and country, and no study has exclusively investigated suicide or self-harm rates among adolescents. Objective: This study aims to determine the association between the internet search volumes of terms related to suicide/self-harm and the number of suicides among South Korean adolescents. We investigated gender differences in this association and the time lag between the internet search volumes of the terms and the connected suicide deaths. Methods: We selected 26 search terms related to suicide and self-harm among South Korean adolescents, and the search volumes of these terms for adolescents aged 13-18 years were obtained from the leading internet search engine in South Korea (Naver Datalab). A data set was constructed by combining data from Naver Datalab and the number of suicide deaths of adolescents on a daily basis from January 1, 2016, to December 31, 2020. Spearman rank correlation and multivariate Poisson regression analyses were performed to identify the association between the search volumes of the terms and the suicide deaths during that period. The time lag between suicide death and the increasing trend in the search volumes of the related terms was estimated from the cross-correlation coefficients. Results: Significant correlations were observed within the search volumes of the 26 terms related to suicide/self-harm. The internet search volumes of several terms were associated with the number of suicide deaths among South Korean adolescents, and this association differed by gender. The search volume for “dropout” showed a statistically significant correlation with the number of suicides in all adolescent population groups. The correlation between the internet search volume for “dropout” and the connected suicide deaths was the strongest for a time lag of 0 days. In females, self-harm and academic score showed significant associations with suicide deaths, but academic score showed a negative correlation, and the time lags with the strongest correlations were 0 and –11 days, respectively. In the total population, self-harm and suicide method were associated with the number of suicides, and the time lags with the strongest correlations were +7 and 0 days, respectively. Conclusions: This study identifies a correlation between suicides and internet search volumes related to suicide/self-harm among South Korean adolescents, but the relatively weak correlation (incidence rate ratio 0.990-1.068) should be interpreted with caution. %M 37079349 %R 10.2196/46254 %U https://www.jmir.org/2023/1/e46254 %U https://doi.org/10.2196/46254 %U http://www.ncbi.nlm.nih.gov/pubmed/37079349 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e42316 %T Suicide Prevention Using Google Ads: Randomized Controlled Trial Measuring Engagement %A Onie,Sandersan %A Berlinquette,Patrick %A Holland,Sarah %A Livingstone,Nicola %A Finemore,Coco %A Gale,Nyree %A Elder,Emma %A Laggis,George %A Heffernan,Cassandra %A Armstrong,Susanne Oliver %A Theobald,Adam %A Josifovski,Natasha %A Torok,Michelle %A Shand,Fiona %A Larsen,Mark %+ Black Dog Institute, 1 Hospital Rd, Randwick, 2031, Australia, 61 (02) 9382 4530, s.onie@blackdog.org.au %K suicide prevention %K suicide %K suicidal %K self harm %K digital advertising %K Google Ads %K search %K suicide hotline %K advertise %K advertising %K campaign %K mental health %K prevention %K digital intervention %K online intervention %D 2023 %7 20.4.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Studies have shown that individuals may search for suicide-related terms on the internet prior to an attempt. Objective: Thus, across 2 studies, we investigated engagement with an advertisement campaign designed to reach individuals contemplating suicide. Methods: First, we designed the campaign to focus on crisis, running a campaign for 16 days in which crisis-related keywords would trigger an ad and landing page to help individuals find the national suicide hotline number. Second, we expanded the campaign to also help individuals contemplating suicide, running the campaign for 19 days with a wider range of keywords through a co-designed website with a wider range of offerings (eg, lived experience stories). Results: In the first study, the ad was shown 16,505 times and was clicked 664 times (4.02% click rate). There were 101 calls to the hotline. In the second study, the ad was shown 120,881 times and clicked 6227 times (5.15% click rate); of these 6227 clicks, there were 1419 (22.79%) engagements with the site, a substantially higher rate than the industry average of 3%. The number of clicks on the ad was high despite a suicide hotline banner likely being present. Conclusions: Search advertisements are a quick, far-reaching, and cost-efficient way of reaching those contemplating suicide and are needed despite suicide hotline banners being present. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623000084684; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385209 %M 37079348 %R 10.2196/42316 %U https://mental.jmir.org/2023/1/e42316 %U https://doi.org/10.2196/42316 %U http://www.ncbi.nlm.nih.gov/pubmed/37079348 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e44722 %T The Impacts of a Psychoeducational Alcohol Resource During Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety: Observational Study %A Peynenburg,Vanessa %A Sapkota,Ram P %A Lozinski,Tristen %A Sundström,Christopher %A Wilhelms,Andrew %A Titov,Nickolai %A Dear,Blake %A Hadjistavropoulos,Heather %+ University of Regina, 3737 Wascana Parkway, Regina, SK, Canada, 1 306 585 5133, hadjista@uregina.ca %K internet-delivered cognitive behavioral therapy %K transdiagnostic %K depression %K anxiety %K alcohol %K drinking %D 2023 %7 18.4.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Problematic alcohol use is common among clients seeking transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for depression or anxiety but is not often addressed in these treatment programs. The benefits of offering clients a psychoeducational resource focused on alcohol use during ICBT for depression or anxiety are unknown. Objective: This observational study aimed to elucidate the impacts of addressing comorbid alcohol use in ICBT for depression and anxiety. Methods: All patients (N=1333) who started an 8-week transdiagnostic ICBT course for depression and anxiety received access to a resource containing information, worksheets, and strategies for reducing alcohol use, including psychoeducation, reasons for change, identifying risk situations, goal setting, replacing drinking with positive activities, and information on relapse prevention. We assessed clients’ use and perceptions of the resource; client characteristics associated with reviewing the resource; and whether reviewing the resource was associated with decreases in clients’ alcohol use, depression, and anxiety at posttreatment and 3-month follow-up among clients dichotomized into low-risk and hazardous drinking categories based on pretreatment Alcohol Use Disorders Identification Test (AUDIT) scores. Results: During the 8-week course, 10.8% (144/1333) of clients reviewed the resource, and those who reviewed the resource provided positive feedback (eg, 127/144, 88.2% of resource reviewers found it worth their time). Furthermore, 18.15% (242/1333) of clients exhibited hazardous drinking, with 14.9% (36/242) of these clients reviewing the resources. Compared with nonreviewers, resource reviewers were typically older (P=.004) and separated, divorced, or widowed (P<.001). Reviewers also consumed more weekly drinks (P<.001), scored higher on the AUDIT (P<.001), and were more likely to exhibit hazardous drinking (P<.001). Regardless of their drinking level (ie, low risk vs hazardous), all clients showed a reduction in AUDIT-Consumption scores (P=.004), depression (P<.001), and anxiety (P<.001) over time; in contrast, there was no change in clients’ drinks per week over time (P=.81). Reviewing alcohol resources did not predict changes in AUDIT-Consumption scores or drinks per week. Conclusions: Overall, ICBT appeared to be associated with a reduction in alcohol consumption scores, but this reduction was not greater among alcohol resource reviewers. Although there was some evidence that the resource was more likely to be used by clients with greater alcohol-related difficulties, the results suggest that further attention should be given to ensuring that those who could benefit from the resource review it to adequately assess the benefits of the resource. %M 37071454 %R 10.2196/44722 %U https://mental.jmir.org/2023/1/e44722 %U https://doi.org/10.2196/44722 %U http://www.ncbi.nlm.nih.gov/pubmed/37071454 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e42777 %T Translating Research Evidence Into Marketplace Application: Cohort Study of Internet-Based Intervention Platforms for Perinatal Depression %A Zeng,Zhen %A Peng,Jiale %A Liu,Lu %A Gong,Wenjie %+ HER Team and XiangYa School of Public Health, Central South University, 238 shangmayuanling, XiangYa Rd, Kaifu District, Changsha, Hunan, 410078, China, 86 13607445252, gongwenjie@csu.edu.cn %K cohort %K digital health %K internet-based intervention platform %K mhealth %K perinatal depression %K quality assessment %D 2023 %7 17.4.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet-based intervention platforms may improve access to mental health care for women with perinatal depression (PND). Though the majority of platforms in the market lack an evidence base, a small number of them are supported by research evidence. Objective: This study aims to assess the current status of internet-based PND intervention platforms supported by published evidence, understand the reasons behind the disappearance of any of these previously accessible platforms, examine adjustments made by those active platforms between research trials and market implementation, and evaluate their current quality. Methods: A cohort of internet-based PND intervention platforms was first identified by systematic searches in multiple academic databases from database inception until March 26, 2021. We searched on the World Wide Web and the iOS and Android app stores to assess which of these were available in the marketplace between April and May 2021. The basic characteristics of all platforms were collected. For inaccessible platforms, inquiries were made via email to the authors of publications to determine the reasons for their unavailability. We compared the intervention-related information of accessible platforms in the marketplace with that reported in original publications and conducted quality assessments using the App Evaluation Model of the American Psychiatric Association. Fisher exact tests were used to compare the functional characteristics in publications of available and unavailable platforms and to investigate potential associations between functional adjustments or quality indices and platform survival time. Results: Out of 35 platforms supported by research evidence, only 19 (54%) were still accessible in the marketplace. The main reason for platforms disappearing was the termination of research projects. No statistically significant differences were found in functional characteristics between available and unavailable platforms. A total of 18 (95%) platforms adapted their core functions from what was reported in related publications. The adjustments included changes to intervention methods (11/19, 58%), target population (10/19, 53%), human resources for intervention support (9/19, 47%), mood assessment and monitoring (8/19, 42%), communication modality (4/19, 21%), and platform type (2/19, 11%). Quality issues across platforms included low frequency of update, lack of crisis management mechanism, poor user interactivity, and weak evidence base or absence of citation of supporting evidence. Platforms that survived longer than 10 years had a higher tendency to use external resources from third parties compared to those that survived less than 10 years (P=.04). No significant differences were found for functional adjustments or other quality indices. Conclusions: Internet-based platforms supported by evidence were not effectively translated into real-world practice. It is unclear if adjustments to accessible platforms made during actual operation may undermine the proven validity of the original research. Future research to explore the reasons behind the success of the implementation of evidence-based platforms in the marketplace is warranted. %M 37067855 %R 10.2196/42777 %U https://www.jmir.org/2023/1/e42777 %U https://doi.org/10.2196/42777 %U http://www.ncbi.nlm.nih.gov/pubmed/37067855 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 6 %N %P e45616 %T A Family-Based Collaborative Care Model for Treatment of Depressive and Anxiety Symptoms in Perinatal Women: Results From a Pilot Study %A Cluxton-Keller,Fallon %A Olson,Ardis %+ Department of Psychiatry, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH, 03756, United States, 1 603 650 4726, Fallon.P.Cluxton-Keller@dartmouth.edu %K anxiety %K depression %K family treatment %K infant care %K maternal health %K parenting %K pediatric primary care %K perinatal anxiety %K perinatal care %K perinatal depression %K video therapy %K women's health %D 2023 %7 13.4.2023 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Untreated perinatal depression and anxiety can have detrimental consequences on family function. Logistical barriers prevent many perinatal women from accessing treatment, and these barriers are compounded for women residing in rural areas. This paper describes a Family-Based Collaborative Care Model (FBCCM) that is designed to bypass barriers to increase access to care for depressed and anxious perinatal women in rural regions of the United States. The FBCCM includes the following two components: (1) a 10-session video-delivered family therapy treatment for perinatal depression and anxiety and (2) a video-delivered infant care provider training on addressing the parenting needs of depressed and anxious mothers. Objective: This paper describes the feasibility of implementing the FBCCM with families and infant care providers. Findings are presented on the preliminary effectiveness of the video-delivered family therapy treatment in reducing maternal depressive and anxiety symptoms, and family conflict. Methods: This pilot study was carried out using an implementation-effectiveness hybrid trial design without a comparison group. Changes in maternal depressive symptoms, maternal anxiety symptoms, and family conflict were measured at posttreatment, 3 months, and 6 months later. Results: On average, mothers (n=24) attended 9.79 (SD 1.02) sessions. On average, their family members (n=24) attended 9.42 (SD 1.28) sessions. A total of 31 infant care providers attended the training on addressing the parenting needs of depressed and anxious mothers. Mothers reported a significant reduction in depressive symptoms (P<.001) and anxiety symptoms (P<.001) from baseline to the 6-month follow-up. Mothers reported a significant reduction in conflict (P<.001), and their family members also reported a significant reduction in conflict (P=.007) from baseline to the 6-month follow-up. Conclusions: The findings from this study provide support for the feasibility and preliminary effectiveness of the FBCCM. The findings will be used to inform a larger study of the FBCCM. %M 37052997 %R 10.2196/45616 %U https://pediatrics.jmir.org/2023/1/e45616 %U https://doi.org/10.2196/45616 %U http://www.ncbi.nlm.nih.gov/pubmed/37052997 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e40671 %T Sensa Mobile App for Managing Stress, Anxiety, and Depression Symptoms: Pilot Cohort Study %A Valinskas,Sarunas %A Nakrys,Marius %A Aleknavicius,Kasparas %A Jonusas,Justinas %+ KiloHealth, Antakalnio st. 17, Vilnius, LT 10312, Lithuania, 370 61456067, justinas.jonusas@kilo.health %K depression %K anxiety %K stress %K depressive %K DASS-21 %K mobile application %K CBT %K cognitive behavioral therapy %K psychotherapy %K mHealth %K mobile health %K Sensa %K app %K application %K health care %K intervention %K effectiveness %K assessment %K symptoms %K treatment %K mental health %D 2023 %7 13.4.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: An increase in depression, anxiety, and stress symptoms worldwide, attributed to the COVID-19 pandemic, has been reported. If not treated, it may negatively affect a person's everyday life by altering physical and social well-being and productivity and increasing expenditure on health care. Cognitive behavioral therapy (CBT)–based interventions are gaining popularity as a means to reduce stress and alleviate anxiety and depression symptoms. Moreover, CBT delivered through a mobile app has the same elements as traditional CBT training (eg, guided discovery). However, unlike conventional training, users of mobile apps are allowed to tailor their own experience at their own speed and schedule. Objective: This study aims to analyze Sensa users’ retrospective data and explore the dose-duration effect to find the optimal usage time when the user showed results. Methods: The study cohort comprised 381 consecutive community-based nonclinical users who started using Sensa between October 2021 and March 2022. All users included in the study took the Depression Anxiety Stress Scale-21 (DASS-21) assessment at least 2 times. Other parameters from the database containing all self-reported data were gender, number of active days, total time of use, and age. The primary outcome of the study was a change in the DASS-21 score. Statistical analyses were performed using GraphPad Prism (version 9, GraphPad Software). In addition, a logistic regression model was created to predict how the obtained independent parameters influenced the DASS-21 score. Results: The main finding of our study was that the majority of participants who started using Sensa were experiencing depression, anxiety, and stress symptoms (92.13%, 80.05%, and 87.93%, respectively). There was a statistically significant decrease of the DASS-21 subdomain scores after the use of the application (anxiety: mean 7.25, SD 4.03 vs mean 6.12, SD 4.00; P=.001; depression: mean 11.05, SD 4.26 vs mean 9.01, SD 4.77; P=.001; stress: mean 11.42, SD 3.44 vs mean 9.96, SD 3.65; P<.001). Finally, the logistic regression model showed that users who were using the app for more than 24 days and had at least 12 active days during that time had 3.463 (95% CI 1.142-11.93) and 2.644 (95% CI 1.024-7.127) times higher chances to reduce their DASS-21 subdomain scores of depression and anxiety, respectively. Conclusions: Using the Sensa mobile app was related to decreased depression, anxiety, and stress symptoms. %M 37052990 %R 10.2196/40671 %U https://formative.jmir.org/2023/1/e40671 %U https://doi.org/10.2196/40671 %U http://www.ncbi.nlm.nih.gov/pubmed/37052990 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e39029 %T Time-Dependent Changes in Depressive Symptoms Among Control Participants in Digital-Based Psychological Intervention Studies: Meta-analysis of Randomized Controlled Trials %A Tong,Alan CY %A Ho,Florence SY %A Chu,Owen HH %A Mak,Winnie WS %+ Department of Psychology, The Chinese University of Hong Kong, Rm 354, Sino Building, New Territories, Hong Kong, 852 39436577, wwsmak@cuhk.edu.hk %K digital-based psychological intervention %K control groups %K meta-analysis %K depression %K depressive symptoms %K mobile phone %D 2023 %7 12.4.2023 %9 Review %J J Med Internet Res %G English %X Background: Digital-based psychological interventions (DPIs) have been shown to be efficacious in many randomized controlled trials (RCTs) in dealing with depression in adults. However, the effects of control comparators in these DPI studies have been largely overlooked, and they may vary in their effects on depression management. Objective: This meta-analytical study aimed to provide a quantitative estimate of the within-subject effects of control groups across different time intervals and explore the moderating effects of control types and symptom severity at baseline. Methods: A systematic literature search was conducted in late September 2021 on selected electronic databases: PubMed; ProQuest; Web of Science; and the Ovid system with MEDLINE, PsycINFO, and Embase. The control conditions in 107 RCTs with a total of 11,803 adults with depressive symptoms were included in the meta-analysis, and effect sizes (Hedges g) were calculated using the standardized mean difference approach. Study quality was assessed using the Cochrane risk-of-bias tool for randomized trials version 2. Results: The control conditions collectively yielded small to moderate effects in reducing depressive symptoms within 8 weeks since the baseline assessment (g=−0.358, 95% CI −0.434 to −0.281). The effects grew to moderate within 9 to 24 weeks (g=−0.549, 95% CI −0.638 to −0.460) and peaked at g=−0.810 (95% CI −0.950 to −0.670) between 25 and 48 weeks. The effects were maintained at moderate to large ranges (g=−0.769, 95% CI −1.041 to −0.498) beyond 48 weeks. The magnitude of the reduction differed across the types of control and severity of symptoms. Care as usual was the most powerful condition of all and produced a large effect (g=−0.950, 95% CI −1.161 to −0.739) in the medium term. The findings showed that waitlist controls also produced a significant symptomatic reduction in the short term (g=−0.291, 95% CI −0.478 to −0.104), refuting the previous suspicion of a nocebo effect. In addition, a large effect on depressive symptom reduction in the long term (g=−1.091, 95% CI −1.210 to −0.972) was noted among participants with severe levels of depressive symptoms at baseline. Conclusions: This study provided evidence that depressive symptoms generally reduced over time among control conditions in research trials of DPIs. Given that different control conditions produce variable and significant levels of symptomatic reduction, future intervention trials must adopt an RCT design and should consider the contents of control treatments when investigating the efficacy of DPIs. The results of waitlist controls confirmed previous findings of spontaneous recovery among people with mild to moderate depressive symptoms in face-to-face studies. Researchers may adopt watchful waiting as participants wait for the availability of digital-based psychological services. %M 37043276 %R 10.2196/39029 %U https://www.jmir.org/2023/1/e39029 %U https://doi.org/10.2196/39029 %U http://www.ncbi.nlm.nih.gov/pubmed/37043276 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e41261 %T Investigation of the Relationship Between Psychiatry Visit and Suicide After Deliberate Self-harm: Longitudinal National Cohort Study %A Kim,Hye Hyeon %A Ko,Chanyoung %A Park,Ji Ae %A Song,In Han %A Park,Yu Rang %+ Department of Biomedical Systems Informatics, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea, 82 2 2228 2494, YURANGPARK@yuhs.ac %K deliberate self-harm %K suicide %K psychiatry %K suicidal %K death %K mortality %K psychiatric %K Korea %D 2023 %7 12.4.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Deliberate self-harm (DSH) along with old age, physical disability, and low socioeconomic status are well-known contributors to suicide-related deaths. In recent years, South Korea has the highest suicide death rate among all Organization for Economic Co-operation and Development countries. Owing to the difficulty of accessing data of individuals with DSH behavior who died by suicide, the factors associated with suicide death in these high-risk individuals have not been sufficiently explored. There have been conflicting findings with regard to the relationship between previous psychiatric visits and suicidal death. Objective: We aimed to address the following 3 questions: Are there considerable differences in demographics, socioeconomic status, and clinical features in individuals who received psychiatric diagnosis (either before DSH or after DSH event) and those who did not? Does receiving a psychiatric diagnosis from the Department of Psychiatry, as opposed to other departments, affect survival? and Which factors related to DSH contribute to deaths by suicide? Methods: We used the Korean National Health Insurance Service Database to design a cohort of 5640 individuals (3067/5640, 54.38% women) who visited the hospital for DSH (International Classification of Diseases codes X60-X84) between 2002 and 2020. We analyzed whether there were significant differences among subgroups of individuals with DSH behavior based on psychiatric diagnosis status (whether they had received a psychiatric diagnosis, either before or after the DSH event) and the department from which they had received the psychiatric diagnosis. Another main outcome of the study was death by suicide. Cox regression models yielded hazard ratios (HRs) for suicide risk. Patterns were plotted using Kaplan-Meier survival curves. Results: There were significant differences in all factors including demographic, health-related, socioeconomic, and survival variables among the groups that were classified according to psychiatric diagnosis status (P<.001). The group that did not receive a psychiatric diagnosis had the lowest survival rate (867/1064, 81.48%). Analysis drawn using different departments from where the individual had received a psychiatric diagnosis showed statistically significant differences in all features of interest (P<.001). The group that had received psychiatric diagnoses from the Department of Psychiatry had the highest survival rate (888/951, 93.4%). These findings were confirmed using the Kaplan-Meier survival curves (P<.001). The severity of DSH (HR 4.31, 95% CI 3.55-5.26) was the most significant contributor to suicide death, followed by psychiatric diagnosis status (HR 1.84, 95% CI 1.47-2.30). Conclusions: Receiving psychiatric assessment from a health care professional, especially a psychiatrist, reduces suicide death in individuals who had deliberately harmed themselves before. The key characteristics of individuals with DSH behavior who die by suicide are male sex, middle age, comorbid physical disabilities, and higher socioeconomic status. %M 37043262 %R 10.2196/41261 %U https://publichealth.jmir.org/2023/1/e41261 %U https://doi.org/10.2196/41261 %U http://www.ncbi.nlm.nih.gov/pubmed/37043262 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e45970 %T Barriers to and Facilitators of a Blended Cognitive Behavioral Therapy Program for Depression and Anxiety Based on Experiences of University Students: Qualitative Interview Study %A Braun,Pia %A Atik,Ece %A Guthardt,Lisa %A Apolinário-Hagen,Jennifer %A Schückes,Magnus %+ Institute of Occupational, Social and Environmental Medicine, Faculty of Medicine, Centre for Health and Society, Heinrich Heine University Düsseldorf, Moorenstr. 5, Düsseldorf, 40225, Germany, 49 211 8106477, jennifer.apolinario.hagen@hhu.de %K digital therapeutics %K blended cognitive behavioral therapy %K bCBT %K depression %K anxiety %K acceptance %K user experiences %K university students %K mobile phone %D 2023 %7 12.4.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Blended cognitive behavioral therapy (bCBT) programs have been proposed to increase the acceptance and adoption of digital therapeutics (DTx) such as digital health apps. These programs allow for more personalized care by combining regular face-to-face therapy sessions with DTx. However, facilitators of and barriers to the use of DTx in bCBT programs have rarely been examined among students, who are particularly at risk for developing symptoms of depression and anxiety disorders. Objective: This study aimed to evaluate the facilitators of and barriers to the use of a bCBT program with the elona therapy app among university students with mild to moderate depression or anxiety symptoms. Methods: Semistructured interviews were conducted via videoconference between January 2022 and April 2022 with 102 students (mean age 23.93, SD 3.63 years; 89/102, 87.2% female) from universities in North Rhine-Westphalia, Germany, after they had completed weekly individual cognitive behavioral therapy sessions (25 minutes each) via videoconference for 6 weeks and regularly used the depression (n=67, 65.7%) or anxiety (n=35, 34.3%) module of the app. The interviews were coded based on grounded theory. Results: Many participants highlighted the intuitive handling of the app and indicated that they perceived it as a supportive tool between face-to-face sessions. Participants listed other benefits, such as increased self-reflection and disorder-specific knowledge as well as the transfer of the content of therapy sessions into their daily lives. Some stated that they would have benefited from more personalized and interactive tasks. In general, participants mentioned the time requirement, increased use of the smartphone, and the feeling of being left alone with potentially arising emotions while working on tasks for the next therapy session as possible barriers to the use of the app. Data security was not considered a major concern. Conclusions: Students mostly had positive attitudes toward elona therapy as part of the bCBT program. Our study shows that DTx complementing face-to-face therapy sessions can be perceived as a helpful tool for university students with mild to moderate anxiety or depression symptoms in their daily lives. Future research could elaborate on whether bCBT programs might also be suitable for students with more severe symptoms of mental disorders. In addition, the methods by which such bCBT programs could be incorporated into the university context to reach students in need of psychological support should be explored. %M 37043272 %R 10.2196/45970 %U https://formative.jmir.org/2023/1/e45970 %U https://doi.org/10.2196/45970 %U http://www.ncbi.nlm.nih.gov/pubmed/37043272 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 12 %N %P e39455 %T Effects of Antidepressants on COVID-19 Outcomes: Retrospective Study on Large-Scale Electronic Health Record Data %A Rahman,Md Mahmudur %A Mahi,Atqiya Munawara %A Melamed,Rachel %A Alam,Mohammad Arif Ul %+ The Richard A Miner School of Computer & Information Sciences, University of Massachusetts, 220 Pawtucket St, Lowell, MA, 01854, United States, 1 978 934 1971, mohammadariful_alam@uml.edu %K causal inference %K treatment effect %K drug effect %K COVID-19 outcomes %K COVID-19 severity %K drug repurposing %K COVID-19 %K depression %K mental health %K data mining %K electronic health record %K machine learning %K antidepressant %K causal inference method %D 2023 %7 11.4.2023 %9 Original Paper %J Interact J Med Res %G English %X Background: Antidepressants exert an anticholinergic effect in varying degrees, and various classes of antidepressants can produce a different effect on immune function. While the early use of antidepressants has a notional effect on COVID-19 outcomes, the relationship between the risk of COVID-19 severity and the use of antidepressants has not been properly investigated previously owing to the high costs involved with clinical trials. Large-scale observational data and recent advancements in statistical analysis provide ample opportunity to virtualize a clinical trial to discover the detrimental effects of the early use of antidepressants. Objective: We primarily aimed to investigate electronic health records for causal effect estimation and use the data for discovering the causal effects of early antidepressant use on COVID-19 outcomes. As a secondary aim, we developed methods for validating our causal effect estimation pipeline. Methods: We used the National COVID Cohort Collaborative (N3C), a database aggregating health history for over 12 million people in the United States, including over 5 million with a positive COVID-19 test. We selected 241,952 COVID-19–positive patients (age >13 years) with at least 1 year of medical history. The study included a 18,584-dimensional covariate vector for each person and 16 different antidepressants. We used propensity score weighting based on the logistic regression method to estimate causal effects on the entire data. Then, we used the Node2Vec embedding method to encode SNOMED-CT (Systematized Nomenclature of Medicine-Clinical Terms) medical codes and applied random forest regression to estimate causal effects. We used both methods to estimate causal effects of antidepressants on COVID-19 outcomes. We also selected few negatively effective conditions for COVID-19 outcomes and estimated their effects using our proposed methods to validate their efficacy. Results: The average treatment effect (ATE) of using any one of the antidepressants was −0.076 (95% CI −0.082 to −0.069; P<.001) with the propensity score weighting method. For the method using SNOMED-CT medical embedding, the ATE of using any one of the antidepressants was −0.423 (95% CI −0.382 to −0.463; P<.001). Conclusions: We applied multiple causal inference methods with novel application of health embeddings to investigate the effects of antidepressants on COVID-19 outcomes. Additionally, we proposed a novel drug effect analysis–based evaluation technique to justify the efficacy of the proposed method. This study offers causal inference methods on large-scale electronic health record data to discover the effects of common antidepressants on COVID-19 hospitalization or a worse outcome. We found that common antidepressants may increase the risk of COVID-19 complications and uncovered a pattern where certain antidepressants were associated with a lower risk of hospitalization. While discovering the detrimental effects of these drugs on outcomes could guide preventive care, identification of beneficial effects would allow us to propose drug repurposing for COVID-19 treatment. %M 36881541 %R 10.2196/39455 %U https://www.i-jmr.org/2023/1/e39455 %U https://doi.org/10.2196/39455 %U http://www.ncbi.nlm.nih.gov/pubmed/36881541 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e44756 %T Treating Depression in Adolescents and Young Adults Using Remote Intensive Outpatient Programs: Quality Improvement Assessment %A Evans-Chase,Michelle %A Solomon,Phyllis %A Peralta,Bethany %A Kornmann,Rachel %A Fenkel,Caroline %+ School of Social Policy & Practice, University of Pennsylvania, 3701 Locust Walk, Philadelphia, PA, 19104, United States, 1 6096023792, meva@upenn.edu %K depression %K IOP %K LGBTQ+ %K mental health %K telehealth %K youth %K young adult %D 2023 %7 11.4.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Youth and young adults face barriers to mental health care, including a shortage of programs that accept youth and a lack of developmentally sensitive programming among those that do. This shortage, along with the associated geographically limited options, has contributed to the health disparities experienced by youth in general and by those with higher acuity mental health needs in particular. Although intensive outpatient programs can be an effective option for youth with more complex mental health needs, place-based intensive outpatient programming locations are still limited to clients who have the ability to travel to the clinical setting several days per week. Objective: The objective of the analysis reported here was to assess changes in depression between intake and discharge among youth and young adults diagnosed with depression attending remote intensive outpatient programming treatment. Analysis of outcomes and the application of findings to programmatic decisions are regular parts of ongoing quality improvement efforts of the program whose results are reported here. Methods: Outcomes data are collected for all clients at intake and discharge. The Patient Health Questionnaire (PHQ) adapted for adolescents is used to measure depression, with changes between intake and discharge regularly assessed for quality improvement purposes using repeated measures t tests. Changes in clinical symptoms are assessed using McNamar chi-square analyses. One-way ANOVA is used to test for differences among age, gender, and sexual orientation groups. For this analysis, 1062 cases were selected using criteria that included a diagnosis of depression and a minimum of 18 hours of treatment over a minimum of 2 weeks of care. Results: Clients ranged in age from 11 to 25 years, with an average of 16 years. Almost one-quarter (23%) identified as nongender binary and 60% identified as members of the lesbian, gay, bisexual, transgender, queer (LGBTQ+) community. Significant decreases (mean difference –6.06) were seen in depression between intake and discharge (t967=–24.68; P<.001), with the symptoms of a significant number of clients (P<.001) crossing below the clinical cutoff for major depressive disorder between intake and discharge (388/732, 53%). No significant differences were found across subgroups defined by age (F2,958=0.47; P=.63), gender identity (F7,886=1.20; P=.30), or sexual orientation (F7,872=0.47; P=.86). Conclusions: Findings support the use of remote intensive outpatient programming to treat depression among youth and young adults, suggesting that it may be a modality that is an effective alternative to place-based mental health treatment. Additionally, findings suggest that the remote intensive outpatient program model may be an effective treatment approach for youth from marginalized groups defined by gender and sexual orientation. This is important given that youth from these groups tend to have poorer outcomes and greater barriers to treatment compared to cisgender, heterosexual youth. %M 37040155 %R 10.2196/44756 %U https://formative.jmir.org/2023/1/e44756 %U https://doi.org/10.2196/44756 %U http://www.ncbi.nlm.nih.gov/pubmed/37040155 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e43904 %T Co-design of a Virtual Reality Cognitive Remediation Program for Depression (bWell-D) With Patient End Users and Clinicians: Qualitative Interview Study Among Patients and Clinicians %A Hernandez Hernandez,Maria Elena %A Michalak,Erin %A Choudhury,Nusrat %A Hewko,Mark %A Torres,Ivan %A Menon,Mahesh %A Lam,Raymond W %A Chakrabarty,Trisha %+ University of British Columbia, Faculty of Medicine, Department of Psychiatry, 2255 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada, 1 604 822 7314, elena.hernandez@ntnu.no %K depression %K cognitive remediation %K cognitive dysfunction %K thematic analysis %K virtual reality %K VR %K qualitative study %K user-centered design %K immersive %K co-design %K depressive %K mental health %K mental illness %D 2023 %7 7.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Major depressive disorder (MDD) is the leading cause of global disability; however, the existing treatments do not always address cognitive dysfunction—a core feature of MDD. Immersive virtual reality (VR) has emerged as a promising modality to enhance the real-world effectiveness of cognitive remediation. Objective: This study aimed to develop the first prototype VR cognitive remediation program for MDD (“bWell-D”). This study gathered qualitative data from end users early in the design process to enhance its efficacy and feasibility in clinical settings. Methods: Semistructured end-user interviews were conducted remotely (n=15 patients and n=12 clinicians), assessing the participants’ perceptions and goals for a VR cognitive remediation program. Video samples of bWell-D were also shared to obtain feedback regarding the program. The interviews were transcribed, coded, and analyzed via thematic analysis. Results: End users showed an optimistic outlook toward VR as a treatment modality, and perceived it as a novel approach with the potential of having multiple applications. The participants expressed a need for an engaging VR treatment that included realistic and multisensorial settings and activities, as well as customizable features. Some skepticism regarding its effectiveness was also reported, especially when the real-world applications of the practiced skills were not made explicit, as well as some concerns regarding equipment accessibility. A home-based or hybrid (ie, home and clinic) treatment modality was preferred. Conclusions: Patients and clinicians considered bWell-D interesting, acceptable, and potentially feasible, and provided suggestions to enhance its real-world applicability. The inclusion of end-user feedback is encouraged when developing future VR programs for clinical purposes. %M 37027183 %R 10.2196/43904 %U https://games.jmir.org/2023/1/e43904 %U https://doi.org/10.2196/43904 %U http://www.ncbi.nlm.nih.gov/pubmed/37027183 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43839 %T The Efficacy and Usability of an Unguided Web-Based Grief Intervention for Adults Who Lost a Loved One During the COVID-19 Pandemic: Randomized Controlled Trial %A Dominguez-Rodriguez,Alejandro %A Sanz-Gomez,Sergio %A González Ramírez,Leivy Patricia %A Herdoiza-Arroyo,Paulina Erika %A Trevino Garcia,Lorena Edith %A de la Rosa-Gómez,Anabel %A González-Cantero,Joel Omar %A Macias-Aguinaga,Valeria %A Miaja,Melina %+ School of Psychology, Universidad Internacional del Ecuador, Av. Simón Bolívar and Av. Jorge Fernández, Quito, 170102, Ecuador, 593 22985 600, pherdoiza@uide.edu.ec %K web-based intervention %K usability %K complicated grief %K hopelessness %K suicidal risk %K depression %K anxiety %K posttraumatic stress %K mobile phone %D 2023 %7 6.4.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: The death of a loved one was a challenge many people faced during the COVID-19 pandemic within the context of extraordinary circumstances and great uncertainty. Grief is an unavoidable part of life, and for most people, feelings of grief decrease naturally over time. However, for some people, grieving can become a particularly painful process with clinical symptoms that may require professional help to resolve. To provide psychological support to people who had lost a loved one during the COVID-19 pandemic, an unguided web-based psychological intervention was developed. Objective: The main objective of this study was to evaluate the efficacy of the web-based treatment, Grief COVID (Duelo COVID in Spanish; ITLAB), in reducing clinical symptoms of complicated grief, depression, posttraumatic stress, hopelessness, anxiety, and suicidal risk in adults. The secondary aim was to validate the usability of the self-applied intervention system. Methods: We used a randomized controlled trial with an intervention group (IG) and a waitlist control group (CG). The groups were assessed 3 times (before beginning the intervention, upon completing the intervention, and 3 months after the intervention). The intervention was delivered on the web in an asynchronous format through the Duelo COVID web page. Participants created an account that could be used on their computers, smartphones, or tablets. The evaluation process was automated as part of the intervention. Results: A total of 114 participants were randomly assigned to the IG or CG and met criteria for inclusion in the study (n=45, 39.5% completed the intervention and n=69, 60.5% completed the waitlist period). Most participants (103/114, 90.4%) were women. The results indicated that the treatment significantly reduced baseline clinical symptoms in the IG for all variables (P<.001 to P=.006), with larger effect sizes for depression, hopelessness, grief, anxiety, and risk of suicide (all effect sizes ≥0.5). The follow-up evaluation showed that symptom reduction was maintained at 3 months after the intervention. The results from the CG showed that participants experienced significantly decreased levels of hopelessness after completing the time on the waitlist (P<.001), but their suicidal risk scores increased. Regarding the usability of the self-applied intervention system, the results indicated a high level of satisfaction with the Grief COVID. Conclusions: The self-applied web-based intervention Grief COVID was effective in reducing symptoms of anxiety, depression, hopelessness, risk of suicide risk, posttraumatic stress disorder, and complicated grief disorder. Grief COVID was evaluated by the participants, who reported that the system was easy to use. These results affirm the importance of developing additional web-based psychological tools to help reduce clinical symptoms in people experiencing grief because of the loss of a loved one during a pandemic. Trial Registration: ClinicalTrials.gov NCT04638842; https://clinicaltrials.gov/ct2/show/NCT04638842 %M 36877800 %R 10.2196/43839 %U https://www.jmir.org/2023/1/e43839 %U https://doi.org/10.2196/43839 %U http://www.ncbi.nlm.nih.gov/pubmed/36877800 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e41751 %T A Probiotic Intervention With Bifidobacterium longum NCC3001 on Perinatal Mood Outcomes (PROMOTE Study): Protocol for a Decentralized Randomized Controlled Trial %A Toh,Melissa P S %A Yang,Chui Yuen %A Lim,Phei Cze %A Loh,Hui Li J %A Bergonzelli,Gabriela %A Lavalle,Luca %A Mardhy,Elias %A Samuel,Tinu Mary %A Suniega-Tolentino,Elvira %A Silva Zolezzi,Irma %A Fries,Lisa R %A Chan,Shiao Yng %+ Nestle Research, Beijing, 3rd floor, Building 5, Courtyard 6 Jiuxianqiao Road, Chaoyang District, Beijing, 100016, China, 86 139 1034 2174, lisa.fries@rd.nestle.com %K perinatal mood disturbances %K pregnancy %K randomized clinical trial %K low mood %K stress %K anxiety %K depression %K probiotics %K mobile phone %D 2023 %7 5.4.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Perinatal mood disorders such as depression and anxiety are common, with subclinical symptomology manifesting as perinatal mood disturbances being even more prevalent. These could potentially affect breastfeeding practices and infant development. Pregnant and lactating women usually limit their exposure to medications, including those for psychological symptoms. Interestingly, the naturally occurring probiotic Bifidobacterium longum (BL) NCC3001 has been shown to reduce anxious behavior in preclinical models and feelings of low mood in nonpregnant human adults. During the COVID-19 pandemic, mental health issues increased, and conventionally conducted clinical trials were restricted by social distancing regulations. Objective: This study, Probiotics on Mothers’ Mood and Stress (PROMOTE), aimed to use a decentralized clinical trial design to test whether BL NCC3001 can reduce symptoms of depression, anxiety, and stress over the perinatal period. Methods: This double-blind, placebo-controlled, randomized, and 3-parallel-arm study aimed to recruit 180 women to evaluate the efficacy of the probiotic taken either during pregnancy and post partum (from 28-32 weeks’ gestation until 12 weeks after delivery; n=60, 33.3%) or post partum only (from birth until 12 weeks after delivery; n=60, 33.3%) in comparison with a placebo control group (n=60, 33.3%). Participants consumed the probiotic or matched placebo in a drink once daily. Mood outcomes were measured using the State-Trait Anxiety Inventory and Edinburgh Postnatal Depression Scale questionnaires, captured electronically at baseline (28-32 weeks’ gestation) and during e-study sessions over 5 further time points (36 weeks’ gestation; 9 days post partum; and 4, 8, and 12 weeks post partum). Saliva and stool samples were collected longitudinally at home to provide mechanistic insights. Results: In total, 520 women registered their interest on our website, of whom 184 (35.4%) were eligible and randomized. Of these 184 participants, 5 (2.7%) withdrew after randomization, leaving 179 (97.3%) who completed the study. Recruitment occurred between November 7, 2020, and August 20, 2021. Advertising on social media brought in 46.9% (244/520) of the prospective participants, followed by parenting-specific websites (116/520, 22.3%). Nationwide recruitment was achieved. Data processing is ongoing, and there are no outcomes to report yet. Conclusions: Multiple converging factors contributed to speedy recruitment and retention of participants despite COVID-19–related restrictions. This decentralized trial design sets a precedent for similar studies, in addition to potentially providing novel evidence on the impact of BL NCC3001 on symptoms of perinatal mood disturbances. This study was ideal for remote conduct: because of the high digital literacy and public trust in digital security in Singapore, the intervention could be self-administered without regular clinical monitoring, and the eligibility criteria and outcomes were measured using electronic questionnaires and self-collected biological samples. This design was particularly suited for a group considered vulnerable—pregnant women—during the challenging times of COVID-19–related social restrictions. Trial Registration: ClinicalTrials.gov NCT04685252; https://clinicaltrials.gov/ct2/show/NCT04685252 International Registered Report Identifier (IRRID): DERR1-10.2196/41751 %M 37018024 %R 10.2196/41751 %U https://www.researchprotocols.org/2023/1/e41751 %U https://doi.org/10.2196/41751 %U http://www.ncbi.nlm.nih.gov/pubmed/37018024 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43293 %T Vickybot, a Chatbot for Anxiety-Depressive Symptoms and Work-Related Burnout in Primary Care and Health Care Professionals: Development, Feasibility, and Potential Effectiveness Studies %A Anmella,Gerard %A Sanabra,Miriam %A Primé-Tous,Mireia %A Segú,Xavier %A Cavero,Myriam %A Morilla,Ivette %A Grande,Iria %A Ruiz,Victoria %A Mas,Ariadna %A Martín-Villalba,Inés %A Caballo,Alejandro %A Esteva,Julia-Parisad %A Rodríguez-Rey,Arturo %A Piazza,Flavia %A Valdesoiro,Francisco José %A Rodriguez-Torrella,Claudia %A Espinosa,Marta %A Virgili,Giulia %A Sorroche,Carlota %A Ruiz,Alicia %A Solanes,Aleix %A Radua,Joaquim %A Also,María Antonieta %A Sant,Elisenda %A Murgui,Sandra %A Sans-Corrales,Mireia %A H Young,Allan %A Vicens,Victor %A Blanch,Jordi %A Caballeria,Elsa %A López-Pelayo,Hugo %A López,Clara %A Olivé,Victoria %A Pujol,Laura %A Quesada,Sebastiana %A Solé,Brisa %A Torrent,Carla %A Martínez-Aran,Anabel %A Guarch,Joana %A Navinés,Ricard %A Murru,Andrea %A Fico,Giovanna %A de Prisco,Michele %A Oliva,Vicenzo %A Amoretti,Silvia %A Pio-Carrino,Casimiro %A Fernández-Canseco,María %A Villegas,Marta %A Vieta,Eduard %A Hidalgo-Mazzei,Diego %+ Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clínic de Barcelona, 170 Villarroel St, Barcelona, 08036, Spain, 34 606699877, dahidalg@clinic.cat %K primary care %K health care workers %K depression %K anxiety %K symptom %K burnout %K digital %K smartphone %K chatbot %K primary care digital support tool in mental health %K PRESTO %D 2023 %7 3.4.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Many people attending primary care (PC) have anxiety-depressive symptoms and work-related burnout compounded by a lack of resources to meet their needs. The COVID-19 pandemic has exacerbated this problem, and digital tools have been proposed as a solution. Objective: We aimed to present the development, feasibility, and potential effectiveness of Vickybot, a chatbot aimed at screening, monitoring, and reducing anxiety-depressive symptoms and work-related burnout, and detecting suicide risk in patients from PC and health care workers. Methods: Healthy controls (HCs) tested Vickybot for reliability. For the simulation study, HCs used Vickybot for 2 weeks to simulate different clinical situations. For feasibility and effectiveness study, people consulting PC or health care workers with mental health problems used Vickybot for 1 month. Self-assessments for anxiety (Generalized Anxiety Disorder 7-item) and depression (Patient Health Questionnaire-9) symptoms and work-related burnout (based on the Maslach Burnout Inventory) were administered at baseline and every 2 weeks. Feasibility was determined from both subjective and objective user-engagement indicators (UEIs). Potential effectiveness was measured using paired 2-tailed t tests or Wilcoxon signed-rank test for changes in self-assessment scores. Results: Overall, 40 HCs tested Vickybot simultaneously, and the data were reliably transmitted and registered. For simulation, 17 HCs (n=13, 76% female; mean age 36.5, SD 9.7 years) received 98.8% of the expected modules. Suicidal alerts were received correctly. For the feasibility and potential effectiveness study, 34 patients (15 from PC and 19 health care workers; 76% [26/34] female; mean age 35.3, SD 10.1 years) completed the first self-assessments, with 100% (34/34) presenting anxiety symptoms, 94% (32/34) depressive symptoms, and 65% (22/34) work-related burnout. In addition, 27% (9/34) of patients completed the second self-assessment after 2 weeks of use. No significant differences were found between the first and second self-assessments for anxiety (t8=1.000; P=.34) or depressive (t8=0.40; P=.70) symptoms. However, work-related burnout scores were moderately reduced (z=−2.07, P=.04, r=0.32). There was a nonsignificant trend toward a greater reduction in anxiety-depressive symptoms and work-related burnout with greater use of the chatbot. Furthermore, 9% (3/34) of patients activated the suicide alert, and the research team promptly intervened with successful outcomes. Vickybot showed high subjective UEI (acceptability, usability, and satisfaction), but low objective UEI (completion, adherence, compliance, and engagement). Vickybot was moderately feasible. Conclusions: The chatbot was useful in screening for the presence and severity of anxiety and depressive symptoms, and for detecting suicidal risk. Potential effectiveness was shown to reduce work-related burnout but not anxiety or depressive symptoms. Subjective perceptions of use contrasted with low objective-use metrics. Our results are promising but suggest the need to adapt and enhance the smartphone-based solution to improve engagement. A consensus on how to report UEIs and validate digital solutions, particularly for chatbots, is required. %M 36719325 %R 10.2196/43293 %U https://www.jmir.org/2023/1/e43293 %U https://doi.org/10.2196/43293 %U http://www.ncbi.nlm.nih.gov/pubmed/36719325 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e44862 %T The Effectiveness of a Smartphone Intervention Targeting Suicidal Ideation in Young Adults: Randomized Controlled Trial Examining the Influence of Loneliness %A McGillivray,Lauren %A Keng-Meng Hui,Nicholas %A Wong,Quincy J J %A Han,Jin %A Qian,Jiahui %A Torok,Michelle %+ Black Dog Institute, University of New South Wales, Hospital Rd, Sydney, 2031, Australia, 61 2 9065 9133, m.torok@unsw.edu.au %K loneliness %K suicidal ideation %K suicide prevention %K digital therapeutics %K smartphone intervention %K apps %D 2023 %7 30.3.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Loneliness is commonly reported by young people and has been shown to contribute to the rapid onset and escalation of depression and suicidal ideation during adolescence. Lonely people may also be particularly susceptible to disengaging from treatment early given the likelihood of their more complex clinical profiles leading to cognitive fatigue. While a smartphone intervention (LifeBuoy) has been shown to effectively reduce suicidal ideation in young adults, poor engagement is a well-documented issue for this therapeutic modality and has been shown to result in poorer treatment outcomes. Objective: This study aims to determine whether loneliness affects how young people experiencing suicidal ideation engage with and benefit from a therapeutic smartphone intervention (LifeBuoy). Methods: A total of 455 community-based Australian young adults (aged 18-25 years) experiencing recent suicidal ideation were randomized to use a dialectical behavioral therapy–based smartphone intervention (LifeBuoy) or an attention-matched control app (LifeBuoy-C) for 6 weeks. Participants completed measures of suicidal ideation, depression, anxiety, and loneliness at baseline (T0), post intervention (T1), and 3 months post intervention (T2). Piecewise linear mixed models were used to examine whether loneliness levels moderated the effect of LifeBuoy and LifeBuoy-C on suicidal ideation and depression across time (T0 to T1; T1 to T2). This statistical method was then used to examine whether app engagement (number of modules completed) influenced the relationship between baseline loneliness and suicidal ideation and depression across time. Results: Loneliness was positively associated with higher levels of overall suicidal ideation (B=0.75, 95% CI 0.08-1.42; P=.03) and depression (B=0.88, 95% CI 0.45-1.32; P<.001), regardless of time point or allocated condition. However, loneliness did not affect suicidal ideation scores across time (time 1: B=1.10, 95% CI –0.25 to 2.46; P=.11; time 2: B=0.43, 95% CI –1.25 to 2.12; P=.61) and depression scores across time (time 1: B=0.00, 95% CI –0.67 to 0.66; P=.99; time 2: B=0.41, 95% CI –0.37 to 1.18; P=.30) in either condition. Similarly, engagement with the LifeBuoy app was not found to moderate the impact of loneliness on suicidal ideation (B=0.00, 95% CI –0.17 to 0.18; P=.98) or depression (B=–0.08, 95% CI –0.19 to 0.03; P=.14). Conclusions: Loneliness was not found to affect young adults’ engagement with a smartphone intervention (LifeBuoy) nor any clinical benefits derived from the intervention. LifeBuoy, in its current form, can effectively engage and treat individuals regardless of how lonely they may be. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12619001671156; https://tinyurl.com/yvpvn5n8 International Registered Report Identifier (IRRID): RR2-10.2196/23655 %M 36995752 %R 10.2196/44862 %U https://mental.jmir.org/2023/1/e44862 %U https://doi.org/10.2196/44862 %U http://www.ncbi.nlm.nih.gov/pubmed/36995752 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 10 %N %P e42167 %T Perceptions of a Digital Mental Health Platform Among Participants With Depressive Disorder, Anxiety Disorder, and Other Clinically Diagnosed Mental Disorders in Singapore: Usability and Acceptability Study %A Phang,Ye Sheng %A Heaukulani,Creighton %A Martanto,Wijaya %A Morris,Robert %A Tong,Mian Mian %A Ho,Roger %+ MOH Office for Healthcare Transformation, 1 Maritime Square, #12-10 Harborfront Centre, Singapore, 099253, Singapore, 65 6679 3147, yesheng.phang@moht.com.sg %K mHealth %K mobile health %K CBT %K cognitive behavioral therapy %K cognitive behavioural therapy %K iCBT %K internet-based cognitive behavioral therapy %K usability %K Post-Study System Usability Questionnaire %K PSSUQ %K acceptability %K mental health %K Singapore %K depression disorder %K anxiety disorder %K mental illness %K anxiety %K depression %K depressive %D 2023 %7 29.3.2023 %9 Original Paper %J JMIR Hum Factors %G English %X Background: The website mindline.sg is a stress management and coping website that can be accessed anonymously in Singapore for free. Although designed to serve individuals who are well or have mild depression and anxiety symptoms, mindline.sg may potentially be used by clinicians as an adjunct therapeutic aid for patients with clinically diagnosed mental disorders. Objective: This study aims to determine the perceived usability, acceptability, and usefulness of mindline.sg among individuals with diagnosed mental disorders in a clinical setting. Methods: A cross-sectional study with 173 participants was conducted in the waiting room of a psychiatrist’s office at the National University Hospital in Singapore. Participants waiting for an appointment were given 30 minutes and a simple set of instructions to use three features of mindline.sg. They subsequently answered a set of web-based survey questions via their smartphones, including a 16-item subset of the Post-Study System Usability Questionnaire (PSSUQ) for usability measurement and 5 questions designed to understand the perceived usefulness and acceptability of mindline.sg. Multiple linear regression is used to determine the associated demographic factors with overall PSSUQ score. A chi-square test is performed to investigate associations of psychiatric condition with users’ responses on acceptability and perceived usefulness of mindline.sg. For this study, P<.05 is considered significant. Results: We observed that the overall (mean 2.86, SD 1.46), system usefulness (mean 2.74, SD 1.46), and information quality (mean 2.98, SD 1.33) subscores of the PSSUQ survey are within a 99% CI of a literature-derived norm, which all have the interpretation of having high perceived usability. However, interface quality (mean 2.98, SD 1.33) scored lower than the literature-derived norm, although it is still better than the neutral score of 4. We find participants with lower than a General Certificate of Education O-Level or N-Level education tend to give a lower usability score as compared to others (β=.49; P=.02). Participants who have not been hospitalized previously due to their condition are also more likely to give a lower PSSUQ score as compared to individuals who have been hospitalized (β=.18; P=.03). The platform mindline.sg is also deemed to be generally useful and acceptable with all the survey questions receiving more than a 60% positive response. We found no association between the type(s) of self-reported psychiatric disorder(s) and the perceived usefulness and acceptability of mindline.sg. Conclusions: Our results show that mindline.sg is generally perceived as usable and acceptable by individuals with a diagnosed mental disorder in Singapore. The study suggests improving usability among individuals with lower education levels. Particularly promising is the finding that previously hospitalized individuals have significantly higher perceived usability and satisfaction of the website, suggesting potential impact could be found among a moderately to severely at-risk clinical population. The effectiveness of mindline.sg as an adjunct therapy for individuals with diagnosed mental disorders should therefore be explored in future studies. %M 36989020 %R 10.2196/42167 %U https://humanfactors.jmir.org/2023/1/e42167 %U https://doi.org/10.2196/42167 %U http://www.ncbi.nlm.nih.gov/pubmed/36989020 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43623 %T The Association of a Geographically Wide Social Media Network on Depression: County-Level Ecological Analysis %A Beauchamp,Alaina M %A Lehmann,Christoph U %A Medford,Richard J %A Hughes,Amy E %+ Peter O'Donnell Jr School of Public Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, United States, 1 2146483232, alaina.beauchamp@utsouthwestern.edu %K Facebook %K social connectedness %K depression %K county-level analysis %K social media %K mental health %K research %K ecological %K geography %K GIS %D 2023 %7 27.3.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Social connectedness decreases human mortality, improves cancer survival, cardiovascular health, and body mass, results in better-controlled glucose levels, and strengthens mental health. However, few public health studies have leveraged large social media data sets to classify user network structure and geographic reach rather than the sole use of social media platforms. Objective: The objective of this study was to determine the association between population-level digital social connectedness and reach and depression in the population across geographies of the United States. Methods: Our study used an ecological assessment of aggregated, cross-sectional population measures of social connectedness, and self-reported depression across all counties in the United States. This study included all 3142 counties in the contiguous United States. We used measures obtained between 2018 and 2020 for adult residents in the study area. The study’s main exposure of interest is the Social Connectedness Index (SCI), a pair-wise composite index describing the “strength of connectedness between 2 geographic areas as represented by Facebook friendship ties.” This measure describes the density and geographical reach of average county residents’ social network using Facebook friendships and can differentiate between local and long-distance Facebook connections. The study’s outcome of interest is self-reported depressive disorder as published by the Centers for Disease Control and Prevention. Results: On average, 21% (21/100) of all adult residents in the United States reported a depressive disorder. Depression frequency was the lowest for counties in the Northeast (18.6%) and was highest for southern counties (22.4%). Social networks in northeastern counties involved moderately local connections (SCI 5-10 the 20th percentile for n=70, 36% of counties), whereas social networks in Midwest, southern, and western counties contained mostly local connections (SCI 1-2 the 20th percentile for n=598, 56.7%, n=401, 28.2%, and n=159, 38.4%, respectively). As the quantity and distance that social connections span (ie, SCI) increased, the prevalence of depressive disorders decreased by 0.3% (SE 0.1%) per rank. Conclusions: Social connectedness and depression showed, after adjusting for confounding factors such as income, education, cohabitation, natural resources, employment categories, accessibility, and urbanicity, that a greater social connectedness score is associated with a decreased prevalence of depression. %M 36972109 %R 10.2196/43623 %U https://www.jmir.org/2023/1/e43623 %U https://doi.org/10.2196/43623 %U http://www.ncbi.nlm.nih.gov/pubmed/36972109 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43213 %T The Longitudinal Impact of Social Media Use on UK Adolescents' Mental Health: Longitudinal Observational Study %A Plackett,Ruth %A Sheringham,Jessica %A Dykxhoorn,Jennifer %+ Research Department of Primary Care & Population Health, University College London, Rowland Hill Street, London, NW3 2PF, United Kingdom, 44 20 3108 3096, ruth.plackett.15@ucl.ac.uk %K social media %K mental health %K depression %K depressive %K anxiety %K adolescent %K adolescence %K mediation analysis %K cohort study %K youth %K young people %K self-esteem %K national survey %K household survey %K computer use %K technology use %K screen time %D 2023 %7 24.3.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Cross-sectional studies have found a relationship between social media use and depression and anxiety in young people. However, few longitudinal studies using representative data and mediation analysis have been conducted to understand the causal pathways of this relationship. Objective: This study aims to examine the longitudinal relationship between social media use and young people’s mental health and the role of self-esteem and social connectedness as potential mediators. Methods: The sample included 3228 participants who were 10- to 15-year-olds from Understanding Society (2009-2019), a UK longitudinal household survey. The number of hours spent on social media was measured on a 5-point scale from “none” to “7 or more hours” at the ages of 12-13 years. Self-esteem and social connectedness (number of friends and happiness with friendships) were measured at the ages of 13-14 years. Mental health problems measured by the Strengths and Difficulties Questionnaire were assessed at the ages of 14-15 years. Covariates included demographic and household variables. Unadjusted and adjusted multilevel linear regression models were used to estimate the association between social media use and mental health. We used path analysis with structural equation modeling to investigate the mediation pathways. Results: In adjusted analysis, there was a nonsignificant linear trend showing that more time spent on social media was related to poorer mental health 2 years later (n=2603, β=.21, 95% CI −0.43 to 0.84; P=.52). In an unadjusted path analysis, 68% of the effect of social media use on mental health was mediated by self-esteem (indirect effect, n=2569, β=.70, 95% CI 0.15-1.30; P=.02). This effect was attenuated in the adjusted analysis, and it was found that self-esteem was no longer a significant mediator (indirect effect, n=2316, β=.24, 95% CI −0.12 to 0.66; P=.22). We did not find evidence that the association between social media and mental health was mediated by social connectedness. Similar results were found in imputed data. Conclusions: There was little evidence to suggest that more time spent on social media was associated with later mental health problems in UK adolescents. This study shows the importance of longitudinal studies to examine this relationship and suggests that prevention strategies and interventions to improve mental health associated with social media use could consider the role of factors like self-esteem. %M 36961482 %R 10.2196/43213 %U https://www.jmir.org/2023/1/e43213 %U https://doi.org/10.2196/43213 %U http://www.ncbi.nlm.nih.gov/pubmed/36961482 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e39894 %T Moral Elevation Online Intervention for Veterans Experiencing Distress Related to Posttraumatic Stress Disorder and Moral Injury (MOVED): Pilot Trial of a 4-Week Positive Psychology Web-Based Intervention %A McGuire,Adam P %A Howard,Binh An Nguyen %A Erickson,Thane M %A Creech,Suzannah K %+ VISN 17 Center of Excellence for Research on Returning War Veterans, 4800 Memorial Dr #151c, Waco, TX, 76711, United States, 1 254 297 5155, adam.mcguire@va.gov %K moral elevation %K web-based intervention %K pilot study %K veterans %K posttraumatic stress disorder %K PTSD %K moral injury %D 2023 %7 24.3.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Veterans with posttraumatic stress disorder (PTSD) and moral injury can encounter several barriers to treatment, including limited access to care and low engagement with therapy. Furthermore, most treatment approaches focus on alleviating distress rather than cultivating positive experiences that could facilitate trauma recovery. A potential way to address these issues is through moral elevation: feeling uplifted and inspired by others’ virtuous actions. Objective: This study aimed to examine the feasibility and acceptability of a novel, web-based moral elevation intervention for veterans with PTSD symptoms and moral injury distress (Moral Elevation Online Intervention for Veterans Experiencing Distress Related to PTSD and Moral Injury [MOVED]). This mixed methods study also examined potential changes in PTSD symptoms, moral injury distress, quality of life, and prosocial behavior. Methods: In this pilot trial, 48 participants were randomized to a MOVED or control condition (24 participants per condition). Both conditions included 8 sessions and lasted 1 month. The MOVED intervention and all survey components across both conditions were administered online. Participants completed self-report measures that assessed PTSD symptoms, moral injury distress, quality of life, and prosocial behavior at baseline and follow-up. Veterans in the MOVED condition also completed individual qualitative interviews at follow-up. We coded qualitative responses to interviews and identified emergent themes. Results: Findings suggest the MOVED intervention was largely feasible, with evidence for moderate-to-high levels of participation, engagement, and retention in MOVED sessions. Both quantitative and qualitative results suggest veterans found MOVED to be acceptable and satisfactory at the overall treatment level. Furthermore, participants reported high scores for helpfulness and engagement at the session level. Veterans who completed MOVED reported large within-person decreases in PTSD symptoms (Cohen d=1.44), approximately twice that of veterans in the control condition (Cohen d=0.78). Those in MOVED also reported medium-sized increases in physical (Cohen d=0.71) and psychological domains of quality of life (Cohen d=0.74), compared with no meaningful changes in the control condition. Unexpectedly, MOVED veterans reported no decrease in moral injury distress, whereas veterans in the control condition endorsed a medium-sized decrease in the total score. There were no changes in prosociality for either condition. Qualitative feedback further supported high levels of perceived acceptability and satisfaction and positive treatment outcomes across a range of domains, including behaviors, cognitions, emotions, and social functioning. Veterans also recommended adaptations to enhance engagement and maximize the impact of intervention content. Conclusions: Overall, findings indicate that veterans with PTSD and moral injury distress were interested in an intervention based on exposure to and engagement with experiences of moral elevation. After further research and refinement guided by future trials, veterans may benefit from this novel approach, which may enhance treatment outcomes and increase treatment accessibility for those in need of additional trauma-focused care. %M 36961494 %R 10.2196/39894 %U https://formative.jmir.org/2023/1/e39894 %U https://doi.org/10.2196/39894 %U http://www.ncbi.nlm.nih.gov/pubmed/36961494 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45456 %T Acoustic Analysis of Speech for Screening for Suicide Risk: Machine Learning Classifiers for Between- and Within-Person Evaluation of Suicidality %A Min,Sooyeon %A Shin,Daun %A Rhee,Sang Jin %A Park,C Hyung Keun %A Yang,Jeong Hun %A Song,Yoojin %A Kim,Min Ji %A Kim,Kyungdo %A Cho,Won Ik %A Kwon,Oh Chul %A Ahn,Yong Min %A Lee,Hyunju %+ Department of Neuropsychiatry, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea, 82 2 2072 2458, wandy04@naver.com %K suicide %K voice analysis %K mood disorder %K artificial intelligence %K screening %K prediction %K digital health tool %D 2023 %7 23.3.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Assessing a patient’s suicide risk is challenging for health professionals because it depends on voluntary disclosure by the patient and often has limited resources. The application of novel machine learning approaches to determine suicide risk has clinical utility. Objective: This study aimed to investigate cross-sectional and longitudinal approaches to assess suicidality based on acoustic voice features of psychiatric patients using artificial intelligence. Methods: We collected 348 voice recordings during clinical interviews of 104 patients diagnosed with mood disorders at baseline and 2, 4, 8, and 12 months after recruitment. Suicidality was assessed using the Beck Scale for Suicidal Ideation and suicidal behavior using the Columbia Suicide Severity Rating Scale. The acoustic features of the voice, including temporal, formal, and spectral features, were extracted from the recordings. A between-person classification model that examines the vocal characteristics of individuals cross sectionally to detect individuals at high risk for suicide and a within-person classification model that detects considerable worsening of suicidality based on changes in acoustic features within an individual were developed and compared. Internal validation was performed using 10-fold cross validation of audio data from baseline to 2-month and external validation was performed using data from 2 to 4 months. Results: A combined set of 12 acoustic features and 3 demographic variables (age, sex, and past suicide attempts) were included in the single-layer artificial neural network for the between-person classification model. Furthermore, 13 acoustic features were included in the extreme gradient boosting machine learning algorithm for the within-person model. The between-person classifier was able to detect high suicidality with 69% accuracy (sensitivity 74%, specificity 62%, area under the receiver operating characteristic curve 0.62), whereas the within-person model was able to predict worsening suicidality over 2 months with 79% accuracy (sensitivity 68%, specificity 84%, area under receiver operating characteristic curve 0.67). The second model showed 62% accuracy in predicting increased suicidality in external sets. Conclusions: Within-person analysis using changes in acoustic features within an individual is a promising approach to detect increased suicidality. Automated analysis of voice can be used to support the real-time assessment of suicide risk in primary care or telemedicine. %M 36951913 %R 10.2196/45456 %U https://www.jmir.org/2023/1/e45456 %U https://doi.org/10.2196/45456 %U http://www.ncbi.nlm.nih.gov/pubmed/36951913 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e44682 %T The Effect of Activity Participation in Middle-Aged and Older People on the Trajectory of Depression in Later Life: National Cohort Study %A Gao,Yan %A Jia,Zhihao %A Zhao,Liangyu %A Han,Suyue %+ School of Physical Education, Shandong University, 17922 Jingshi Road, Lixia District, Jinan, Shandong, 250061, China, 86 18663709793, gaoyanluck@sdu.edu.cn %K activity participation %K middle-aged and older people %K depression %K cohort study %K developmental %D 2023 %7 23.3.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: More activity participation is an important means of handling depression and promoting positive aging, but the impact of changes in activity participation on the developmental trajectory of depression has not been fully studied. Objective: The purpose of this study is to study the relationship between current activity participation and depression in middle-aged and older people (≥45 years old) and the relationship between activity participation and the developmental trajectory of depression in later life in China. Methods: This study used data from the China Health and Retirement Longitudinal Study (CHARLS) across 7 years and included a total of 4818 middle-aged and older people (≥45 years old). Controlling for relevant control variables, the latent growth curve model and the cross-lag model were used to assess the effect of changes in activity participation on the depression trajectory in later life and the main lag relationship between activity participation and depression. Activity participation as well as depression were measured using the self-reported activity and health status based on the CHARLS questionnaire. Results: Among the 4818 respondents, the mean values of physical activity participation, social leisure activity participation, and depression ranged from 76.98 (SD 15.16) to 83.95 (SD 5.72), from 7.43 (SD 8.67) to 9.25 (SD 10.16), and from 7.61 (SD 5.72) to 8.82 (SD 6.51), respectively. Our findings revealed that activity participation could be related to depression. Physical activity participation predicted initial depression (β=–0.631, P<.001) and its trajectory (β=0.461, P<.001). However, social leisure activity participation predicted initial depression (β=–0.223, P<.001) but did not predict its trajectory (β=0.067, P=.159). Finally, cross-lag regression analysis further demonstrated the predictive effect of activity participation on depression. Conclusions: This study demonstrates the prediction of activity participation for future depression in the Chinese middle-aged and older populations. The data showed that activity participation is significantly associated with changes in depression and future depression among middle-aged and older people in China. The Chinese government should encourage middle-aged and older people to participate in various activities, which can effectively prevent the aggravation of depression and also have a positive significance for positive aging. %M 36951932 %R 10.2196/44682 %U https://publichealth.jmir.org/2023/1/e44682 %U https://doi.org/10.2196/44682 %U http://www.ncbi.nlm.nih.gov/pubmed/36951932 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e43066 %T Effectiveness of Digital Mental Health Tools to Reduce Depressive and Anxiety Symptoms in Low- and Middle-Income Countries: Systematic Review and Meta-analysis %A Kim,Jiyeong %A Aryee,Lois M D %A Bang,Heejung %A Prajogo,Steffi %A Choi,Yong K %A Hoch,Jeffrey S %A Prado,Elizabeth L %+ Department of Public Health Sciences, School of Medicine, University of California, Davis, 1 Shields Avenue, Davis, CA, 95616, United States, 1 5307522793, jiykim@ucdavis.edu %K digital mental health %K mHealth %K mobile health %K digital health %K low- and middle-income country %K depression %K anxiety %K mobile phone %D 2023 %7 20.3.2023 %9 Review %J JMIR Ment Health %G English %X Background: Depression and anxiety contribute to an estimated 74.6 million years of life with disability, and 80% of this burden occurs in low- and middle-income countries (LMICs), where there is a large gap in care. Objective: We aimed to systematically synthesize available evidence and quantify the effectiveness of digital mental health interventions in reducing depression and anxiety in LMICs. Methods: In this systematic review and meta-analysis, we searched PubMed, Embase, and Cochrane databases from the inception date to February 2022. We included randomized controlled trials conducted in LMICs that compared groups that received digital health interventions with controls (active control, treatment as usual, or no intervention) on depression or anxiety symptoms. Two reviewers independently extracted summary data reported in the papers and performed study quality assessments. The outcomes were postintervention measures of depression or anxiety symptoms (Hedges g). We calculated the pooled effect size weighted by inverse variance. Results: Among 11,196 retrieved records, we included 80 studies in the meta-analysis (12,070 participants n=6052, 50.14% in the intervention group and n=6018, 49.85% in the control group) and 96 studies in the systematic review. The pooled effect sizes were −0.61 (95% CI −0.78 to −0.44; n=67 comparisons) for depression and −0.73 (95% CI −0.93 to −0.53; n=65 comparisons) for anxiety, indicating that digital health intervention groups had lower postintervention depression and anxiety symptoms compared with controls. Although heterogeneity was considerable (I2=0.94 for depression and 0.95 for anxiety), we found notable sources of variability between the studies, including intervention content, depression or anxiety symptom severity, control type, and age. Grading of Recommendations, Assessments, Development, and Evaluation showed that the evidence quality was overall high. Conclusions: Digital mental health tools are moderately to highly effective in reducing depression and anxiety symptoms in LMICs. Thus, they could be effective options to close the gap in depression and anxiety care in LMICs, where the usual mental health care is minimal. Trial Registration: PROSPERO CRD42021289709; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=289709 %M 36939820 %R 10.2196/43066 %U https://mental.jmir.org/2023/1/e43066 %U https://doi.org/10.2196/43066 %U http://www.ncbi.nlm.nih.gov/pubmed/36939820 %0 Journal Article %@ 2562-0959 %I JMIR Publications %V 6 %N %P e42360 %T A Digital Self-help Intervention for Atopic Dermatitis: Analysis of Secondary Outcomes From a Feasibility Study %A Kern,Dorian %A Ljótsson,Brjánn %A Lönndahl,Louise %A Hedman-Lagerlöf,Erik %A Bradley,Maria %A Lindefors,Nils %A Kraepelien,Martin %+ Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Norra Stationsgatan 69, Stockholm, 11364, Sweden, 46 723243235, dorian.kern@ki.se %K atopic dermatitis %K eczema %K pruritus %K cognitive behavioral therapy %K CBT %K dermatitis %K skin %K dermatology %K self-management %K self-guided %K self-help %K digital health %K digital intervention %K stress %K depressive %K depression %K mental health %D 2023 %7 20.3.2023 %9 Original Paper %J JMIR Dermatol %G English %X Background: Atopic dermatitis (AD) is a common inflammatory skin disease characterized by dry skin, eczematous lesions, and an often severe pruritus. The disease may have a negative effect on quality of life and is also associated with symptoms of anxiety and depression. Few individuals with AD receive any form of behavioral intervention. Behavioral interventions for AD are potentially efficacious but need to be constructed so that they are safe, credible, and user-friendly. We have previously reported on a feasibility study that demonstrated that a self-management version of a digital intervention based on cognitive behavioral therapy (CBT) for AD can potentially be effective in reducing AD symptoms. The aim of this secondary report was to further examine treatment feasibility and preliminary effects on dermatological quality of life, itching sensations, depressive symptoms, and perceived stress. Objective: This is a secondary report on intervention credibility, usability, adverse events, and preliminary effects on secondary measures of a self-management digital intervention for atopic dermatitis. Methods: In total, 21 adults with AD, recruited nationwide in Sweden, were assessed by telephone, and used the digital intervention for 8 weeks. Participants were also assessed directly afterward and 3 months after the end of the intervention. There was no therapist guidance. Feasibility indicators included intervention credibility, usability, and possible adverse effects. Other measures included preliminary effects on dermatological quality of life, itching sensations, depressive symptoms, and perceived stress. Results: The intervention was regarded as credible and no serious adverse events were reported. System usability was, however, found to be below the predetermined cutoff for acceptable usability. Preliminary effects at 3-month follow-up were in the moderate to large range for dermatological quality of life (Cohen d=0.89, 95% CI 0.18-1.56), itching sensations (Cohen d=0.85, 95% CI 0.15-1.52), depressive symptoms (Cohen d=0.78, 95% CI 0.1-1.45), and perceived stress (Cohen d=0.75, 95% CI 0.01-1.36). Conclusions: This 8-week self-management digital CBT-based intervention was, together with telephone calls before and after, a feasible intervention for participants with AD. Preliminary effects were promising and should be explored further in a randomized controlled trial. Intervention usability was, however, rated below cutoff scores. Efforts should be made to improve written material to increase usability. %M 37632924 %R 10.2196/42360 %U https://derma.jmir.org/2023/1/e42360 %U https://doi.org/10.2196/42360 %U http://www.ncbi.nlm.nih.gov/pubmed/37632924 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e39253 %T The Efficacy of Be a Mom, a Web-Based Intervention to Prevent Postpartum Depression: Examining Mechanisms of Change in a Randomized Controlled Trial %A Carona,Carlos %A Pereira,Marco %A Araújo-Pedrosa,Anabela %A Canavarro,Maria Cristina %A Fonseca,Ana %+ Center for Research in Neuropsychology and Cognitive-Behavioral Intervention, University of Coimbra, Colégio Novo St., Coimbra, 3000-115, Portugal, 351 239851450, ccarona@fpce.uc.pt %K Be a Mom %K randomized controlled trial %K postpartum depression %K web-based interventions %K cognitive behavioral therapy %K prevention %K mobile phone %D 2023 %7 17.3.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Postpartum depression (PPD) is treatable and preventable, but most women do not seek professional help for their perinatal depressive symptoms. One increasingly popular approach of improving access to care is the use of web-based intervention programs. Objective: The objective of this study was 2-fold: first, to assess the efficacy of Be a Mom, a brief web-based selective or indicated preventive intervention, in reducing depressive and anxiety symptoms of women at high risk for PPD; and second, to examine mechanisms of change linking modifiable self-regulatory skills (ie, emotion regulation, self-compassion, and psychological flexibility) to improved perinatal mental health outcomes. Methods: This 2-arm, open-label randomized controlled trial involved a sample of 1053 perinatal women presenting high risk for PPD who were allocated to the Be a Mom intervention group or a waitlist control group and completed self-report measures at baseline and postintervention assessments. Univariate latent change score models were computed to determine changes over time in adjustment processes and outcomes, with a multigroup-model approach to detect differences between the intervention and control groups and a 2-wave latent change score model to examine whether changes in processes were related to changes in outcomes. Results: Be a Mom was found to be effective in reducing depressive (intervention group: µΔ=–3.35; P<.001 vs control group: µΔ=–1.48; P<.001) and anxiety symptoms (intervention group: µΔ=–2.24; P<.001 vs control group: µΔ=–0.43; P=.04) in comparison with the control group, where such changes were inexistent or much smaller. All 3 psychological processes under study improved statistically significantly in posttreatment assessments: emotion regulation ability (Δχ23=12.3; P=.007) and psychological flexibility (Δχ23=34.9; P<.001) improved only in the intervention group, and although self-compassion increased in both groups (Δχ23=65.6; P<.001), these improvements were considerably greater in the intervention group. Conclusions: These results suggest that Be a Mom, a low-intensity cognitive behavioral therapy program, is a promising first-line intervention for helping perinatal women, particularly those with early-onset PPD symptoms. Trial Registration: ClinicalTrials.gov NCT03024645; https://clinicaltrials.gov/ct2/show/NCT03024645 %M 36930182 %R 10.2196/39253 %U https://mental.jmir.org/2023/1/e39253 %U https://doi.org/10.2196/39253 %U http://www.ncbi.nlm.nih.gov/pubmed/36930182 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e43600 %T Clinical and Psychosocial Outcomes Associated With a Tele-behavioral Health Platform for Families: Retrospective Study %A Loo,Theoren %A Hunt,Justin %A Grodberg,David %A Bravata,Dena %+ Child Study Center, Yale University School of Medicine, 333 Cedar St, New Haven, CT, 06510, United States, 1 203 785 2513, david.grodberg@yale.edu %K adolescent %K child %K family health %K resilience, psychological %K mental health %K caregiver stress %K anxiety %K depression %K behavior %K program %K educational psychotherapy %K psychiatry %K care %D 2023 %7 17.3.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: The burden of pediatric mental illness in the United States has steadily worsened over the past decade. A recent increase in employer-sponsored behavioral health programs has focused on the needs of the general population. However, these programs do not provide the specialty mental health care required for children, adolescents, and their families. Objective: This study aimed to evaluate the effects of a technology-enabled pediatric and family behavioral health service on clinical outcomes among children and caregiver strain. The service is available to commercially insured populations and provides educational content; tele-behavioral health care, including coaching, therapy, and psychiatry; and care escalation and coordination. Methods: A retrospective cohort analysis of members using the service between February and September 2022 was conducted. Clinical outcomes for children and their caregivers were collected using the Pediatric Symptom Checklist-17 (PSC-17), Generalized Anxiety Disorder 7-item (GAD-7), Patient Health Questionnaire 8-item (PHQ-8), and Caregiver Strain Questionnaire-Short Form 7 (CGSQ-SF7). Rates of reliable improvement were determined by calculating the reliable change index for each outcome. Paired, 2-tailed t tests were used to evaluate significant changes in assessment scores at follow-up compared to baseline. Results: Of the 4139 participants who enrolled with the service, 48 (1.2%) were referred out for more intensive care, 2393 (57.8%) were referred to coaching, and 1698 (41%) were referred to therapy and psychiatry. Among the 703 members who completed the intervention and provided pre- and postintervention outcomes data, 386 (54.9%) used psychoeducational content, 345 (49.1%) received coaching, and 358 (50.9%) received therapy and psychiatry. In coaching, 75% (183/244) of participants showed reliable improvement on the PSC-17 total score, 72.5% (177/244) on the PSC-17 internalizing score, and 31.5% (105/333) on the CGSQ-SF7 total score (average improvement: PSC-17 total score, 3.37 points; P<.001; PSC-17 internalizing score, 1.58 points; P<.001; and CGSQ-SF7 total score, 1.02 points; P<.001). In therapy and psychiatry, 68.8% (232/337) of participants showed reliable improvement on the PSC-17 total score, 70.6% (238/337) on the PSC-17 internalizing score, 65.2% (219/336) on the CGSQ-SF7 total score, 70.7% (82/116) on the GAD-7 score, and 67.5% (77/114) on the PHQ-8 score (average improvement: PSC-17 total score, 3.16 points; P<.001; PSC-17 internalizing score, 1.66 points; P<.001; CGSQ-SF7 total score, 1.06 points; P<.001; GAD-7 score, 3.00 points; P<.001; and PHQ-8 score, 2.91 points; P<.001). Conclusions: Tele-behavioral health offerings can be effective in improving caregiver strain and psychosocial functioning and depression and anxiety symptoms in a pediatric population. Moreover, these digital mental health offerings may provide a scalable solution to children and their families who lack access to essential pediatric mental health services. %M 36930214 %R 10.2196/43600 %U https://formative.jmir.org/2023/1/e43600 %U https://doi.org/10.2196/43600 %U http://www.ncbi.nlm.nih.gov/pubmed/36930214 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e41793 %T Association Between Social Networking Site Use Intensity and Depression Among Chinese Pregnant Women: Cross-sectional Study %A Wang,Rui %A Cong,Shengnan %A Sha,Lijuan %A Sun,Xiaoqing %A Zhu,Rong %A Feng,Jingyi %A Wang,Jianfang %A Tang,Xiaomei %A Zhao,Dan %A Zhu,Qing %A Fan,Xuemei %A Ren,Ziqi %A Zhang,Aixia %+ Department of Nursing, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, 123 Tianfei Alley, Qinhuai District, Nanjing, 210004, China, 86 13401920998, zhangaixia@njmu.edu.cn %K antenatal depression %K social network site %K social media %K WeChat %K upward social comparison %K rumination %D 2023 %7 15.3.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite extensive debates about the mental health impacts of the use of social networking sites (SNSs), including WeChat, the association and mechanisms between social interaction of WeChat use intensity and antenatal depression are unclear. Objective: We aimed to test the mediating roles of upward social comparison on social interaction of WeChat and rumination in the association between social interaction of WeChat use intensity and antenatal depression. Methods: A cross-sectional survey was conducted in four hospitals with the self-reported measures of social interaction of WeChat use intensity, upward social comparison on social interaction of WeChat, rumination, antenatal depression, and control variables. The mediation analysis was performed through Model 6 from the PROCESS macro 4.0 in SPSS 26. Results: Results from 2661 participants showed that antenatal depression was unrelated to social interaction of WeChat use intensity (P=.54), but was significantly positively related to the attitude toward social interaction of WeChat (P=.01). The direct effect of attitude toward social interaction of WeChat use on antenatal depression was not statistically significant (β=–.03, P=.05). The results supported an indirect relationship between attitude toward social interaction of WeChat use and antenatal depression via (1) upward social comparison on social interaction of WeChat (indirect effect value=0.04, 95% CI 0.03 to 0.06); (2) rumination (indirect effect value=–0.02, 95% CI –0.04 to –0.01); and (3) upward social comparison on social interaction of WeChat and rumination in sequence (indirect effect value=0.07, 95% CI 0.06 to 0.08). Conclusions: Our findings highlight the necessity of focusing on attitudes toward SNS use, and the importance of upward social comparison and rumination in understanding the effect of SNS use on antenatal depression. %M 36920458 %R 10.2196/41793 %U https://www.jmir.org/2023/1/e41793 %U https://doi.org/10.2196/41793 %U http://www.ncbi.nlm.nih.gov/pubmed/36920458 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e41273 %T Acceptability and Feasibility of “Village,” a Digital Communication App for Young People Experiencing Low Mood, Thoughts of Self-harm, and Suicidal Ideation to Obtain Support From Family and Friends: Mixed Methods Pilot Open Trial %A Thabrew,Hiran %A Kumar,Harshali %A Steadman,Evandah %+ Department of Psychological Medicine, The University go Auckland, 20-22 Park Road, Grafton, Auckland, 1142, New Zealand, 64 021402055, h.thabrew@auckland.ac.nz %K youth %K suicide %K self-harm %K depression %K support %K application %K mobile phone %D 2023 %7 13.3.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Young people experiencing low mood, thoughts related to self-harm, and suicidal ideation often struggle to communicate their emotions and receive timely support from family and friends. Technologically delivered support interventions may be useful in addressing this need. Objective: This paper aimed to evaluate the acceptability and feasibility of “Village,” a communication app co-designed with young people and their family and friends from New Zealand. Methods: A mixed methods pilot open trial design was adopted. Participants were primarily recruited via social media advertisements and clinicians in specialist mental health services over an 8-month period. The primary outcomes were acceptability of the app (via thematically analyzed qualitative feedback and retention rates) and feasibility of conducting a larger randomized controlled trial gauged via effectiveness of recruitment methods, completion of chosen outcome measures, and occurrence of unanticipated operational issues. Secondary outcomes were app usability, safety, and changes in symptoms of depression (via the Patient Health Questionnaire–9 modified for adolescents), suicidal ideation (on the Suicidal Ideation Questionnaire), and functioning (using the World Health Organization Disability Assessment Schedule 2.0 or Child and Youth version). Results: A total of 26 young people (“users”) were enrolled in the trial, of which 21 recruited friends and family members (“buddies”) and completed quantitative outcome measures at baseline, 4 weeks, and 3 months. Furthermore, 13 users and 12 buddies also provided qualitative feedback about the app, identifying the key themes of appeal of app features and layout, usefulness of its content, and technological challenges (primarily with onboarding and notifications). Users gave Village a mean rating of 3.8 (range 2.7-4.6) out of 5 on a 5-point scale for app quality and an overall star rating of 3.4 out of 5 for subjective quality. Within this limited sample, users reported a clinically significant reduction in depressive symptoms (P=.007), but nonsignificant changes in suicidal ideation and functioning. The embedded risk detection software was activated on 3 occasions, and no additional support was required for users. Conclusions: During this open trial, Village was found to be acceptable, usable, and safe. The feasibility of a larger randomized controlled trial was also confirmed after some modifications to the recruitment strategy and app. Trial Registration: Australian New Zealand Clinical Trials Network Registry ACTRN12620000241932p; https://tinyurl.com/ya6t4fx2 %M 36912882 %R 10.2196/41273 %U https://formative.jmir.org/2023/1/e41273 %U https://doi.org/10.2196/41273 %U http://www.ncbi.nlm.nih.gov/pubmed/36912882 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 10 %N %P e37351 %T Text Messages Exchanged Between Individuals With Opioid Use Disorder and Their mHealth e-Coaches: Content Analysis Study %A Ranjit,Yerina S %A Davis,Warren M %A Fentem,Andrea %A Riordan,Raven %A Roscoe,Rikki %A Cavazos-Rehg,Patricia %+ Department of Communication, University of Missouri, 207 Switzler Hall, Columbia, MO, 65211, United States, 1 573 882 4431, ranjity@missouri.edu %K opioid use disorder %K opioid %K opium %K overdose %K drug %K substance use %K content analysis %K text message intervention %K text message %K text messaging %K mobile health %K mHealth %K social support %K e-coach %K counseling %K mental health %K depression %K recovery support %K eHealth %K digital health %D 2023 %7 10.3.2023 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Opioid use disorder (OUD) has affected 2.2 million people in the United States. About 7.2 million people reported using illicit drugs in 2019, which contributed to over 70,000 overdose deaths. SMS text messaging interventions have been shown to be effective in OUD recovery. However, the interpersonal communication between individuals in OUD treatment and a support team on digital platforms has not been well examined. Objective: This study aims to understand the communication between participants undergoing OUD recovery and their e-coaches by examining the SMS text messages exchanged from the lens of social support and the issues related to OUD treatment. Methods: A content analysis of messages exchanged between individuals recovering from OUD and members of a support team was conducted. Participants were enrolled in a mobile health intervention titled “uMAT-R,” a primary feature of which is the ability for patients to instantly connect with a recovery support staff or an “e-coach” via in-app messaging. Our team analyzed dyadic text-based messages of over 12 months. In total, 70 participants’ messages and 1196 unique messages were analyzed using a social support framework and OUD recovery topics. Results: Out of 70 participants, 44 (63%) were between the ages of 31 and 50 years, 47 (67%) were female, 41 (59%) were Caucasian, and 42 (60%) reported living in unstable housing conditions. An average of 17 (SD 16.05) messages were exchanged between each participant and their e-coach. Out of 1196 messages, 64% (n=766) messages were sent by e-coaches and 36% (n=430) by participants. Messages of emotional support occurred the most, with 196 occurrences (n=9, 0.8%) and e-coaches (n=187, 15.6%). Messages of material support had 110 occurrences (participants: n=8, 0.7%; e-coaches: n=102, 8.5%). With OUD recovery topics, opioid use risk factors appeared in most (n=72) occurrences (patient: n=66, 5.5%; e-coach: n=6, 0.5%), followed by a message of avoidance of drug use 3.9% (n=47), which occurred mainly from participants. Depression was correlated with messages of social support (r=0.27; P=.02). Conclusions: Individuals with OUD who had mobile health needs tended to engage in instant messaging with the recovery support staff. Participants who are engaged in messaging often engage in conversations around risk factors and avoidance of drug use. Instant messaging services can be instrumental in providing the social and educational support needs of individuals recovering from OUD. %M 36897632 %R 10.2196/37351 %U https://humanfactors.jmir.org/2023/1/e37351 %U https://doi.org/10.2196/37351 %U http://www.ncbi.nlm.nih.gov/pubmed/36897632 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e38493 %T Evaluating the Utility of a Psychoeducational Serious Game (SPARX) in Protecting Inuit Youth From Depression: Pilot Randomized Controlled Trial %A Bohr,Yvonne %A Litwin,Leah %A Hankey,Jeffrey Ryan %A McCague,Hugh %A Singoorie,Chelsea %A Lucassen,Mathijs F G %A Shepherd,Matthew %A Barnhardt,Jenna %+ LaMarsh Centre for Child and Youth Research, York University, 4700 Keele Street, Toronto, ON, M3J1P3, Canada, 1 6475616464, jrhankey@yorku.ca %K psychoeducation %K cognitive behavioral therapy %K Inuit youth %K Nunavut %K depression %K suicide %K resilience %K serious game %K youth %K mental health %K teen %K adolescent %K pilot study %K community %D 2023 %7 9.3.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Inuit youth in Northern Canada show considerable resilience in the face of extreme adversities. However, they also experience significant mental health needs and some of the highest adolescent suicide rates in the world. Disproportionate rates of truancy, depression, and suicide among Inuit adolescents have captured the attention of all levels of government and the country. Inuit communities have expressed an urgent imperative to create, or adapt, and then evaluate prevention and intervention tools for mental health. These tools should build upon existing strengths, be culturally appropriate for Inuit communities, and be accessible and sustainable in Northern contexts, where mental health resources are often scarce. Objective: This pilot study assesses the utility, for Inuit youth in Canada, of a psychoeducational e-intervention designed to teach cognitive behavioral therapy strategies and techniques. This serious game, SPARX, had previously demonstrated effectiveness in addressing depression with Māori youth in New Zealand. Methods: The Nunavut Territorial Department of Health sponsored this study, and a team of Nunavut-based community mental health staff facilitated youth’s participation in an entirely remotely administered pilot trial using a modified randomized control approach with 24 youths aged 13-18 across 11 communities in Nunavut. These youth had been identified by the community facilitators as exhibiting low mood, negative affect, depressive presentations, or significant levels of stress. Entire communities, instead of individual youth, were randomly assigned to an intervention group or a waitlist control group. Results: Mixed models (multilevel regression) revealed that participating youth felt less hopeless (P=.02) and engaged in less self-blame (P=.03), rumination (P=.04), and catastrophizing (P=.03) following the SPARX intervention. However, participants did not show a decrease in depressive symptoms or an increase in formal resilience indicators. Conclusions: Preliminary results suggest that SPARX may be a good first step for supporting Inuit youth with skill development to regulate their emotions, challenge maladaptive thoughts, and provide behavioral management techniques such as deep breathing. However, it will be imperative to work with youth and communities to design, develop, and test an Inuit version of the SPARX program, tailored to fit the interests of Inuit youth and Elders in Canada and to increase engagement and effectiveness of the program. Trial Registration: ClinicalTrials.gov NCT05702086; https://www.clinicaltrials.gov/ct2/show/NCT05702086 %M 36892940 %R 10.2196/38493 %U https://games.jmir.org/2023/1/e38493 %U https://doi.org/10.2196/38493 %U http://www.ncbi.nlm.nih.gov/pubmed/36892940 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e41100 %T Supervised Relation Extraction Between Suicide-Related Entities and Drugs: Development and Usability Study of an Annotated PubMed Corpus %A Karapetian,Karina %A Jeon,Soo Min %A Kwon,Jin-Won %A Suh,Young-Kyoon %+ School of Computer Science and Engineering, Kyungpook National University, Rm. 520, IT-5, 80 Daehak-ro, Bukgu, Daegu, 41566, Republic of Korea, 82 53 950 6372, yksuh@knu.ac.kr %K suicide %K adverse drug events %K information extraction %K relation classification %K bidirectional encoder representations from transformers %K pharmacovigilance %K natural language processing %K PubMed %K corpus %K language model %D 2023 %7 8.3.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Drug-induced suicide has been debated as a crucial issue in both clinical and public health research. Published research articles contain valuable data on the drugs associated with suicidal adverse events. An automated process that extracts such information and rapidly detects drugs related to suicide risk is essential but has not been well established. Moreover, few data sets are available for training and validating classification models on drug-induced suicide. Objective: This study aimed to build a corpus of drug-suicide relations containing annotated entities for drugs, suicidal adverse events, and their relations. To confirm the effectiveness of the drug-suicide relation corpus, we evaluated the performance of a relation classification model using the corpus in conjunction with various embeddings. Methods: We collected the abstracts and titles of research articles associated with drugs and suicide from PubMed and manually annotated them along with their relations at the sentence level (adverse drug events, treatment, suicide means, or miscellaneous). To reduce the manual annotation effort, we preliminarily selected sentences with a pretrained zero-shot classifier or sentences containing only drug and suicide keywords. We trained a relation classification model using various Bidirectional Encoder Representations from Transformer embeddings with the proposed corpus. We then compared the performances of the model with different Bidirectional Encoder Representations from Transformer–based embeddings and selected the most suitable embedding for our corpus. Results: Our corpus comprised 11,894 sentences extracted from the titles and abstracts of the PubMed research articles. Each sentence was annotated with drug and suicide entities and the relationship between these 2 entities (adverse drug events, treatment, means, and miscellaneous). All of the tested relation classification models that were fine-tuned on the corpus accurately detected sentences of suicidal adverse events regardless of their pretrained type and data set properties. Conclusions: To our knowledge, this is the first and most extensive corpus of drug-suicide relations. %M 36884281 %R 10.2196/41100 %U https://www.jmir.org/2023/1/e41100 %U https://doi.org/10.2196/41100 %U http://www.ncbi.nlm.nih.gov/pubmed/36884281 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45528 %T The Effects of Online Self-management Interventions for Patients With Mood Disorders: Protocol for a Systematic Review and Meta-analysis %A Ahn,Junggeun %A Kim,Jiu %+ College of Nursing, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea, 82 10 5114 4013, wldn825@snu.ac.kr %K self-management %K mood disorders %K online interventions %K systematic review %K intervention program %K cognitive behavioral therapy %K psychoeducation %K electronic database %K development %K mental health %D 2023 %7 8.3.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Self-management has become important as a complementary approach to the recovery of patients with mood disorders, and the need for a remote intervention program has been revealed in relation to the COVID-19 pandemic. Objective: The aim of this review is to systematically review the studies for evidence on the effects of online self-management interventions based on cognitive behavioral therapy or psychoeducation for patients with mood disorders and to verify the statistical significance of the effectiveness of the interventions. Methods: A comprehensive literature search will be conducted using a search strategy in nine electronic bibliographic databases and will include all randomized controlled trial studies conducted up through December 2021. In addition, unpublished dissertations will be reviewed to minimize publication bias and to include a wider range of research. All steps in selecting the final studies to be included in the review will be performed independently by two researchers, and any discrepancies will be resolved through discussion. Results: Institutional review board approval was not required because this study was not conducted on people. Systematic literature searches, data extraction, narrative synthesis, meta-analysis, and final writing of the systematic review and meta-analysis are expected to be completed by 2023. Conclusions: This systematic review will provide a rationale for the development of web-based or online self-management interventions for the recovery of patients with mood disorders and will be used as a clinically meaningful reference in terms of mental health management. International Registered Report Identifier (IRRID): DERR1-10.2196/45528 %M 36884280 %R 10.2196/45528 %U https://www.researchprotocols.org/2023/1/e45528 %U https://doi.org/10.2196/45528 %U http://www.ncbi.nlm.nih.gov/pubmed/36884280 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e39675 %T Statewide Assessment of North Carolina Nurse Practitioners' Knowledge of and Attitudes Toward Suicide Awareness and Prevention: Protocol for a Statewide Mixed Methods Study %A Whitaker-Brown,Charlene %A Cornelius,Judith Bacchus %A Smoot,Jaleesa %A Khadka,Anjala %A Patil,Arundhati %+ School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte, 9201 University City Blvd, Charlotte, NC, 28223, United States, 1 704 687 7964, cdwhitak@uncc.edu %K mixed methods %K suicide awareness %K suicide prevention %K nurse practitioner %K knowledge and skills %K stigma %K suicide %K awareness %K nurse %K public health %K treatment %K prevention %K metal health %K mental illness %K United States %K skills %D 2023 %7 7.3.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is a major public health problem, which affects people of all ages and ethnicities. Despite being preventable, the rates of suicide have steadily climbed (more than a third) over the past 2 decades. Objective: Nurse practitioners (NPs) must be responsible for recognizing suicide risk and providing appropriate treatment referrals in addition to having an important role in suicide prevention. The reasons why NPs may not pursue suicide prevention training are their lack of suicide awareness and prevention, limited experiences with suicidal patients, and the stigma associated with mental illness. Before we begin to address the gaps within suicide awareness and prevention skills, we need to first examine NPs’ knowledge of and attitudes (stigma) toward suicide prevention. Methods: This study will comprise a mixed methods approach. First, quantitative data will be collected using the Suicide Knowledge and Skills Questionnaireand the Suicide Stigma Scale (Brief version) questionnaire. An email will be sent to the NPs explaining the purpose of the study. If they consent, they will click on a link to access the surveys on a secure site. In our previous research with this sample, email reminders to nonresponders after 2 and 4 weeks were sent. The quantitative component will be used to inform the qualitative interviews of this study. The Suicide Knowledge and Skills Questionnaire is a 13-item questionnaire comprising 2 subscales: suicide knowledge and suicide skills. All questions are rated on a 5-point Likert scale (1=completely disagree to 5=completely agree). The survey has been shown to differentiate between those with suicide training and those without and has a Cronbach α score of .84. The Suicide Stigma Scale (Brief version) is a 16-item survey that assesses stigma regarding suicide. The items are measured on a 5-point Likert scale (1: strongly disagree to 5: strongly agree) and have a Cronbach α of .98. Results: This study was funded by the Faculty Research Grants program through the Office of the Vice Chancellor for Research and Economic Development at the University of North Carolina at Charlotte. Institutional review board approval was obtained in April 2022. Recruitment occurred between summer and winter 2022. Interview conduction began in December 2022 and will conclude in March 2023. Data will be analyzed during spring and summer 2023. Conclusions: The study results will add to the literature on NPs’ knowledge of and attitudes (stigma) toward suicide prevention. It represents a first step in addressing gaps within suicide awareness and prevention skills, among NPs in their respective practice settings. International Registered Report Identifier (IRRID): PRR1-10.2196/39675 %M 36881461 %R 10.2196/39675 %U https://www.researchprotocols.org/2023/1/e39675 %U https://doi.org/10.2196/39675 %U http://www.ncbi.nlm.nih.gov/pubmed/36881461 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 6 %N %P e40937 %T Digital Behavioral Activation Interventions During the Perinatal Period: Scoping Review %A Mancinelli,Elisa %A Dell'Arciprete,Gaia %A Pattarozzi,Davide %A Gabrielli,Silvia %A Salcuni,Silvia %+ Department of Developmental and Socialization Psychology, University of Padova, Via Venezia 8, Padova, 35121, Italy, 39 3342799698, elisa.mancinelli@phd.unipd.it %K behavioral activation %K eHealth %K perinatal care %K depression symptoms %K scoping review %K mobile phone %D 2023 %7 28.2.2023 %9 Review %J JMIR Pediatr Parent %G English %X Background: Pregnancy is a complex period that implies many biopsychosocial changes, and the way women adapt to these changes impacts their well-being and the chances of developing mental health problems. During the perinatal period, women have expressed a preference for support delivered on the web. In this regard, interventions such as behavioral activation (BA), which are brief and structured psychosocial interventions, seem particularly suited to be delivered through digital solutions. Objective: This study aimed to map the literature investigating digital BA interventions deployed during the perinatal period. We paid particular attention to the methodological underpinnings of the studies, the potential impact of BA interventions on symptoms other than depression, and the existence of differences occurring when these interventions were administered during pregnancy versus the postpartum period. Methods: A systematic search compliant with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews) guidelines was conducted considering 5 bibliographic databases; reference lists and key journals were also screened by 2 independent authors following a double-blind approach. Results: A total of 7 studies published between 2013 and 2022 were included. In total, 2 studies were protocols for randomized controlled trials, 5 were empirical studies, and 1 was a qualitative study. All studies focused on the postpartum period, except for 1 that focused on the broader perinatal period. Promising effects on depression symptoms were reported but not on other psychosocial symptoms. Low intervention adherence has emerged, whereas the usability associated with the digital means used to deploy interventions was scarcely addressed; moreover, information on the digital platforms used was poorly reported overall. Conclusions: Our findings highlight the scarcity and preliminary nature of digital BA interventions deployed during the perinatal period, where the focus seems more on treatment rather than prevention. Moreover, future studies should also consider and address usability and user engagement, given their relevance to intervention efficacy. %M 36853756 %R 10.2196/40937 %U https://pediatrics.jmir.org/2023/1/e40937 %U https://doi.org/10.2196/40937 %U http://www.ncbi.nlm.nih.gov/pubmed/36853756 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e42677 %T Association of Depression With Precautionary Behavior Compliance, COVID-19 Fear, and Health Behaviors in South Korea: National Cross-sectional Study %A Shin,Hyerine %A Kim,Ji-Su %A Lee,HyunHae %+ Department of Nursing, Chung-ang University, 84 Heukseok-ro, Dongjak-gu, Seoul, 06974, Republic of Korea, 82 10 7117 5088, jisu80@cau.ac.kr %K COVID-19 %K precautionary behaviors %K COVID-19 fear %K health behavior deterioration %K gender differences %D 2023 %7 22.2.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: As of January 2022, the number of people infected with COVID-19 worldwide has exceeded 350 million. As the COVID-19 pandemic continues, people are affected in a wide range of areas of life, which in turn causes numerous psychological problems. Depression is a serious problem for people who have suffered from COVID-19. Depression can worsen COVID-19 precautionary behavior compliance or the health behavior itself. In addition, these depressive symptoms may have different characteristics depending on the individual’s gender. Objective: The aim of this study was to determine whether depression is a factor that may affect COVID-19 fear, precautionary behavior compliance, and health behavior, and how these characteristic trends differ by gender. Methods: This was a secondary analysis of data from the 2020 Korea Community Health Survey (KCHS), a national cross-sectional survey conducted with complex sampling analysis. In 2020, the KCHS included COVID-19–related questions. For this study, we used the KCHS data from both the COVID-19–related questions and the Patient Health Questionnaire-9 scale. After weighting the data according to the KCHS guidelines, we calculated the distribution of men and women according to depression level. The data were collected using multiple-choice questions related to precautionary behavior compliance, COVID-19–related fears, and health behavior changes. Results: Of the 204,787 participants, those who were clinically depressed had a greater tendency to not comply with precautionary behaviors. Regarding COVID-19, “fear” showed a decreasing trend in both men (adjusted odds ratio [AOR] 0.72, 95% CI 0.61-0.83) and women (AOR 0.74, 95% CI 0.63-0.86) with clinically relevant depression. Moreover, for both men and women, health behaviors deteriorated as depression intensified; the AOR for sleep duration changes was 2.28 (95% CI 2.00-2.59) in men and was 2.15 (95% CI 1.96-2.36) in women. Notably, the responses of clinically depressed women revealed a doubled increase in both their drinking (AOR 2.25, 95% CI 1.88-2.70) and smoking (AOR 2.71, 95% CI 1.95-3.77) habits compared with those of nondepressed women. Conclusions: Both men and women with more severe depression were more likely to violate precautionary health behaviors as their depression worsened. Health behaviors also deteriorated for both genders, but women tended to show a greater change. Therefore, additional studies and interventions for vulnerable groups such as severely depressed people are needed. More research is also necessary to develop interventions based on statistical comparisons of men and women. %M 36716130 %R 10.2196/42677 %U https://publichealth.jmir.org/2023/1/e42677 %U https://doi.org/10.2196/42677 %U http://www.ncbi.nlm.nih.gov/pubmed/36716130 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e42203 %T Quality of Life and Mental Health of Chinese Sexual and Gender Minority Women and Cisgender Heterosexual Women: Cross-sectional Survey and Mediation Analysis %A Wu,Chanchan %A Chau,Pui Hing %A Choi,Edmond Pui Hang %+ School of Nursing, The University of Hong Kong, 5/F, Academic Building, 3 Sassoon Road, Pok Fu Lam, Hong Kong, 999077, China (Hong Kong), 852 3917 6972, h0714919@connect.hku.hk %K quality of life %K depression %K anxiety %K self-esteem %K sexual and gender minority women %K mental health %K mediation analysis %K China %K minority %K women %K survey %K social %D 2023 %7 22.2.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Health-related research on sexual minority populations in China is lacking, and research on sexual and gender minority women (SGMW, including transgender women and persons of other gender identities assigned female at birth of all sexual orientations, and cisgender women with nonheterosexual orientations) is even less. Currently, there are limited surveys related to mental health in Chinese SGMW, but there are no studies on their quality of life (QOL), no studies comparing the QOL of SGMW with that of cisgender heterosexual women (CHW), and no studies on the relationship between sexual identity and the QOL as well as associated mental health variables. Objective: This study aims to evaluate the QOL and mental health in a diverse sample of Chinese women and make comparisons between SGMW and CHW and then investigate the relationship between sexual identity and the QOL through the role of mental health. Methods: A cross-sectional online survey was conducted from July to September 2021. All participants completed a structured questionnaire containing the World Health Organization Quality of Life–abbreviated short version (WHOQOL-BREF), the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder scale (GAD-7), and the Rosenberg Self-Esteem Scale (RSES). Results: In total, 509 women aged 18-56 years were recruited, including 250 (49.1%) CHW and 259 (50.9%) SGMW. Independent t tests showed that the SGMW reported significantly lower levels of QOL, higher levels of depression and anxiety symptoms, and lower self-esteem than the CHW. Pearson correlations showed that every domain and the overall QOL were positively associated with mental health variables, with moderate-to-strong correlations (r range 0.42-0.75, P<.001). Multiple linear regressions found that participants belonging to the SGMW group, current smokers, and women with no steady partner were associated with a worse overall QOL. The mediation analysis found that depression, anxiety, and self-esteem significantly completely mediated the relationship between sexual identity and physical, social, and environment domains of the QOL, while the relationship between sexual identity and the overall QOL and psychological QOL was partially mediated by depression and self-esteem. Conclusions: The SGMW had poorer levels of QOL and a worse mental health status than the CHW. The study findings affirm the importance of assessing mental health and highlight the need to design targeted health improvement programs for the SGMW population, who may be at higher risk of a poor QOL and mental health. %M 36811941 %R 10.2196/42203 %U https://publichealth.jmir.org/2023/1/e42203 %U https://doi.org/10.2196/42203 %U http://www.ncbi.nlm.nih.gov/pubmed/36811941 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e42935 %T Association Between the Severity of Depressive Symptoms and Human-Smartphone Interactions: Longitudinal Study %A Yang,Xiao %A Knights,Jonathan %A Bangieva,Victoria %A Kambhampati,Vinayak %+ Mindstrong Health, 101 Jefferson Dr. Suite 228, Menlo Park, CA, 94025, United States, 1 8889952230, vwendy@gmail.com %K depression %K human-smartphone interaction %K longitudinal data analysis %K within-person effect %K between-person effect %K nonergodicity %D 2023 %7 22.2.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Various behavioral sensing research studies have found that depressive symptoms are associated with human-smartphone interaction behaviors, including lack of diversity in unique physical locations, entropy of time spent in each location, sleep disruption, session duration, and typing speed. These behavioral measures are often tested against the total score of depressive symptoms, and the recommended practice to disaggregate within- and between-person effects in longitudinal data is often neglected. Objective: We aimed to understand depression as a multidimensional process and explore the association between specific dimensions and behavioral measures computed from passively sensed human-smartphone interactions. We also aimed to highlight the nonergodicity in psychological processes and the importance of disaggregating within- and between-person effects in the analysis. Methods: Data used in this study were collected by Mindstrong Health, a telehealth provider that focuses on individuals with serious mental illness. Depressive symptoms were measured by the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult Survey every 60 days for a year. Participants’ interactions with their smartphones were passively recorded, and 5 behavioral measures were developed and were expected to be associated with depressive symptoms according to either theoretical proposition or previous empirical evidence. Multilevel modeling was used to explore the longitudinal relations between the severity of depressive symptoms and these behavioral measures. Furthermore, within- and between-person effects were disaggregated to accommodate the nonergodicity commonly found in psychological processes. Results: This study included 982 records of DSM Level 1 depressive symptom measurements and corresponding human-smartphone interaction data from 142 participants (age range 29-77 years; mean age 55.1 years, SD 10.8 years; 96 female participants). Loss of interest in pleasurable activities was associated with app count (γ10=−0.14; P=.01; within-person effect). Depressed mood was associated with typing time interval (γ05=0.88; P=.047; within-person effect) and session duration (γ05=−0.37; P=.03; between-person effect). Conclusions: This study contributes new evidence for associations between human-smartphone interaction behaviors and the severity of depressive symptoms from a dimensional perspective, and it highlights the importance of considering the nonergodicity of psychological processes and analyzing the within- and between-person effects separately. %M 36811951 %R 10.2196/42935 %U https://formative.jmir.org/2023/1/e42935 %U https://doi.org/10.2196/42935 %U http://www.ncbi.nlm.nih.gov/pubmed/36811951 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e44210 %T Layperson-Facilitated Internet-Delivered Cognitive Behavioral Therapy for Homebound Older Adults With Depression: Protocol for a Randomized Controlled Trial %A Kayser,Jay %A Wang,Xu %A Wu,Zhenke %A Dimoji,Asha %A Xiang,Xiaoling %+ School of Social Work, University of Michigan, 1080 S University Ave, Ann Arbor, MI, 48109, United States, 1 (734) 764 3309, jaykayse@umich.edu %K depression %K depressive %K gerontology %K gerontological %K geriatric %K psychotherapy %K older adult %K elder %K home based %K community based %K community living %K homebound %K low-income %K eHealth %K mHealth %K digital mental health %K internet intervention %K iCBT %K CBT %K mental health %K cognitive behavioral therapy %K internet based %K internet delivered %D 2023 %7 22.2.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression in older adults has serious biological, psychological, and social consequences. Homebound older adults experience a high burden of depression and significant barriers to accessing mental health treatments. Few interventions to address their specific needs have been developed. Existing treatment modalities can be challenging to scale up, are not tailored to unique population concerns, and require significant staffing support. Technology-assisted, layperson-facilitated psychotherapy has the potential to overcome these challenges. Objective: The aim of this study is to assess the efficacy of a layperson-facilitated internet-delivered cognitive behavioral therapy program tailored for homebound older adults. The novel intervention, Empower@Home, was developed based on user-centered design principles and partnerships between researchers, social service agencies, care recipients, and other stakeholders serving low-income homebound older adults. Methods: This 2-arm, 20-week pilot randomized controlled trial (RCT) with a waitlist control crossover design aims to enroll 70 community-dwelling older adults with elevated depressive symptoms. The treatment group will receive the 10-week intervention immediately, whereas the waitlist control group will cross over and receive the intervention after 10 weeks. This pilot is part of a multiphase project involving a single-group feasibility study (completed in December 2022). This project consists of a pilot RCT (described in this protocol) and an implementation feasibility study running in parallel with the pilot RCT. The primary clinical outcome of the pilot is the change in depressive symptoms after the intervention and at the 20-week postrandomization follow-up. Additional outcomes include acceptability, adherence, and changes in anxiety, social isolation, and quality of life. Results: Institutional review board approval was obtained for the proposed trial in April 2022. Recruitment for the pilot RCT began in January 2023 and is anticipated to end in September 2023. On completion of the pilot trial, we will examine the preliminary efficacy of the intervention on depression symptoms and other secondary clinical outcomes in an intention-to-treat analysis. Conclusions: Although web-based cognitive behavioral therapy programs are available, most programs have low adherence and very few are tailored for older adults. Our intervention addresses this gap. Older adults, particularly those with mobility difficulties and multiple chronic health conditions, could benefit from internet-based psychotherapy. This approach can serve a pressing need in society while being cost-effective, scalable, and convenient. This pilot RCT builds on a completed single-group feasibility study by determining the preliminary effects of the intervention compared with a control condition. The findings will provide a foundation for a future fully-powered randomized controlled efficacy trial. If our intervention is found to be effective, implications extend to other digital mental health interventions and populations with physical disabilities and access restrictions who face persistent disparities in mental health. Trial Registration: ClinicalTrials.gov NCT05593276; https://clinicaltrials.gov/ct2/show/NCT05593276 International Registered Report Identifier (IRRID): PRR1-10.2196/44210 %M 36811937 %R 10.2196/44210 %U https://www.researchprotocols.org/2023/1/e44210 %U https://doi.org/10.2196/44210 %U http://www.ncbi.nlm.nih.gov/pubmed/36811937 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e44205 %T Using a Safety Planning Mobile App to Address Suicidality in Young People Attending Community Mental Health Services in Ireland: Protocol for a Pilot Randomized Controlled Trial %A Melia,Ruth %A Francis,Kady %A Duggan,Jim %A Bogue,John %A O'Sullivan,Mary %A Young,Karen %A Chambers,Derek %A McInerney,Shane J %A O'Dea,Edmond %A Bernert,Rebecca %+ Department of Psychology, University of Limerick, Castletroy, Limerick, V94 T9PX, Ireland, 353 61 202 700, ruth.melia@ul.ie %K suicide prevention %K mobile health %K mHealth %K safety planning %K SafePlan %K mobile phone %D 2023 %7 21.2.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Over 700,000 people die by suicide annually, making it the fourth leading cause of death among those aged 15-29 years globally. Safety planning is recommended best practice when individuals at risk of suicide present to health services. A safety plan, developed in collaboration with a health care practitioner, details the steps to be taken in an emotional crisis. SafePlan, a safety planning mobile app, was designed to support young people experiencing suicidal thoughts and behaviors and to record their plan in a way that is accessible immediately and in situ. Objective: The aim of this study is to assess the feasibility and acceptability of the SafePlan mobile app for patients experiencing suicidal thoughts and behaviors and their clinicians within Irish community mental health services, examine the feasibility of study procedures for both patients and clinicians, and determine if the SafePlan condition yields superior outcomes when compared with the control condition. Methods: A total of 80 participants aged 16-35 years accessing Irish mental health services will be randomized (1:1) to receive the SafePlan app plus treatment as usual or treatment as usual plus a paper-based safety plan. The feasibility and acceptability of the SafePlan app and study procedures will be evaluated using both qualitative and quantitative methodologies. The primary outcomes are feasibility outcomes and include the acceptability of the app to participants and clinicians, the feasibility of delivery in this setting, recruitment, retention, and app use. The feasibility and acceptability of the following measures in a full randomized controlled trial will also be assessed: the Beck Scale for Suicide Ideation, Columbia Suicide Severity Rating Scale, Coping Self-Efficacy Scale, Interpersonal Needs Questionnaire, and Client Service Receipt Inventory. A repeated measures design with outcome data collected at baseline, post intervention (8 weeks), and at 6-month follow-up will be used to compare changes in suicidal ideation for the intervention condition relative to the waitlist control condition. A cost-outcome description will also be undertaken. Thematic analyses will be used to analyze the qualitative data gathered through semistructured interviews with patients and clinicians. Results: As of January 2023, funding and ethics approval have been acquired, and clinician champions across mental health service sites have been established. Data collection is expected to commence by April 2023. The submission of completed manuscript is expected by April 2025. Conclusions: The framework for Decision-making after Pilot and feasibility Trials will inform the decision to progress to a full trial. The results will inform patients, researchers, clinicians, and health services of the feasibility and acceptability of the SafePlan app in community mental health services. The findings will have implications for further research and policy regarding the broader integration of safety planning apps. Trial Registration: OSF Registries osf.io/3y54m; https://osf.io/3y54m International Registered Report Identifier (IRRID): PRR1-10.2196/44205 %M 36809171 %R 10.2196/44205 %U https://www.researchprotocols.org/2023/1/e44205 %U https://doi.org/10.2196/44205 %U http://www.ncbi.nlm.nih.gov/pubmed/36809171 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e43419 %T Prediction of Suicidal Behaviors in the Middle-aged Population: Machine Learning Analyses of UK Biobank %A Wang,Junren %A Qiu,Jiajun %A Zhu,Ting %A Zeng,Yu %A Yang,Huazhen %A Shang,Yanan %A Yin,Jin %A Sun,Yajing %A Qu,Yuanyuan %A Valdimarsdóttir,Unnur A %A Song,Huan %+ West China Biomedical Big Data Center, West China Hospital, Sichuan University, Guo Xue Lane 37, Chengdu, 610021, China, 86 28 85164176, songhuan@wchscu.cn %K suicide %K suicidal behaviors %K risk prediction %K machine learning approach %K genetic susceptibility %K machine learning %K behavior %K data %K model %K sex %K risk %K cost-effective %D 2023 %7 20.2.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Suicidal behaviors, including suicide deaths and attempts, are major public health concerns. However, previous suicide models required a huge amount of input features, resulting in limited applicability in clinical practice. Objective: We aimed to construct applicable models (ie, with limited features) for short- and long-term suicidal behavior prediction. We further validated these models among individuals with different genetic risks of suicide. Methods: Based on the prospective cohort of UK Biobank, we included 223 (0.06%) eligible cases of suicide attempts or deaths, according to hospital inpatient or death register data within 1 year from baseline and randomly selected 4460 (1.18%) controls (1:20) without such records. We similarly identified 833 (0.22%) cases of suicidal behaviors 1 to 6 years from baseline and 16,660 (4.42%) corresponding controls. Based on 143 input features, mainly including sociodemographic, environmental, and psychosocial factors; medical history; and polygenic risk scores (PRS) for suicidality, we applied a bagged balanced light gradient-boosting machine (LightGBM) with stratified 10-fold cross-validation and grid-search to construct the full prediction models for suicide attempts or deaths within 1 year or between 1 and 6 years. The Shapley Additive Explanations (SHAP) approach was used to quantify the importance of input features, and the top 20 features with the highest SHAP values were selected to train the applicable models. The external validity of the established models was assessed among 50,310 individuals who participated in UK Biobank repeated assessments both overall and by the level of PRS for suicidality. Results: Individuals with suicidal behaviors were on average 56 years old, with equal sex distribution. The application of these full models in the external validation data set demonstrated good model performance, with the area under the receiver operating characteristic (AUROC) curves of 0.919 and 0.892 within 1 year and between 1 and 6 years, respectively. Importantly, the applicable models with the top 20 most important features showed comparable external-validated performance (AUROC curves of 0.901 and 0.885) as the full models, based on which we found that individuals in the top quintile of predicted risk accounted for 91.7% (n=11) and 80.7% (n=25) of all suicidality cases within 1 year and during 1 to 6 years, respectively. We further obtained comparable prediction accuracy when applying these models to subpopulations with different genetic susceptibilities to suicidality. For example, for the 1-year risk prediction, the AUROC curves were 0.907 and 0.885 for the high (>2nd tertile of PRS) and low (<1st) genetic susceptibilities groups, respectively. Conclusions: We established applicable machine learning–based models for predicting both the short- and long-term risk of suicidality with high accuracy across populations of varying genetic risk for suicide, highlighting a cost-effective method of identifying individuals with a high risk of suicidality. %M 36805366 %R 10.2196/43419 %U https://publichealth.jmir.org/2023/1/e43419 %U https://doi.org/10.2196/43419 %U http://www.ncbi.nlm.nih.gov/pubmed/36805366 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e43800 %T Prevalence and Associated Factors of Maternal Depression and Anxiety Among African Immigrant Women in Alberta, Canada: Quantitative Cross-sectional Survey Study %A Nwoke,Chinenye Nmanma %A Awosoga,Oluwagbohunmi A %A McDonald,Sheila %A Bonifacio,Glenda T %A Leung,Brenda M Y %+ Faculty of Health Sciences, University of Lethbridge, 4401 University Drive, Lethbridge, AB, T1K 3M4, Canada, 1 4035617125, chinenye.nwoke@uleth.ca %K African women %K immigrant women %K mental health %K pregnancy %K postpartum health %K depression %K anxiety %D 2023 %7 20.2.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Although there is a significant body of evidence on maternal mental health, an inadequate focus has been placed on African immigrant women. This is a significant limitation given the rapidly changing demographics in Canada. The prevalence of maternal depression and anxiety among African immigrant women in Alberta and Canada, as well as the associated risk factors, are not well understood and remain largely unknown. Objective: The purpose of this study was to investigate the prevalence and associated factors of maternal depression and anxiety among African immigrant women living in Alberta, Canada up to 2 years postpartum. Methods: This cross-sectional study surveyed 120 African immigrant women within 2 years of delivery in Alberta, Canada from January 2020 to December 2020. The English version of the Edinburgh Postnatal Depression Scale-10 (EPDS-10), the Generalized Anxiety Disorder-7 (GAD-7) scale, and a structured questionnaire regarding associated factors were administered to all participants. A cutoff score of 13 on the EPDS-10 was indicative of depression, while a cutoff score of 10 on the GAD-7 scale was indicative of anxiety. Multivariable logistic regression was used to determine the factors significantly associated with maternal depression and anxiety. Results: Among the 120 African immigrant women, 27.5% (33/120) met the EPDS-10 cutoff score for depression and 12.1% (14/116) met the GAD-7 cutoff score for anxiety. The majority of respondents with maternal depression were younger (18/33, 56%), had a total household income of CAD $60,000 or more (US $45,000 or more; 21/32, 66%), rented their homes (24/33, 73%), had an advanced degree (19/33, 58%), were married (26/31, 84%), were recent immigrants (19/30, 63%), had friends in the city (21/31, 68%), had a weak sense of belonging in the local community (26/31, 84%), were satisfied with their settlement process (17/28, 61%), and had access to a regular medical doctor (20/29, 69%). In addition, the majority of respondents with maternal anxiety were nonrecent immigrants (9/14, 64%), had friends in the city (8/13, 62%), had a weak sense of belonging in the local community (12/13, 92%), and had access to a regular medical doctor (7/12, 58%). The multivariable logistic regression model identified demographic and social factors significantly associated with maternal depression (maternal age, working status, presence of friends in the city, and access to a regular medical doctor) and maternal anxiety (access to a regular medical doctor and sense of belonging in the local community). Conclusions: Social support and community belonging initiatives may improve the maternal mental health outcomes of African immigrant women. Given the complexities immigrant women face, more research is needed on a comprehensive approach for public health and preventive strategies regarding maternal mental health after migration, including increasing access to family doctors. %M 36808093 %R 10.2196/43800 %U https://formative.jmir.org/2023/1/e43800 %U https://doi.org/10.2196/43800 %U http://www.ncbi.nlm.nih.gov/pubmed/36808093 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e44300 %T Testing the Impact of the #chatsafe Intervention on Young People’s Ability to Communicate Safely About Suicide on Social Media: Protocol for a Randomized Controlled Trial %A Robinson,Jo %A La Sala,Louise %A Cooper,Charlie %A Spittal,Matthew %A Rice,Simon %A Lamblin,Michelle %A Brown,Ellie %A Nolan,Hayley %A Battersby-Coulter,Rikki %A Rajaram,Gowri %A Thorn,Pinar %A Pirkis,Jane %A May-Finlay,Summer %A Silenzio,Vincent %A Skehan,Jaelea %A Krysinska,Karolina %A Bellairs-Walsh,India %+ Orygen, 35 Poplar Road, Parkville, 3052, Australia, 61 412999140, jo.robinson@orygen.org.au %K suicide %K young people %K social media %K intervention, sexual health, randomized-controlled trial %D 2023 %7 17.2.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is the leading cause of death among Australians. One commonly cited explanation is the impact of social media, in particular, the ways in which young people use social media to communicate about their own experiences and their exposure to suicide-related content posted by others. Guidelines designed to assist mainstream media to safely report about suicide are widespread. Until recently, no guidelines existed that targeted social media or young people. In response, we developed the #chatsafe guidelines and a supporting social media campaign, which together make up the #chatsafe intervention. The intervention was tested in a pilot study with positive results. However, the study was limited by the lack of a control group. Objective: The aim of this study is to assess the impact of the #chatsafe social media intervention on young people’s safety and confidence when communicating on the web about suicide. Methods: The study employs a pragmatic, parallel, superiority randomized controlled design. It will be conducted in accordance with the Consolidated Standards of Reporting Trials statement over 18 months. Participants will be 400 young people aged 16-25 years (200 per arm). Participants will be recruited via social media advertising and assessed at 3 time points: time 1—baseline; time 2—8-week postintervention commencement; and time 3—4-week postintervention. They will be asked to complete a weekly survey to monitor safety and evaluate each piece of social media content. The intervention comprises an 8-week social media campaign including social media posts shared on public Instagram profiles. The intervention group will receive the #chatsafe suicide prevention content and the control group will receive sexual health content. Both groups will receive 24 pieces of content delivered to their mobile phones via text message. The primary outcome is safety when communicating on the web about suicide, as measured via the purpose-designed #chatsafe online safety questionnaire. Additional outcomes include willingness to intervene against suicide, internet self-efficacy, safety, and acceptability. Results: The study was funded in November 2020, approved by the University of Melbourne Human Research Ethics Committee on October 7, 2022, and prospectively registered with the Australian New Zealand Clinical Trials registry. Trial recruitment began in November 2022 and study completion is anticipated by June 2024. Conclusions: This will be the first randomized controlled trial internationally to test the impact of a social media intervention designed to equip young people to communicate safely on the web about suicide. Given the rising rates of youth suicide in Australia and the acceptability of social media among young people, incorporating social media–based interventions into the suicide prevention landscape is an obvious next step. This intervention, if effective, could also be extended internationally, thereby improving web-based safety for young people not just in Australia but globally. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12622001397707; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384318 International Registered Report Identifier (IRRID): DERR1-10.2196/44300 %M 36800220 %R 10.2196/44300 %U https://www.researchprotocols.org/2023/1/e44300 %U https://doi.org/10.2196/44300 %U http://www.ncbi.nlm.nih.gov/pubmed/36800220 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e42811 %T The Use of Crisis Services Following the Mass School Shooting in Uvalde, Texas: Quasi-Experimental Event Study %A Weitzel,Kirsty J %A Chew,Robert F %A Miller,Adam Bryant %A Oppenheimer,Caroline W %A Lowe,Ashley %A Yaros,Anna %+ Center for Data Science and AI, RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC, United States, 1 9195416000, kweitzel@rti.org %K mass shooting %K Crisis Text Line %K firearms %K mental health %K suicide %K trauma %K indirect exposure %K public health %K crisis management %K mental health support %K mass casualty %K shooting %K crisis service %D 2023 %7 8.2.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Mass shootings result in widespread psychological trauma for survivors and members of the affected community. However, less is known about the broader effects of indirect exposure (eg, media) to mass shootings. Crisis lines offer a unique opportunity to examine real-time data on the widespread psychological effects of mass shootings. Objective: Crisis Text Line is a not-for-profit company that provides 24/7 confidential SMS text message–based mental health support and crisis intervention service. This study examines changes in the volume and composition of firearm-related conversations at Crisis Text Line before and after the mass school shooting at Robb Elementary School on May 24, 2022, in Uvalde, Texas. Methods: A quasi-experimental event study design was used to compare the actual volume of firearm-related conversations received by Crisis Text Line post shooting to forecasted firearm conversation volume under the counterfactual scenario that a shooting had not occurred. Conversations related to firearms were identified among all conversations using keyword searches. Firearm conversation volume was predicted using a seasonal autoregressive integrated moving average model trained on the 3 months of data leading up to the shooting. Additionally, proportions of issue tags (topics coded post conversation by volunteer crisis counselors at Crisis Text Line after the exchange) were compared in the 4 days before (n=251) and after (n=417) the shooting to assess changes in conversation characteristics. The 4-day window was chosen to reflect the number of days conversation volume remained above forecasted levels. Results: There was a significant increase in the number of conversations mentioning firearms following the shooting, with the largest spike (compared to forecasted numbers) occurring the day after the shooting (n=159) on May 25, 2022. By May 28, the volume reverted to within the 95% CI of the forecasted volume (n=77). Within firearm conversations, “grief” issue tags showed a significant increase in proportion in the week following the shooting, while “isolation/loneliness,” “relationships,” and “suicide” issue tags showed a significant decrease in proportions the week following the shooting. Conclusions: The results suggest that the Uvalde school shooting may have contributed to an increase in demand for crisis services, above what would be expected given historical trends. Additionally, we found that these firearm-related crises conversations immediately post event are more likely to be related to grief and less likely to be related to suicide, loneliness, and relationships. Our findings provide some of the first data showing the real-time repercussions for the broader population exposed to school shooting events. This work adds to a growing evidence base documenting and measuring the rippling effects of mass shootings outside of those directly impacted. %M 36753321 %R 10.2196/42811 %U https://publichealth.jmir.org/2023/1/e42811 %U https://doi.org/10.2196/42811 %U http://www.ncbi.nlm.nih.gov/pubmed/36753321 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e43401 %T Effectiveness of a Patient-Centered Assessment With a Solution-Focused Approach (DIALOG-A) in the Routine Care of Colombian Adolescents With Depression and Anxiety: Protocol for a Multicenter Cluster Randomized Controlled Trial %A Gómez-Restrepo,Carlos %A Romero,Jose Alejandro Rumbo %A Rodriguez,Martha %A Ospina-Pinillos,Laura %A Stanislaus Sureshkumar,Diliniya %A Priebe,Stefan %A Bird,Victoria %+ Unit for Social and Community Psychiatry, Wolfson Institute of Population Health, Queen Mary University of London, Newham Centre for Mental Health, Cherry Tree Way, London, E13 8SP, United Kingdom, 44 20754043802340, v.j.bird@qmul.ac.uk %K randomised controlled trial %K adolescent %K mental health %K depression %K anxiety %K telemedicine %K primary health care %K Colombia %D 2023 %7 8.2.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Colombia is a middle-income country in South America, which has historically had high rates of mental health problems, coupled with a scarcity of mental health care. There is growing concern for the mental health of the adolescent population within this region. There is a significant treatment gap for young people, especially those living in the most vulnerable areas. DIALOG+ is a low-cost patient-centered intervention that can potentially improve the delivery of care and quality of life for adolescents with mental health problems. Objective: This exploratory randomized controlled trial aims to evaluate the effectiveness, acceptability, and feasibility of an adapted version of the DIALOG+ intervention (DIALOG-A) in the community treatment of Colombian adolescents with depression and anxiety. Methods: In total, 18 clinicians and 108 adolescents will be recruited from primary health care services in Bogota and Duitama, Colombia. Clinicians will be randomized 2:1 to either the intervention (12 clinicians:72 adolescents) or control group (6 clinicians:36 adolescents). In the intervention arm, clinicians will use DIALOG-A with adolescents once per month over 6 months. The control arm will continue to receive routine care. Outcomes will be measured at baseline, 6 months, and 9 months following randomization. Semistructured interviews with all clinicians and a subset of adolescents in the intervention arm will be conducted at the end of the intervention period. Quantitative and qualitative analysis of the data will be conducted. Results: Trial recruitment was completed toward the end of October 2022, and follow-up is anticipated to last through to October 2023. Conclusions: This is the first study to test an adapted resource-orientated intervention (DIALOG-A) in the treatment of adolescents with depression and anxiety attending primary care services. If the results are positive, DIALOG-A can be implemented in the routine care of adolescents with these mental health problems and provide valuable insight to other middle-income countries. Trial Registration: ISRCTN Registry ISRCTN13980767; https://www.isrctn.com/ISRCTN13980767?q=ISRCTN13980767 International Registered Report Identifier (IRRID): DERR1-10.2196/43401 %M 36753329 %R 10.2196/43401 %U https://www.researchprotocols.org/2023/1/e43401 %U https://doi.org/10.2196/43401 %U http://www.ncbi.nlm.nih.gov/pubmed/36753329 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e42919 %T Mobile Mental Health in Women’s Community-Based Organizations: Protocol for a Pilot Randomized Controlled Trial %A Bhat,Amritha %A Goud,B Ramakrishna %A Kalidindi,Bharat %A Ruben,Johnson Pradeep %A Devadass,Dhinagaran %A Waghmare,Abijeet %A Collins,Pamela Y %A Raj,Tony %A Srinivasan,Krishnamachari %+ Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Box 356560, Seattle, WA, 98195, United States, 1 2065433117, amritha@uw.edu %K mobile mental health %K women %K community-based %K depression %K rural %K stepped care %D 2023 %7 8.2.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Of every 10 women in rural India, 1 suffers from a common mental disorder such as depression, and untreated depression is associated with significant morbidity and mortality. Several factors lead to a large treatment gap, specifically for women in rural India, including stigma, lack of provider mental health workforce, and travel times. There is an urgent need to improve the rates of detection and treatment of depression among women in rural India without overburdening the scarce mental health resources. Objective: We propose to develop, test, and deploy a mental health app, MITHRA (Multiuser Interactive Health Response Application), for depression screening and brief intervention, designed for use in women’s self-help groups (SHGs) in rural India. Methods: We will use focus groups with SHG members and community health workers to guide the initial development of the app, followed by iterative modification based on input from a participatory design group consisting of proposed end users of the app (SHG members). The final version of the app will then be deployed for testing in a pilot cluster randomized trial, with 3 SHGs randomized to receive the app and 3 to receive enhanced care as usual. Results: This study was funded in June 2021. As of September 2022, we have completed both focus groups, 1 participatory design group, and app development. Conclusions: Delivering app-based depression screening and treatment in community settings such as SHGs can address stigma and transportation-related barriers to access to depression care and overcome cultural and contextual barriers to mobile health use. It can also address the mental health workforce shortage. If we find that the MITHRA approach is feasible, we will test the implementation and effectiveness of MITHRA in multiple SHGs across India in a larger randomized controlled trial. This approach of leveraging community-based organizations to improve the reach of depression screening and treatment is applicable in rural and underserved areas across the globe. International Registered Report Identifier (IRRID): DERR1-10.2196/42919 %M 36753310 %R 10.2196/42919 %U https://www.researchprotocols.org/2023/1/e42919 %U https://doi.org/10.2196/42919 %U http://www.ncbi.nlm.nih.gov/pubmed/36753310 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e43388 %T Time to Think “Meta”: A Critical Viewpoint on the Risks and Benefits of Virtual Worlds for Mental Health %A Paquin,Vincent %A Ferrari,Manuela %A Sekhon,Harmehr %A Rej,Soham %+ Department of Psychiatry, McGill University, 1033 Avenue des Pins, Montreal, QC, H3A 1A1, Canada, 1 514 398 4909, vincent.paquin2@mail.mcgill.ca %K metaverse %K digital media %K virtual reality %K mental health %K addiction %K social functioning %K virtual %K technology %K augmented reality %K gaming %K social media %K cognitive %K physical activity %K behavior %K psychological %K development %K patient %K policy %D 2023 %7 7.2.2023 %9 Viewpoint %J JMIR Serious Games %G English %X The metaverse is gaining traction in the general population and has become a priority of the technological industry. Defined as persistent virtual worlds that exist in virtual or augmented reality, the metaverse proposes to afford a range of activities of daily life, from socializing and relaxing to gaming, shopping, and working. Because of its scope, its projected popularity, and its immersivity, the metaverse may pose unique opportunities and risks for mental health. In this viewpoint article, we integrate existing evidence on the mental health impacts of video games, social media, and virtual reality to anticipate how the metaverse could influence mental health. We outline 2 categories of mechanisms related to mental health: experiences or behaviors afforded by the metaverse and experiences or behaviors displaced by it. The metaverse may benefit mental health by affording control (over an avatar and its virtual environment), cognitive activation, physical activity, social connections, and a sense of autonomy and competence. However, repetitive rewarding experiences may lead to addiction-like behaviors, and high engagement in virtual worlds may facilitate and perpetuate the avoidance of challenges in the offline environment. Further, time spent in virtual worlds may displace (reduce) other determinants of mental health, such as sleep rhythms and offline social capital. Importantly, individuals will differ in their uses of and psychological responses to the metaverse, resulting in heterogeneous impacts on their mental health. Their technological motivations, developmental stage, sociodemographic context, and prior mental health problems are some of the factors that may modify and frame the positive and negative effects of the metaverse on their mental health. In conclusion, as the metaverse is being scaffolded by the industry and by its users, there is a window of opportunity for researchers, clinicians, and people with lived experience to coproduce knowledge on its possible impacts on mental health and illness, with the hope of influencing policy-making, technological development, and counseling of patients. %M 36661284 %R 10.2196/43388 %U https://games.jmir.org/2023/1/e43388 %U https://doi.org/10.2196/43388 %U http://www.ncbi.nlm.nih.gov/pubmed/36661284 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e44059 %T Direct and Indirect Predictors of Medication Adherence With Bipolar Disorder: Path Analysis %A Cohen,Bar %A Sixsmith,Andrew %A Pollock Star,Ariel %A Haglili,Ophir %A O'Rourke,Norm %+ Department of Epidemiology, Biostatistics and Community Health Sciences, Ben-Gurion University of the Negev, Building M6, Room #308, P.O. Box 653, Be'er Sheva, 8421637, Israel, 972 8 6477301, ORourke@bgu.ac.il %K alcohol misuse %K bipolar disorder %K cognitive loss %K depression %K hypo/mania %K mania %K medication adherence %K mental health %K path analysis %K perceived cognitive failures %K polypharmacy %K psychiatric disorder %K psychosocial %D 2023 %7 7.2.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Despite the efficacy of treatment and severity of symptoms, medication adherence by many with bipolar disorder (BD) is variable at best. This poses a significant challenge for BD care management. Objective: For this study, we set out to identify psychosocial and psychiatric predictors of medication adherence with BD. Methods: Using microtargeted social media advertising, we recruited an international sample of young and older adults with BD living in North America (Canada and the United States), Western Europe (eg, United Kingdom and Ireland), Australia and New Zealand (N=92). On average, participants were 55.35 (SD 9.65; range 22-73) years of age, had been diagnosed with BD 14.25 (SD 11.14; range 1-46) years ago, and were currently prescribed 2.40 (SD 1.28; range 0-6) psychotropic medications. Participants completed questionnaires online including the Morisky Medication Adherence Scale. Results: Medication adherence did not significantly differ across BD subtypes, country of residence, or prescription of lithium versus other mood stabilizers (eg, anticonvulsants). Path analyses indicate that alcohol misuse and subjective or perceived cognitive failures are direct predictors of medication adherence. BD symptoms, psychological well-being, and the number of comorbid psychiatric conditions emerged as indirect predictors of medication adherence via perceived cognitive failures. Conclusions: Alcohol misuse did not predict perceived cognitive failures. Nor did age predict medication adherence or cognitive failures. This is noteworthy given the 51-year age range of participants. That is, persons in their 20s with BD reported similar levels of medication adherence and perceived cognitive failures as those in their 60s. This suggests that perceived cognitive loss is a facet of adult life with BD, in contrast to the assumption that accelerated cognitive aging with BD begins in midlife. %M 36749623 %R 10.2196/44059 %U https://formative.jmir.org/2023/1/e44059 %U https://doi.org/10.2196/44059 %U http://www.ncbi.nlm.nih.gov/pubmed/36749623 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e42864 %T Providing Human Support for the Use of Digital Mental Health Interventions: Systematic Meta-review %A Werntz,Alexandra %A Amado,Selen %A Jasman,Megyn %A Ervin,Ariel %A Rhodes,Jean E %+ Center for Evidence-Based Mentoring, University of Massachusetts Boston, 100 Morrissey Boulevard, Boston, MA, 02125, United States, 1 6172876368, jean.rhodes@umb.edu %K digital mental health interventions %K human support %K supportive accountability %K systematic meta-review %D 2023 %7 6.2.2023 %9 Review %J J Med Internet Res %G English %X Background: Digital mental health interventions (DMHIs) have been increasingly deployed to bridge gaps in mental health care, particularly given their promising efficacy. Nevertheless, attrition among DMHI users remains high. In response, human support has been studied as a means of improving retention to and outcomes of DMHIs. Although a growing number of studies and meta-analyses have investigated the effects of human support for DMHIs on mental health outcomes, systematic empirical evidence of its effectiveness across mental health domains remains scant. Objective: We aimed to summarize the results of meta-analyses of human support versus no support for DMHI use across various outcome domains, participant samples, and support providers. Methods: We conducted a systematic meta-review of meta-analyses, comparing the effects of human support with those of no support for DMHI use, with the goal of qualitatively summarizing data across various outcome domains, participant samples, and support providers. We used MEDLINE, PubMed, and PsycINFO electronic databases. Articles were included if the study had a quantitative meta-analysis study design; the intervention targeted mental health symptoms and was delivered via a technology platform (excluding person-delivered interventions mediated through telehealth, text messages, or social media); the outcome variables included mental health symptoms such as anxiety, depression, stress, posttraumatic stress disorder symptoms, or a number of these symptoms together; and the study included quantitative comparisons of outcomes in which human support versus those when no or minimal human support was provided. Results: The results of 31 meta-analyses (505 unique primary studies) were analyzed. The meta-analyses reported 45 effect sizes; almost half (n=22, 48%) of them showed that human-supported DMHIs were significantly more effective than unsupported DMHIs. A total of 9% (4/45) of effect sizes showed that unsupported DMHIs were significantly more effective. No clear patterns of results emerged regarding the efficacy of human support for the outcomes assessed (including anxiety, depression, posttraumatic stress disorder, stress, and multiple outcomes). Human-supported DMHIs may be more effective than unsupported DMHIs for individuals with elevated mental health symptoms. There were no clear results regarding the type of training for those providing support. Conclusions: Our findings highlight the potential of human support in improving the effects of DMHIs. Specifically, evidence emerged for stronger effects of human support for individuals with greater symptom severity. There was considerable heterogeneity across meta-analyses in the level of detail regarding the nature of the interventions, population served, and support delivered, making it difficult to draw strong conclusions regarding the circumstances under which human support is most effective. Future research should emphasize reporting detailed descriptions of sample and intervention characteristics and describe the mechanism through which they believe the coach will be most useful for the DMHI. %M 36745497 %R 10.2196/42864 %U https://www.jmir.org/2023/1/e42864 %U https://doi.org/10.2196/42864 %U http://www.ncbi.nlm.nih.gov/pubmed/36745497 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e36964 %T The Empowering Role of Web-Based Help Seeking on Depressive Symptoms: Systematic Review and Meta-analysis %A Bizzotto,Nicole %A Marciano,Laura %A de Bruijn,Gert-Jan %A Schulz,Peter Johannes %+ Università della Svizzera italiana, Via Buffi 13, Lugano, 6900, Switzerland, 41 58 666 4724, peter.schulz@usi.ch %K web-based help-seeking %K support groups %K depressive symptoms %K internet %K mental health %K empowerment %D 2023 %7 2.2.2023 %9 Review %J J Med Internet Res %G English %X Background: Most research on web-based help seeking for mental health problems has focused on the antecedents of this behavior. Therefore, little is known about the outcomes of web-based help seeking in general or in specific mental health issues. Objective: This study was a systematic review and meta-analysis of the literature on the antecedents and consequences of web-based help-seeking behaviors for depressive symptoms. Methods: A systematic literature search was carried out in 6 scientific databases, leading to 48 studies (for a total of 314,921 participants) included in the qualitative synthesis and 19 included in the meta-analysis. Results: The results indicated a positive relationship between depressive symptoms and web-based help-seeking behaviors through online support groups (r=0.089; P=.009), and Generation Z (r=0.102; P=.008) tended to participate in support groups more than previous generations. In addition, web-based help seeking was positively related to empowerment (r=0.245; P=.004). Other forms of support reported included the internet and specific self-help tools, but no significant relationships were found with depressive symptoms. Conclusions: More studies examining the outcomes are needed, together with a more rigorous assessment of web-based help-seeking behaviors. Ultimately, we propose a summary framework for the literature on this topic, including the antecedents, patterns of use, and outcomes of web-based help seeking in the context of depressive symptoms. %M 36729571 %R 10.2196/36964 %U https://www.jmir.org/2023/1/e36964 %U https://doi.org/10.2196/36964 %U http://www.ncbi.nlm.nih.gov/pubmed/36729571 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e43003 %T The Association of Acute Signs and Symptoms of COVID-19 and Exacerbation of Depression and Anxiety in Patients With Clinically Mild COVID-19: Retrospective Observational Study %A Sung,Sumi %A Kim,Su Hwan %A Lee,Changwoo %A Kim,Youlim %A Bae,Ye Seul %A Chie,Eui Kyu %+ Office of Hospital Information, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea, 82 2 2072 7600, ekchie93@snu.ac.kr %K COVID-19 %K depression %K anxiety %K vital signs %K symptoms %K electronic health records %D 2023 %7 30.1.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: To date, the association between acute signs and symptoms of COVID-19 and the exacerbation of depression and anxiety in patients with clinically mild COVID-19 has not been evaluated. Objective: This study was designed to assess the correlation between acute signs and symptoms of COVID-19 and the exacerbation of depression and anxiety in patients with clinically mild COVID-19 at a residential treatment center in South Korea. Methods: This retrospective study assessed 2671 patients with COVID-19 admitted to 4 residential treatment centers operated by Seoul National University Hospital, South Korea, from March 2020 to April 2022. Depression and anxiety were assessed using the 2-item Patient Health Questionnaire (PHQ-2) and 2-item Generalized Anxiety Disorder (GAD-2) scale, respectively. The exacerbation of depression and anxiety symptoms was identified from the differences in PHQ-2 and GAD-2 scores between admission and discharge, respectively. The patients’ clinical characteristics, including acute signs and symptoms of COVID-19, GAD-2 and PHQ-2 scores, were obtained from electronic health records. Demographic characteristics, a summary of vital signs, and COVID-19 symptoms were analyzed and compared between the patient groups with and those without exacerbated PHQ-2 and GAD-2 scores using the chi-square test. We applied logistic regression to identify the association between acute signs and symptoms of COVID-19 and the exacerbation of depression and anxiety. Results: Sleep disorders were associated with exacerbated depression (odds ratio [OR] 1.09, 95% CI 1.05-1.13) and anxiety (OR 1.1, 95% CI 1.06-1.14), and the sore throat symptom was associated with exacerbated anxiety symptoms (OR 1.03, 95% CI 1.00-1.07). Patients with abnormal oxygen saturation during quarantine were more likely to have exacerbated depression (OR 1.27, 95% CI 1.00-1.62), and those with an abnormal body temperature during quarantine were more likely to experience anxiety (OR 1.08, 95% CI 1.01-1.16). As anticipated, patients who experienced psychological symptoms at admission were more likely to experience depression (OR 1.91, 95% CI 1.52-2.41) and anxiety (OR 1.98, 95% CI 1.54-2.53). Meanwhile, the PHQ-2 and GAD-2 scores measured at admission revealed that lower the score, higher the possibility of exacerbation of both depression (OR 0.15, 95% CI 0.11-0.22) and anxiety (OR 0.13, 95% CI 0.10-0.19). Conclusions: Results from this study suggest the importance of further interventions for patients with abnormal oxygen saturation, abnormal body temperatures, sore throat, and sleep disorder symptoms or initial psychological symptoms to mitigate the exacerbation of depression and anxiety. In addition, this study highlights the usability of short and efficient scales such as the PHQ-2 and GAD-2 in the assessment of the mental health of patients with clinically mild COVID-19 symptoms who were quarantined at home during the pandemic era. %M 36645439 %R 10.2196/43003 %U https://publichealth.jmir.org/2023/1/e43003 %U https://doi.org/10.2196/43003 %U http://www.ncbi.nlm.nih.gov/pubmed/36645439 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e41422 %T ReachCare Mobile Apps for Patients Experiencing Suicidality in the Emergency Department: Development and Usability Testing Using Mixed Methods %A Larkin,Celine %A Djamasbi,Soussan %A Boudreaux,Edwin D %A Varzgani,Fatima %A Garner,Roscoe %A Siddique,Mariam %A Pietro,John %A Tulu,Bengisu %+ Department of Emergency Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave, Worcester, MA, 01655, United States, 1 7743291688, celine.larkin@umassmed.edu %K suicide %K emergency department %K mobile app %K usability %K engagement %K mobile phone %D 2023 %7 27.1.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Many individuals with suicide risk present to acute care settings such as emergency departments (EDs). However, staffing and time constraints mean that many EDs are not well equipped to deliver evidence-based interventions for patients experiencing suicidality. An existing intervention initiated in the ED for patients with suicide risk (Emergency Department Safety Assessment and Follow-up Evaluation [ED-SAFE]) has been found to be effective but faces trenchant barriers for widespread adoption. Objective: On the basis of the ED-SAFE intervention, we aimed to develop 2 apps for patients with suicide risk: a web app guiding patients through safety planning in the ED (ED app) and a smartphone app providing patients components of the ED-SAFE program on their phones after discharge (patient app). We then tested the usability of these apps with patients presenting to the ED with suicide risk. Methods: Using a user-centered design framework, we first developed user personas to explore the needs and characteristics of patients who are at risk for suicide using inputs from clinicians (n=3) and suicidologists (n=4). Next, we validated these personas during interviews with individuals with lived experience of suicidality (n=6) and used them to inform our application designs. We field-tested the apps with ED patients presenting with suicide risk (n=14) in 2 iterative cycles to assess their usability and engagement using a mixed methods approach. We also rated the quality and fidelity of the safety plans created. Results: We developed 2 interoperable and complementary apps. The first is a web app designed for use on a tablet device during ED admission that guides the patient by creating a safety plan using a chatbot-style interface. The second is a smartphone app for use after discharge and allows the patient to view, edit, and share their completed safety plan; access self-care education, helplines, and behavioral health referrals; and track follow-up appointments with the study clinician. The initial prototype usability testing (n=9) demonstrated satisfactory scores (ED app System Usability Scale [SUS], mean 78.6/100, SD 24.1; User Engagement Scale, mean 3.74/5, SD 0.72; patient app SUS, mean 81.7/100, SD 20.1). After refining the apps based on participant feedback, the second cycle testing (n=5) showed improvement (ED app SUS, mean 90.5/100, SD 9.9; User Engagement Scale, mean 4.07/5, SD 0.36; patient app SUS, mean 97.0/100, SD 1.9). The quality ratings for completed safety plans were satisfactory (Safety Planning Intervention Scoring Algorithm-Brief, mean 27.4, SD 3.4). Conclusions: By adopting a user-centered approach and creating personas to guide development, we were able to create apps for ED patients with suicide risk and obtain satisfactory usability, engagement, and quality scores. Developing digital health tools based on user-centered design principles that deliver evidence-based intervention components may help overcome trenchant implementation barriers in challenging health care settings. %M 36705961 %R 10.2196/41422 %U https://formative.jmir.org/2023/1/e41422 %U https://doi.org/10.2196/41422 %U http://www.ncbi.nlm.nih.gov/pubmed/36705961 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e41013 %T Neural Correlates of the DEEPP (Anti-suicidal Response to Ketamine in Treatment-Resistant Bipolar Depression) Study: Protocol for a Pilot, Open-Label Clinical Trial %A Knyahnytska,Yuliya %A Zomorrodi,Reza %A Kaster,Tyler %A Voineskos,Daphne %A Trevizol,Alisson %A Blumberger,Daniel %+ Centre for Addiction and Mental Health, 1025 Queen Street West, Toronto, ON, Canada, 1 4165358501, Yuliya.Knyahnytska@camh.ca %K bipolar depression %K suicidality %K ketamine intervention %K neurophysiological markers of response %D 2023 %7 27.1.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is among the top 10 leading causes of death worldwide. Of people who died by suicide, the majority are diagnosed with depression. It is estimated that 25%-60% of people with bipolar depression (BD) will attempt suicide at least once, and 10%-15% will die by suicide. Several treatments, such as lithium, clozapine, electroconvulsive therapy, and cognitive behavioral therapy, have been shown to be effective in treating suicidality. However, these treatments can be difficult to tolerate or may take months to take effect. Ketamine, a glutamate N-methyl-D-aspartate antagonist, has been shown to have rapid antisuicidal effect and antidepressant qualities, and is thus a promising intervention to target acute suicidality in patients with BD. However, the biological mechanism underlying its therapeutic action remains poorly understood. Enhancing our understanding of underlying mechanisms of action for ketamine’s effectiveness in reducing suicidality is critical to establishing biological markers of treatment response and developing tailored, personalized interventions for patients with BD. Objective: This is an open-label clinical trial to test the safety and feasibility of repeated ketamine infusions to treat acute suicidality. The primary objective is to test the safety and feasibility of ketamine intervention. The secondary objective is to examine ketamine’s potential neurophysiological mechanisms of action by assessing cortical excitation and inhibition to determine potential biomarkers of clinical response. Other objectives are to evaluate the effect of ketamine on acute suicidality and other clinical outcomes, such as depressive symptoms and quality of life, to inform a future larger trial. Methods: This open-label clinical trial aims to test the safety and feasibility of repeated ketamine infusions in patients with BD for suicidality and to assess ketamine’s neurophysiological effects. A sterile form of racemic ketamine hydrochloride will be administered over a 40-minute intravenous infusion 2 times per week on nonconsecutive days for 4 weeks (8 sessions). We will recruit 30 adults (24-65 year olds) over 2 years from an academic psychiatric hospital in Toronto, Canada. Results: This study is currently ongoing and actively recruiting participants. So far, 5 participants have completed the trial, 1 is currently in active treatment, and 8 participants are on the waitlist to be screened. We anticipate initial results being available in the fall of 2023. This proposal was presented as a poster presentation at the Research to Reality Global Summit on Psychedelic-Assisted Therapies and Medicine, held in May 2022 in Toronto, Canada. Conclusions: Developing effective interventions for acute suicidality in high-risk populations such as those with BD remains a major therapeutic challenge. Ketamine is a promising treatment due to its rapid antidepressant and antisuicidal effects, but its underlying neurophysiological mechanisms of action remain unknown. Trial Registration: ClinicalTrials.gov NCT05177146; https://clinicaltrials.gov/ct2/show/NCT05177146 International Registered Report Identifier (IRRID): DERR1-10.2196/41013 %M 36573651 %R 10.2196/41013 %U https://www.researchprotocols.org/2023/1/e41013 %U https://doi.org/10.2196/41013 %U http://www.ncbi.nlm.nih.gov/pubmed/36573651 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e34474 %T Automatic Depression Detection Using Smartphone-Based Text-Dependent Speech Signals: Deep Convolutional Neural Network Approach %A Kim,Ah Young %A Jang,Eun Hye %A Lee,Seung-Hwan %A Choi,Kwang-Yeon %A Park,Jeon Gue %A Shin,Hyun-Chool %+ Department of Electronics Engineering, Soongsil University, 511 Sang-do dong, Seoul, 156743, Republic of Korea, 82 28287165, shinhc@ssu.ac.kr %K depression %K major depressive disorder %K MDD %K automatic depression detection %K ADD %K mobile health %K deep learning %K speech analysis %K acoustic %K mobile phone %K smartphone %D 2023 %7 25.1.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Automatic diagnosis of depression based on speech can complement mental health treatment methods in the future. Previous studies have reported that acoustic properties can be used to identify depression. However, few studies have attempted a large-scale differential diagnosis of patients with depressive disorders using acoustic characteristics of non-English speakers. Objective: This study proposes a framework for automatic depression detection using large-scale acoustic characteristics based on the Korean language. Methods: We recruited 153 patients who met the criteria for major depressive disorder and 165 healthy controls without current or past mental illness. Participants' voices were recorded on a smartphone while performing the task of reading predefined text-based sentences. Three approaches were evaluated and compared to detect depression using data sets with text-dependent read speech tasks: conventional machine learning models based on acoustic features, a proposed model that trains and classifies log-Mel spectrograms by applying a deep convolutional neural network (CNN) with a relatively small number of parameters, and models that train and classify log-Mel spectrograms by applying well-known pretrained networks. Results: The acoustic characteristics of the predefined text-based sentence reading automatically detected depression using the proposed CNN model. The highest accuracy achieved with the proposed CNN on the speech data was 78.14%. Our results show that the deep-learned acoustic characteristics lead to better performance than those obtained using the conventional approach and pretrained models. Conclusions: Checking the mood of patients with major depressive disorder and detecting the consistency of objective descriptions are very important research topics. This study suggests that the analysis of speech data recorded while reading text-dependent sentences could help predict depression status automatically by capturing the characteristics of depression. Our method is smartphone based, is easily accessible, and can contribute to the automatic identification of depressive states. %M 36696160 %R 10.2196/34474 %U https://www.jmir.org/2023/1/e34474 %U https://doi.org/10.2196/34474 %U http://www.ncbi.nlm.nih.gov/pubmed/36696160 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e37289 %T Analyzing User-Generated Web-Based Posts of Adolescents’ Emotional, Behavioral, and Symptom Responses to Beliefs About Depression: Qualitative Thematic Analysis %A Dysthe,Kim Kristoffer %A Røssberg,Jan Ivar %A Brandtzaeg,Petter Bae %A Skjuve,Marita %A Haavet,Ole Rikard %A Følstad,Asbjørn %A Klovning,Atle %+ Department of General Practice/Family Medicine, University of Oslo, Kirkeveien 166, Oslo, 0450, Norway, 47 47 22 85 05 50, k.k.dysthe@medisin.uio.no %K adolescent %K depression %K internet %K education %K preventive psychiatry %K early medical intervention %K health literacy %K cognitive behavioral therapy %D 2023 %7 24.1.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is common during adolescence. Early intervention can prevent it from developing into more progressive mental disorders. Combining information technology and clinical psychoeducation is a promising way to intervene at an earlier stage. However, data-driven research on the cognitive response to health information targeting adolescents with symptoms of depression is lacking. Objective: This study aimed to fill this knowledge gap through a new understanding of adolescents’ cognitive response to health information about depression. This knowledge can help to develop population-specific information technology, such as chatbots, in addition to clinical therapeutic tools for use in general practice. Methods: The data set consists of 1870 depression-related questions posted by adolescents on a public web-based information service. Most of the posts contain descriptions of events that lead to depression. On a sample of 100 posts, we conducted a qualitative thematic analysis based on cognitive behavioral theory investigating behavioral, emotional, and symptom responses to beliefs associated with depression. Results: Results were organized into four themes. (1) Hopelessness, appearing as a set of negative beliefs about the future, possibly results from erroneous beliefs about the causal link between risk factors and the course of depression. We found beliefs about establishing a sturdy therapy alliance as a responsibility resting on the patient. (2) Therapy hesitancy seemed to be associated with negative beliefs about therapy prognosis and doubts about confidentiality. (3) Social shame appeared as a consequence of impaired daily function when the cause is not acknowledged. (4) Failing to attain social interaction appeared to be associated with a negative symptom response. In contrast, actively obtaining social support reduces symptoms and suicidal thoughts. Conclusions: These results could be used to meet the clinical aims stated by earlier psychoeducation development, such as instilling hope through direct reattribution of beliefs about the future; challenging causal attributions, thereby lowering therapy hesitancy; reducing shame through the mechanisms of externalization by providing a tentative diagnosis despite the risk of stigmatizing; and providing initial symptom relief by giving advice on how to open up and reveal themselves to friends and family and balance the message of self-management to fit coping capabilities. An active counseling style advises the patient to approach the social environment, demonstrating an attitude toward self-action. %M 36692944 %R 10.2196/37289 %U https://www.jmir.org/2023/1/e37289 %U https://doi.org/10.2196/37289 %U http://www.ncbi.nlm.nih.gov/pubmed/36692944 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e42866 %T The Feasibility of Implementing Remote Measurement Technologies in Psychological Treatment for Depression: Mixed Methods Study on Engagement %A de Angel,Valeria %A Adeleye,Fadekemi %A Zhang,Yuezhou %A Cummins,Nicholas %A Munir,Sara %A Lewis,Serena %A Laporta Puyal,Estela %A Matcham,Faith %A Sun,Shaoxiong %A Folarin,Amos A %A Ranjan,Yatharth %A Conde,Pauline %A Rashid,Zulqarnain %A Dobson,Richard %A Hotopf,Matthew %+ Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, E3.08, 3rd Floor East Wing, de Crespigny park, London, SE5 8AF, United Kingdom, 44 20 7848 0002, valeria.de_angel@kcl.ac.uk %K depression %K anxiety %K digital health %K wearable devices %K smartphone %K passive sensing %K mobile health %K mHealth %K digital phenotyping %K mobile phone %D 2023 %7 24.1.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Remote measurement technologies (RMTs) such as smartphones and wearables can help improve treatment for depression by providing objective, continuous, and ecologically valid insights into mood and behavior. Engagement with RMTs is varied and highly context dependent; however, few studies have investigated their feasibility in the context of treatment. Objective: A mixed methods design was used to evaluate engagement with active and passive data collection via RMT in people with depression undergoing psychotherapy. We evaluated the effects of treatment on 2 different types of engagement: study attrition (engagement with study protocol) and patterns of missing data (engagement with digital devices), which we termed data availability. Qualitative interviews were conducted to help interpret the differences in engagement. Methods: A total of 66 people undergoing psychological therapy for depression were followed up for 7 months. Active data were gathered from weekly questionnaires and speech and cognitive tasks, and passive data were gathered from smartphone sensors and a Fitbit (Fitbit Inc) wearable device. Results: The overall retention rate was 60%. Higher-intensity treatment (χ21=4.6; P=.03) and higher baseline anxiety (t56.28=−2.80, 2-tailed; P=.007) were associated with attrition, but depression severity was not (t50.4=−0.18; P=.86). A trend toward significance was found for the association between longer treatments and increased attrition (U=339.5; P=.05). Data availability was higher for active data than for passive data initially but declined at a sharper rate (90%-30% drop in 7 months). As for passive data, wearable data availability fell from a maximum of 80% to 45% at 7 months but showed higher overall data availability than smartphone-based data, which remained stable at the range of 20%-40% throughout. Missing data were more prevalent among GPS location data, followed by among Bluetooth data, then among accelerometry data. As for active data, speech and cognitive tasks had lower completion rates than clinical questionnaires. The participants in treatment provided less Fitbit data but more active data than those on the waiting list. Conclusions: Different data streams showed varied patterns of missing data, despite being gathered from the same device. Longer and more complex treatments and clinical characteristics such as higher baseline anxiety may reduce long-term engagement with RMTs, and different devices may show opposite patterns of missingness during treatment. This has implications for the scalability and uptake of RMTs in health care settings, the generalizability and accuracy of the data collected by these methods, feature construction, and the appropriateness of RMT use in the long term. %M 36692937 %R 10.2196/42866 %U https://mental.jmir.org/2023/1/e42866 %U https://doi.org/10.2196/42866 %U http://www.ncbi.nlm.nih.gov/pubmed/36692937 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e35748 %T Social Support and Technology Use and Their Association With Mental and Physical Health During the COVID-19 Pandemic Among Asian Americans: The COMPASS Cross-sectional Study %A Park,Linda G %A Meyer,Oanh L %A Dougan,Marcelle M %A Golden,Bethany %A Ta,Kevin %A Nam,Bora %A Tsoh,Janice Y %A Tzuang,Marian %A Park,Van M Ta %+ Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, San Francisco, CA, 94143, United States, 1 415 502 6616, Linda.Park@ucsf.edu %K health disparities %K mental health %K depression %K anxiety %K social support technology %K COVID-19 %K pandemic %K disparity %K support %K technology %K physical health %K race %K survey %K population %K discrimination %K outcome %K AAPI %D 2023 %7 23.1.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The global COVID-19 pandemic disproportionately affected Asian Americans and Pacific Islanders (AAPIs) and revealed significant health disparities with reports of increased discrimination and xenophobia. Among AAPIs, the pandemic exacerbated their social, linguistic, and geographic isolation. Social support may be especially important for AAPIs given the salience of collectivism as a cultural value. Another mechanism for support among AAPIs was technology use, as it is generally widespread among this population. However, older adults may not perceive the same benefits. Objective: We examined social support and technology use and their relationships with mental and physical health outcomes through the COVID-19 pandemic among AAPIs. Methods: Data were drawn from the COVID-19 Effects on the Mental and Physical Health of AAPI Survey Study (COMPASS) for the time period of October 2020 to February 2021. COMPASS was a cross-sectional, multilingual, national survey conducted online, by phone, and in person with AAPI adults who were ≥18 years of age, in collaboration with academic and community partners in the United States. Data were analyzed using multivariable linear regression using the outcome variables of mental and physical health with various predictors such as social support and technology use. We tested for interactions specific to age and ethnicity. Results: Among 4631 AAPIs (mean age 45.9, SD 16.3 years; 2992/4631, 63.1% female), we found that (1) increased social support was associated with better physical health, (2) total social support was positively associated with better mental health, (3) higher technology use was associated with poorer mental health and inversely associated with poorer physical health, (4) the association of technology use with mental health was weaker among those with low social support (vs those with high social support), (5) adults younger than 60 years old (vs ≥60 years old) were more negatively affected with social support and mental health, and (6) Korean Americans appeared to be a high-risk group for poor physical health with increased technology use. Conclusions: Our paper identified mental and physical health needs along with supportive therapies observed among AAPIs during the pandemic. Future research on how social support can be leveraged, especially among AAPIs younger than 60 years old, and how various types of technology are being utilized are important to guide the recovery efforts to address both mental and physical disparities across communities as a result of the COVID-19 pandemic. %M 36395324 %R 10.2196/35748 %U https://publichealth.jmir.org/2023/1/e35748 %U https://doi.org/10.2196/35748 %U http://www.ncbi.nlm.nih.gov/pubmed/36395324 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e37225 %T Digital Phenotyping for Differential Diagnosis of Major Depressive Episode: Narrative Review %A Ettore,Eric %A Müller,Philipp %A Hinze,Jonas %A Riemenschneider,Matthias %A Benoit,Michel %A Giordana,Bruno %A Postin,Danilo %A Hurlemann,Rene %A Lecomte,Amandine %A Musiol,Michel %A Lindsay,Hali %A Robert,Philippe %A König,Alexandra %+ Department of Psychiatry and Memory Clinic, University Hospital of Nice, 30 Voie Romaine, Nice, 06000, France, 33 633306394, ettore.e@chu-nice.fr %K depression %K bipolar disorder %K posttraumatic stress disorder %K differential diagnosis %K digital phenotyping %K speech analysis %K nonverbal behavior %K physiological measures %K posttraumatic stress disorder %K mental health %K clinical interview %K diagnosis %K mental disorder %K interview %K digital health %K psychotrauma %K digital %K information %D 2023 %7 23.1.2023 %9 Review %J JMIR Ment Health %G English %X Background: Major depressive episode (MDE) is a common clinical syndrome. It can be found in different pathologies such as major depressive disorder (MDD), bipolar disorder (BD), posttraumatic stress disorder (PTSD), or even occur in the context of psychological trauma. However, only 1 syndrome is described in international classifications (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]/International Classification of Diseases 11th Revision [ICD-11]), which do not take into account the underlying pathology at the origin of the MDE. Clinical interviews are currently the best source of information to obtain the etiological diagnosis of MDE. Nevertheless, it does not allow an early diagnosis and there are no objective measures of extracted clinical information. To remedy this, the use of digital tools and their correlation with clinical symptomatology could be useful. Objective: We aimed to review the current application of digital tools for MDE diagnosis while highlighting shortcomings for further research. In addition, our work was focused on digital devices easy to use during clinical interview and mental health issues where depression is common. Methods: We conducted a narrative review of the use of digital tools during clinical interviews for MDE by searching papers published in PubMed/MEDLINE, Web of Science, and Google Scholar databases since February 2010. The search was conducted from June to September 2021. Potentially relevant papers were then compared against a checklist for relevance and reviewed independently for inclusion, with focus on 4 allocated topics of (1) automated voice analysis, behavior analysis by (2) video and physiological measures, (3) heart rate variability (HRV), and (4) electrodermal activity (EDA). For this purpose, we were interested in 4 frequently found clinical conditions in which MDE can occur: (1) MDD, (2) BD, (3) PTSD, and (4) psychological trauma. Results: A total of 74 relevant papers on the subject were qualitatively analyzed and the information was synthesized. Thus, a digital phenotype of MDE seems to emerge consisting of modifications in speech features (namely, temporal, prosodic, spectral, source, and formants) and in speech content, modifications in nonverbal behavior (head, hand, body and eyes movement, facial expressivity, and gaze), and a decrease in physiological measurements (HRV and EDA). We not only found similarities but also differences when MDE occurs in MDD, BD, PTSD, or psychological trauma. However, comparative studies were rare in BD or PTSD conditions, which does not allow us to identify clear and distinct digital phenotypes. Conclusions: Our search identified markers from several modalities that hold promise for helping with a more objective diagnosis of MDE. To validate their potential, further longitudinal and prospective studies are needed. %M 36689265 %R 10.2196/37225 %U https://mental.jmir.org/2023/1/e37225 %U https://doi.org/10.2196/37225 %U http://www.ncbi.nlm.nih.gov/pubmed/36689265 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e42672 %T Wearable Artificial Intelligence for Anxiety and Depression: Scoping Review %A Abd-alrazaq,Alaa %A AlSaad,Rawan %A Aziz,Sarah %A Ahmed,Arfan %A Denecke,Kerstin %A Househ,Mowafa %A Farooq,Faisal %A Sheikh,Javaid %+ AI Center for Precision Health, Weill Cornell Medicine-Qatar, P.O. Box 5825, Doha Al Luqta St, Ar-Rayyan, Doha, Qatar, 974 55708549, alaa_alzoubi88@yahoo.com %K wearable artificial intelligence %K artificial intelligence %K wearable devices %K anxiety %K depression %K scoping review %K mobile phone %D 2023 %7 19.1.2023 %9 Review %J J Med Internet Res %G English %X Background: Anxiety and depression are the most common mental disorders worldwide. Owing to the lack of psychiatrists around the world, the incorporation of artificial intelligence (AI) into wearable devices (wearable AI) has been exploited to provide mental health services. Objective: This review aimed to explore the features of wearable AI used for anxiety and depression to identify application areas and open research issues. Methods: We searched 8 electronic databases (MEDLINE, PsycINFO, Embase, CINAHL, IEEE Xplore, ACM Digital Library, Scopus, and Google Scholar) and included studies that met the inclusion criteria. Then, we checked the studies that cited the included studies and screened studies that were cited by the included studies. The study selection and data extraction were carried out by 2 reviewers independently. The extracted data were aggregated and summarized using narrative synthesis. Results: Of the 1203 studies identified, 69 (5.74%) were included in this review. Approximately, two-thirds of the studies used wearable AI for depression, whereas the remaining studies used it for anxiety. The most frequent application of wearable AI was in diagnosing anxiety and depression; however, none of the studies used it for treatment purposes. Most studies targeted individuals aged between 18 and 65 years. The most common wearable device used in the studies was Actiwatch AW4 (Cambridge Neurotechnology Ltd). Wrist-worn devices were the most common type of wearable device in the studies. The most commonly used category of data for model development was physical activity data, followed by sleep data and heart rate data. The most frequently used data set from open sources was Depresjon. The most commonly used algorithm was random forest, followed by support vector machine. Conclusions: Wearable AI can offer great promise in providing mental health services related to anxiety and depression. Wearable AI can be used by individuals for the prescreening assessment of anxiety and depression. Further reviews are needed to statistically synthesize the studies’ results related to the performance and effectiveness of wearable AI. Given its potential, technology companies should invest more in wearable AI for the treatment of anxiety and depression. %M 36656625 %R 10.2196/42672 %U https://www.jmir.org/2023/1/e42672 %U https://doi.org/10.2196/42672 %U http://www.ncbi.nlm.nih.gov/pubmed/36656625 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e40135 %T Effects of a Neuroscience-Based Mindfulness Meditation Program on Psychological Health: Pilot Randomized Controlled Trial %A Lynn,Sarah %A Basso,Julia C %+ Department of Human Nutrition, Foods and Exercise, Virginia Tech, Integrated Life Sciences Building, 1981 Kraft Drive, Blacksburg, VA, 24060, United States, 1 8567456363, jbasso@vt.edu %K meditation %K mindfulness %K mental health %K compassion %K self-compassion %K digital %K medical education %K neuroscience education %K depression %K psychological health %K mental illness %K anxiety %D 2023 %7 19.1.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Mindfulness and meditation have a rich historical tradition, and a growing scientific base of evidence supports their use in creating positive psychological and neuroplastic changes for practitioners. Although meditation can be taught in various ways, the scientific community has yet to systematically study the impact of different types of meditation on neuropsychological outcomes, especially as it pertains to digital implementation. Therefore, it is critical that the instruction of mindfulness be evidence based because meditation is being used in both scientific and clinical settings. Objective: This study investigated the use of teacher cueing and the integration of neuroscience education into a meditation program. Compassion cueing was chosen as the element of experimental manipulation because traditional lineages of Buddhist meditation teach compassion for self and others as one of the primary outcomes of meditation. We hypothesized that participants receiving compassion cueing would have enhanced neuropsychological outcomes compared with those receiving functional cueing and that gains in neuroscience knowledge would relate to positive neuropsychological outcomes. Methods: Participants (n=89) were randomized to receive either functional cueing (control group) or compassion cueing (experimental group) and engaged with five 10-minute meditation sessions a week for 4 weeks. All intervention sessions were administered through digital presentation. All participants completed ecological momentary assessments before and after the daily intervention, as well as pre- and postintervention questionnaires. Results: Participants demonstrated significant benefits over time, including increased mindfulness and self-compassion, decreased depression, and gains in neuroscience content (all P<.001); however, no significant between-group differences were found. Daily scores from each day of the intervention showed a statistically significant shift from active toward settled. Importantly, long-term increases in mindfulness were positively correlated to changes in compassion (r=0.326; P=.009) and self-compassion (r=0.424; P<.001) and negatively correlated to changes in anxiety (r=–0.266; P=.03) and depression (r=–0.271; P=.03). Finally, the acute effects of meditation were significantly correlated to the longitudinal outcomes (with a small-to-medium effect size), especially those relevant to mindfulness. Conclusions: We developed a novel neuroscience-based education–meditation program that enhanced self-regulation as evidenced by improved mindfulness, self-compassion, and mood state. Our findings demonstrate the behavioral importance of engaging with mindfulness meditation and reinforce the idea that the benefits of meditation are independent of teacher cueing behavior. Future studies will need to investigate the brain-based changes underlying these meditation-induced outcomes. %M 36656631 %R 10.2196/40135 %U https://formative.jmir.org/2023/1/e40135 %U https://doi.org/10.2196/40135 %U http://www.ncbi.nlm.nih.gov/pubmed/36656631 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e40342 %T When Heart Beats Differently in Depression: Review of Nonlinear Heart Rate Variability Measures %A Čukić,Milena %A Savić,Danka %A Sidorova,Julia %+ Empa Materials Science and Technology, Empa Swiss Federal Institute, Lerchenfeldstrasse 5, St Gallen, 9014, Switzerland, 41 +41587657070, milena.cukic@gmail.com %K heart rate variability %K HRV %K electrocardiogram %K ECG %K depression %K autonomous nervous system %K ANS %K nonlinear measures %K cardiac risk %K cardiovascular %K mortality %K heart dynamics %K ECG analysis %K analysis %K online %D 2023 %7 17.1.2023 %9 Review %J JMIR Ment Health %G English %X Background: Disturbed heart dynamics in depression seriously increases mortality risk. Heart rate variability (HRV) is a rich source of information for studying this dynamics. This paper is a meta-analytic review with methodological commentary of the application of nonlinear analysis of HRV and its possibility to address cardiovascular diseases in depression. Objective: This paper aimed to appeal for the introduction of cardiological screening to patients with depression, because it is still far from established practice. The other (main) objective of the paper was to show that nonlinear methods in HRV analysis give better results than standard ones. Methods: We systematically searched on the web for papers on nonlinear analyses of HRV in depression, in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 framework recommendations. We scrutinized the chosen publications and performed random-effects meta-analysis, using the esci module in jamovi software where standardized effect sizes (ESs) are corrected to yield the proof of the practical utility of their results. Results: In all, 26 publications on the connection of nonlinear HRV measures and depression meeting our inclusion criteria were selected, examining a total of 1537 patients diagnosed with depression and 1041 healthy controls (N=2578). The overall ES (unbiased) was 1.03 (95% CI 0.703-1.35; diamond ratio 3.60). We performed 3 more meta-analytic comparisons, demonstrating the overall effectiveness of 3 groups of nonlinear analysis: detrended fluctuation analysis (overall ES 0.364, 95% CI 0.237-0.491), entropy-based measures (overall ES 1.05, 95% CI 0.572-1.52), and all other nonlinear measures (overall ES 0.702, 95% CI 0.422-0.982). The effectiveness of the applied methods of electrocardiogram analysis was compared and discussed in the light of detection and prevention of depression-related cardiovascular risk. Conclusions: We compared the ESs of nonlinear and conventional time and spectral methods (found in the literature) and demonstrated that those of the former are larger, which recommends their use for the early screening of cardiovascular abnormalities in patients with depression to prevent possible deleterious events. %M 36649063 %R 10.2196/40342 %U https://mental.jmir.org/2023/1/e40342 %U https://doi.org/10.2196/40342 %U http://www.ncbi.nlm.nih.gov/pubmed/36649063 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e38955 %T Efficacy of Virtual Care for Depressive Disorders: Systematic Review and Meta-analysis %A Schiller,Crystal Edler %A Prim,Julianna %A Bauer,Anna E %A Lux,Linda %A Lundegard,Laura Claire %A Kang,Michelle %A Hellberg,Samantha %A Thompson,Katherine %A Webber,Theresa %A Teklezghi,Adonay %A Pettee,Noah %A Gaffney,Katherine %A Hodgins,Gabrielle %A Rahman,Fariha %A Steinsiek,J Nikki %A Modi,Anita %A Gaynes,Bradley N %+ Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, 304 MacNider Hall, Chapel Hill, NC, 27599-7160, United States, 1 919 966 4810, crystal_schiller@med.unc.edu %K depression %K virtual %K treatment %K therapy %K efficacy %K virtual care %K meta-analysis %K review %K mental health %K depressive disorder %K virtual intervention %K digital intervention %K digital health %K eHealth %K health outcome %K digital mental health %K health intervention %D 2023 %7 9.1.2023 %9 Review %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic has created an epidemic of distress-related mental disorders such as depression, while simultaneously necessitating a shift to virtual domains of mental health care; yet, the evidence to support the use of virtual interventions is unclear. Objective: The purpose of this study was to evaluate the efficacy of virtual interventions for depressive disorders by addressing three key questions: (1) Does virtual intervention provide better outcomes than no treatment or other control conditions (ie, waitlist, treatment as usual [TAU], or attention control)? (2) Does in-person intervention provide better outcomes than virtual intervention? (3) Does one type of virtual intervention provide better outcomes than another? Methods: We searched the PubMed, EMBASE, and PsycINFO databases for trials published from January 1, 2010, to October 30, 2021. We included randomized controlled trials of adults with depressive disorders that tested a virtual intervention and used a validated depression measure. Primary outcomes were defined as remission (ie, no longer meeting the clinical cutoff for depression), response (ie, a clinically significant reduction in depressive symptoms), and depression severity at posttreatment. Two researchers independently selected studies and extracted data using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Risk of bias was evaluated based on Agency for Healthcare and Research Quality guidelines. We calculated odds ratios (ORs) for binary outcomes and standardized mean differences (SMDs) for continuous outcomes. Results: We identified 3797 references, 24 of which were eligible. Compared with waitlist, virtual intervention had higher odds of remission (OR 10.30, 95% CI 5.70-18.60; N=619 patients) and lower posttreatment symptom severity (SMD 0.81, 95% CI 0.52-1.10; N=1071). Compared with TAU and virtual attention control conditions, virtual intervention had higher odds of remission (OR 2.27, 95% CI 1.10-3.35; N=512) and lower posttreatment symptom severity (SMD 0.25, 95% CI 0.09-0.42; N=573). In-person intervention outcomes were not significantly different from virtual intervention outcomes (eg, remission OR 0.84, CI 0.51-1.37; N=789). No eligible studies directly compared one active virtual intervention to another. Conclusions: Virtual interventions were efficacious compared with control conditions, including waitlist control, TAU, and attention control. Although the number of studies was relatively small, the strength of evidence was moderate that in-person interventions did not yield significantly better outcomes than virtual interventions for depressive disorders. %M 36622747 %R 10.2196/38955 %U https://mental.jmir.org/2023/1/e38955 %U https://doi.org/10.2196/38955 %U http://www.ncbi.nlm.nih.gov/pubmed/36622747 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e37270 %T Assessment and Disruption of Ruminative Episodes to Enhance Mobile Cognitive Behavioral Therapy Just-in-Time Adaptive Interventions in Clinical Depression: Pilot Randomized Controlled Trial %A Wang,Liyuan %A Miller,Lynn %+ Children's Hospital, Los Angeles, Department of Adolescent and Young Adult, 3250 Wilshire Blvd, Suite 1202, Los Angeles, CA, 90027-0000, United States, 1 7654911022, liwang@chla.usc.edu %K depressive rumination %K mobile health %K mHealth %K just-in-time adaptive intervention %K depression %K mental health %K mobile phone %D 2023 %7 5.1.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: A just-in-time adaptive intervention (JITAI) is “designed to address the dynamically changing needs of individuals via the provision of the type or amount of support needed, at the right time when needed.” If and how rumination-focused cognitive behavioral therapy (RFCBT), the gold standard, blocks emotional cascades underlying rumination is unclear. Furthermore, cognitive behavioral therapy has been successfully used as a mobile variant, but RFCBT has not been adapted for a mobile variant (mobile RFCBT [MRFCBT]) or for a JITAI variant. Objective: This study aimed to pilot-test a fully automated JITAI leveraging RFCBT and ways to identify and block cascading depressive rumination. Methods: Patients in therapy for clinical depression were recruited for a randomized controlled trial (RCT). After consenting to be part of the RCT, they were randomly assigned to either of the 2 mobile versions of the RFCBT conditions personalized to the individual’s rumination timing patterns (JITAI-MRFCBT) or a no-treatment control condition through a double-blind procedure. Although the initial design was to have a 3-armed trial with 2 JITAI conditions (a JITAI and a narrative JITAI condition), we later opted to collapse those 2 conditions into 1 JITAI condition because of the low number of participants. All participants were recruited and participated through their smartphones, receiving 5 SMS text message reminders on each of the 35 days to self-report their rumination-related symptoms (eg, rumination episodes and duration). In the JITAI-MRFCBT condition, they also received treatment materials. The first 7 days provided a rumination baseline, and the last 7 days provided a postintervention rumination value. In total, 42% (25/59) of volunteers were eligible and provided their phone numbers, 20% (5/25) of whom never replied to the SMS text message reminding them to start the RCT. A total of 90% (18/20) of volunteers completed it (ie, finishing, as prespecified, 80% of the questionnaires and training tasks) and, therefore, were included in the analysis. Results: Using independent 2-tailed t tests with bootstrapping, results showed that participants in the JITAI-MRFCBT condition, compared with those in the control condition, reported a greater reduction in counts of rumination episodes (mean −25.28, SD 14.50 vs mean 1.44, SD 4.12, P<.001) and greater reduced average time (minutes) spent in rumination (mean −21.53, SD 17.6 vs mean 1.47, SD 1.5; P=.04). Results also suggest that, compared with those in the control group, those in treatment reduced ruminative carryover from one episode to the next. Conclusions: The results suggest that JITAI-MRFCBT may reduce negative rumination by providing RFCBT just in time following rumination, thereby blocking the next rumination episode using the same trigger. This study supports a subsequent, full-scale JITAI and the importance of leveraging mobile smartphone technology with MRFCBT to curb depressive symptoms. Trial Registration: ClinicalTrials.gov NCT04554706; https://clinicaltrials.gov/ct2/show/NCT04554706 %M 36602841 %R 10.2196/37270 %U https://formative.jmir.org/2023/1/e37270 %U https://doi.org/10.2196/37270 %U http://www.ncbi.nlm.nih.gov/pubmed/36602841 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 12 %P e31367 %T Centering Lived Experience in Developing Digital Interventions for Suicide and Self-injurious Behaviors: User-Centered Design Approach %A Kruzan,Kaylee Payne %A Meyerhoff,Jonah %A Biernesser,Candice %A Goldstein,Tina %A Reddy,Madhu %A Mohr,David C %+ Center for Behavioral Intervention Technologies, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Dr, Chicago, IL, 60611, United States, 1 3125036585, kaylee.kruzan@northwestern.edu %K user-centered design %K intervention %K suicide %K nonsuicidal self-injury %K lived experience %K technology-enabled services %K digital intervention %K engagement %K mobile phone %D 2021 %7 24.12.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The prevalence of self-injurious thoughts and behaviors (SITB) signals a growing public health crisis. Despite a recognized need for improved and scalable interventions, the field of SITB intervention faces several challenges: existing interventions are often time and resource intensive, most individuals with SITB do not seek formal mental health care, and efficacious treatments are characterized by small effects. Combined, these challenges indicate a need for improved SITB interventions for individuals in formal treatment and those who are not treatment engaged but are at high risk of worsening mental health and future suicide attempts. Objective: We present a methodological approach and set of techniques that may address these challenges by centering the lived experience of individuals with SITB in the process of developing needed services: user-centered design (UCD). Methods: We highlight the value of UCD in the context of digital interventions for SITB by describing the UCD approach and explicating how it can be leveraged to include lived experience throughout the development and evaluation process. We provide a detailed case example highlighting 3 phases of the early development process that can be used to design an intervention that is engaging and meets end-user needs. In addition, we point to novel applications of UCD to complement new directions in SITB research. Results: In this paper, we offer a 2-pronged approach to meet these challenges. First, in terms of addressing access to effective interventions, digital interventions hold promise to extend the reach of evidence-based treatments outside of brick-and-mortar health care settings. Second, to address challenges related to treatment targets and engagement, we propose involving individuals with lived experience in the design and research process. Conclusions: UCD offers a well-developed and systematic process to center the unique needs, preferences, and perceived barriers of individuals with lived SITB experience in the development and evaluation of digital interventions. %M 34951602 %R 10.2196/31367 %U https://mental.jmir.org/2021/12/e31367 %U https://doi.org/10.2196/31367 %U http://www.ncbi.nlm.nih.gov/pubmed/34951602 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 12 %P e32653 %T Exploring the Effects of In-App Components on Engagement With a Symptom-Tracking Platform Among Participants With Major Depressive Disorder (RADAR-Engage): Protocol for a 2-Armed Randomized Controlled Trial %A White,Katie M %A Matcham,Faith %A Leightley,Daniel %A Carr,Ewan %A Conde,Pauline %A Dawe-Lane,Erin %A Ranjan,Yatharth %A Simblett,Sara %A Henderson,Claire %A Hotopf,Matthew %+ Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, 16 de Crespigny Park, London, SE5 8AF, United Kingdom, 44 7850684847, katie.white@kcl.ac.uk %K app %K engagement %K major depressive disorder %K remote measurement technologies %K research %K mobile phone %D 2021 %7 21.12.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Multi-parametric remote measurement technologies (RMTs) comprise smartphone apps and wearable devices for both active and passive symptom tracking. They hold potential for understanding current depression status and predicting future depression status. However, the promise of using RMTs for relapse prediction is heavily dependent on user engagement, which is defined as both a behavioral and experiential construct. A better understanding of how to promote engagement in RMT research through various in-app components will aid in providing scalable solutions for future remote research, higher quality results, and applications for implementation in clinical practice. Objective: The aim of this study is to provide the rationale and protocol for a 2-armed randomized controlled trial to investigate the effect of insightful notifications, progress visualization, and researcher contact details on behavioral and experiential engagement with a multi-parametric mobile health data collection platform, Remote Assessment of Disease and Relapse (RADAR)–base. Methods: We aim to recruit 140 participants upon completion of their participation in the RADAR Major Depressive Disorder study in the London site. Data will be collected using 3 weekly tasks through an active smartphone app, a passive (background) data collection app, and a Fitbit device. Participants will be randomly allocated at a 1:1 ratio to receive either an adapted version of the active app that incorporates insightful notifications, progress visualization, and access to researcher contact details or the active app as usual. Statistical tests will be used to assess the hypotheses that participants using the adapted app will complete a higher percentage of weekly tasks (behavioral engagement: primary outcome) and score higher on self-awareness measures (experiential engagement). Results: Recruitment commenced in April 2021. Data collection was completed in September 2021. The results of this study will be communicated via publication in 2022. Conclusions: This study aims to understand how best to promote engagement with RMTs in depression research. The findings will help determine the most effective techniques for implementation in both future rounds of the RADAR Major Depressive Disorder study and, in the long term, clinical practice. Trial Registration: ClinicalTrials.gov NCT04972474; http://clinicaltrials.gov/ct2/show/NCT04972474 International Registered Report Identifier (IRRID): DERR1-10.2196/32653 %M 34932005 %R 10.2196/32653 %U https://www.researchprotocols.org/2021/12/e32653 %U https://doi.org/10.2196/32653 %U http://www.ncbi.nlm.nih.gov/pubmed/34932005 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 12 %P e26584 %T Quality Social Connection as an Active Ingredient in Digital Interventions for Young People With Depression and Anxiety: Systematic Scoping Review and Meta-analysis %A Dewa,Lindsay H %A Lawrance,Emma %A Roberts,Lily %A Brooks-Hall,Ellie %A Ashrafian,Hutan %A Fontana,Gianluca %A Aylin,Paul %+ Institute of Global Health Innovation, Imperial College London, Reynolds Building, 3rd Floor, London, W6 8RP, United Kingdom, 44 020 7594 0815, l.dewa@imperial.ac.uk %K mental health %K digital interventions %K young people %K quality social connection %K depression %K anxiety %K systematic review %K meta-analysis %K patient and public involvement %K mobile phone %D 2021 %7 17.12.2021 %9 Review %J J Med Internet Res %G English %X Background: Disrupted social connections may negatively affect youth mental health. In contrast, sustained quality social connections (QSCs) can improve mental health outcomes. However, few studies have examined how these quality connections affect depression and anxiety outcomes within digital interventions, and conceptualization is limited. Objective: The aim of this study is to conceptualize, appraise, and synthesize evidence on QSC within digital interventions (D-QSC) and the impact on depression and anxiety outcomes for young people aged 14-24 years. Methods: A systematic scoping review and meta-analysis was conducted using the Joanna Briggs Institute methodological frameworks and guided by experts with lived experience. Reporting was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The MEDLINE, Embase, PsycINFO, and CINAHL databases were searched against a comprehensive combination of key concepts on June 24, 2020. The search concepts included young people, digital intervention, depression, anxiety, and social connection. Google was also searched. A reviewer independently screened abstracts and titles and full text, and 9.99% (388/3882) of these were screened by a second reviewer. A narrative synthesis was used to structure the findings on indicators of D-QSC and mechanisms that facilitate the connection. Indicators of D-QSC from the included studies were synthesized to produce a conceptual framework. Results: Of the 5715 publications identified, 42 (0.73%) were included. Among the included studies, there were 23,319 participants. Indicators that D-QSC was present varied and included relatedness, having a sense of belonging, and connecting to similar people. However, despite the variation, most of the indicators were associated with improved outcomes for depression and anxiety. Negative interactions, loneliness, and feeling ignored indicated that D-QSC was not present. In 24% (10/42) of the applicable studies, a meta-analysis showed a significant decrease in depression (–25.6%, 95% CI –0.352 to –0.160; P<.001) and anxiety (–15.1%, 95% CI –0.251 to –0.051; P=.003) after a D-QSC. Digital mechanisms that helped create a quality connection included anonymity, confidentiality, and peer support. In contrast, mechanisms that hindered the connection included disconnection from the real world and inability to see body language. Data synthesis also identified a 5-component conceptual framework of D-QSC that included rapport, identity and commonality, valued interpersonal dynamic, engagement, and responded to and accepted. Conclusions: D-QSC is an important and underconsidered component for youth depression and anxiety outcomes. Researchers and developers should consider targeting improved QSC between clinicians and young people within digital interventions for depression. Future research should build on our framework to further examine relationships among individual attributes of QSC, various digital interventions, and different populations. %M 34927592 %R 10.2196/26584 %U https://www.jmir.org/2021/12/e26584 %U https://doi.org/10.2196/26584 %U http://www.ncbi.nlm.nih.gov/pubmed/34927592 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 12 %P e33452 %T Examining the Impact of Digital Components Across Different Phases of Treatment in a Blended Care Cognitive Behavioral Therapy Intervention for Depression and Anxiety: Pragmatic Retrospective Study %A Wu,Monica S %A Wickham,Robert E %A Chen,Shih-Yin %A Chen,Connie %A Lungu,Anita %+ Lyra Health, 287 Lorton Ave, Burlingame, CA, 94010, United States, 1 877 505 7147, mwu@lyrahealth.com %K blended care %K cognitive-behavioral therapy %K depression %K anxiety %K digital %K phase %K mental health %K digital health %K digital therapy %D 2021 %7 17.12.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression and anxiety incur significant personal and societal costs. Effective psychotherapies exist, such as cognitive behavioral therapy (CBT); however, timely access to quality care is limited by myriad barriers. Blended care therapy models incorporate traditional face-to-face therapy with scalable, digital components of care, expanding the reach of evidence-based care. Objective: The aim of this study is to determine the effectiveness of a blended care CBT program (BC-CBT) in real-world settings and examine the unique impacts of the (1) digital components of care (video lessons and digital exercises) and (2) phase of treatment (early versus late) in decreasing symptoms of anxiety and depression. Methods: This retrospective cohort analysis included 3401 US-based individuals enrolled in a BC-CBT program, who presented with clinical levels of depression and/or anxiety. The treatment program consisted of regular therapy sessions augmented by clinician-assigned digital video lessons and exercises. A growth curve model incorporating time-varying covariates examined the relationship between engagement with BCT components (ie, therapy sessions, digital video lessons, and digital exercises) during the early (weeks 0-7) and late (weeks 8-15) phases of treatment, and weekly symptom reports on depression and anxiety measures. Results: On average, a significant decline in depression and anxiety symptoms was observed during the initial weeks of treatment (P<.001), with a continued, though slower, decline over subsequent weeks (P<.001). Each session completed was associated with significant decreases in anxiety (b=–0.72) and depression (b=–0.83) in the early phase, as well as in the late phase (anxiety, b=–0.47; depression, b=–0.27). Significant decreases in anxiety (b=–0.15) and depression (b=–0.12) were observed for time spent on video lessons (measured in 10-minute intervals) in the early phase of treatment. Engaging with exercises was associated with statistically significant increases in anxiety symptoms (b=0.03) during the early phase of treatment. However, sensitivity analyses examining the effects of exercises in isolation revealed significant decreases in anxiety (b=–0.05) in the early phase, suggesting a potential suppression effect in the larger model. Conclusions: Using a retrospective cohort design, therapy sessions and digital video lessons were uniquely predictive of improvements in depression and anxiety symptoms, and their effects were modulated based on the phase of treatment (early vs late). Future research should investigate whether other treatment variables, such as therapeutic alliance or familiarity with technology, are related to differential effects on various components of care. %M 34927591 %R 10.2196/33452 %U https://formative.jmir.org/2021/12/e33452 %U https://doi.org/10.2196/33452 %U http://www.ncbi.nlm.nih.gov/pubmed/34927591 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 12 %P e26814 %T An Adjunctive Internet-Based Intervention to Enhance Treatment for Depression in Adults: Randomized Controlled Trial %A Pérez,J Carola %A Fernández,Olga %A Cáceres,Cristián %A Carrasco,Álvaro E %A Moessner,Markus %A Bauer,Stephanie %A Espinosa-Duque,Daniel %A Gloger,Sergio %A Krause,Mariane %+ Facultad de Psicología, Universidad del Desarrollo, Avda La Plaza 680, Las Condes, Santiago, 7610658, Chile, 56 997 051 989, janetperez@udd.cl %K depression %K e-mental health %K blended care %K internet %D 2021 %7 16.12.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Internet-based interventions promise to enhance the accessibility of mental health care for a greater number of people and in more remote places. Their effectiveness has been shown for the prevention and treatment of various mental disorders. However, their potential when delivered as add-on to conventional treatment (ie, blended care) is less clear. Objective: The aim of this study is to study the effectiveness of an internet intervention (ASCENSO) implemented in addition to face-to-face treatment as usual (TAU) for depression. Methods: A 2-arm, parallel-group, randomized controlled trial was conducted in an outpatient private mental health care center in Chile. In all, 167 adults, diagnosed with major depressive disorder, without severe comorbidities, and with internet access, were included. Eighty-four participants were assigned to the intervention group and received medical and psychological TAU from the mental health center plus access to the ASCENSO online platform. The control group (n=83) received only TAU. The ASCENSO platform includes psycho-educational information, depressive symptom monitoring and feedback, and managing emergencies based on the principles of cognitive behavioral therapy. Emergency management was mental health provider–assisted. TAU includes access to primary care physicians and psychiatrists, to a brief individual psychotherapy, and to medication when needed. The baseline questionnaires were administered in person, and 6- and 9-months assessments were conducted online. Depression symptoms and quality of life were measured by self-administered questionnaires, and treatment adherence was determined via the Mental Health Center’s internal records. The usage of ASCENSO was assessed by server logs. Reduction on depressive symptomatology was considered as the primary outcome of the intervention and quality of life as a secondary outcome. Results: Of the 84 participants in the intervention group, 5 participants (6%) never accessed the online platform. Of the remaining 79 participants who accessed ASCENSO, 1 (1%, 1/79) did not answer any of the symptom questionnaire, and most participants (72/79, 91%) answered the monitoring questionnaires irregularly. The ASCENSO intervention implemented in addition to face-to-face care did not improve the outcome of the usual care delivered at the mental health center, either in terms of reduction of depressive symptoms (F2,6087= 0.48; P=.62) or in the improvement of quality of life (EQ-5D-3L: F2,7678=0.24; P=.79 and EQ-VAS: F2,6670= 0.13; P=.88). In contrast, for the primary (F2,850=78.25; P<.001) and secondary outcomes (EQ-5D-3L: F2,1067=37.87; EQ-VAS: F2,4390= 51.69; P<.001) in both groups, there was an improvement from baseline to 6 months (P<.001), but there was no change at 9 months. In addition, no effects on adherence to or use of TAU were found. Finally, the dropout rate for the face-to-face treatment component was 54% (45/84) for the intervention group versus 39% (32/83) for the control group (P=.07). Conclusions: The fact that the adjunctive access to ASCENSO did not improve outcome could be due to both the rather high effectiveness of TAU and to patients’ limited use of the online platform. Trial Registration: ClinicalTrials.gov NCT03093467; https://clinicaltrials.gov/ct2/show/NCT03093467 %M 34927594 %R 10.2196/26814 %U https://mental.jmir.org/2021/12/e26814 %U https://doi.org/10.2196/26814 %U http://www.ncbi.nlm.nih.gov/pubmed/34927594 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 12 %P e33695 %T Harnessing Innovative Technologies to Train Nurses in Suicide Safety Planning With Hospitalized Patients: Protocol for Formative and Pilot Feasibility Research %A Darnell,Doyanne %A Areán,Patricia A %A Dorsey,Shannon %A Atkins,David C %A Tanana,Michael J %A Hirsch,Tad %A Mooney,Sean D %A Boudreaux,Edwin D %A Comtois,Katherine Anne %+ Department of Psychiatry & Behavioral Sciences, University of Washington, 325 Ninth Avenue, Box 359911, Seattle, WA, 98104, United States, 1 206 744 9108, darnelld@uw.edu %K suicide prevention %K hospital %K training %K e-learning %K artificial intelligence %K implementation science %K user-centered design %K task-shifting %K quality assessment %K fidelity %D 2021 %7 15.12.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is the 10th leading cause of death in the United States, with >47,000 deaths in 2019. Most people who died by suicide had contact with the health care system in the year before their death. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill-building are resource intensive and difficult to implement. Advances in artificial intelligence technology hold promise for improving the scalability and sustainability of training methods, as it is now possible for computers to assess the intervention delivery skills of trainees and provide feedback to guide skill improvements. Much remains to be known about how best to integrate these novel technologies into continuing education for health care providers. Objective: In Project WISE (Workplace Integrated Support and Education), we aim to develop e-learning training in suicide safety planning, enhanced with novel skill-building technologies that can be integrated into the routine workflow of nurses serving patients hospitalized for medical or surgical reasons or traumatic injury. The research aims include identifying strategies for the implementation and workflow integration of both the training and safety planning with patients, adapting 2 existing technologies to enhance general counseling skills for use in suicide safety planning (a conversational agent and an artificial intelligence–based feedback system), observing training acceptability and nurse engagement with the training components, and assessing the feasibility of recruitment, retention, and collection of longitudinal self-report and electronic health record data for patients identified as at risk of suicide. Methods: Our developmental research includes qualitative and observational methods to explore the implementation context and technology usability, formative evaluation of the training paradigm, and pilot research to assess the feasibility of conducting a future cluster randomized pragmatic trial. The trial will examine whether patients hospitalized for medical or surgical reasons or traumatic injury who are at risk of suicide have better suicide-related postdischarge outcomes when admitted to a unit with nurses trained using the skill-building technology than those admitted to a unit with untrained nurses. The research takes place at a level 1 trauma center, which is also a safety-net hospital and academic medical center. Results: Project WISE was funded in July 2019. As of September 2021, we have completed focus groups and usability testing with 27 acute care and 3 acute and intensive care nurses. We began data collection for research aims 3 and 4 in November 2021. All research has been approved by the University of Washington institutional review board. Conclusions: Project WISE aims to further the national agenda to improve suicide prevention in health care settings by training nurses in suicide prevention with medically hospitalized patients using novel e-learning technologies. International Registered Report Identifier (IRRID): DERR1-10.2196/33695 %M 34914618 %R 10.2196/33695 %U https://www.researchprotocols.org/2021/12/e33695 %U https://doi.org/10.2196/33695 %U http://www.ncbi.nlm.nih.gov/pubmed/34914618 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 12 %P e17062 %T User Reviews of Depression App Features: Sentiment Analysis %A Meyer,Julien %A Okuboyejo,Senanu %+ School of Health Services Management, Ted Rogers School of Management, Ryerson University, 350 Victoria Street, Office: TRS 3-081, Toronto, ON, M4T 1G6, Canada, 1 4169795000 ext 6296, julien.meyer@ryerson.ca %K mHealth %K depression %K app reviews %K natural language processing %K app features %K emotions %K use %K linguistic inquiry word count %K mobile phone %D 2021 %7 14.12.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Mental health in general, and depression in particular, remain undertreated conditions. Mobile health (mHealth) apps offer tremendous potential to overcome the barriers to accessing mental health care and millions of depression apps have been installed and used. However, little is known about the effect of these apps on a potentially vulnerable user population and the emotional reactions that they generate, even though emotions are a key component of mental health. App reviews, spontaneously posted by the users on app stores, offer up-to-date insights into the experiences and emotions of this population and are increasingly decisive in influencing mHealth app adoption. Objective: This study aims to investigate the emotional reactions of depression app users to different app features by systematically analyzing the sentiments expressed in app reviews. Methods: We extracted 3261 user reviews of depression apps. The 61 corresponding apps were categorized by the features they offered (psychoeducation, medical assessment, therapeutic treatment, supportive resources, and entertainment). We then produced word clouds by features and analyzed the reviews using the Linguistic Inquiry Word Count 2015 (Pennebaker Conglomerates, Inc), a lexicon-based natural language analytical tool that analyzes the lexicons used and the valence of a text in 4 dimensions (authenticity, clout, analytic, and tone). We compared the language patterns associated with the different features of the underlying apps. Results: The analysis highlighted significant differences in the sentiments expressed for the different features offered. Psychoeducation apps exhibited more clout but less authenticity (ie, personal disclosure). Medical assessment apps stood out for the strong negative emotions and the relatively negative ratings that they generated. Therapeutic treatment app features generated more positive emotions, even though user feedback tended to be less authentic but more analytical (ie, more factual). Supportive resources (connecting users to physical services and people) and entertainment apps also generated fewer negative emotions and less anxiety. Conclusions: Developers should be careful in selecting the features they offer in their depression apps. Medical assessment features may be riskier as users receive potentially disturbing feedback on their condition and may react with strong negative emotions. In contrast, offering information, contacts, or even games may be safer starting points to engage people with depression at a distance. We highlight the necessity to differentiate how mHealth apps are assessed and vetted based on the features they offer. Methodologically, this study points to novel ways to investigate the impact of mHealth apps and app features on people with mental health issues. mHealth apps exist in a rapidly changing ecosystem that is driven by user satisfaction and adoption decisions. As such, user perceptions are essential and must be monitored to ensure adoption and avoid harm to a fragile population that may not benefit from traditional health care resources. %M 34904955 %R 10.2196/17062 %U https://formative.jmir.org/2021/12/e17062 %U https://doi.org/10.2196/17062 %U http://www.ncbi.nlm.nih.gov/pubmed/34904955 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 12 %P e31293 %T Effectiveness of Videoconference-Delivered Cognitive Behavioral Therapy for Adults With Psychiatric Disorders: Systematic and Meta-Analytic Review %A Matsumoto,Kazuki %A Hamatani,Sayo %A Shimizu,Eiji %+ Research Center for Child Mental Development, Chiba University, 1-8-1, Inohana, Chuo-ku,, Chiba, Japan, 81 43 226 2975, axpa0219@chiba-u.jp %K videoconference-delivered cognitive behavioral therapy %K depression %K anxiety %K psychiatric disorders %K systematic review %K meta-analysis %K digital health %K mental health %K cognitive therapy %K internet-based therapy %K cognition %K neurodevelopment %K communication technology %K health technology %K psychological disorders %K anxiety disorder %D 2021 %7 13.12.2021 %9 Review %J J Med Internet Res %G English %X Background: Cognitive behavioral therapy (CBT) is the gold standard of psychotherapy for psychiatric disorders. However, the format of delivering CBT in person limits access to the intervention. The advancements in information and communication technology, especially the internet, present an opportunity for cognitive behavioral therapists to service patients or clients in remote areas through videoconferencing. Although many randomized controlled trials of videoconference-delivered cognitive behavioral therapy (VCBT) have already been conducted, the overall estimated effect size of VCBT for psychiatric disorders has not been examined by systematic reviews and meta-analyses. Objective: This study attempts to evaluate the effectiveness of VCBT for psychiatric disorders through a systematic and meta-analytic review. Methods: A systematic review and meta-analysis of studies in which VCBT was directly compared to control groups (such as treatment as usual, attention control, wait-list control, and other minimal supports) was carried out. To identify previous studies that meet our study objective, 2 independent reviewers undertook a systematic search through seven databases: MEDLINE (via PubMed), Web of Science, Science Direct, PsycINFO, CINAHL, LILACS, and SciELO. Other databases (ClinicalTrials.gov and Cochrane Central Resister of Controlled Trials) were also checked. All studies included in the review were assessed using the quality criteria of the Cochrane Collaboration. Statistical analysis was performed by using Cochrane Review Manager (RevMan, version 5.4.0). Standardized mean difference was used in major meta-analyses where a P value of .05 or less was the threshold for statistical significance. A heterogeneity test and the chi-square test were performed to assess the presence and extent of statistical heterogeneity with significance set at P<.10. Funnel plots were visually inspected to assess the risk of bias. Subgroup analyses were conducted for each disorder to estimate intervention effects. Results: The systematic search resulted in 16 studies (total N=1745) that met the criteria for this study and were included in the review. There were 10 studies on depressive symptoms, 3 on chronic pain, 1 on generalized anxiety disorder, 1 on obsessive-compulsive disorder, and 1 on hypochondriasis. The quality and risk of bias was also assessed. Results showed a pooled effect size (Hedge g) post treatment of −0.49 (95% CI –0.68 to –0.29), indicating that VCBT is effective for clients with psychiatric disorders. Study quality did not affect outcomes. Conclusions: While the overall results indicate the effectiveness of VCBT, there are still only a limited number of studies on specific psychiatric and somatic conditions. Therefore, more randomized controlled trials are needed to establish the effectiveness of VCBT for different disorders. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42021224832; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=224832 %M 34898445 %R 10.2196/31293 %U https://www.jmir.org/2021/12/e31293 %U https://doi.org/10.2196/31293 %U http://www.ncbi.nlm.nih.gov/pubmed/34898445 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 12 %P e26665 %T Evaluation of Repeated Web-Based Screening for Predicting Postpartum Depression: Prospective Cohort Study %A Haßdenteufel,Kathrin %A Lingenfelder,Katrin %A Schwarze,Cornelia E %A Feisst,Manuel %A Brusniak,Katharina %A Matthies,Lina Maria %A Goetz,Maren %A Wallwiener,Markus %A Wallwiener,Stephanie %+ Department of Obstetrics and Gynecology, Heidelberg University, Im Neuenheimer Feld 440, Heidelberg, D-69120, Germany, 49 62215637551, stephanie.wallwiener@med.uni-heidelberg.de %K postpartum depression %K Edinburgh Postnatal Depression Scale %K screening %K pregnancy %K algorithm %D 2021 %7 10.12.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Postpartum depression (PPD) is a severe mental disorder that often results in poor maternal-infant attachment and negatively impacts infant development. Universal screening has recently been recommended to identify women at risk, but the optimal screening time during pregnancy has not been defined so far. Thus, web-based technologies with widespread use among women of childbearing age create new opportunities to detect pregnancies with a high risk for adverse mental health outcomes at an early stage. Objective: The aim of this study was to stratify the risk for PPD and to determine the optimal screening time during pregnancy by using a web-based screening tool collecting electronic patient-reported outcomes (ePROs) as the basis for a screening algorithm. Methods: In total, 214 women were repeatedly tested for depressive symptoms 5 times during and 3 times after pregnancy by using the Edinburgh Postnatal Depression Scale (EPDS), accessible on a web-based pregnancy platform, developed by the authors of this study. For each prenatal assessment, the area under the curve (AUC), sensitivity, specificity, and predictive values for PPD were calculated. Multivariate logistic regression analyses were applied to identify further potential predictors, such as age, education, parity, relationship quality, and anxiety, to increase predictive accuracy. Results: Digitally collected data from 214 pregnant women were analyzed. The predictive accuracy of depressive symptoms 3 and 6 months postpartum was reasonable to good regarding the screening in the second (AUC=0.85) and third (AUC=0.75) trimester. The multivariate logistic regression analyses resulted in an excellent AUC of 0.93 at 3 months and a good AUC of 0.87 at 6 months postpartum. Conclusions: The best predictive accuracy for PPD has been shown for screening between the 24th and the 28th gestational week (GW) and seems to be beneficial for identifying women at risk. In combination with the aforementioned predictive factors, the discriminatory power improved, particularly at 3 months postpartum. Screening for depression during pregnancy, combined with the women’s personal risk profile, can be used as a starting point for developing a digital screening algorithm. Thereby, web-based assessment tools constitute feasible, efficient, and cost-effective approaches. Thus, they seem to be beneficial in detecting high-risk pregnancies in order to improve maternal and infant birth outcomes in the long term. %M 34890349 %R 10.2196/26665 %U https://mental.jmir.org/2021/12/e26665 %U https://doi.org/10.2196/26665 %U http://www.ncbi.nlm.nih.gov/pubmed/34890349 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 12 %P e17185 %T Internet and Face-to-face Cognitive Behavioral Therapy for Postnatal Depression Compared With Treatment as Usual: Randomized Controlled Trial of MumMoodBooster %A Milgrom,Jeannette %A Danaher,Brian G %A Seeley,John R %A Holt,Christopher J %A Holt,Charlene %A Ericksen,Jennifer %A Tyler,Milagra S %A Gau,Jeff M %A Gemmill,Alan W %+ Parent-Infant Research Institute, Heidelberg Repatriation Hospital, 300 Waterdale Rd, Heidelberg Heights, 3081, Australia, 61 3 9496 4496, alan.gemmill@austin.org.au %K postnatal depression %K postpartum depression %K postnatal anxiety %K postpartum anxiety %K cognitive behavioral therapy %K internet intervention %K web-based intervention %K randomized controlled trial %K online intervention %K treatment %K mobile phone %D 2021 %7 8.12.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Previous research has confirmed that symptoms of postnatal depression (PND) can be ameliorated through internet-delivered psychological interventions. Advantages of internet-delivered treatment include anonymity, convenience, and catering to women who are unable to access face-to-face (FTF) treatments. To date, no research has examined the efficacy of such interventions compared directly with FTF treatments in women clinically diagnosed with PND. Objective: This study aims to compare the efficacy of one of the first web-based cognitive behavioral therapy (CBT) interventions (internet CBT+coach calls) for PND (MumMoodBooster [MMB]) with FTF-CBT in a randomized controlled trial (RCT). Methods: In this study, 116 postnatal women with a Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) diagnosis of major or minor depression were randomized to MMB (39/116, 33.6%), FTF-CBT (39/116, 33.6%), or a treatment-as-usual (TAU) control condition (38/116, 32.8%). Diagnostic status was determined at baseline and at 21-week follow-up using the Structured Clinical Interview for the DSM-IV. Severity of anxiety and depressive symptoms was evaluated using the Depression Anxiety Stress Scales and the revised Beck Depression Inventory at baseline, 12-week follow-up (after treatment), and 21-week follow-up. Results: Of the 116 participants, 107 (92.2%) had a diagnosis of major depression at baseline. Rates of remission from a major or minor depressive episode at 21 weeks in both the FTF-CBT and MMB groups were superior to that of the TAU group (56.6% and 47.7% less likely to be depressed, respectively) and they were not significantly different from each other. Although remission rates differed between TAU and FTF-CBT, growth models showed that, in terms of symptom reduction across time, the FTF-CBT treatment was not significantly better than TAU. By comparison, MMB was statistically superior to both TAU and FTF-CBT in reducing symptoms of depression, anxiety, and stress from baseline to the 21-week follow-up (large and moderate effect sizes). Thus, after 21 weeks, the average symptom scores for depression and anxiety of women receiving MMB were approximately half those of women in both the TAU and FTF-CBT groups. Conclusions: In this RCT, MMB was at least as effective as FTF-CBT in achieving remission from a diagnosed PND episode. MMB was superior to TAU and FTF-CBT in encouraging and maintaining reduction of symptom severity over the 21-week follow-up for depressed postnatal women. These findings replicate results of prior studies on MMB that showed clinically significant improvements in depressive symptoms, and they provide direct empirical support that internet-delivered treatment for depressed postnatal women is a viable alternative to FTF treatment. The generalizability of the results needs to be examined in future research, as RCTs of internet-based versus FTF treatments necessarily involve a subset of people who are willing to undertake either modality of treatment. Trial Registration: Australia and New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000881730; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364683&isReview=true %M 34889742 %R 10.2196/17185 %U https://www.jmir.org/2021/12/e17185 %U https://doi.org/10.2196/17185 %U http://www.ncbi.nlm.nih.gov/pubmed/34889742 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 12 %P e26733 %T Effects of Social Networking Service (SNS) Addiction on Mental Health Status in Chinese University Students: Structural Equation Modeling Approach Using a Cross-sectional Online Survey %A Wang,Tingxuan %A Wong,Janet Y H %A Wang,Man Ping %A Li,Amanda Chiu Yin %A Kim,Sang Suk %A Lee,Jung Jae %+ School of Nursing, The University of Hong Kong, 4/F William MW Mong Block Building, 21 Sassoon Rd, Pokfulam, Hong Kong, China, 852 39176971, leejay@hku.hk %K social networking service %K SNS %K addiction %K depression %K anxiety %K psychosocial status %K youth %K mental health %D 2021 %7 8.12.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Although social networking services (SNSs) have become popular among young people, problematic SNS use has also increased. However, little is known about SNS addiction and its association with SNS use patterns and mental health status. Objective: This study aims to test the mediating role of SNS addiction between SNS use patterns and mental health status among Chinese university students in Hong Kong (HK). Methods: An online cross-sectional survey was conducted using a convenience sampling method. In total, 533 university students (323 [66.9%] female, mean age [SD]=20.87 [2.68] years) were recruited from February to March 2019. Multiple linear regression was used to assess the association between SNS use and SNS addiction. Structural equation modeling (SEM) was performed to examine the pathways and associations among SNS use, SNS addiction, psychosocial status, and mental health status (including anxiety and depressive symptoms). Results: A longer time spent on SNSs per day (>3 h), a longer time spent on each SNS access (≥31 min), a higher frequency of SNS access (≤every 30 min), a longer duration of SNS use before sleeping (≥61 min), and a shorter duration from waking to first SNS use (≤5 min) were significantly associated with a higher level of SNS addiction (adjusted beta [aβ]=6.03, 95% CI 4.66-7.40; aβ=4.99, 95% CI 3.14-6.83; aβ=5.89, 95% CI 4.14-7.64; aβ=5.92, 95% CI 4.19-7.65; and aβ=3.27, 95% CI 1.73-4.82, respectively). SEM showed a significant mediating effect of SNS addiction in the relationship between SNS use and psychosocial status, and mental health status, including an indirect effect (β=0.63, 95% CI 0.37-0.93) and the total effect (β=0.44, 95% CI 0.19-0.72), while the direct effect was insignificant (β=–0.19, 95% CI –0.49 to 0.08). Conclusions: SNS use patterns were associated with SNS addiction, and SNS addiction mediated the associations between SNS use, psychosocial status, and mental health status of Chinese university students in HK. The findings suggest that screening for and addressing excessive SNS use are needed to prevent SNS addiction and mental distress among young people. %M 34889760 %R 10.2196/26733 %U https://www.jmir.org/2021/12/e26733 %U https://doi.org/10.2196/26733 %U http://www.ncbi.nlm.nih.gov/pubmed/34889760 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 12 %P e29661 %T Effectiveness and Feasibility of Internet-Based Interventions for Grief After Bereavement: Systematic Review and Meta-analysis %A Zuelke,Andrea E %A Luppa,Melanie %A Löbner,Margrit %A Pabst,Alexander %A Schlapke,Christine %A Stein,Janine %A Riedel-Heller,Steffi G %+ Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Str. 55, Leipzig, 04103, Germany, 49 3419715483, andrea.zuelke@medizin.uni-leipzig.de %K grief %K systematic review %K meta-analysis %K internet-based %K online therapy %D 2021 %7 8.12.2021 %9 Review %J JMIR Ment Health %G English %X Background: Although grief and its symptoms constitute a normal reaction to experiences of loss, some of those affected still report elevated levels of distress after an extended period, often termed complicated grief. Beneficial treatment effects of face-to-face therapies, for example, grief counseling or cognitive behavioral therapy against complicated grief, have been reported. Evaluations of internet- and mobile-based interventions targeting symptoms of grief in bereaved individuals with regard to objective quality criteria are currently lacking. Objective: We aim to conduct a systematic review and meta-analysis on the effectiveness and feasibility of internet- and mobile-based interventions against symptoms of grief after bereavement. Methods: We conducted systematic literature searches of randomized controlled trials or feasibility studies published before January 9, 2020, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, in PubMed, PsycINFO, Web of Science Core Collection, and the Cochrane Library. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations system. We further assessed aspects of feasibility and rated quality of interventions using criteria suggested by an expert panel on mental health care (German Association for Psychiatry, Psychotherapy, and Psychosomatics). A random-effects meta-analysis was conducted to assess between-group effect sizes. Results: In total, 9 trials (N=1349) were included. Of these, 7 studies were analyzed meta-analytically. Significant effects were found for symptoms of grief (g=0.54, 95% CI 0.32-0.77), depression (g=0.44, 95% CI 0.20-0.68), and posttraumatic stress (g=0.82, 95% CI 0.63-1.01). Heterogeneity was moderate for grief and depression (I2=48.75% and 55.19%, respectively) and low for posttraumatic stress symptoms (I2=0%). The overall quality of evidence was graded low (grief and depression) to moderate (posttraumatic stress). User satisfaction with the interventions was high, as was the quality of the interventions assessed using objective quality criteria. Conclusions: Internet- or mobile-based interventions might constitute an effective treatment approach against symptoms of grief in bereaved adults. However, the small sample sizes and limited number of studies included in the review warrant further investigation. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42012002100; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131428 %M 34889769 %R 10.2196/29661 %U https://mental.jmir.org/2021/12/e29661 %U https://doi.org/10.2196/29661 %U http://www.ncbi.nlm.nih.gov/pubmed/34889769 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 12 %P e32007 %T Examining the Theoretical Framework of Behavioral Activation for Major Depressive Disorder: Smartphone-Based Ecological Momentary Assessment Study %A van Genugten,Claire Rosalie %A Schuurmans,Josien %A Hoogendoorn,Adriaan W %A Araya,Ricardo %A Andersson,Gerhard %A Baños,Rosa %A Botella,Cristina %A Cerga Pashoja,Arlinda %A Cieslak,Roman %A Ebert,David Daniel %A García-Palacios,Azucena %A Hazo,Jean-Baptiste %A Herrero,Rocío %A Holtzmann,Jérôme %A Kemmeren,Lise %A Kleiboer,Annet %A Krieger,Tobias %A Smoktunowicz,Ewelina %A Titzler,Ingrid %A Topooco,Naira %A Urech,Antoine %A Smit,Johannes H %A Riper,Heleen %+ Department of Research and Innovation, GGZ inGeest, Specialized Mental Health Care, Oldenaller 1, Amsterdam, 1081HJ, Netherlands, 31 0207884666, c.genugten@ggzingeest.nl %K depression %K behavioral activation %K theoretical framework %K ecological momentary assessment %K random-intercept cross-lagged panel model %K behavior %K framework %K EMA %K smartphone %K mental health %K treatment %K engagement %K mood %D 2021 %7 6.12.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Behavioral activation (BA), either as a stand-alone treatment or as part of cognitive behavioral therapy, has been shown to be effective for treating depression. The theoretical underpinnings of BA derive from Lewinsohn et al’s theory of depression. The central premise of BA is that having patients engage in more pleasant activities leads to them experiencing more pleasure and elevates their mood, which, in turn, leads to further (behavioral) activation. However, there is a dearth of empirical evidence about the theoretical framework of BA. Objective: This study aims to examine the assumed (temporal) associations of the 3 constructs in the theoretical framework of BA. Methods: Data were collected as part of the “European Comparative Effectiveness Research on Internet-based Depression Treatment versus treatment-as-usual” trial among patients who were randomly assigned to receive blended cognitive behavioral therapy (bCBT). As part of bCBT, patients completed weekly assessments of their level of engagement in pleasant activities, the pleasure they experienced as a result of these activities, and their mood over the course of the treatment using a smartphone-based ecological momentary assessment (EMA) application. Longitudinal cross-lagged and cross-sectional associations of 240 patients were examined using random intercept cross-lagged panel models. Results: The analyses did not reveal any statistically significant cross-lagged coefficients (all P>.05). Statistically significant cross-sectional positive associations between activities, pleasure, and mood levels were identified. Moreover, the levels of engagement in activities, pleasure, and mood slightly increased over the duration of the treatment. In addition, mood seemed to carry over, over time, while both levels of engagement in activities and pleasurable experiences did not. Conclusions: The results were partially in accordance with the theoretical framework of BA, insofar as the analyses revealed cross-sectional relationships between levels of engagement in activities, pleasurable experiences deriving from these activities, and enhanced mood. However, given that no statistically significant temporal relationships were revealed, no conclusions could be drawn about potential causality. A shorter measurement interval (eg, daily rather than weekly EMA reports) might be more attuned to detecting potential underlying temporal pathways. Future research should use an EMA methodology to further investigate temporal associations, based on theory and how treatments are presented to patients. Trial Registration: ClinicalTrials.gov, NCT02542891, https://clinicaltrials.gov/ct2/show/NCT02542891; German Clinical Trials Register, DRKS00006866, https://tinyurl.com/ybja3xz7; Netherlands Trials Register, NTR4962, https://www.trialregister.nl/trial/4838; ClinicalTrials.Gov, NCT02389660, https://clinicaltrials.gov/ct2/show/NCT02389660; ClinicalTrials.gov, NCT02361684, https://clinicaltrials.gov/ct2/show/NCT02361684; ClinicalTrials.gov, NCT02449447, https://clinicaltrials.gov/ct2/show/NCT02449447; ClinicalTrials.gov, NCT02410616, https://clinicaltrials.gov/ct2/show/NCT02410616; ISRCTN registry, ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725 %M 34874888 %R 10.2196/32007 %U https://mental.jmir.org/2021/12/e32007 %U https://doi.org/10.2196/32007 %U http://www.ncbi.nlm.nih.gov/pubmed/34874888 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 12 %P e30439 %T Language, Speech, and Facial Expression Features for Artificial Intelligence–Based Detection of Cancer Survivors’ Depression: Scoping Meta-Review %A Smrke,Urška %A Mlakar,Izidor %A Lin,Simon %A Musil,Bojan %A Plohl,Nejc %+ Faculty of Electrical Engineering and Computer Science, University of Maribor, Koroška cesta 46, Maribor, 2000, Slovenia, 386 31262861, urska.smrke@um.si %K artificial intelligence %K cancer %K depression %K facial expression %K language %K oncology %K review %K screening %K speech %K symptom %D 2021 %7 6.12.2021 %9 Review %J JMIR Ment Health %G English %X Background: Cancer survivors often experience disorders from the depressive spectrum that remain largely unrecognized and overlooked. Even though screening for depression is recognized as essential, several barriers prevent its successful implementation. It is possible that better screening options can be developed. New possibilities have been opening up with advances in artificial intelligence and increasing knowledge on the connection of observable cues and psychological states. Objective: The aim of this scoping meta-review was to identify observable features of depression that can be intercepted using artificial intelligence in order to provide a stepping stone toward better recognition of depression among cancer survivors. Methods: We followed a methodological framework for scoping reviews. We searched SCOPUS and Web of Science for relevant papers on the topic, and data were extracted from the papers that met inclusion criteria. We used thematic analysis within 3 predefined categories of depression cues (ie, language, speech, and facial expression cues) to analyze the papers. Results: The search yielded 1023 papers, of which 9 met the inclusion criteria. Analysis of their findings resulted in several well-supported cues of depression in language, speech, and facial expression domains, which provides a comprehensive list of observable features that are potentially suited to be intercepted by artificial intelligence for early detection of depression. Conclusions: This review provides a synthesis of behavioral features of depression while translating this knowledge into the context of artificial intelligence–supported screening for depression in cancer survivors. %M 34874883 %R 10.2196/30439 %U https://mental.jmir.org/2021/12/e30439 %U https://doi.org/10.2196/30439 %U http://www.ncbi.nlm.nih.gov/pubmed/34874883 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 12 %P e34016 %T Predicting the Number of Suicides in Japan Using Internet Search Queries: Vector Autoregression Time Series Model %A Taira,Kazuya %A Hosokawa,Rikuya %A Itatani,Tomoya %A Fujita,Sumio %+ Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, 53, Shogoinkawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan, 81 75 751 3927, taira.kazuya.5m@kyoto-u.ac.jp %K suicide %K internet search engine %K infoveillance %K query %K time series analysis %K vector autoregression model %K COVID-19 %K suicide-related terms %K internet %K information seeking %K time series %K model %K loneliness %K mental health %K prediction %K Japan %K behavior %K trend %D 2021 %7 3.12.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The number of suicides in Japan increased during the COVID-19 pandemic. Predicting the number of suicides is important to take timely preventive measures. Objective: This study aims to clarify whether the number of suicides can be predicted by suicide-related search queries used before searching for the keyword “suicide.” Methods: This study uses the infoveillance approach for suicide in Japan by search trends in search engines. The monthly number of suicides by gender, collected and published by the National Police Agency, was used as an outcome variable. The number of searches by gender with queries associated with “suicide” on “Yahoo! JAPAN Search” from January 2016 to December 2020 was used as a predictive variable. The following five phrases highly relevant to suicide were used as search terms before searching for the keyword “suicide” and extracted and used for analyses: “abuse”; “work, don’t want to go”; “company, want to quit”; “divorce”; and “no money.” The augmented Dickey-Fuller and Johansen tests were performed for the original series and to verify the existence of unit roots and cointegration for each variable, respectively. The vector autoregression model was applied to predict the number of suicides. The Breusch-Godfrey Lagrangian multiplier (BG-LM) test, autoregressive conditional heteroskedasticity Lagrangian multiplier (ARCH-LM) test, and Jarque-Bera (JB) test were used to confirm model convergence. In addition, a Granger causality test was performed for each predictive variable. Results: In the original series, unit roots were found in the trend model, whereas in the first-order difference series, both men (minimum tau 3: −9.24; max tau 3: −5.38) and women (minimum tau 3: −9.24; max tau 3: −5.38) had no unit roots for all variables. In the Johansen test, a cointegration relationship was observed among several variables. The queries used in the converged models were “divorce” for men (BG-LM test: P=.55; ARCH-LM test: P=.63; JB test: P=.66) and “no money” for women (BG-LM test: P=.17; ARCH-LM test: P=.15; JB test: P=.10). In the Granger causality test for each variable, “divorce” was significant for both men (F104=3.29; P=.04) and women (F104=3.23; P=.04). Conclusions: The number of suicides can be predicted by search queries related to the keyword “suicide.” Previous studies have reported that financial poverty and divorce are associated with suicide. The results of this study, in which search queries on “no money” and “divorce” predicted suicide, support the findings of previous studies. Further research on the economic poverty of women and those with complex problems is necessary. %M 34823225 %R 10.2196/34016 %U https://publichealth.jmir.org/2021/12/e34016 %U https://doi.org/10.2196/34016 %U http://www.ncbi.nlm.nih.gov/pubmed/34823225 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 12 %P e30702 %T Depression, Anxiety, and Daily Activity Among Adolescents Before and During the COVID-19 Pandemic: Cross-sectional Survey Study %A Jolliff,Anna %A Zhao,Qianqian %A Eickhoff,Jens %A Moreno,Megan %+ Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin - Madison, 2870 University Avenue, Suite 200, Madison, WI, 53705, United States, 1 5035539361, ajolliff@wisc.edu %K COVID-19 %K pandemic %K adolescent %K depression %K anxiety %K socioeconomic status %K survey %K mental health %D 2021 %7 2.12.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The COVID-19 pandemic has resulted in significant changes to adolescents’ daily lives and, potentially, to their mental health. The pandemic has also disproportionately affected historically marginalized and at-risk communities, including people of color, socioeconomically disadvantaged people, people identifying as female, and youth. Objective: This study aimed to understand differences in depression and anxiety among 2 groups of adolescents in the United States before and during the COVID-19 pandemic, and to examine demographic and daily activity variables associated with depression and anxiety. Methods: Online surveys were distributed in 2019 and 2020. Demographic questions were asked at the time of enrollment, and included participants’ age, gender, race and ethnicity, and socioeconomic status (SES). The 8-item Patient Health Questionnaire was used to assess symptoms of depression, and the 7-item Generalized Anxiety Disorder scale was used to assess symptoms of anxiety. A total of 4 pandemic-specific daily activity questions were asked only of the pandemic group. Analyses of covariance compared depression and anxiety between prepandemic and pandemic groups. Demographic and lifestyle variables were included as covariates. Results: The sample comprised a total of 234 adolescents, with 100 participants in the prepandemic group and 134 participants in the pandemic group. Within the pandemic group, 94% (n=126) of adolescents reported being out of school due to the pandemic, and another 85.8% (n=115) and 57.1% (n=76) were prevented from extracurricular activities and exercise, respectively. Higher depression was seen in the pandemic group, with a least-squares adjusted mean of 7.62 (SD 1.36) compared to 6.28 (SD 1.42) in the prepandemic group, although the difference was not significant (P=.08). There was no significant difference in anxiety scores between the 2 groups (least-squares adjusted means 5.52, SD 1.30 vs 5.01, SD 1.36; P=.48). Within the pandemic group, lower SES was predictive of anxiety, such that those in the pandemic group of lower SES were more anxious than their higher-SES peers (least-squares adjusted means 11.17, SD 2.34 vs 8.66, SD 2.16; P=.02). Within the pandemic group, being out of work or school and not partaking in extracurricular activities or exercise due to the pandemic were not associated with higher depression or anxiety scores. Conclusions: In this study, neither being in the pandemic group nor experiencing changes in daily activity due to the pandemic was associated with higher depression or anxiety. However, we found that adolescents from lower SES backgrounds experienced significantly more anxiety during the pandemic than their more privileged peers. Both instrumental and mental health interventions for low-income adolescents are imperative. %M 34609316 %R 10.2196/30702 %U https://formative.jmir.org/2021/12/e30702 %U https://doi.org/10.2196/30702 %U http://www.ncbi.nlm.nih.gov/pubmed/34609316 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 12 %P e28734 %T Transitioning From In-Person to Remote Clinical Research on Depression and Traumatic Brain Injury During the COVID-19 Pandemic: Study Modifications and Preliminary Feasibility From a Randomized Controlled Pilot Study %A Fisher,Lauren B %A Tuchman,Sylvie %A Curreri,Andrew J %A Markgraf,Maggie %A Nyer,Maren B %A Cassano,Paolo %A Iverson,Grant L %A Fava,Maurizio %A Zafonte,Ross D %A Pedrelli,Paola %+ Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA, 02114, United States, 1 617 643 0877, fisher.lauren@mgh.harvard.edu %K COVID-19 %K telemental health %K clinical trial %K traumatic brain injury %K depression %K cognitive behavioral therapy %D 2021 %7 1.12.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Telehealth has provided many researchers, especially those conducting psychosocial research, with the tools necessary to transition from in-person to remote clinical trials during the COVID-19 pandemic. A growing body of research supports the effectiveness of telemental health for a variety of psychiatric conditions, but few studies have examined telemental health for individuals with comorbid medical diagnoses. Furthermore, little is known about the remote implementation of clinical trials examining telemental health interventions. Objective: This paper outlines the procedural modifications used to facilitate conversion of an in-person randomized controlled trial of cognitive behavioral therapy (CBT) for depression in individuals with traumatic brain injury (TBI; CBT-TBI) to a telemental health study administered remotely. Methods: Given the nature of remote implementation and specific challenges experienced by individuals with TBI, considerations related to treatment delivery, remote consent, data management, neuropsychological assessment, safety monitoring, and delivery of supportive material have been discussed. Feasibility, acceptability, and safety were evaluated by examining attendance and participant responses on self-report measures of treatment satisfaction and suicidal behavior. Results: High rates of treatment attendance, assessment completion, study retention, and satisfaction with the intervention and modality were reported by participants who completed at least one telemental health CBT-TBI session. Conclusions: Study modifications are necessary when conducting a study remotely, and special attention should be paid to comorbidities and population-specific challenges (eg, cognitive impairment). Preliminary data support the feasibility, acceptability, and safety of remotely conducting a randomized controlled trial of CBT-TBI. Trial Registration: ClinicalTrials.gov NCT03307070; https://clinicaltrials.gov/ct2/show/NCT03307070 %M 34662285 %R 10.2196/28734 %U https://formative.jmir.org/2021/12/e28734 %U https://doi.org/10.2196/28734 %U http://www.ncbi.nlm.nih.gov/pubmed/34662285 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e32199 %T Examining the Effectiveness of Gamification in Mental Health Apps for Depression: Systematic Review and Meta-analysis %A Six,Stephanie G %A Byrne,Kaileigh A %A Tibbett,Thomas P %A Pericot-Valverde,Irene %+ Department of Psychology, Clemson University, 418 Brackett Hall, Clemson, SC, 29634, United States, 1 864 656 3935, kaileib@clemson.edu %K depression %K reward %K gamification %K mental health apps %K apps %D 2021 %7 29.11.2021 %9 Review %J JMIR Ment Health %G English %X Background: Previous research showed that computerized cognitive behavioral therapy can effectively reduce depressive symptoms. Some mental health apps incorporate gamification into their app design, yet it is unclear whether features differ in their effectiveness to reduce depressive symptoms over and above mental health apps without gamification. Objective: The aim of this study was to determine whether mental health apps with gamification elements differ in their effectiveness to reduce depressive symptoms when compared to those that lack these elements. Methods: A meta-analysis of studies that examined the effect of app-based therapy, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness, on depressive symptoms was performed. A total of 5597 articles were identified via five databases. After screening, 38 studies (n=8110 participants) remained for data extraction. From these studies, 50 total comparisons between postintervention mental health app intervention groups and control groups were included in the meta-analysis. Results: A random effects model was performed to examine the effect of mental health apps on depressive symptoms compared to controls. The number of gamification elements within the apps was included as a moderator. Results indicated a small to moderate effect size across all mental health apps in which the mental health app intervention effectively reduced depressive symptoms compared to controls (Hedges g=–0.27, 95% CI –0.36 to –0.17; P<.001). The gamification moderator was not a significant predictor of depressive symptoms (β=–0.03, SE=0.03; P=.38), demonstrating no significant difference in effectiveness between mental health apps with and without gamification features. A separate meta-regression also did not show an effect of gamification elements on intervention adherence (β=–1.93, SE=2.28; P=.40). Conclusions: The results show that both mental health apps with and without gamification elements were effective in reducing depressive symptoms. There was no significant difference in the effectiveness of mental health apps with gamification elements on depressive symptoms or adherence. This research has important clinical implications for understanding how gamification elements influence the effectiveness of mental health apps on depressive symptoms. %M 34847058 %R 10.2196/32199 %U https://mental.jmir.org/2021/11/e32199 %U https://doi.org/10.2196/32199 %U http://www.ncbi.nlm.nih.gov/pubmed/34847058 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e29487 %T Studies of Depression and Anxiety Using Reddit as a Data Source: Scoping Review %A Boettcher,Nick %+ Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada, 1 (403) 220 4286, nkboettc@ucalgary.ca %K depression %K anxiety %K mental health %K Reddit %K social media %K review %D 2021 %7 25.11.2021 %9 Review %J JMIR Ment Health %G English %X Background: The study of depression and anxiety using publicly available social media data is a research activity that has grown considerably over the past decade. The discussion platform Reddit has become a popular social media data source in this nascent area of study, in part because of the unique ways in which the platform is facilitative of research. To date, no work has been done to synthesize existing studies on depression and anxiety using Reddit. Objective: The objective of this review is to understand the scope and nature of research using Reddit as a primary data source for studying depression and anxiety. Methods: A scoping review was conducted using the Arksey and O’Malley framework. MEDLINE, Embase, CINAHL, PsycINFO, PsycARTICLES, Scopus, ScienceDirect, IEEE Xplore, and ACM academic databases were searched. Inclusion criteria were developed using the participants, concept, and context framework outlined by the Joanna Briggs Institute Scoping Review Methodology Group. Eligible studies featured an analytic focus on depression or anxiety and used naturalistic written expressions from Reddit users as a primary data source. Results: A total of 54 studies were included in the review. Tables and corresponding analyses delineate the key methodological features, including a comparatively larger focus on depression versus anxiety, an even split of original and premade data sets, a widespread analytic focus on classifying the mental health states of Reddit users, and practical implications that often recommend new methods of professionally delivered monitoring and outreach for Reddit users. Conclusions: Studies of depression and anxiety using Reddit data are currently driven by a prevailing methodology that favors a technical, solution-based orientation. Researchers interested in advancing this research area will benefit from further consideration of conceptual issues surrounding the interpretation of Reddit data with the medical model of mental health. Further efforts are also needed to locate accountability and autonomy within practice implications, suggesting new forms of engagement with Reddit users. %M 34842560 %R 10.2196/29487 %U https://mental.jmir.org/2021/11/e29487 %U https://doi.org/10.2196/29487 %U http://www.ncbi.nlm.nih.gov/pubmed/34842560 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e29666 %T Effects of Internet-Based Cognitive Behavioral Therapy for Harmful Alcohol Use and Alcohol Dependence as Self-help or With Therapist Guidance: Three-Armed Randomized Trial %A Johansson,Magnus %A Berman,Anne H %A Sinadinovic,Kristina %A Lindner,Philip %A Hermansson,Ulric %A Andréasson,Sven %+ Department of Global Public Health, Karolinska Institutet, Solnavägen 1E, Stockholm, 11365, Sweden, 46 727249971, magnus.johansson.1@ki.se %K alcohol dependence %K alcohol use disorders %K internet-based interventions %K internet-based cognitive behavioral therapy %K ICBT %K cognitive behavioral therapy %K CBT %K eHealth %K alcohol use %K substance abuse %K outcomes %K help-seeking behavior %K internet-based interventions %K alcohol dependence %K mobile phone %D 2021 %7 24.11.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Alcohol use is a major contributor to health loss. Many persons with harmful use or alcohol dependence do not obtain treatment because of limited availability or stigma. They may use internet-based interventions as an alternative way of obtaining support. Internet-based interventions have previously been shown to be effective in reducing alcohol consumption in studies that included hazardous use; however, few studies have been conducted with a specific focus on harmful use or alcohol dependence. The importance of therapist guidance in internet-based cognitive behavioral therapy (ICBT) programs is still unclear. Objective: This trial aims to investigate the effects of a web-based alcohol program with or without therapist guidance among anonymous adult help-seekers. Methods: A three-armed randomized controlled trial was conducted to compare therapist-guided ICBT and self-help ICBT with an information-only control condition. Swedish-speaking adult internet users with alcohol dependence (3 or more International Classification of Diseases, Tenth Revision criteria) or harmful alcohol use (alcohol use disorder identification test>15) were included in the study. Participants in the therapist-guided ICBT and self-help ICBT groups had 12-week access to a program consisting of 5 main modules, as well as a drinking calendar with automatic feedback. Guidance was given by experienced therapists trained in motivational interviewing. The primary outcome measure was weekly alcohol consumption in standard drinks (12 g of ethanol). Secondary outcomes were alcohol-related problems measured using the total alcohol use disorder identification test-score, diagnostic criteria for alcohol dependence and alcohol use disorder, depression, anxiety, health, readiness to change, and access to other treatments or support. Follow-up was conducted 3 (posttreatment) and 6 months after recruitment. Results: During the recruitment period, from March 2015 to March 2017, 1169 participants were included. Participants had a mean age of 45 (SD 13) years, and 56.72% (663/1169) were women. At the 3-month follow-up, the therapist-guided ICBT and control groups differed significantly in weekly alcohol consumption (−3.84, 95% Cl −6.53 to −1.16; t417=2.81; P=.005; Cohen d=0.27). No significant differences were found in weekly alcohol consumption between the self-help ICBT group and the therapist-guided ICBT at 3 months, between the self-help ICBT and the control group at 3 months, or between any of the groups at the 6-month follow-up. A limitation of the study was the large number of participants who were completely lost to follow-up (477/1169, 40.8%). Conclusions: In this study, a therapist-guided ICBT program was not found to be more effective than the same program in a self-help ICBT version for reducing alcohol consumption or other alcohol-related outcomes. In the short run, therapist-guided ICBT was more effective than information. Only some internet help-seekers may need a multisession program and therapist guidance to change their drinking when they use internet-based interventions. Trial Registration: ClinicalTrials.gov NCT02377726; https://clinicaltrials.gov/ct2/show/NCT02377726 %M 34821563 %R 10.2196/29666 %U https://www.jmir.org/2021/11/e29666 %U https://doi.org/10.2196/29666 %U http://www.ncbi.nlm.nih.gov/pubmed/34821563 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e29838 %T Machine Learning Methods for Predicting Postpartum Depression: Scoping Review %A Saqib,Kiran %A Khan,Amber Fozia %A Butt,Zahid Ahmad %+ School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada, 1 5198884567 ext 45107, zahid.butt@uwaterloo.ca %K machine learning %K postpartum depression %K big data %K mobile phone %D 2021 %7 24.11.2021 %9 Review %J JMIR Ment Health %G English %X Background: Machine learning (ML) offers vigorous statistical and probabilistic techniques that can successfully predict certain clinical conditions using large volumes of data. A review of ML and big data research analytics in maternal depression is pertinent and timely, given the rapid technological developments in recent years. Objective: This study aims to synthesize the literature on ML and big data analytics for maternal mental health, particularly the prediction of postpartum depression (PPD). Methods: We used a scoping review methodology using the Arksey and O’Malley framework to rapidly map research activity in ML for predicting PPD. Two independent researchers searched PsycINFO, PubMed, IEEE Xplore, and the ACM Digital Library in September 2020 to identify relevant publications in the past 12 years. Data were extracted from the articles’ ML model, data type, and study results. Results: A total of 14 studies were identified. All studies reported the use of supervised learning techniques to predict PPD. Support vector machine and random forest were the most commonly used algorithms in addition to Naive Bayes, regression, artificial neural network, decision trees, and XGBoost (Extreme Gradient Boosting). There was considerable heterogeneity in the best-performing ML algorithm across the selected studies. The area under the receiver operating characteristic curve values reported for different algorithms were support vector machine (range 0.78-0.86), random forest method (0.88), XGBoost (0.80), and logistic regression (0.93). Conclusions: ML algorithms can analyze larger data sets and perform more advanced computations, which can significantly improve the detection of PPD at an early stage. Further clinical research collaborations are required to fine-tune ML algorithms for prediction and treatment. ML might become part of evidence-based practice in addition to clinical knowledge and existing research evidence. %M 34822337 %R 10.2196/29838 %U https://mental.jmir.org/2021/11/e29838 %U https://doi.org/10.2196/29838 %U http://www.ncbi.nlm.nih.gov/pubmed/34822337 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 11 %P e32327 %T A Quality-of-Life Evaluation Study Assessing Health-Related Quality of Life in Patients Receiving Medicinal Cannabis (the QUEST Initiative): Protocol for a Longitudinal Observational Study %A Tait,Margaret-Ann %A Costa,Daniel S J %A Campbell,Rachel %A Norman,Richard %A Schug,Stephan %A Rutherford,Claudia %+ School of Psychology, Faculty of Science, The University of Sydney, Level 6, Chris O’Brien Lifehouse (C39Z), University of Sydney, Sydney, 2006, Australia, 61 2 8627 1558, margaret-ann.tait@sydney.edu.au %K medicinal cannabis %K patient-reported outcomes %K quality of life %K chronic pain %K pain management %K mental health %K depression %K anxiety %K cannabis oil %D 2021 %7 24.11.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Evidence supports several countries introducing legislation to allow cannabis-based medicine as an adjunctive treatment for the symptomatic relief of chronic pain, chemotherapy-induced nausea, spasticity in multiple sclerosis (MS), epileptic seizures, depression, and anxiety. However, clinical trial participants do not represent the entire spectrum of disease and health status seen in patients currently accessing medicinal cannabis in practice. Objective: This study aims to collect real-world data to evaluate health-related quality of life in patients prescribed medicinal cannabis oil and describe any differences over time, from before starting therapy to after 3 and 12 months of therapy. Methods: Adult patients newly prescribed medicinal cannabis oil by authorized prescribers and under the Special Access Schemes across Australia will be screened for eligibility and invited to participate. A sample size of 2142 is required, with a 3-month follow-up. All participants will complete the EuroQol 5-Dimension; European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-30; Depression, Anxiety, and Stress Scale-21; Patients’ Global Impression of Change; Patient-Reported Outcomes Measurement Information System (PROMIS) Short Form (SF) version 1.0: Sleep Disturbance 8b; and PROMIS SF Fatigue 13a questionnaires. Patients with chronic pain conditions will also complete the PROMIS SF version 1.0: Pain Intensity 3a and PROMIS SF version 1.0: Pain Interference 8a. Patients with movement disorders will also complete Quality of Life in Neurological Disorders (Neuro-QoL) SF version 1.0: Upper Extremity Function (Fine Motor and Activities of Daily Living) and if chorea is indicated, the Neuro-QoL SF version 2.0: Huntington’s Disease health-related Quality of LIFE-Chorea 6a. All questionnaires will be administered at baseline, 2 weeks (titration), monthly up to 3 months, and then every 2 months up to 1 year. Results: Recruitment commenced in November 2020. By June 2021, 1095 patients were screened for the study by 69 physicians in centers across 6 Australian states: Australian Capital Territory, New South Wales, Queensland, South Australia, Victoria, and Western Australia. Of the patients screened, 833 (39% of the target sample size) provided consent and completed baseline questionnaires. Results are expected to be published in 2022. Results of this study will show whether patient-reported outcomes improve in patients accessing prescribed medicinal cannabis from baseline to 3 months and whether any changes are maintained over a 12-month period. This study will also identify differences in improvements in patient-reported outcomes among patients with different chronic conditions (eg, chronic pain, MS, epilepsy, Parkinson disease, or cancer). Conclusions: This protocol contains detailed methods that will be used across multiple sites in Australia. The findings from this study have the potential to be integral to treatment assessment and recommendations for patients with chronic pain and other health indicators for accessing medicinal cannabis. Trial Registration: Australian New Zealand Clinical Trials Registry: ANZCTRN12621000063819; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380807&isReview=true International Registered Report Identifier (IRRID): DERR1-10.2196/32327 %M 34821570 %R 10.2196/32327 %U https://www.researchprotocols.org/2021/11/e32327 %U https://doi.org/10.2196/32327 %U http://www.ncbi.nlm.nih.gov/pubmed/34821570 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 4 %N 4 %P e27630 %T Internet-Based Psychotherapy Intervention for Depression Among Older Adults Receiving Home Care: Qualitative Study of Participants’ Experiences %A Xiang,Xiaoling %A Kayser,Jay %A Sun,Yihang %A Himle,Joseph %+ School of Social Work, University of Michigan, 1080 S University Ave, Ann Arbor, MI, 48109, United States, 1 7347636581, xiangxi@umich.edu %K internet-based cognitive behavioral therapy %K homebound older adults %K home care %K direct care workers %K depression %K qualitative study %D 2021 %7 22.11.2021 %9 Original Paper %J JMIR Aging %G English %X Background: Depression is common among homebound older adults. Internet-based cognitive behavioral therapy (iCBT) is a promising but understudied approach for treating depression among older adults with disabilities. Objective: This study aims to understand the experiences of homebound older adults who participated in a pilot feasibility trial of an iCBT for depression. Methods: The participants included 21 homebound older adults who participated in a generic iCBT program that was not specifically designed for older adults and 8 home care workers who assisted in the iCBT program. Informants completed semistructured individual interviews, which were transcribed verbatim and analyzed using methods informed by grounded theory. A hierarchical code structure of themes and subthemes was developed after an iterative process of constant comparisons and questionings of the initial codes. The data analysis was conducted by using dedoose, a web app for mixed methods research. Results: Three themes and various subthemes emerged related to participants’ experience of the iCBT intervention, as follows: intervention impact, which involved subthemes related to participants’ perceived impact of the intervention; challenges and difficulties, which involved subthemes on the challenges and difficulties that participants experienced in the intervention; and facilitators, which involved subthemes on the factors that facilitated intervention use and engagement. Conclusions: iCBT is a promising intervention for homebound older adults experiencing depression. Home care workers reported improved relationships with their clients and that the program did not add a burden to their duties. Future programs should involve accessible technical features and age-adapted content to improve user experience, uptake, and adherence. Trial Registration: ClinicalTrials.gov NCT04267289; https://clinicaltrials.gov/ct2/show/NCT04267289 %M 34813491 %R 10.2196/27630 %U https://aging.jmir.org/2021/4/e27630 %U https://doi.org/10.2196/27630 %U http://www.ncbi.nlm.nih.gov/pubmed/34813491 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 11 %P e29970 %T Demographics Associated With Stress, Severe Mental Distress, and Anxiety Symptoms During the COVID-19 Pandemic in Japan: Nationwide Cross-sectional Web-Based Survey %A Midorikawa,Haruhiko %A Tachikawa,Hirokazu %A Taguchi,Takaya %A Shiratori,Yuki %A Takahashi,Asumi %A Takahashi,Sho %A Nemoto,Kiyotaka %A Arai,Tetsuaki %+ Department of Disaster and Community Psychiatry, University of Tsukuba, Igakukei Gakukeitou 873, 1-1-1 Tennoudai, Tsukuba, 305-8577, Japan, 81 29 853 3057, tachikawa@md.tsukuba.ac.jp %K COVID-19 %K mental health %K stress %K depression %K anxiety %K occupation %K public health %K demographic factors %K epidemiology %K occupational health %D 2021 %7 22.11.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: With the spread of COVID-19, the deterioration of public mental health has become a major global and social problem. Objective: The purpose of this study was to elucidate the relationship between the 3 mental health problems associated with COVID-19, that is, perceived stress, severe mental distress, and anxiety symptoms, and the various demographic factors, including occupation. Methods: A nationwide web-based questionnaire survey was conducted in Japan from August 4 to 31, 2020. In addition to sociodemographic data, the degrees of perceived stress, severe mental distress, and anxiety symptoms associated with COVID-19 were measured. After performing a descriptive statistical analysis, factors related to stress, severe mental distress, and anxiety symptoms were analyzed using logistic regression analysis. Results: A total of 8203 respondents submitted survey responses, among whom 34.9% (2861/8203) felt intense stress associated with COVID-19, 17.1% (1403/8203) were depressed, and 13.5% (1110/8203) had severe anxiety symptoms. The logistic regression analysis showed that each of the 3 mental health problems were prevalent in females, nonbinary gender, people in their 50s, 60s and older, respondents who visited psychiatrists, and those currently in psychiatric care. Severe mental distress and anxiety symptoms were associated with the number of effective lifestyle coping strategies during the lockdown period. Severe mental distress was only prevalent in teenagers and respondents in their 20s, as students tended to develop stress and severe mental distress. With regard to occupation, working in nursing care and welfare, education and research, and medical and health sectors was associated with stress; however, working in these occupations was not associated with severe mental distress and anxiety symptoms. Unemployment was associated with severe mental distress and anxiety symptoms. All 3 mental health problems were prevalent in part-time workers and those working in entertainment and arts sectors. Conclusions: Gender, age, occupation, history of psychiatric visits, and stress coping mechanisms were associated with mental health during the COVID-19 pandemic, but their associations with stress, severe mental distress, and anxiety symptoms differed. In addition, the actual state of mental health varied according to the respondents’ occupation. It is necessary to consider the impact of the COVID-19 pandemic on mental health not only at the individual level but also at the occupational level. %M 34653018 %R 10.2196/29970 %U https://publichealth.jmir.org/2021/11/e29970 %U https://doi.org/10.2196/29970 %U http://www.ncbi.nlm.nih.gov/pubmed/34653018 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e32306 %T A Smartphone-Based Self-Management Intervention for Individuals with Bipolar Disorder (LiveWell): Qualitative Study on User Experiences of the Behavior Change Process %A Jonathan,Geneva K %A Dopke,Cynthia A %A Michaels,Tania %A Martin,Clair R %A Ryan,Chloe %A McBride,Alyssa %A Babington,Pamela %A Goulding,Evan H %+ Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, 680 N Lake Shore Dr Suite 1520, Chicago, IL, 60660, United States, 1 312 503 1189, e-goulding@fsm.northwestern.edu %K behavioral intervention technology %K mHealth %K bipolar disorder %K depression %K illness management %K smartphone %K behavior change %K early warning signs %K self-management %K qualitative %K behavior %K intervention %K management %K user experience %K perception %K utilization %D 2021 %7 22.11.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Bipolar disorder is a severe mental illness characterized by recurrent episodes of depressed, elevated, and mixed mood states. The addition of psychotherapy to pharmacological management can decrease symptoms, lower relapse rates, and improve quality of life; however, access to psychotherapy is limited. Mental health technologies such as smartphone apps are being studied as a means to increase access to and enhance the effectiveness of adjunctive psychotherapies for bipolar disorder. Individuals with bipolar disorder find this intervention format acceptable, but our understanding of how people utilize and integrate these tools into their behavior change and maintenance processes remains limited. Objective: The objective of this study was to explore how individuals with bipolar disorder perceive and utilize a smartphone intervention for health behavior change and maintenance. Methods: Individuals with bipolar disorder were recruited via flyers placed at university-affiliated and private outpatient mental health practices to participate in a pilot study of LiveWell, a smartphone-based self-management intervention. At the end of the study, all participants completed in-depth qualitative exit interviews. The behavior change framework developed to organize the intervention design was used to deductively code behavioral targets and determinants involved in target engagement. Inductive coding was used to identify themes not captured by this framework. Results: In terms of behavioral targets, participants emphasized the importance of managing mood episode–related signs and symptoms. They also discussed the importance of maintaining regular routines, sleep duration, and medication adherence. Participants emphasized that receiving support from a coach as well as seeking and receiving assistance from family, friends, and providers were important for managing behavioral targets and staying well. In terms of determinants, participants stressed the important role of monitoring for their behavior change and maintenance efforts. Monitoring facilitated self-awareness and reflection, which was considered valuable for staying well. Some participants also felt that the intervention facilitated learning information necessary for managing bipolar disorder but others felt that the information provided was too basic. Conclusions: In addition to addressing acceptability, satisfaction, and engagement, a person-based design of mental health technologies can be used to understand how people experience the impact of these technologies on their behavior change and maintenance efforts. This understanding may then be used to guide ongoing intervention development. The participants’ perceptions aligned with the intervention’s primary behavioral targets and use of a monitoring tool as a core intervention feature. Participant feedback further indicates that developing additional content and tools to address building and engaging social support may be an important avenue for improving LiveWell. A comprehensive behavior change framework to understand participant perceptions of their behavior change and maintenance efforts may help facilitate ongoing intervention development. %M 34813488 %R 10.2196/32306 %U https://mental.jmir.org/2021/11/e32306 %U https://doi.org/10.2196/32306 %U http://www.ncbi.nlm.nih.gov/pubmed/34813488 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e29330 %T Effects of an Immersive Virtual Reality Exergame on University Students’ Anxiety, Depression, and Perceived Stress: Pilot Feasibility and Usability Study %A Xu,Wenge %A Liang,Hai-Ning %A Baghaei,Nilufar %A Ma,Xiaoyue %A Yu,Kangyou %A Meng,Xuanru %A Wen,Shaoyue %+ Department of Computing, School of Advanced Technology, Xi'an Jiaotong-Liverpool University, 111 Renai Road, Suzhou Industrial Park, Suzhou, 215123, China, 86 51288161516, haining.liang@xjtlu.edu.cn %K university students %K depression %K anxiety %K stress %K immersive virtual reality %K exergame %D 2021 %7 22.11.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: In recent years, there has been an increase in the number of students with depression, anxiety, and perceived stress. A solution that has been increasingly used for improving health and well-being is exergaming. The effects and acceptability of exergames have been studied widely but mostly with older adults. The feasibility and usability of exergames among university students, especially those of immersive virtual reality (iVR) exergames, remain unexplored. Objective: This study aimed to explore the feasibility of a 6-week iVR exergame–based intervention in reducing anxiety, depression, and perceived stress among university students and to examine the usability and acceptability of such games. Methods: A total of 31 university students were recruited to participate in a 6-week study in which they needed to play a boxing-style iVR exergame called FitXR (FitXR Limited) twice per week (30 minutes per session). Their anxiety (Beck Anxiety Inventory), depression (Beck Depression Inventory-II), and perceived stress (Perceived Stress Scale) levels were measured before and after intervention. Results: A total of 15 participants completed the 6-week study. Our results suggested that participants’ mean depression scores decreased significantly from 8.33 (SD 5.98) to 5.40 (SD 5.14) after the intervention (P=.01). In addition, most participants (14/15, 93%) believed that the iVR exergame has good usability. Furthermore, most participants (14/15, 93%) were satisfied with the iVR gameplay experience and would play the iVR exergame again in the future. Of the 15 participants, 11 (73%) would recommend the iVR exergame to their friends. Conclusions: The results gained from this study show that the iVR exergame has good usability, is highly acceptable, and has the potential to reduce depression levels among university students. %M 34813487 %R 10.2196/29330 %U https://games.jmir.org/2021/4/e29330 %U https://doi.org/10.2196/29330 %U http://www.ncbi.nlm.nih.gov/pubmed/34813487 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e30309 %T Momentary Manifestations of Negative Symptoms as Predictors of Clinical Outcomes in People at High Risk for Psychosis: Experience Sampling Study %A Paetzold,Isabell %A Hermans,Karlijn S F M %A Schick,Anita %A Nelson,Barnaby %A Velthorst,Eva %A Schirmbeck,Frederike %A , %A van Os,Jim %A Morgan,Craig %A van der Gaag,Mark %A de Haan,Lieuwe %A Valmaggia,Lucia %A McGuire,Philip %A Kempton,Matthew %A Myin-Germeys,Inez %A Reininghaus,Ulrich %+ Department of Public Mental Health, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, J 5 1, Mannheim, 68159, Germany, 49 62117031931, ulrich.reininghaus@zi-mannheim.de %K ecological momentary assessment %K psychotic disorder %K psychopathology %D 2021 %7 19.11.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Negative symptoms occur in individuals at ultrahigh risk (UHR) for psychosis. Although there is evidence that observer ratings of negative symptoms are associated with level of functioning, the predictive value of subjective experience in daily life for individuals at UHR has not been studied yet. Objective: This study therefore aims to investigate the predictive value of momentary manifestations of negative symptoms for clinical outcomes in individuals at UHR. Methods: Experience sampling methodology was used to measure momentary manifestations of negative symptoms (blunted affective experience, lack of social drive, anhedonia, and social anhedonia) in the daily lives of 79 individuals at UHR. Clinical outcomes (level of functioning, illness severity, UHR status, and transition status) were assessed at baseline and at 1- and 2-year follow-ups. Results: Lack of social drive, operationalized as greater experienced pleasantness of being alone, was associated with poorer functioning at the 2-year follow-up (b=−4.62, P=.01). Higher levels of anhedonia were associated with poorer functioning at the 1-year follow-up (b=5.61, P=.02). Higher levels of social anhedonia were associated with poorer functioning (eg, disability subscale: b=6.36, P=.006) and greater illness severity (b=−0.38, P=.045) at the 1-year follow-up. In exploratory analyses, there was evidence that individuals with greater variability of positive affect (used as a measure of blunted affective experience) experienced a shorter time to remission from UHR status at follow-up (hazard ratio=4.93, P=.005). Conclusions: Targeting negative symptoms in individuals at UHR may help to predict clinical outcomes and may be a promising target for interventions in the early stages of psychosis. %M 34807831 %R 10.2196/30309 %U https://mental.jmir.org/2021/11/e30309 %U https://doi.org/10.2196/30309 %U http://www.ncbi.nlm.nih.gov/pubmed/34807831 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e30995 %T Integrating SMS Text Messages Into a Preventive Intervention for Postpartum Depression Delivered via In-Home Visitation Programs: Feasibility and Acceptability Study %A Barrera,Alinne Z %A Hamil,Jaime %A Tandon,Darius %+ Department of Psychology, Palo Alto University, 1791 Arastradero Road, Palo Alto, CA, 94304, United States, 1 6504333854, abarrera@paloaltou.edu %K perinatal mental health %K postpartum depression %K public health %K SMS %K technology %D 2021 %7 18.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The Mothers and Babies (MB) Course is recognized by the US Preventive Services Task Force as an evidence-based preventive intervention for postpartum depression (PPD) that should be recommended to pregnant women at risk for PPD. Objective: This report examines the feasibility and acceptability of enhancing the MB 1-on-1 intervention by adding 36 SMS text messages that target 3 areas: reinforcement of skills, between-session homework reminders, and responding to self-monitoring texts (ie, MB Plus Text Messaging [MB-TXT]). Methods: In partnership with 9 home visiting programs, 28 ethnically and racially diverse pregnant women (mean 25.6, SD 9.0 weeks) received MB-TXT. Feasibility was defined by home visitors’ adherence to logging into the HealthySMS platform to enter session data and trigger SMS text messages within 7 days of the in-person session. The acceptability of MB-TXT was measured by participants’ usefulness and understanding ratings of the SMS text messages and responses to the self-monitoring SMS text messages. Results: On average, home visitors followed the study protocol and entered session-specific data between 5.50 and 61.17 days following the MB 1-on-1 sessions. A high proportion of participants responded to self-monitoring texts (25/28, 89%) and rated the text message content as very useful and understandable. Conclusions: This report contributes to a growing body of research focusing on digital adaptations of the MB course. SMS is a low-cost, accessible digital tool that can be integrated into existing interventions. With appropriate resources to support staff, it can be implemented in community-based organizations and health care systems that serve women at risk for PPD. Trial Registration: ClinicalTrials.gov NCT03420755; https://clinicaltrials.gov/ct2/show/NCT03420755 %M 34792478 %R 10.2196/30995 %U https://formative.jmir.org/2021/11/e30995 %U https://doi.org/10.2196/30995 %U http://www.ncbi.nlm.nih.gov/pubmed/34792478 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e32876 %T Machine Learning–Based Predictive Modeling of Anxiety and Depressive Symptoms During 8 Months of the COVID-19 Global Pandemic: Repeated Cross-sectional Survey Study %A Hueniken,Katrina %A Somé,Nibene Habib %A Abdelhack,Mohamed %A Taylor,Graham %A Elton Marshall,Tara %A Wickens,Christine M %A Hamilton,Hayley A %A Wells,Samantha %A Felsky,Daniel %+ Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, 250 College St, 12th Floor, Toronto, ON, M5T 1R8, Canada, 1 (416) 535 8501 ext 33587, Daniel.Felsky@camh.ca %K mental health %K machine learning %K COVID-19 %K emotional distress %K emotion %K distress %K prediction %K model %K anxiety %K depression %K symptom %K cross-sectional %K survey %D 2021 %7 17.11.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The COVID-19 global pandemic has increased the burden of mental illness on Canadian adults. However, the complex combination of demographic, economic, and lifestyle factors and perceived health risks contributing to patterns of anxiety and depression has not been explored. Objective: The aim of this study is to harness flexible machine learning methods to identify constellations of factors related to symptoms of mental illness and to understand their changes over time during the COVID-19 pandemic. Methods: Cross-sectional samples of Canadian adults (aged ≥18 years) completed web-based surveys in 6 waves from May to December 2020 (N=6021), and quota sampling strategies were used to match the English-speaking Canadian population in age, gender, and region. The surveys measured anxiety and depression symptoms, sociodemographic characteristics, substance use, and perceived COVID-19 risks and worries. First, principal component analysis was used to condense highly comorbid anxiety and depression symptoms into a single data-driven measure of emotional distress. Second, eXtreme Gradient Boosting (XGBoost), a machine learning algorithm that can model nonlinear and interactive relationships, was used to regress this measure on all included explanatory variables. Variable importance and effects across time were explored using SHapley Additive exPlanations (SHAP). Results: Principal component analysis of responses to 9 anxiety and depression questions on an ordinal scale revealed a primary latent factor, termed “emotional distress,” that explained 76% of the variation in all 9 measures. Our XGBoost model explained a substantial proportion of variance in emotional distress (r2=0.39). The 3 most important items predicting elevated emotional distress were increased worries about finances (SHAP=0.17), worries about getting COVID-19 (SHAP=0.17), and younger age (SHAP=0.13). Hopefulness was associated with emotional distress and moderated the impacts of several other factors. Predicted emotional distress exhibited a nonlinear pattern over time, with the highest predicted symptoms in May and November and the lowest in June. Conclusions: Our results highlight factors that may exacerbate emotional distress during the current pandemic and possible future pandemics, including a role of hopefulness in moderating distressing effects of other factors. The pandemic disproportionately affected emotional distress among younger adults and those economically impacted. %M 34705663 %R 10.2196/32876 %U https://mental.jmir.org/2021/11/e32876 %U https://doi.org/10.2196/32876 %U http://www.ncbi.nlm.nih.gov/pubmed/34705663 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e25455 %T Clinician Perspectives on Using Computational Mental Health Insights From Patients’ Social Media Activities: Design and Qualitative Evaluation of a Prototype %A Yoo,Dong Whi %A Ernala,Sindhu Kiranmai %A Saket,Bahador %A Weir,Domino %A Arenare,Elizabeth %A Ali,Asra F %A Van Meter,Anna R %A Birnbaum,Michael L %A Abowd,Gregory D %A De Choudhury,Munmun %+ School of Interactive Computing, Georgia Institute of Technology, 756 W Peachtree St NW, Atlanta, GA, 30308, United States, 1 4043858603, yoo@gatech.edu %K mental health %K social media %K information technology %D 2021 %7 16.11.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Previous studies have suggested that social media data, along with machine learning algorithms, can be used to generate computational mental health insights. These computational insights have the potential to support clinician-patient communication during psychotherapy consultations. However, how clinicians perceive and envision using computational insights during consultations has been underexplored. Objective: The aim of this study is to understand clinician perspectives regarding computational mental health insights from patients’ social media activities. We focus on the opportunities and challenges of using these insights during psychotherapy consultations. Methods: We developed a prototype that can analyze consented patients’ Facebook data and visually represent these computational insights. We incorporated the insights into existing clinician-facing assessment tools, the Hamilton Depression Rating Scale and Global Functioning: Social Scale. The design intent is that a clinician will verbally interview a patient (eg, How was your mood in the past week?) while they reviewed relevant insights from the patient’s social media activities (eg, number of depression-indicative posts). Using the prototype, we conducted interviews (n=15) and 3 focus groups (n=13) with mental health clinicians: psychiatrists, clinical psychologists, and licensed clinical social workers. The transcribed qualitative data were analyzed using thematic analysis. Results: Clinicians reported that the prototype can support clinician-patient collaboration in agenda-setting, communicating symptoms, and navigating patients’ verbal reports. They suggested potential use scenarios, such as reviewing the prototype before consultations and using the prototype when patients missed their consultations. They also speculated potential negative consequences: patients may feel like they are being monitored, which may yield negative effects, and the use of the prototype may increase the workload of clinicians, which is already difficult to manage. Finally, our participants expressed concerns regarding the prototype: they were unsure whether patients’ social media accounts represented their actual behaviors; they wanted to learn how and when the machine learning algorithm can fail to meet their expectations of trust; and they were worried about situations where they could not properly respond to the insights, especially emergency situations outside of clinical settings. Conclusions: Our findings support the touted potential of computational mental health insights from patients’ social media account data, especially in the context of psychotherapy consultations. However, sociotechnical issues, such as transparent algorithmic information and institutional support, should be addressed in future endeavors to design implementable and sustainable technology. %M 34783667 %R 10.2196/25455 %U https://mental.jmir.org/2021/11/e25455 %U https://doi.org/10.2196/25455 %U http://www.ncbi.nlm.nih.gov/pubmed/34783667 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e29201 %T A Smartphone Intervention for People With Serious Mental Illness: Fully Remote Randomized Controlled Trial of CORE %A Ben-Zeev,Dror %A Chander,Ayesha %A Tauscher,Justin %A Buck,Benjamin %A Nepal,Subigya %A Campbell,Andrew %A Doron,Guy %+ Behavioral Research in Technology and Engineering Center, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, United States, 1 206 685 9655, dbenzeev@uw.edu %K mobile health %K schizophrenia %K bipolar disorder %K depression %K mobile phone %D 2021 %7 12.11.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: People with serious mental illness (SMI) have significant unmet mental health needs. Development and testing of digital interventions that can alleviate the suffering of people with SMI is a public health priority. Objective: The aim of this study is to conduct a fully remote randomized waitlist-controlled trial of CORE, a smartphone intervention that comprises daily exercises designed to promote reassessment of dysfunctional beliefs in multiple domains. Methods: Individuals were recruited via the web using Google and Facebook advertisements. Enrolled participants were randomized into either active intervention or waitlist control groups. Participants completed the Beck Depression Inventory-Second Edition (BDI-II), Generalized Anxiety Disorder-7 (GAD-7), Hamilton Program for Schizophrenia Voices, Green Paranoid Thought Scale, Recovery Assessment Scale (RAS), Rosenberg Self-Esteem Scale (RSES), Friendship Scale, and Sheehan Disability Scale (SDS) at baseline (T1), 30-day (T2), and 60-day (T3) assessment points. Participants in the active group used CORE from T1 to T2, and participants in the waitlist group used CORE from T2 to T3. Both groups completed usability and accessibility measures after they concluded their intervention periods. Results: Overall, 315 individuals from 45 states participated in this study. The sample comprised individuals with self-reported bipolar disorder (111/315, 35.2%), major depressive disorder (136/315, 43.2%), and schizophrenia or schizoaffective disorder (68/315, 21.6%) who displayed moderate to severe symptoms and disability levels at baseline. Participants rated CORE as highly usable and acceptable. Intent-to-treat analyses showed significant treatment×time interactions for the BDI-II (F1,313=13.38; P<.001), GAD-7 (F1,313=5.87; P=.01), RAS (F1,313=23.42; P<.001), RSES (F1,313=19.28; P<.001), and SDS (F1,313=10.73; P=.001). Large effects were observed for the BDI-II (d=0.58), RAS (d=0.61), and RSES (d=0.64); a moderate effect size was observed for the SDS (d=0.44), and a small effect size was observed for the GAD-7 (d=0.20). Similar changes in outcome measures were later observed in the waitlist control group participants following crossover after they received CORE (T2 to T3). Approximately 41.5% (64/154) of participants in the active group and 60.2% (97/161) of participants in the waitlist group were retained at T2, and 33.1% (51/154) of participants in the active group and 40.3% (65/161) of participants in the waitlist group were retained at T3. Conclusions: We successfully recruited, screened, randomized, treated, and assessed a geographically dispersed sample of participants with SMI entirely via the web, demonstrating that fully remote clinical trials are feasible in this population; however, study retention remains challenging. CORE showed promise as a usable, acceptable, and effective tool for reducing the severity of psychiatric symptoms and disability while improving recovery and self-esteem. Rapid adoption and real-world dissemination of evidence-based mobile health interventions such as CORE are needed if we are to shorten the science-to-service gap and address the significant unmet mental health needs of people with SMI during the COVID-19 pandemic and beyond. Trial Registration: ClinicalTrials.gov NCT04068467; https://clinicaltrials.gov/ct2/show/NCT04068467 %M 34766913 %R 10.2196/29201 %U https://www.jmir.org/2021/11/e29201 %U https://doi.org/10.2196/29201 %U http://www.ncbi.nlm.nih.gov/pubmed/34766913 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e26221 %T Dropout From an Internet-Delivered Cognitive Behavioral Therapy Intervention for Adults With Depression and Anxiety: Qualitative Study %A Lawler,Kate %A Earley,Caroline %A Timulak,Ladislav %A Enrique,Angel %A Richards,Derek %+ E-Mental Health Research Group, School of Psychology, Trinity College Dublin, College Green, Dublin, Ireland, 353 851510008, lawlerka@tcd.ie %K depression %K anxiety %K iCBT %K dropout %K internet interventions %D 2021 %7 12.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Treatment dropout continues to be reported from internet-delivered cognitive behavioral therapy (iCBT) interventions, and lower completion rates are generally associated with lower treatment effect sizes. However, evidence is emerging to suggest that completion of a predefined number of modules is not always necessary for clinical benefit or consideration of the needs of each individual patient. Objective: The aim of this study is to perform a qualitative analysis of patients’ experiences with an iCBT intervention in a routine care setting to achieve a deeper insight into the phenomenon of dropout. Methods: A total of 15 purposively sampled participants (female: 8/15, 53%) from a larger parent randomized controlled trial were interviewed via telephone using a semistructured interview schedule that was developed based on the existing literature and research on dropout in iCBT. Data were analyzed using a descriptive-interpretive approach. Results: The experience of treatment leading to dropout can be understood in terms of 10 domains: relationship to technology, motivation to start, background knowledge and attitudes toward iCBT, perceived change in motivation, usage of the program, changes due to the intervention, engagement with content, experience interacting with the supporter, experience of web-based communication, and termination of the supported period. Conclusions: Patients who drop out of treatment can be distinguished in terms of their change in motivation: those who felt ready to leave treatment early and those who had negative reasons for dropping out. These 2 groups of participants have different treatment experiences, revealing the potential attributes and nonattributes of dropout. The reported between-group differences should be examined further to consider those attributes that are strongly descriptive of the experience and regarded less important than those that have become loosely affiliated. %M 34766909 %R 10.2196/26221 %U https://formative.jmir.org/2021/11/e26221 %U https://doi.org/10.2196/26221 %U http://www.ncbi.nlm.nih.gov/pubmed/34766909 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e29146 %T Googling for Suicide–Content and Quality Analysis of Suicide-Related Websites: Thematic Analysis %A Chen,Wen %A Boggero,Andrea %A Del Puente,Giovanni %A Olcese,Martina %A Prestia,Davide %A Jahrami,Haitham %A Chalghaf,Nasr %A Guelmami,Noomen %A Azaiez,Fairouz %A Bragazzi,Nicola Luigi %+ Laboratory for Industrial and Applied Mathematics, Department of Mathematics and Statistics, York University, 4700 Keele St, Toronto, ON, M3J 1P3, Canada, 1 416 736 2100, bragazzi@yorku.ca %K suicide %K internet %K world wide web %K content analysis %K HONcode %K mental health %K webpage %K health information %K eHealth %D 2021 %7 11.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Suicide represents a public health concern, imposing a dramatic burden. Prosuicide websites are “virtual pathways” facilitating a rise in suicidal behaviors, especially among socially isolated, susceptible individuals. Objective: The aim of this study is to characterize suicide-related webpages in the Italian language. Methods: The first 5 most commonly used search engines in Italy (ie, Bing, Virgilio, Yahoo, Google, and Libero) were mined using the term “suicidio” (Italian for suicide). For each search, the first 100 webpages were considered. Websites resulting from each search were collected and duplicates deleted so that unique webpages could be analyzed and rated with the HONcode instrument Results: A total of 65 webpages were included: 12.5% (8/64) were antisuicide and 6.3% (4/64) explicitly prosuicide. The majority of the included websites had a mixed or neutral attitude toward suicide (52/64, 81.2%) and had informative content and purpose (39/64, 60.9%). Most webpages targeted adolescents as an age group (38/64, 59.4%), contained a reference to other psychiatric disorders or comorbidities (42/64, 65.6%), included medical/professional supervision or guidance (45/64, 70.3%), lacked figures or pictures related to suicide (41/64, 64.1%), and did not contain any access restraint (62/64, 96.9%). The major shortcoming to this study is the small sample size of webpages analyzed and the search limited to the keyword “suicide.” Conclusions: Specialized mental health professionals should try to improve their presence online by providing high-quality material. %M 34689118 %R 10.2196/29146 %U https://formative.jmir.org/2021/11/e29146 %U https://doi.org/10.2196/29146 %U http://www.ncbi.nlm.nih.gov/pubmed/34689118 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e28874 %T Mobile Diary App Versus Paper-Based Diary Cards for Patients With Borderline Personality Disorder: Economic Evaluation %A Laursen,Sidsel Lund %A Helweg-Jørgensen,Stig %A Langergaard,Astrid %A Søndergaard,Jesper %A Sørensen,Sabrina Storgaard %A Mathiasen,Kim %A Lichtenstein,Mia Beck %A Ehlers,Lars Holger %+ Department of Clinical Medicine, Danish Center for Healthcare Improvements, Aalborg University, Fredrik Bajers Vej 5, Aalborg Oest, 9220, Denmark, 45 99408257, lehlers@dcm.aau.dk %K borderline personality disorder %K dialectical behavior therapy %K mobile app %K psychotherapy %K cost-consequence %K mHealth %K mobile phone %D 2021 %7 11.11.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The cost-effectiveness of using a mobile diary app as an adjunct in dialectical behavior therapy (DBT) in patients with borderline personality disorder is unknown. Objective: This study aims to perform an economic evaluation of a mobile diary app compared with paper-based diary cards in DBT treatment for patients with borderline personality disorder in a psychiatric outpatient facility. Methods: This study was conducted alongside a pragmatic, multicenter, randomized controlled trial. The participants were recruited at 5 Danish psychiatric outpatient facilities and were randomized to register the emotions, urges, and skills used in a mobile diary app or on paper-based diary cards. The participants in both groups received DBT delivered by the therapists. A cost-consequence analysis with a time horizon of 12 months was performed. Consequences included quality-adjusted life years (QALYs), depression severity, borderline severity, suicidal behavior, health care use, treatment compliance, and system usability. All relevant costs were included. Focus group interviews were conducted with patients, therapists, researchers, and industry representatives to discuss the potential advantages and disadvantages of using a mobile diary app. Results: A total of 78 participants were included in the analysis. An insignificantly higher number of participants in the paper group dropped out before the start of treatment (P=.07). Of those starting treatment, participants in the app group had an average of 37.1 (SE 27.55) more days of treatment and recorded an average of 3.16 (SE 5.10) more skills per week than participants in the paper group. Participants in both groups had a QALY gain and a decrease in depression severity, borderline severity, and suicidal behavior. Significant differences were found in favor of the paper group for both QALY gain (adjusted difference −0.054; SE 0.03) and reduction in depression severity (adjusted difference −1.11; SE 1.57). The between-group difference in total costs ranged from US $107.37 to US $322.10 per participant during the 12 months. The use of services in the health care sector was similar across both time points and groups (difference: psychiatric hospitalization <5 and <5; general practice −1.32; SE 3.68 and 2.02; SE 3.19). Overall, the patients showed high acceptability and considered the app as being easy to use. Therapists worried about potential negative influences on the therapist-patient interaction from new work tasks accompanying the introduction of the new technology but pointed at innovation potential from digital database registrations. Conclusions: This study suggests both positive and negative consequences of mobile diary apps as adjuncts to DBT compared with paper diary cards. More research is needed to draw conclusions regarding its cost-effectiveness. Trial Registration: ClinicalTrials.gov NCT03191565; http://clinicaltrials.gov/ct2/show/NCT03191565 International Registered Report Identifier (IRRID): RR2-10.2196/17737 %M 34762057 %R 10.2196/28874 %U https://www.jmir.org/2021/11/e28874 %U https://doi.org/10.2196/28874 %U http://www.ncbi.nlm.nih.gov/pubmed/34762057 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e31944 %T Seeking Mental Health Support Among College Students in Video-Based Social Media: Content and Statistical Analysis of YouTube Videos %A Choi,Bogeum %A Kim,Heejun %A Huh-Yoo,Jina %+ Department of Information Science, University of North Texas, 3940 North Elm, Suite E295G, Denton, TX, 76203, United States, 1 940 369 8285, heejun.kim@unt.edu %K mental health %K college student %K social media %K YouTube %K help-seeking %K experiential knowledge %K video types %K content analysis %K time distribution analysis %K depression %K anxiety %K student %K knowledge %K stigma %K strategy %K engagement %D 2021 %7 11.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Mental health is a highly stigmatized disease, especially for young people. Due to its free, accessible format, college students increasingly use video-based social media for many aspects of information needs, including how-to tips, career, or health-related needs. The accessibility of video-based social media brings potential in supporting stigmatized contexts, such as college students’ mental health. Understanding which kinds of videos about college students’ mental health have increased viewer engagement will help build a foundation for exploring this potential. Little research has been done to identify video types systematically, how they have changed over time, and their associations on viewer engagement both short term and long term. Objective: This study aims to identify strategies for using video-based social media to combat stigmatized diseases, such as mental health, among college students. We identify who, with what perspective, purpose, and content, makes up the videos available on social media (ie, YouTube) about college students’ mental health and how these factors associate with viewer engagement. We then identify effective strategies for designing video-based social media content for supporting college students’ mental health. Methods: We performed inductive content analysis to identify different types of YouTube videos concerning college students’ mental health (N=452) according to video attributes, including poster, perspective, and purpose. Time analysis showed how video types have changed over time. Fisher’s exact test was used to examine the relationships between video attributes. The Mann-Whitney U test was used to test the association between video types and viewer engagement. Lastly, we investigated the difference in viewer engagement across time between two major types of videos (ie, individuals’ storytelling and organization’s informational videos). Results: Time trend analysis showed a notable increase in the number of (1) videos by individuals, (2) videos that represent students’ perspectives, and (3) videos that share stories and experiential knowledge over the recent years. Fisher’s exact test found all video attributes (ie, poster, perspective, and purpose) are significantly correlated with each other. In addition, the Mann-Whitney U test found that poster (individual vs organization) and purpose (storytelling vs sharing information) type has a significant association with viewer engagement (P<.001). Lastly, individuals’ storytelling videos had a greater engagement in the short term and the long term. Conclusions: The study shows that YouTube videos on college students’ mental health can be well differentiated by the types of posters and the purpose of the videos. Taken together, the videos where individuals share their personal stories, as well as experiential knowledge (ie, tips and advice), engaged more viewers in both the short term and long term. Individuals’ videos on YouTube showed the potential to support college students' mental health in unique ways, such as providing social support, validating experience, and sharing the positive experience of help-seeking. %M 34762060 %R 10.2196/31944 %U https://formative.jmir.org/2021/11/e31944 %U https://doi.org/10.2196/31944 %U http://www.ncbi.nlm.nih.gov/pubmed/34762060 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e30313 %T Development of a Severity Score and Comparison With Validated Measures for Depression and Anxiety: Validation Study %A Lynch,William %A Platt,Michael L %A Pardes,Adam %+ NeuroFlow, Inc, 111 S Independence Mall E, Suite 701, Philadelphia, PA, United States, 1 267 671 7316, adam@neuroflow.com %K PHQ-9 %K GAD-7 %K depression assessment %K anxiety assessment %K measurement-based care %K integrated behavioral health %D 2021 %7 10.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Less than 10% of the individuals seeking behavioral health care receive measurement-based care (MBC). Technology has the potential to implement MBC in a secure and efficient manner. To test this idea, a mobile health (mHealth) platform was developed with the goal of making MBC easier to deliver by clinicians and more accessible to patients within integrated behavioral health care. Data from over 3000 users of the mHealth platform were used to develop an output severity score, a robust screening measure for depression and anxiety. Objective: The aim of this study is to compare severity scores with scores from validated assessments for depression and anxiety and scores from clinician review to evaluate the potential added value of this new measure. Methods: The severity score uses patient-reported and passively collected data related to behavioral health on an mHealth platform. An artificial intelligence–derived algorithm was developed that condenses behavioral health data into a single, quantifiable measure for longitudinal tracking of an individual’s depression and anxiety symptoms. Linear regression and Bland-Altman analyses were used to evaluate the relationships and differences between severity scores and Personal Health Questionnaire-9 (PHQ-9) or Generalized Anxiety Disorder-7 (GAD-7) scores from over 35,000 mHealth platform users. The severity score was also compared with a review by a panel of expert clinicians for a subset of 250 individuals. Results: Linear regression results showed a strong correlation between the severity score and PHQ-9 (r=0.74; P<.001) and GAD-7 (r=0.80; P<.001) changes. A strong positive correlation was also found between the severity score and expert panel clinical review (r=0.80-0.84; P<.001). However, Bland-Altman analysis and the evaluation of outliers on regression analysis showed that the severity score was significantly different from the PHQ-9. Conclusions: Clinicians can reliably use the mHealth severity score as a proxy measure for screening and monitoring behavioral health symptoms longitudinally. The severity score may identify at-risk individuals who are not identified by the PHQ-9. Further research is warranted to evaluate the sensitivity and specificity of the severity score. %M 34757319 %R 10.2196/30313 %U https://formative.jmir.org/2021/11/e30313 %U https://doi.org/10.2196/30313 %U http://www.ncbi.nlm.nih.gov/pubmed/34757319 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e27897 %T Mediating Effects of Stigma and Depressive Symptoms in a Social Media–Based Intervention to Improve Long-term Quality of Life Among People Living With HIV: Secondary Analysis of a Randomized Controlled Trial %A Li,Yiran %A Guo,Yan %A Hong,Y Alicia %A Zeng,Chengbo %A Zeng,Yu %A Zhang,Hanxi %A Zhu,Mengting %A Qiao,Jiaying %A Cai,Weiping %A Li,Linghua %A Liu,Cong %+ Department of Medical Statistics, School of Public Health, Sun Yat-sen University, #74 2nd Zhongshan Road, Guangzhou, 510080, China, 86 020 87334202, guoy8@mail.sysu.edu.cn %K mHealth %K HIV %K depressive symptoms %K quality of life %K structural equation model %D 2021 %7 9.11.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile health (mHealth) interventions have been shown to effectively improve the quality of life (QOL) among people living with HIV. However, little is known about the long-term effects of mHealth interventions. Objective: This study aims to explore the intervention mechanisms of a social media–based intervention, Run4Love, on the QOL of people with HIV over across a 9-month follow-up period. Methods: We recruited people living with HIV who were concurrently experiencing elevated depressive symptoms from an HIV outpatient clinic in South China. A total of 300 eligible participants were randomized either to the intervention group or the control group in a 1:1 ratio after they provided informed consent and completed a baseline survey. The intervention group received a 3-month WeChat-based intervention, comprising cognitive-behavioral stress management (CBSM) courses and physical activity promotion. The control group received a printed brochure on nutrition guidelines in addition to the usual care for HIV treatment. Neither participants nor the research staff were blinded to group assignment. All patients were followed at 3, 6, and 9 months. The primary outcome was depressive symptoms. Structural equation model (SEM) with longitudinal data was conducted to examine the sequential mediating effects of HIV-related stigma and depressive symptoms on the long-term intervention effects on participants’ QOL. Results: About 91.3% (274/300), 88.3% (265/300), and 86.7% (260/300) of all participants completed follow-up surveys at 3, 6, and 9 months, respectively. Results showed that the intervention had significantly improved participants' QOL at 9 months, via complete mediating effects of reduced HIV-related stigma at 3 months and decreased depressive symptoms at 6 months. No adverse events were reported. Conclusions: These findings underscore the critical roles of HIV-related stigma and depressive symptoms in an mHealth intervention with long-term effects on QOL improvements. We call for targeted mHealth interventions to improve QOL among people living with HIV, especially social media–based interventions that can address HIV-related stigma and alleviate depressive symptoms. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://www.chictr.org.cn/showproj.aspx?proj=21019 %M 34751654 %R 10.2196/27897 %U https://www.jmir.org/2021/11/e27897 %U https://doi.org/10.2196/27897 %U http://www.ncbi.nlm.nih.gov/pubmed/34751654 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e30580 %T A Text Message Intervention for Adolescents With Depression and Their Parents or Caregivers to Overcome Cognitive Barriers to Mental Health Treatment Initiation: Focus Groups and Pilot Trial %A Suffoletto,Brian %A Goldstein,Tina %A Brent,David %+ Department of Emergency Medicine, Stanford University, 900 Welch Road, Suite 350, Palo Alto, CA, 94304, United States, 1 4129016892, suffbp@stanford.edu %K adolescent %K depression %K help seeking %K text message %K intervention %D 2021 %7 9.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Many adolescents with depression do not pursue mental health treatment following a health care provider referral. We developed a theory-based automated SMS text message intervention (Text to Connect [T2C]) that attempts to reduce cognitive barriers to the initiation of mental health care. Objective: In this two-phase study, we seek to first understand the potential of T2C and then test its engagement, usability, and potential efficacy among adolescents with depression and their parents or caregivers. Methods: In phase 1, we conducted focus groups with adolescents with depression (n=9) and their parents or caregivers (n=9) separately, and transcripts were examined to determine themes. In phase 2, we conducted an open trial of T2C comprising adolescents with depression referred to mental health care (n=43) and their parents or caregivers (n=28). We assessed usability by examining program engagement, usability ratings, and qualitative feedback at the 4-week follow-up. We also assessed potential effectiveness by examining changes in perceived barriers to treatment and mental health care initiation from baseline to 4 weeks. Results: In phase 1, we found that the themes supported the T2C approach. In phase 2, we observed high engagement with daily negative affect check-ins, high usability ratings, and decreased self-reported barriers to mental health treatment over time among adolescents. Overall, 52% (22/42) of the adolescents who completed follow-up reported that they had attended an appointment with a mental health care specialist. Of the 20 adolescents who had not attended a mental health care appointment, 5% (1/20) reported that it was scheduled for a future date, 10% (2/20) reported that the primary care site did not have the ability to help them schedule a mental health care appointment, and 15% (3/20) reported that they were no longer interested in receiving mental health care. Conclusions: The findings from this study suggest that T2C is acceptable to adolescents with depression and most parents or caregivers; it is used at high rates; and it may be helpful to reduce cognitive barriers to mental health care initiation. %M 34751665 %R 10.2196/30580 %U https://formative.jmir.org/2021/11/e30580 %U https://doi.org/10.2196/30580 %U http://www.ncbi.nlm.nih.gov/pubmed/34751665 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e18969 %T Exploring the Barriers to and Motivators for Using Digital Mental Health Interventions Among Construction Personnel in Nigeria: Qualitative Study %A Nwaogu,Janet Mayowa %A Chan,Albert P C %A Naslund,John A %A Hon,Carol K H %A Belonwu,Christopher %A Yang,Jackie %+ Department of Building and Real Estate, The Hong Kong Polytechnic University, Kowloon, Hong Kong, 852 52243597, janet.nwaogu@connect.polyu.hk %K mental health %K construction personnel %K digital technology %K digital intervention %K barriers %K motivators %K mobile phone %D 2021 %7 9.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Work-related stress in the construction industry increases the prevalence of depression and anxiety among personnel. In low-resource settings such as Nigeria, construction personnel face high demands and severe working conditions but only have a few services to address their mental health needs. With emerging research showing that digital interventions can be used to self-manage mental health across diverse settings, there may be new opportunities to support construction personnel in the construction industry. Objective: This study aims to determine the use of digital interventions for mental health management among construction personnel in Nigeria and to explore the factors that facilitate or impede the use of these interventions. Methods: This qualitative study explored the perspectives of a convenience sample of 62 construction personnel. The data were subjected to inductive content analysis. Results: A total of 6 barrier and 3 motivator themes were identified and categorized into 2 groups. The barrier themes were subcategorized into barriers to adoption and barriers to persistent use, whereas the motivator themes were subcategorized into intrinsic and extrinsic motivators. Lack of awareness and knowledge about the interventions may constitute a barrier to adoption and use. Participants frequently reported concerns regarding their effectiveness and usability. Conclusions: This study provides an understanding of the design needs required to facilitate sustained self-management of mental health based on the experiences and expectations of construction personnel with digital interventions. %M 34751652 %R 10.2196/18969 %U https://formative.jmir.org/2021/11/e18969 %U https://doi.org/10.2196/18969 %U http://www.ncbi.nlm.nih.gov/pubmed/34751652 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e24471 %T Suicide Risk and Protective Factors in Online Support Forum Posts: Annotation Scheme Development and Validation Study %A Chancellor,Stevie %A Sumner,Steven A %A David-Ferdon,Corinne %A Ahmad,Tahirah %A De Choudhury,Munmun %+ Department of Computer Science & Engineering, University of Minnesota - Twin Cities, 200 Union Street SE, 4-189 Keller Hall, Minneapolis, MN, 55455, United States, 1 612 625 4002, steviec@umn.edu %K online communities %K suicide crisis %K construct validity %K annotation scheme %K Reddit %K annotation %D 2021 %7 8.11.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Online communities provide support for individuals looking for help with suicidal ideation and crisis. As community data are increasingly used to devise machine learning models to infer who might be at risk, there have been limited efforts to identify both risk and protective factors in web-based posts. These annotations can enrich and augment computational assessment approaches to identify appropriate intervention points, which are useful to public health professionals and suicide prevention researchers. Objective: This qualitative study aims to develop a valid and reliable annotation scheme for evaluating risk and protective factors for suicidal ideation in posts in suicide crisis forums. Methods: We designed a valid, reliable, and clinically grounded process for identifying risk and protective markers in social media data. This scheme draws on prior work on construct validity and the social sciences of measurement. We then applied the scheme to annotate 200 posts from r/SuicideWatch—a Reddit community focused on suicide crisis. Results: We documented our results on producing an annotation scheme that is consistent with leading public health information coding schemes for suicide and advances attention to protective factors. Our study showed high internal validity, and we have presented results that indicate that our approach is consistent with findings from prior work. Conclusions: Our work formalizes a framework that incorporates construct validity into the development of annotation schemes for suicide risk on social media. This study furthers the understanding of risk and protective factors expressed in social media data. This may help public health programming to prevent suicide and computational social science research and investigations that rely on the quality of labels for downstream machine learning tasks. %M 34747705 %R 10.2196/24471 %U https://mental.jmir.org/2021/11/e24471 %U https://doi.org/10.2196/24471 %U http://www.ncbi.nlm.nih.gov/pubmed/34747705 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e29873 %T Reducing Intrusive Memories of Childhood Trauma Using a Visuospatial Intervention: Case Study in Iceland %A Thorarinsdottir,Kristjana %A Holmes,Emily A %A Hardarson,Johann %A Hedinsdottir,Unnur %A Kanstrup,Marie %A Singh,Laura %A Hauksdottir,Arna %A Halldorsdottir,Thorhildur %A Gudmundsdottir,Berglind %A Valdimarsdottir,Unnur %A Thordardottir,Edda Bjork %A Gamble,Beau %A Bjornsson,Andri %+ Department of Psychology, University of Iceland, Sæmundargata 12, Reykjavik, 101, Iceland, 354 6942001, kth35@hi.is %K psychological trauma %K intrusive memories %K case report %K visuospatial interference task %K Tetris gameplay %K mental imagery %K mobile phone %D 2021 %7 4.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Additional interventions are needed for survivors of psychological trauma because of several barriers to and limitations of existing treatment options (eg, need to talk about the trauma in detail). Case studies are an important step in exploring the development of novel interventions, allowing detailed examination of individual responses to treatment over time. Here, we present a case study that aims to test a novel intervention designed to disrupt memory reconsolidation, taking a single-symptom approach by focusing on intrusive memories of a traumatic event. Objective: This study aims to examine a novel brief cognitive intervention to reduce the number of intrusive memories of trauma in an Icelandic setting and to extend previous studies by examining long-term effects for up to 3 months. The intervention was guided by a clinical psychologist and comprised a brief memory reminder, followed by Tetris gameplay with mental rotation, targeting one memory at a time in each session. Methods: This was a single case study in Iceland with a woman in her 50s (drawn from an epidemiological study of trauma) with subthreshold posttraumatic stress disorder and a diagnosis of obsessive-compulsive disorder and social anxiety disorder. The participant had four different intrusive memories from a traumatic event that happened in her childhood. The primary outcome was the change in the number of intrusive memories from baseline to intervention phase and to follow-ups. The number of intrusions was monitored in a daily diary for 4 weeks preintervention, 8 weeks during the intervention, and 1 week at 1-month and 3-month follow-ups. Intrusions were targeted one by one over six intervention sessions, creating four repetitions of an AB design (ie, length of baseline A and intervention phase B varied for each memory). We examined changes in both the total number of intrusions (summed across all four memories) and individually for each memory. In addition, we explored whether having fewer intrusive memories would have an impact on functioning, posttraumatic stress, and depression or anxiety symptoms. Results: The total number of intrusions per week was 12.6 at baseline, 6.1 at the intervention phase (52% reduction from baseline), 3.0 at the 1-month follow-up (76% reduction), and 1.0 at the 3-month follow-up (92% reduction). Reductions in the symptoms of posttraumatic stress and depression were observed postintervention. Sleep, concentration, stress, and functioning improved. The participant considered the gameplay intervention acceptable and helpful in that she found that the memories disappeared while she was playing. Conclusions: This guided brief cognitive intervention reduced the number of intrusive memories over the intervention phase and follow-ups. The brief memory reminder was well tolerated, removing the need to discuss trauma in detail. The next steps require an extension to more cases and exploring remote delivery of the intervention. %M 34734830 %R 10.2196/29873 %U https://formative.jmir.org/2021/11/e29873 %U https://doi.org/10.2196/29873 %U http://www.ncbi.nlm.nih.gov/pubmed/34734830 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 11 %P e30711 %T Web-Based Eye Movement Desensitization and Reprocessing for Adults With Suicidal Ideation: Protocol for a Randomized Controlled Trial %A Winkler,Olga %A Dhaliwal,Raman %A Greenshaw,Andrew %A O'Shea,Katie %A Abba-Aji,Adam %A Chima,Chidi %A Purdon,Scot E %A Burback,Lisa %+ Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Centre, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 780 342 5410, burback@ualberta.ca %K suicide %K trauma %K eye movement desensitization and reprocessing (EMDR) %K telemedicine %K psychotherapy %K digital health %K eHealth %K remote delivery %K virtual care %D 2021 %7 4.11.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Adversity and traumatic experiences increase the likelihood of suicidal thoughts and behaviors. Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based, trauma-focused psychotherapy that desensitizes painful memories, so that reminders in the present no longer provoke overwhelming emotional responses. Preliminary evidence suggests that EMDR can be used as an acute intervention in suicidal patients, including those with major depressive disorder. In addition, because of social distancing restrictions during the COVID-19 pandemic, clinicians have been using EMDR on the web and, in the absence of formal evaluations of web-based EMDR, informal reports indicate good results. Objective: The primary aim of this randomized controlled trial is to investigate whether remotely delivered EMDR (targeting experiences associated with suicidal thinking) reduces suicidal thoughts. Secondary aims include examining the impact of remotely delivered EMDR on symptoms of depression, anxiety, posttraumatic stress, emotional dysregulation, and dissociation. We will also report on adverse events in the EMDR group to explore whether targeting suicidal ideation with EMDR is safe. Finally, we will compare dropout rates between the treatment groups. Methods: In this randomized controlled trial, 80 adults who express suicidal ideation and meet the study criteria will receive either 12 sessions of twice weekly EMDR plus treatment as usual or treatment as usual alone. EMDR sessions will focus on the most distressing and intrusive memories associated with suicidal ideation. Data for primary and secondary objectives will be collected at baseline, 2 months, and 4 months after enrollment. A subsequent longer-term analysis, beyond the scope of this protocol, will examine differences between the groups with respect to the number of posttreatment emergency room visits, hospitalizations, and overall health care use in the year before and after therapy. Results: The protocol was approved by the University of Alberta Research Health Ethics Board (protocol ID Pro00090989). Funding for this study was provided by the Mental Health Foundation (grant RES0048906). Recruitment started in May 2021, with a projected completion date of March 2023. Conclusions: The results of this trial will contribute to knowledge on whether web-based delivery of EMDR is a safe and effective treatment for reducing suicidal ideation and potentially reducing the incidence of suicide attempts in this patient population. Trial Registration: ClinicalTrials.gov NCT04181047; https://clinicaltrials.gov/ct2/show/NCT04181047 International Registered Report Identifier (IRRID): DERR1-10.2196/30711 %M 34734835 %R 10.2196/30711 %U https://www.researchprotocols.org/2021/11/e30711 %U https://doi.org/10.2196/30711 %U http://www.ncbi.nlm.nih.gov/pubmed/34734835 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e31274 %T Adherence With Online Therapy vs Face-to-Face Therapy and With Online Therapy vs Care as Usual: Secondary Analysis of Two Randomized Controlled Trials %A Lippke,Sonia %A Gao,Lingling %A Keller,Franziska Maria %A Becker,Petra %A Dahmen,Alina %+ Department of Psychology and Methods, Jacobs University Bremen, Campus Ring 1, Bremen, 28759, Germany, 49 421200 ext 4730, s.lippke@jacobs-university.de %K psychotherapeutic aftercare %K medical rehabilitation %K online therapy %K face-to-face therapy %K care as usual %K retention %K dropout %D 2021 %7 3.11.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Adherence to internet-delivered interventions targeting mental health such as online psychotherapeutic aftercare is important for the intervention’s impact. High dropout rates limit the impact and generalizability of findings. Baseline differences may be putting patients at risk for dropping out, making comparisons between online with face-to-face (F2F) therapy and care as usual (CAU) necessary to examine. Objective: This study investigated adherence to online, F2F, and CAU interventions as well as study dropout among these groups and the subjective evaluation of the therapeutic relationship. Sociodemographic, social-cognitive, and health-related variables were considered. Methods: In a randomized controlled trial, 6023 patients were recruited, and 300 completed the baseline measures (T1), 144 completed T2 (retention 44%-52%), and 95 completed T3 (retention 24%-36%). Sociodemographic variables (eg, age, gender, marital status, educational level), social-cognitive determinants (eg, self-efficacy, social support), health-related variables (eg, depressiveness), and expectation towards the treatment for patients assigned to online or F2F were measured at T1. Results: There were no significant differences between the groups regarding dropout rates (χ21=0.02-1.06, P≥.30). Regarding adherence to the treatment condition, the online group outperformed the F2F and CAU conditions (P≤.01), indicating that patients randomized into the F2F and CAU control groups were much more likely to show nonadherent behavior in comparison with the online therapy groups. Within study groups, gender differences were significant only in the CAU group at T2, with women being more likely to drop out. At T3, age and marital status were also only significant in the CAU group. Patients in the online therapy group were significantly more satisfied with their treatment than patients in the F2F group (P=.02; Eta²=.09). Relationship satisfaction and success satisfaction were equally high (P>.30; Eta²=.02). Combining all study groups, patients who reported lower depressiveness scores at T1 (T2: odds ratio [OR] 0.55, 95% CI 0.35-0.87; T3: OR 0.56, 95% CI 0.37-0.92) were more likely to be retained, and patients who had higher self-efficacy (T2: OR 0.57, 95% CI 0.37-0.89; T3: OR 0.52, 95% CI 0.32-0.85) were more likely to drop out at T2 and T3. Additionally, at T3, the lower social support that patients reported was related to a higher likelihood of remaining in the study (OR 0.68, 95% CI 0.48-0.96). Comparing the 3 intervention groups, positive expectation was significantly related with questionnaire completion at T2 and T3 after controlling for other variables (T2: OR 1.64, 95% CI 1.08-2.50; T3: OR 1.59, 95% CI 1.01-2.51). Conclusions: While online interventions have many advantages over F2F variants such as saving time and effort to commute to F2F therapy, they also create difficulties for therapists and hinder their ability to adequately react to patients’ challenges. Accordingly, patient characteristics that might put them at risk for dropping out or not adhering to the treatment plan should be considered in future research and practice. Online aftercare, as described in this research, should be provided more often to medical rehabilitation patients. Trial Registration: ClinicalTrials.gov NCT04989842; https://clinicaltrials.gov/ct2/show/NCT04989842 %M 34730541 %R 10.2196/31274 %U https://www.jmir.org/2021/11/e31274 %U https://doi.org/10.2196/31274 %U http://www.ncbi.nlm.nih.gov/pubmed/34730541 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e30961 %T An Online Assessment to Evaluate the Role of Cognitive Biases and Emotion Regulation Strategies for Mental Health During the COVID-19 Lockdown of 2020: Structural Equation Modeling Study %A Blanco,Ivan %A Boemo,Teresa %A Sanchez-Lopez,Alvaro %+ Department of Clinical Psychology, School of Psychology, Complutense University of Madrid, Campus de Somosaguas, Pozuelo de Alarcon, 28223, Spain, 34 650692547, ivan.blanco.martinez@ucm.es %K COVID-19 %K emotion regulation %K cognitive biases %K psychological adjustment %K resilience %D 2021 %7 2.11.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Extant research supports causal roles of cognitive biases in stress regulation under experimental conditions. However, their contribution to psychological adjustment in the face of ecological major stressors has been largely unstudied. Objective: We developed a novel online method for the ecological examination of attention and interpretation biases during major stress (ie, the COVID-19 lockdown in March/April 2020) and tested their relations with the use of emotion regulation strategies (ie, reappraisal and rumination) to account for individual differences in psychological adjustment to major COVID-19–related stressors (ie, low depression and anxiety, and high well-being and resilience). Methods: Participants completed an online protocol evaluating the psychological impact of COVID-19–related stressors and the use of emotion regulation strategies in response to them, during the initial weeks of the lockdown of March/April 2020. They also completed a new online cognitive task designed to remotely assess attention and interpretation biases for negative information. The psychometric properties of the online cognitive bias assessments were very good, supporting their feasibility for ecological evaluation. Results: Structural equation models showed that negative interpretation bias was a direct predictor of worst psychological adjustment (higher depression and anxiety, and lower well-being and resilience; χ29=7.57; root mean square error of approximation=0.000). Further, rumination mediated the influence of interpretation bias in anxiety (P=.045; 95% CI 0.03-3.25) and resilience (P=.001; 95% CI −6.34 to −1.65), whereas reappraisal acted as a mediator of the influence of both attention (P=.047; 95% CI −38.71 to −0.16) and interpretation biases (P=.04; 95% CI −5.25 to −0.12) in well-being. Conclusions: This research highlights the relevance of individual processes of attention and interpretation during periods of adversity and identifies modifiable protective factors that can be targeted through online interventions. %M 34517337 %R 10.2196/30961 %U https://mental.jmir.org/2021/11/e30961 %U https://doi.org/10.2196/30961 %U http://www.ncbi.nlm.nih.gov/pubmed/34517337 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e25298 %T A Text Messaging Intervention (StayWell at Home) to Counteract Depression and Anxiety During COVID-19 Social Distancing: Pre-Post Study %A Aguilera,Adrian %A Hernandez-Ramos,Rosa %A Haro-Ramos,Alein Y %A Boone,Claire Elizabeth %A Luo,Tiffany Christina %A Xu,Jing %A Chakraborty,Bibhas %A Karr,Chris %A Darrow,Sabrina %A Figueroa,Caroline Astrid %+ School of Social Welfare, University of California, Berkeley, 120 Haviland Hall, MC7400, School of Social Welfare, Berkeley, CA, 94720, United States, 1 (510) 642 8564, aguila@berkeley.edu %K mobile health %K COVID-19 %K text messaging %K cognitive behavioral therapy %K anxiety %K depression %K microrandomized trials %K mHealth %K intervention %K mental health %K SMS %D 2021 %7 1.11.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Social distancing and stay-at-home orders are critical interventions to slow down person-to-person transmission of COVID-19. While these societal changes help contain the pandemic, they also have unintended negative consequences, including anxiety and depression. We developed StayWell, a daily skills-based SMS text messaging program, to mitigate COVID-19–related depression and anxiety symptoms among people who speak English and Spanish in the United States. Objective: This paper describes the changes in StayWell participants’ anxiety and depression levels after 60 days of exposure to skills-based SMS text messages. Methods: We used self-administered, empirically supported web-based questionnaires to assess the demographic and clinical characteristics of StayWell participants. Anxiety and depression were measured using the 2-item Generalized Anxiety Disorder (GAD-2) scale and the 8-item Patient Health Questionnaire-8 (PHQ-8) scale at baseline and 60-day timepoints. We used 2-tailed paired t tests to detect changes in PHQ-8 and GAD-2 scores from baseline to follow-up measured 60 days later. Results: The analytic sample includes 193 participants who completed both the baseline and 60-day exit questionnaires. At the 60-day time point, there were significant reductions in both PHQ-8 and GAD-2 scores from baseline. We found an average reduction of –1.72 (95% CI –2.35 to –1.09) in PHQ-8 scores and –0.48 (95% CI –0.71 to –0.25) in GAD-2 scores. These improvements translated to an 18.5% and 17.2% reduction in mean PHQ-8 and GAD-2 scores, respectively. Conclusions: StayWell is an accessible, low-intensity population-level mental health intervention. Participation in StayWell focused on COVID-19 mental health coping skills and was related to improved depression and anxiety symptoms. In addition to improvements in outcomes, we found high levels of engagement during the 60-day intervention period. Text messaging interventions could serve as an important public health tool for disseminating strategies to manage mental health. Trial Registration: ClinicalTrials.gov NCT04473599; https://clinicaltrials.gov/ct2/show/NCT04473599 International Registered Report Identifier (IRRID): RR2-10.2196/23592 %M 34543230 %R 10.2196/25298 %U https://mental.jmir.org/2021/11/e25298 %U https://doi.org/10.2196/25298 %U http://www.ncbi.nlm.nih.gov/pubmed/34543230 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e31064 %T Acceptability, Engagement, and Exploratory Outcomes of an Emotional Well-being App: Mixed Methods Preliminary Evaluation and Descriptive Analysis %A Eisenstadt,Amelia %A Liverpool,Shaun %A Metaxa,Athina-Marina %A Ciuvat,Roberta Maria %A Carlsson,Courtney %+ Evidence Based Practice Unit, University College London and Anna Freud National Centre for Children and Families, The Kantor Centre of Excellence, 4-8 Rodney Street, London, N1 9JH, United Kingdom, 44 20 7794 2313, mia.eisenstadt@annafreud.org %K smartphone %K app %K well-being %K awareness %K mental health %K formative %K mobile phone %D 2021 %7 1.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: There is growing evidence suggesting that the emotional well-being of the public has been negatively affected in the past year. Consequently, demand for well-being support has increased. Although there is substantial empirical support for mental health apps that target diagnosed conditions, there is less research on emotional well-being apps. Among existing well-being apps, few studies have been conducted on apps that are based on lived experience and those that seek to enhance users’ understanding of their emotional patterns. Thus, the acceptability of these novel apps requires further evaluation before upscaling. Objective: This evaluation aims to describe the acceptability, engagement, and preliminary outcomes of using an app (Paradym) designed to promote emotional well-being and positive mental health. Methods: This is a pre-post, mixed-methods, single-arm evaluation that is aggregated with digital analytics data. We anonymously collected real-world data on the demographics and well-being of the participants as well as the usability and acceptance of the app using validated questionnaires and open-ended questions. Participants tested the app for a minimum of 2 weeks before completing the follow-up measures. Google Analytics was used to record the level of app engagement. Chi-square and 2-tailed t tests were conducted to analyze quantitative data, and a thematic analysis approach was adopted for qualitative data. Results: A total of 115 participants completed baseline questionnaires, of which 79.1% (91/115) users downloaded the app. The sample was diverse in terms of ethnicity, including 43.4% (50/115) people who self-identified as belonging to minority ethnic groups. Most of the participants were female (78/115, 67.8%) and between the ages of 18 and 25 years (39/115, 33.9%). A total of 34 app users who completed questionnaires at baseline and follow-up provided valuable feedback to inform the future directions of Paradym. Favorable themes emerged describing the app’s content, functionality, and underlying principles. Although usability feedback varied across items, a considerable number of participants (22/34, 64%) found that the app was easy to use. Google Analytics revealed that at least 79% (27/34) of people used the app daily. On the basis of preliminary observations, app users experience increased mental well-being. Post hoc analyses indicated that the reduction in depression scores (t33=−2.16) and the increase in the well-being measures (t33=2.87) were statistically significant. No adverse events were reported during the follow-up period. Conclusions: The findings of this evaluation are encouraging and document positive preliminary evidence for the Paradym app. %M 34569466 %R 10.2196/31064 %U https://formative.jmir.org/2021/11/e31064 %U https://doi.org/10.2196/31064 %U http://www.ncbi.nlm.nih.gov/pubmed/34569466 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e29280 %T Organizational Readiness for Implementing an Internet-Based Cognitive Behavioral Therapy Intervention for Depression Across Community Mental Health Services in Albania and Kosovo: Directed Qualitative Content Analysis %A Doukani,Asmae %A Cerga Pashoja,Arlinda %A Fanaj,Naim %A Qirjako,Gentiana %A Meksi,Andia %A Mustafa,Sevim %A Vis,Christiaan %A Hug,Juliane %+ Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom, 44 7787447507, arlinda.cerga-pashoja@lshtm.ac.uk %K e-mental health %K digital mental health %K internet-based cognitive behavioral therapy %K implementation science %K organizational readiness for implementing change %K community mental health center %K qualitative interviews %K content analysis %K Albania and Kosovo %D 2021 %7 1.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The use of digital mental health programs such as internet-based cognitive behavioral therapy (iCBT) holds promise in increasing the quality and access of mental health services. However very little research has been conducted in understanding the feasibility of implementing iCBT in Eastern Europe. Objective: The aim of this study was to qualitatively assess organizational readiness for implementing iCBT for depression within community mental health centers (CMHCs) across Albania and Kosovo. Methods: We used qualitative semistructured focus group discussions that were guided by Bryan Weiner’s model of organizational readiness for implementing change. The questions broadly explored shared determination to implement change (change commitment) and shared belief in their collective capability to do so (change efficacy). Data were collected between November and December 2017. A range of health care professionals working in and in association with CMHCs were recruited from 3 CMHCs in Albania and 4 CMHCs in Kosovo, which were participating in a large multinational trial on the implementation of iCBT across 9 countries (Horizon 2020 ImpleMentAll project). Data were analyzed using a directed approach to qualitative content analysis, which used a combination of both inductive and deductive approaches. Results: Six focus group discussions involving 69 mental health care professionals were conducted. Participants from Kosovo (36/69, 52%) and Albania (33/69, 48%) were mostly females (48/69, 70%) and nurses (26/69, 38%), with an average age of 41.3 years. A directed qualitative content analysis revealed several barriers and facilitators potentially affecting the implementation of digital CBT interventions for depression in community mental health settings. While commitment for change was high, change efficacy was limited owing to a range of situational factors. Barriers impacting “change efficacy” included lack of clinical fit for iCBT, high stigma affecting help-seeking behaviors, lack of human resources, poor technological infrastructure, and high caseload. Facilitators included having a high interest and capability in receiving training for iCBT. For “change commitment,” participants largely expressed welcoming innovation and that iCBT could increase access to treatments for geographically isolated people and reduce the stigma associated with mental health care. Conclusions: In summary, participants perceived iCBT positively in relation to promoting innovation in mental health care, increasing access to services, and reducing stigma. However, a range of barriers was also highlighted in relation to accessing the target treatment population, a culture of mental health stigma, underdeveloped information and communications technology infrastructure, and limited appropriately trained health care workforce, which reduce organizational readiness for implementing iCBT for depression. Such barriers may be addressed through (1) a public-facing campaign that addresses mental health stigma, (2) service-level adjustments that permit staff with the time, resources, and clinical supervision to deliver iCBT, and (3) establishment of a suitable clinical training curriculum for health care professionals. Trial Registration: ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883 %M 34723822 %R 10.2196/29280 %U https://formative.jmir.org/2021/11/e29280 %U https://doi.org/10.2196/29280 %U http://www.ncbi.nlm.nih.gov/pubmed/34723822 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 10 %P e27908 %T Toward an Extended Definition of Major Depressive Disorder Symptomatology: Digital Assessment and Cross-validation Study %A Martin-Key,Nayra A %A Mirea,Dan-Mircea %A Olmert,Tony %A Cooper,Jason %A Han,Sung Yeon Sarah %A Barton-Owen,Giles %A Farrag,Lynn %A Bell,Emily %A Eljasz,Pawel %A Cowell,Daniel %A Tomasik,Jakub %A Bahn,Sabine %+ Cambridge Centre for Neuropsychiatric Research, Department of Chemical Engineering and Biotechnology, University of Cambridge, Philippa Fawcett Drive, Cambridge, CB3 0AS, United Kingdom, 44 1223 334151, sb209@cam.ac.uk %K major depressive disorder %K subthreshold depression, transdiagnostic symptoms %K digital assessment %K digital mental health %K mobile phone %D 2021 %7 28.10.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Diagnosing major depressive disorder (MDD) is challenging, with diagnostic manuals failing to capture the wide range of clinical symptoms that are endorsed by individuals with this condition. Objective: This study aims to provide evidence for an extended definition of MDD symptomatology. Methods: Symptom data were collected via a digital assessment developed for a delta study. Random forest classification with nested cross-validation was used to distinguish between individuals with MDD and those with subthreshold symptomatology of the disorder using disorder-specific symptoms and transdiagnostic symptoms. The diagnostic performance of the Patient Health Questionnaire–9 was also examined. Results: A depression-specific model demonstrated good predictive performance when distinguishing between individuals with MDD (n=64) and those with subthreshold depression (n=140) (area under the receiver operating characteristic curve=0.89; sensitivity=82.4%; specificity=81.3%; accuracy=81.6%). The inclusion of transdiagnostic symptoms of psychopathology, including symptoms of depression, generalized anxiety disorder, insomnia, emotional instability, and panic disorder, significantly improved the model performance (area under the receiver operating characteristic curve=0.95; sensitivity=86.5%; specificity=90.8%; accuracy=89.5%). The Patient Health Questionnaire–9 was excellent at identifying MDD but overdiagnosed the condition (sensitivity=92.2%; specificity=54.3%; accuracy=66.2%). Conclusions: Our findings are in line with the notion that current diagnostic practices may present an overly narrow conception of mental health. Furthermore, our study provides proof-of-concept support for the clinical utility of a digital assessment to inform clinical decision-making in the evaluation of MDD. %M 34709182 %R 10.2196/27908 %U https://formative.jmir.org/2021/10/e27908 %U https://doi.org/10.2196/27908 %U http://www.ncbi.nlm.nih.gov/pubmed/34709182 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 10 %P e27676 %T Professional Care Experiences of Persons With Suicidal Ideation and Behavior: Model Development Based on a Qualitative Meta-Synthesis %A Hechinger,Mareike %A Fringer,André %+ Institute of Nursing, School of Health Professions, Zurich University of Applied Sciences, Katharina-Sulzer-Platz 9, Winterthur, 8400, Switzerland, 41 58 934 64 79, andre.fringer@zhaw.ch %K nursing care %K health care professionals %K suicidal behavior %K suicidal inclinations %K suicidal ideation %K inpatient %K outpatient %K eHealth %K mHealth %K mental health %K suicide %K stress %D 2021 %7 28.10.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Health care professionals (HCPs) are challenged in caring for persons with suicidal ideation or behavior. For affected persons, professional care is essential, and being interviewed about their experiences can be stressful. The experiences of persons ideating or attempting suicide are essential to designing eHealth products to support them in crises and provide continuous care. Objective: This study aimed to synthesize published qualitative research about how persons with suicidal thoughts or behavior experience inpatient or outpatient care. A model will be derived from the meta-synthesis to guide HCPs in their work with affected persons and provide a thorough needs assessment for eHealth development. Methods: A qualitative meta-synthesis was conducted using an inductive approach, as proposed by Sandelowski and Barroso. The inclusion criteria were studies in English and German that dealt with persons who ideated or attempted suicide. Relevant articles were identified by searching the PubMed and Cinahl databases and by hand searching relevant journals and reference lists. The findings of each study were analyzed using initial and axial coding, followed by selective coding. Finally, a conceptual model was derived. Results: In total, 3170 articles were identified in the systematic literature search. Articles were screened independently by 2 researchers based on the eligibility criteria. Finally, 12 studies were included. The central phenomenon observed among persons ideating or attempting suicide is their process from feeling unanchored to feeling anchored in life again. During inpatient and outpatient care, they experience being dependent on the skills and attitudes of HCPs. While helpful skills and attitudes support persons ideating or attempting suicide to reach their feeling of being anchored in life again, adverse interactions are experienced negatively and might lead to prolonging or maintaining the feeling of being unanchored in life. Conclusions: The study promotes a differentiated view of the experiences of persons ideating or attempting suicide. The derived conceptual model can guide HCPs in their work with affected persons to support affected persons during their recovery. Moreover, the conceptual model is useable as a springboard to develop eHealth solutions for crisis situations and long-term care. %M 34709191 %R 10.2196/27676 %U https://formative.jmir.org/2021/10/e27676 %U https://doi.org/10.2196/27676 %U http://www.ncbi.nlm.nih.gov/pubmed/34709191 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 10 %P e24872 %T Digital Biomarkers for Depression Screening With Wearable Devices: Cross-sectional Study With Machine Learning Modeling %A Rykov,Yuri %A Thach,Thuan-Quoc %A Bojic,Iva %A Christopoulos,George %A Car,Josip %+ Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Rd, Clinical Sciences Building, Level 18, Singapore, 308232, Singapore, 65 +85291725838, josip.car@gmail.com %K depression %K digital biomarkers %K screening %K wearable electronic device %K fitness tracker %K circadian rhythm %K rest-activity rhythm %K heart rate %K machine learning %D 2021 %7 25.10.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depression is a prevalent mental disorder that is undiagnosed and untreated in half of all cases. Wearable activity trackers collect fine-grained sensor data characterizing the behavior and physiology of users (ie, digital biomarkers), which could be used for timely, unobtrusive, and scalable depression screening. Objective: The aim of this study was to examine the predictive ability of digital biomarkers, based on sensor data from consumer-grade wearables, to detect risk of depression in a working population. Methods: This was a cross-sectional study of 290 healthy working adults. Participants wore Fitbit Charge 2 devices for 14 consecutive days and completed a health survey, including screening for depressive symptoms using the 9-item Patient Health Questionnaire (PHQ-9), at baseline and 2 weeks later. We extracted a range of known and novel digital biomarkers characterizing physical activity, sleep patterns, and circadian rhythms from wearables using steps, heart rate, energy expenditure, and sleep data. Associations between severity of depressive symptoms and digital biomarkers were examined with Spearman correlation and multiple regression analyses adjusted for potential confounders, including sociodemographic characteristics, alcohol consumption, smoking, self-rated health, subjective sleep characteristics, and loneliness. Supervised machine learning with statistically selected digital biomarkers was used to predict risk of depression (ie, symptom severity and screening status). We used varying cutoff scores from an acceptable PHQ-9 score range to define the depression group and different subsamples for classification, while the set of statistically selected digital biomarkers remained the same. For the performance evaluation, we used k-fold cross-validation and obtained accuracy measures from the holdout folds. Results: A total of 267 participants were included in the analysis. The mean age of the participants was 33 (SD 8.6, range 21-64) years. Out of 267 participants, there was a mild female bias displayed (n=170, 63.7%). The majority of the participants were Chinese (n=211, 79.0%), single (n=163, 61.0%), and had a university degree (n=238, 89.1%). We found that a greater severity of depressive symptoms was robustly associated with greater variation of nighttime heart rate between 2 AM and 4 AM and between 4 AM and 6 AM; it was also associated with lower regularity of weekday circadian rhythms based on steps and estimated with nonparametric measures of interdaily stability and autocorrelation as well as fewer steps-based daily peaks. Despite several reliable associations, our evidence showed limited ability of digital biomarkers to detect depression in the whole sample of working adults. However, in balanced and contrasted subsamples comprised of depressed and healthy participants with no risk of depression (ie, no or minimal depressive symptoms), the model achieved an accuracy of 80%, a sensitivity of 82%, and a specificity of 78% in detecting subjects at high risk of depression. Conclusions: Digital biomarkers that have been discovered and are based on behavioral and physiological data from consumer wearables could detect increased risk of depression and have the potential to assist in depression screening, yet current evidence shows limited predictive ability. Machine learning models combining these digital biomarkers could discriminate between individuals with a high risk of depression and individuals with no risk. %M 34694233 %R 10.2196/24872 %U https://mhealth.jmir.org/2021/10/e24872 %U https://doi.org/10.2196/24872 %U http://www.ncbi.nlm.nih.gov/pubmed/34694233 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 10 %P e31862 %T Evaluating the Clinical Feasibility of an Artificial Intelligence–Powered, Web-Based Clinical Decision Support System for the Treatment of Depression in Adults: Longitudinal Feasibility Study %A Popescu,Christina %A Golden,Grace %A Benrimoh,David %A Tanguay-Sela,Myriam %A Slowey,Dominique %A Lundrigan,Eryn %A Williams,Jérôme %A Desormeau,Bennet %A Kardani,Divyesh %A Perez,Tamara %A Rollins,Colleen %A Israel,Sonia %A Perlman,Kelly %A Armstrong,Caitrin %A Baxter,Jacob %A Whitmore,Kate %A Fradette,Marie-Jeanne %A Felcarek-Hope,Kaelan %A Soufi,Ghassen %A Fratila,Robert %A Mehltretter,Joseph %A Looper,Karl %A Steiner,Warren %A Rej,Soham %A Karp,Jordan F %A Heller,Katherine %A Parikh,Sagar V %A McGuire-Snieckus,Rebecca %A Ferrari,Manuela %A Margolese,Howard %A Turecki,Gustavo %+ Aifred Health Inc., 1250 Rue Guy Suite #600, Montreal, QC, H3H 2T4, Canada, 1 5144637813, david.benrimoh@mail.mcgill.com %K clinical decision support system %K major depressive disorder %K artificial intelligence %K feasibility %K usability %K mobile phone %D 2021 %7 25.10.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Approximately two-thirds of patients with major depressive disorder do not achieve remission during their first treatment. There has been increasing interest in the use of digital, artificial intelligence–powered clinical decision support systems (CDSSs) to assist physicians in their treatment selection and management, improving the personalization and use of best practices such as measurement-based care. Previous literature shows that for digital mental health tools to be successful, the tool must be easy for patients and physicians to use and feasible within existing clinical workflows. Objective: This study aims to examine the feasibility of an artificial intelligence–powered CDSS, which combines the operationalized 2016 Canadian Network for Mood and Anxiety Treatments guidelines with a neural network–based individualized treatment remission prediction. Methods: Owing to the COVID-19 pandemic, the study was adapted to be completed entirely remotely. A total of 7 physicians recruited outpatients diagnosed with major depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Patients completed a minimum of one visit without the CDSS (baseline) and 2 subsequent visits where the CDSS was used by the physician (visits 1 and 2). The primary outcome of interest was change in appointment length after the introduction of the CDSS as a proxy for feasibility. Feasibility and acceptability data were collected through self-report questionnaires and semistructured interviews. Results: Data were collected between January and November 2020. A total of 17 patients were enrolled in the study; of the 17 patients, 14 (82%) completed the study. There was no significant difference in appointment length between visits (introduction of the tool did not increase appointment length; F2,24=0.805; mean squared error 58.08; P=.46). In total, 92% (12/13) of patients and 71% (5/7) of physicians felt that the tool was easy to use; 62% (8/13) of patients and 71% (5/7) of physicians rated that they trusted the CDSS. Of the 13 patients, 6 (46%) felt that the patient-clinician relationship significantly or somewhat improved, whereas 7 (54%) felt that it did not change. Conclusions: Our findings confirm that the integration of the tool does not significantly increase appointment length and suggest that the CDSS is easy to use and may have positive effects on the patient-physician relationship for some patients. The CDSS is feasible and ready for effectiveness studies. Trial Registration: ClinicalTrials.gov NCT04061642; http://clinicaltrials.gov/ct2/show/NCT04061642 %M 34694234 %R 10.2196/31862 %U https://formative.jmir.org/2021/10/e31862 %U https://doi.org/10.2196/31862 %U http://www.ncbi.nlm.nih.gov/pubmed/34694234 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 10 %P e28262 %T Internet Search Activity of Young People With Mood Disorders Who Are Hospitalized for Suicidal Thoughts and Behaviors: Qualitative Study of Google Search Activity %A Moon,Khatiya C %A Van Meter,Anna R %A Kirschenbaum,Michael A %A Ali,Asra %A Kane,John M %A Birnbaum,Michael L %+ Department of Psychiatry, Zucker Hillside Hospital, 75-59 263rd Street, Kaufmann Building, Suite k204, Glen Oaks, NY, 11004, United States, 1 7184704367, kmoon2@northwell.edu %K suicide %K mood disorders %K depression %K internet %K search engine %K Google search %K digital health %K mobile health %K adolescent %K young adult %D 2021 %7 22.10.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Little is known about the internet search activity of people with suicidal thoughts and behaviors (STBs). This data source has the potential to inform both clinical and public health efforts, such as suicide risk assessment and prevention. Objective: We aimed to evaluate the internet search activity of suicidal young people to find evidence of suicidal ideation and behavioral health–related content. Methods: Individuals aged between 15 and 30 years (N=43) with mood disorders who were hospitalized for STBs provided access to their internet search history. Searches that were conducted in the 3-month period prior to hospitalization were extracted and manually evaluated for search themes related to suicide and behavioral health. Results: A majority (27/43, 63%) of participants conducted suicide-related searches. Participants searched for information that exactly matched their planned or chosen method of attempting suicide in 21% (9/43) of cases. Suicide-related search queries also included unusual suicide methods and references to suicide in popular culture. A majority of participants (33/43, 77%) had queries related to help-seeking themes, including how to find inpatient and outpatient behavioral health care. Queries related to mood and anxiety symptoms were found among 44% (19/43) of participants and included references to panic disorder, the inability to focus, feelings of loneliness, and despair. Queries related to substance use were found among 44% (19/43) of participants. Queries related to traumatic experiences were present among 33% (14/43) of participants. Few participants conducted searches for crisis hotlines (n=3). Conclusions: Individuals search the internet for information related to suicide prior to hospitalization for STBs. The improved understanding of the search activity of suicidal people could inform outreach, assessment, and intervention strategies for people at risk. Access to search data may also benefit the ongoing care of suicidal patients. %M 34677139 %R 10.2196/28262 %U https://mental.jmir.org/2021/10/e28262 %U https://doi.org/10.2196/28262 %U http://www.ncbi.nlm.nih.gov/pubmed/34677139 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 10 %P e25489 %T High Work-Related Stress and Anxiety as a Response to COVID-19 Among Health Care Workers in South Korea: Cross-sectional Online Survey Study %A Ahn,Myung Hee %A Shin,Yong-Wook %A Suh,Sooyeon %A Kim,Jeong Hye %A Kim,Hwa Jung %A Lee,Kyoung-Uk %A Chung,Seockhoon %+ Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea, 82 2 3010 3411, schung@amc.seoul.kr %K COVID-19 %K health personnel %K occupational stress %K anxiety %K depression %K stress %K mental health %K South Korea %K health care worker %K assessment %K intervention %D 2021 %7 22.10.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The COVID-19 outbreak had a severe impact on health care workers' psychological health. It is important to establish a process for psychological assessment and intervention for health care workers during epidemics. Objective: We investigated risk factors associated with psychological impacts for each health care worker group, to help optimize psychological interventions for health care workers in countries affected by the COVID-19 pandemic. Methods: Respondents (n=1787) from 2 hospitals in Korea completed a web-based survey during the period from April 14 to 30, 2020. The web-based survey collected demographic information, psychiatric history, and responses to the 9-item Stress and Anxiety to Viral Epidemics (SAVE-9), 9-item Patient Health Questionnaire (PHQ-9), and 7-item Generalized Anxiety Disorder-7 (GAD-7) scales. We performed logistic regression to assess contributing factors as predictor variables, using health care workers’ depression as outcome variables. Results: Among 1783 health care workers, nursing professionals had significantly higher levels of depression (PHQ-9 score: meannurse 5.5, SD 4.6; meanother 3.8, SD 4.2; P<.001), general anxiety (GAD-7 score: meannurse 4.0, SD 4.1; meanother 2.7, SD 3.6; P<.001), and virus-related anxiety symptoms (SAVE-9 score: meannurse 21.6, SD 5.9; meanother 18.6, SD 6.3; P<.001). Among nursing professionals, single workers reported more severe depressive symptoms than married workers (PHQ-9 score ≥10; meannurse 20.3%; meanother 14.1%; P=.02), and junior (<40 years) workers reported more anxiety about the viral epidemic (SAVE-9 anxiety score; meannurse 15.6, SD 4.1; meanother 14.7, SD 4.4; P=.002). Logistic regression revealed that hospital (adjusted odds ratio [OR] 1.45, 95% CI 1.06-1.99), nursing professionals (adjusted OR 1.37, 95% CI 1.02-1.98), single workers (adjusted OR 1.51, 95% CI 1.05-2.16), higher stress and anxiety to the viral infection (high SAVE-9 score, adjusted OR 1.20, 95% CI 1.17-1.24), and past psychiatric history (adjusted OR 3.26, 95% CI 2.15-4.96) were positively associated with depression. Conclusions: Psychological support and interventions should be considered for health care workers, especially nursing professionals, those who are single, and those with high SAVE-9 scores. %M 34478401 %R 10.2196/25489 %U https://publichealth.jmir.org/2021/10/e25489 %U https://doi.org/10.2196/25489 %U http://www.ncbi.nlm.nih.gov/pubmed/34478401 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 10 %P e32100 %T Outcomes of a Blended Care Coaching Program for Clients Presenting With Moderate Levels of Anxiety and Depression: Pragmatic Retrospective Study %A Wu,Monica S %A Chen,Shih-Yin %A Wickham,Robert E %A O’Neil-Hart,Shane %A Chen,Connie %A Lungu,Anita %+ Lyra Health, 287 Lorton Ave, Burlingame, CA, 94010, United States, 1 877 505 7147, mwu@lyrahealth.com %K blended care %K coaching %K cognitive %K behavior %K depression %K anxiety %K digital health %K retrospective %K mental health %K CBT %K cognitive behavioral therapy %K outcome %K video conference %D 2021 %7 21.10.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression and anxiety are leading causes of disability worldwide, but access to quality mental health care is limited by myriad factors. Cognitive-behavioral coaching is rooted in evidence-based principles and has the potential to address some of these unmet care needs. Harnessing technology to facilitate broader dissemination within a blended care model shows additional promise for overcoming barriers to care. Objective: The aim of this study is to evaluate the outcomes of a blended care coaching (BCC) program for clients presenting with moderate levels of anxiety and depression in real-world settings. Methods: This study examined retrospective data from US-based individuals (N=1496) who presented with moderate levels of depression and anxiety symptoms and who received blended care coaching services. Using a short-term framework, clients met with coaches via a secure video conference platform and also received digital video lessons and exercises. To evaluate the effectiveness of the BCC program, mixed effects modeling was used to examine growth trajectories of anxiety and depression scores over the course of care. Results: Out of the total sample of 1496 clients, 75.9% (n=1136) demonstrated reliable improvement, and 88.6% (n=1326) recovered based on either the Generalized Anxiety Disorder-7 scale (anxiety) or Patient Health Questionnaire-9 (depression). On average, clients exhibited a significant decline in anxiety and depression symptoms during the initial weeks of coaching, with a continued decline over subsequent weeks at a lower rate. Engaging in a coaching session was associated with lower anxiety (b=–1.04) and depression (b=–0.79) symptoms in the same week, as well as lower anxiety (b=–0.74) and depression (b=–0.91) symptoms the following week (P<.001). Conclusions: The BCC program demonstrated strong outcomes in decreasing symptomology for clients presenting with moderate levels of anxiety and depression. When clients received coaching sessions, significant decreases in symptoms were observed, reflecting the importance of session attendance. Additionally, the steepest declines in symptoms tended to occur during the initial weeks of coaching, emphasizing the importance of client buy-in and early engagement. Collectively, these findings have implications for addressing unmet mental health care needs in a more accessible, cost-effective manner. %M 34673534 %R 10.2196/32100 %U https://mental.jmir.org/2021/10/e32100 %U https://doi.org/10.2196/32100 %U http://www.ncbi.nlm.nih.gov/pubmed/34673534 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 10 %P e31241 %T Assessing the Real-time Influence of Racism-Related Stress and Suicidality Among Black Men: Protocol for an Ecological Momentary Assessment Study %A Adams,Leslie %A Igbinedion,Godwin %A DeVinney,Aubrey %A Azasu,Enoch %A Nestadt,Paul %A Thrul,Johannes %A Joe,Sean %+ Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Baltimore, MD, 21205-1900, United States, 1 410 955 1906, ladams36@jhu.edu %K Black men %K suicide %K racism %K ecological momentary assessment %D 2021 %7 20.10.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is the third leading cause of death among Black adults aged 18-35 years. Although men represent a majority of suicide deaths among Black adults, less is known regarding the extent to which unique cultural stressors, such as racism-related stress (eg, racial discrimination), are salient in exacerbating suicide risk among Black men. Moreover, few studies examine the daily influence of racism-related stressors on suicide outcomes using real-time smartphone-based approaches. Smartphone-based mobile health approaches using ecological momentary assessments (EMA) provide an opportunity to assess and characterize racism-related stressors as a culturally sensitive suicide risk factor among Black young adult men. Objective: The goal of this study is to describe a protocol development process that aims to capture real-time racism-related stressors and suicide outcomes using a smartphone-based EMA platform (MetricWire). Methods: Guided by the Interpersonal Theory of Suicide (ITS), we developed a brief EMA protocol using a multiphased approach. First, we conducted a literature review to identify brief measures previously used in EMA studies, with special emphasis on studies including Black participants. The identified measures were then shortened to items with the highest construct validity (eg, factor loadings) and revised to reflect momentary or daily frequency. Feasibility and acceptability of the study protocol will be assessed using self-report survey and qualitative responses. To protect participants from harm, a three-tier safety protocol was developed to identify participants with moderate, elevated, and acute risk based on EMA survey response to trigger outreach by the study coordinator. Results: The final EMA protocol, which will be completed over a 7-day period, is comprised of 15 questions administered 4 times per day and a daily questionnaire of 22 items related to sleep-related impairment and disruption, as well as racism-related stress. Study recruitment is currently underway. We anticipate the study will be completed in February 2023. Dissemination will be conducted through peer-reviewed publications and conference presentations. Conclusions: This protocol will address gaps in our understanding of Black men’s suicide outcomes in the social contexts that they regularly navigate and will clarify the temporal role of racism-related stressors that influence suicidal outcomes. International Registered Report Identifier (IRRID): PRR1-10.2196/31241 %M 34668869 %R 10.2196/31241 %U https://www.researchprotocols.org/2021/10/e31241 %U https://doi.org/10.2196/31241 %U http://www.ncbi.nlm.nih.gov/pubmed/34668869 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 10 %P e30491 %T Learning About the Current State of Digital Mental Health Interventions for Canadian Youth to Inform Future Decision-Making: Mixed Methods Study %A Kemp,Jessica %A Chorney,Jill %A Kassam,Iman %A MacDonald,Julie %A MacDonald,Tara %A Wozney,Lori %A Strudwick,Gillian %+ Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 1001 Queen St W, Toronto, ON, M6J 1H4, Canada, 1 416 535 8501, gillian.strudwick@camh.ca %K youth mental health %K digital mental health %K COVID-19 %K digital mental health interventions %K e-mental health %D 2021 %7 19.10.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has increased the demand for youth mental health services in Canada as disruptions to clinical care continue to persist due to the risk of transmission and exposure to the virus. Digital mental health interventions, including web-based resources and mobile apps, have provided opportunities to support youth mental health remotely across Canada. There is a need to better understand how these digital interventions are being selected, recommended, and used in various regions across Canada. Objective: A national jurisdictional scan was completed to (1) determine what web-based programs, apps, and websites are promoted and licensed in Canada for youth mental health; (2) identify criteria and decision-making processes that Canadian jurisdictions use to select web-based programs, apps, and websites for youth mental health; and (3) identify upcoming trends, innovations, and digital mental health possibilities that are emerging in the youth sector. Methods: The aims of the jurisdictional scan were addressed through a review of related academic and grey literature; stakeholder interviews, including individuals involved in various areas of the youth mental health sector; and a social media review of pertinent Twitter content. Results: A total of 66 web-based resources and apps were identified for use by youth in Canada. 16 stakeholder interviews were completed and included discussions with researchers, clinicians, youth organizations, and others involved in digital interventions for youth mental health. These discussions identified a limited use of frameworks used to guide decision-making processes when selecting digital interventions. Many clinicians agreed on a similar set of eligibility requirements for youth mental health apps and digital resources, such as the evidence base and cultural relevance of the intervention. Stakeholders also identified upcoming trends and innovations in the youth digital mental health space, including artificial intelligence, digital phenotyping, and personalized therapy. Over 4 weeks, 2184 tweets were reviewed to identify and compare global and national trends and innovations involving digital mental health and youth. Key trends included the promotion of regional chat services as well as the effects of the COVID-19 pandemic on youth mental health and access to care. Conclusions: As organizations begin to plan for the delivery of mental health care following the pandemic, there are concerns about the sustainability of these digital mental health interventions as well as a need for services to be more informed by the experiences and preferences of youth. %M 34665141 %R 10.2196/30491 %U https://www.jmir.org/2021/10/e30491 %U https://doi.org/10.2196/30491 %U http://www.ncbi.nlm.nih.gov/pubmed/34665141 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 10 %P e28071 %T Psychological Impact of the COVID-19 Pandemic and Social Determinants on the Portuguese Population: Protocol for a Web-Based Cross-sectional Study %A Aguiar,A %A Pinto,M %A Duarte,R %+ EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, Porto, 4050-600, Portugal, 351 222061820, ana.aguiar@ispup.up.pt %K COVID-19 %K public health %K mental health %K study protocol %K psychological impact %K anxiety %K depression %K grief %K behavior change %D 2021 %7 19.10.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The COVID-19 outbreak and consequent physical distance measures implemented worldwide have caused significant stress, anxiety, and mental health implications among the general population. Unemployment, working from home, and day-to-day changes may lead to a greater risk of poor mental health outcomes. Objective: This paper describes the protocol for a web-based cross-sectional study that aims to address the impact of the COVID-19 pandemic on mental health. Methods: Individuals from the general population aged 18 years or more and living in Portugal were included in this study. Data collection took place between November 10, 2020, and February 10, 2021. An exponential, nondiscriminative, snowball sampling method was applied to recruit participants. A web-based survey was developed and shared on social media platforms (eg, Facebook, Instagram, Twitter, LinkedIn, and WhatsApp groups) and through e-mail lists for recruitment of the seeds. Results: Data analysis will be performed in accordance with the different variables and outcomes of interest by using quantitative methods, qualitative methods, or mixed methods, as applicable. A total of 929 individuals had completed the web-based survey during the 3-month period; thus, our final sample comprised 929 participants. Results of the survey will be disseminated in national and international scientific journals in 2021-2022. Conclusions: We believe that the findings of this study will have broad implications for understanding the psychological impact of the COVID-19 pandemic on Portuguese residents, as well as aspects related to the informal economy. We also hope that the findings of this study are able to provide insights and guidelines for the Portuguese government to implement action. Finally, we expect this protocol to provide a roadmap for other countries and researchers that would like to implement a similar questionnaire considering the related conclusions. International Registered Report Identifier (IRRID): DERR1-10.2196/28071 %M 34516387 %R 10.2196/28071 %U https://www.researchprotocols.org/2021/10/e28071 %U https://doi.org/10.2196/28071 %U http://www.ncbi.nlm.nih.gov/pubmed/34516387 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 10 %P e29764 %T Digital Health Literacy in Bipolar Disorder: International Web-Based Survey %A Morton,Emma %A Ho,Kendall %A Barnes,Steven J %A Michalak,Erin E %+ Department of Psychiatry, University of British Columbia, 420-5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada, 1 604 827 3393, erin.michalak@ubc.ca %K eHealth %K health literacy %K bipolar disorder %K self-management %D 2021 %7 19.10.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Web-based resources can support people with bipolar disorder (BD) to improve their knowledge and self-management. However, publicly available resources are heterogeneous in terms of their quality and ease of use. Characterizing digital health literacy (the skillset that enable people to navigate and make use of health information in a web-based context) in BD will support the development of educational resources. Objective: The aim of this study was to develop understanding of digital health literacy and its predictors in people with BD. Methods: A web-based survey was used to explore self-reported digital health literacy (as measured by the e-Health Literacy Scale [eHEALS]) in people with BD. Multiple regression analysis was used to evaluate potential predictors, including demographic/clinical characteristics and technology use. Results: A total of 919 respondents (77.9% female; mean age 36.9 years) completed the survey. Older age (β=0.09; P=.01), postgraduate education (β=0.11; P=.01), and current use of self-management apps related to BD (β=0.13; P<.001) were associated with higher eHEALS ratings. Conclusions: Levels of self-reported digital health literacy were comparable or higher than other studies in the general population and specific physical/mental health conditions. However, individuals with BD who are younger, have completed less education, or are less familiar with mental health apps may require extra support to safely and productively navigate web-based health resources. Relevant educational initiatives are discussed. Future studies should evaluate skill development interventions for less digitally literate groups. %M 34665143 %R 10.2196/29764 %U https://mental.jmir.org/2021/10/e29764 %U https://doi.org/10.2196/29764 %U http://www.ncbi.nlm.nih.gov/pubmed/34665143 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 10 %P e24208 %T Impact of App-Delivered Mindfulness Meditation on Functional Connectivity, Mental Health, and Sleep Disturbances Among Physician Assistant Students: Randomized, Wait-list Controlled Pilot Study %A Smith,Jeremy L %A Allen,Jason W %A Haack,Carla I %A Wehrmeyer,Kathryn L %A Alden,Kayley G %A Lund,Maha B %A Mascaro,Jennifer S %+ Department of Radiology and Imaging Sciences, Emory University, 1364 Clifton Road Northeast, Atlanta, GA, 30322, United States, 1 404 989 0524, jsmi304@emory.edu %K mindfulness %K meditation %K resting state %K fMRI %K connectivity %K mobile phone %D 2021 %7 19.10.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Health care provider and trainee burnout results in substantial national and institutional costs and profound social effects. Identifying effective solutions and interventions to cultivate resilience among health care trainees is critical. Although less is known about the mental health needs of physician assistants (PAs) or PA students, accumulating research indicates that they experience similarly alarming rates of burnout, depression, and emotional exhaustion. Mobile app–delivered mindfulness meditation may be an effective part of salubrious programming to bolster long-term resilience and health among PA students. Objective: This study aims to examine the impact of app-delivered mindfulness meditation on self-reported mental health symptoms among PA students. A secondary aim is to investigate changes in brain connectivity to identify neurobiological changes related to changes in mental health symptoms. Methods: We recruited PA students enrolled in their third semester of PA school and used a longitudinal, randomized, wait-list–controlled design. Participants randomized to the mindfulness group were provided 1-year subscriptions to the 10% Happier app, a consumer-based meditation app, and asked to practice every day for 8 weeks. Before randomization and again after completion of the 8-week program, all participants completed resting-state functional magnetic resonance imaging as well as self-report assessments of burnout, depression, anxiety, and sleep impairment. App use was acquired as a measure of mindfulness practice time. Results: PA students randomized to the mindfulness group reported improvements in sleep impairment compared with those randomized to the wait-list control group (ηp2=0.42; P=.01). Sleep impairment decreased significantly in the mindfulness group (19% reduction; P=.006) but not in the control group (1% reduction; P=.71). There were no other significant changes in mental health for those randomized to app-delivered mindfulness. Across all students, changes in sleep impairment were associated with increased resting-state functional connectivity between the medial prefrontal cortex (a component of the default mode network) and the superior temporal gyrus, as well as between areas important for working memory. Changes in connectivity predicted categorical conversion from impaired to nonimpaired sleep in the mindfulness group. Conclusions: This pilot study is the first to examine app-based mindfulness for PA students’ mental health and investigate the impact of mindfulness on PA students’ brain function. These findings suggest that app-delivered mindfulness may be an effective tool to improve sleep dysfunction and that it may be an important part of the programming necessary to reduce the epidemic of suffering among health profession trainees. %M 34665153 %R 10.2196/24208 %U https://formative.jmir.org/2021/10/e24208 %U https://doi.org/10.2196/24208 %U http://www.ncbi.nlm.nih.gov/pubmed/34665153 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 10 %P e29160 %T A Mobile App to Identify Lifestyle Indicators Related to Undergraduate Mental Health (Smart Healthy Campus): Observational App-Based Ecological Momentary Assessment %A Brogly,Chris %A Shoemaker,J Kevin %A Lizotte,Daniel J %A Kueper,Jacqueline K %A Bauer,Michael %+ Faculty of Information and Media Studies, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada, 1 (519) 661 2111, cbrogly@uwo.ca %K smartphones %K undergraduates %K mental health %K lifestyle %K postsecondary institutions %K mHealth %K mobile application %K ecological momentary assessment %K mobile phone %D 2021 %7 19.10.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Undergraduate studies are challenging, and mental health issues can frequently occur in undergraduate students, straining campus resources that are already in demand for somatic problems. Cost-effective measures with ubiquitous devices, such as smartphones, offer the potential to deliver targeted interventions to monitor and affect lifestyle, which may result in improvements to student mental health. However, the avenues by which this can be done are not particularly well understood, especially in the Canadian context. Objective: The aim of this study is to deploy an initial version of the Smart Healthy Campus app at Western University, Canada, and to analyze corresponding data for associations between psychosocial factors (measured by a questionnaire) and behaviors associated with lifestyle (measured by smartphone sensors). Methods: This preliminary study was conducted as an observational app-based ecological momentary assessment. Undergraduate students were recruited over email, and sampling using a custom 7-item questionnaire occurred on a weekly basis. Results: First, the 7-item Smart Healthy Campus questionnaire, derived from fully validated questionnaires—such as the Brief Resilience Scale; General Anxiety Disorder-7; and Depression, Anxiety, and Stress Scale–21—was shown to significantly correlate with the mental health domains of these validated questionnaires, illustrating that it is a viable tool for a momentary assessment of an overview of undergraduate mental health. Second, data collected through the app were analyzed. There were 312 weekly responses and 813 sensor samples from 139 participants from March 2019 to March 2020; data collection concluded when COVID-19 was declared a pandemic. Demographic information was not collected in this preliminary study because of technical limitations. Approximately 69.8% (97/139) of participants only completed one survey, possibly because of the absence of any incentive. Given the limited amount of data, analysis was not conducted with respect to time, so all data were analyzed as a single collection. On the basis of mean rank, students showing more positive mental health through higher questionnaire scores tended to spend more time completing questionnaires, showed more signs of physical activity based on pedometers, and had their devices running less and plugged in charging less when sampled. In addition, based on mean rank, students on campus tended to report more positive mental health through higher questionnaire scores compared with those who were sampled off campus. Some data from students found in or near residences were also briefly examined. Conclusions: Given these limited data, participants tended to report a more positive overview of mental health when on campus and when showing signs of higher levels of physical activity. These early findings suggest that device sensors related to physical activity and location are useful for monitoring undergraduate students and designing interventions. However, much more sensor data are needed going forward, especially given the sweeping changes in undergraduate studies due to COVID-19. %M 34665145 %R 10.2196/29160 %U https://formative.jmir.org/2021/10/e29160 %U https://doi.org/10.2196/29160 %U http://www.ncbi.nlm.nih.gov/pubmed/34665145 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 10 %P e29615 %T Validity and Reliability of the Self-administered Psycho-TherApy-SystemS (SELFPASS) Item Pool for the Daily Mood Tracking of Depressive Symptoms: Cross-sectional Web-Based Survey %A Mayer,Gwendolyn %A Hummel,Svenja %A Gronewold,Nadine %A Oetjen,Neele %A Hilbel,Thomas %A Schultz,Jobst-Hendrik %+ Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Im Neuenheimer Feld 130 3, Heidelberg, 69120, Germany, 49 6221 56 35685, gwendolyn.mayer@med.uni-heidelberg.de %K self-management %K mood tracking %K validity %K reliability %K item pool %K questionnaire %K depression %K anxiety %K mood assessment %D 2021 %7 18.10.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: e-Mental health apps targeting depression have gained increased attention in mental health care. Daily self-assessment is an essential part of e-mental health apps. The Self-administered Psycho-TherApy-SystemS (SELFPASS) app is a self-management app to manage depressive and comorbid anxiety symptoms of patients with a depression diagnosis. A self-developed item pool with 40 depression items and 12 anxiety items is included to provide symptom-specific suggestions for interventions. However, the psychometric properties of the item pool have not yet been evaluated. Objective: The aim of this study is to investigate the validity and reliability of the SELFPASS item pool. Methods: A weblink with the SELFPASS item pool and validated mood assessment scales was distributed to healthy subjects and patients who had received a diagnosis of a depressive disorder within the last year. Two scores were derived from the SELFPASS item pool: SELFPASS depression (SP-D) and SELFPASS anxiety (SP-A). Reliability was examined using Cronbach α. Construct validity was assessed through Pearson correlations with the Patient Health Questionnaire-9 (PHQ-9), the General Anxiety Disorder Scale-7 (GAD-7), and the WHO-5-Wellbeing-Scale (WHO-5). Logistic regression analysis was performed as an indicator for concurrent criterion validity of SP-D and SP-A. Factor analysis was performed to provide information about the underlying factor structure of the item pool. Item-scale correlations were calculated in order to determine item quality. Results: A total of 284 participants were included, with 192 (67.6%) healthy subjects and 92 (32.4%) patients. Cronbach α was set to .94 for SP-D and α=.88 for SP-A. We found significant positive correlations between SP-D and PHQ-9 scores (r=0.87; P<.001) and between SP-A and GAD-7 scores (r=0.80; P<.001), and negative correlations between SP-D and WHO-5 scores (r=–0.80; P<.001) and between SP-A and WHO-5 scores (r=–0.69; P<.001). Increasing scores of SP-D and SP-A led to increased odds of belonging to the patient group (SP-D: odds ratio 1.03, 95% CI 1.01-1.05; P<.001; SP-A: 1.05, 1.05-1.01; P=.01). The item pool yielded 2 factors: one that consisted of mood-related items and another with somatic-related items. Conclusions: The SELFPASS item pool showed good psychometric properties in terms of reliability, construct, and criterion validity. The item pool is an appropriate source for daily mood tracking in future e-mental health apps among patients with depression. Our study provides general recommendations for future developments as well as recommendations within the item pool. %M 34661547 %R 10.2196/29615 %U https://mental.jmir.org/2021/10/e29615 %U https://doi.org/10.2196/29615 %U http://www.ncbi.nlm.nih.gov/pubmed/34661547 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 10 %P e32271 %T Acceptability, Engagement, and Effects of a Mobile Digital Intervention to Support Mental Health for Young Adults Transitioning to College: Pilot Randomized Controlled Trial %A Suffoletto,Brian %A Goldstein,Tina %A Gotkiewicz,Dawn %A Gotkiewicz,Emily %A George,Brandie %A Brent,David %+ Department of Emergency Medicine, Stanford University, 900 Welch Road, Suite 350, Palo Alto, CA, 94304, United States, 1 412 901 6892, suffbp@stanford.edu %K college %K mental health %K self-management %K digital intervention %K mHealth %D 2021 %7 14.10.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The transition from high school to college can exacerbate mental health problems in young adults yet barriers prevent seamless mental health care. Existing digital support tools show promise but are not yet designed to optimize engagement or implementation. Objective: The goal of the research was to test acceptability and effects of an automated digital Mobile Support Tool for Mental Health (MoST-MH) for young adults transitioning to college. Methods: Youths aged 18 years and older with a current mental health diagnosis preparing to transition to college (n=52; 85% female [45/52], 91% White [48/52]) were recruited from a primary care (n=31) and a mental health clinic (n=21). Participants were randomized 2:1 to either receive MoST-MH (n=34) or enhanced Usual Care (eUC; n=18). MoST-MH included periodic text message and web-based check-ins of emotional health, stressors, negative impacts, and self-efficacy that informed tailored self-care support messages. Both eUC and MoST-MH participants received links to a library of psychoeducational videos and were asked to complete web-based versions of the Mental Health Self-Efficacy Scale (MHSES), College Counseling Center Assessment of Psychological Symptoms (CCAPS), and Client Service Receipt Inventory for Mental Health (C-SRI) monthly for 3 months and the Post-Study System Usability Scale (PSSUQ) at 3-months. Results: MoST-MH participants were sent a median of 5 (range 3 to 10) text message check-in prompts over the 3-month study period and 100% were completed; participants were sent a median of 2 (range 1 to 8) web-based check-in prompts among which 78% (43/55) were completed. PSSUQ scores indicate high usability (mean score 2.0). Results from the completer analysis demonstrated reductions in mental health symptoms over time and significant between-group effects of MoST-MH compared to eUC on depressive symptom severity (d=0.36, 95% CI 0.08 to 0.64). No significant differences in mental health self-efficacy or mental health health care use were observed. Conclusions: In this pilot trial, we found preliminary evidence that MoST-MH was engaged with at high rates and found to be highly usable and reduced depression symptoms relative to eUC among youth with mental health disorders transitioning to college. Findings were measured during the COVID-19 pandemic, and the study was not powered to detect differences in outcomes between groups; therefore, further testing is needed. Trial Registration: ClinicalTrials.gov NCT04560075; https://clinicaltrials.gov/ct2/show/NCT04560075 %M 34647893 %R 10.2196/32271 %U https://formative.jmir.org/2021/10/e32271 %U https://doi.org/10.2196/32271 %U http://www.ncbi.nlm.nih.gov/pubmed/34647893 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 10 %P e29495 %T Text Messaging Versus Email Messaging to Support Patients With Major Depressive Disorder: Protocol for a Randomized Hybrid Type II Effectiveness-Implementation Trial %A Adu,Medard Kofi %A Shalaby,Reham %A Eboreime,Ejemai %A Sapara,Adegboyega %A Nkire,Nnamdi %A Chawla,Rajan %A Chima,Chidi %A Achor,Michael %A Osiogo,Felix %A Chue,Pierre %A Greenshaw,Andrew J %A Agyapong,Vincent Israel %+ Department of Psychiatry, Faculty of Medicine, Dalhousie University, 5909 Veterans' Memorial Lane, 8th Floor Abbie J. Lane Memorial Building QEII Health Sciences Centre, Halifax, NS, T6G 2B7, Canada, 1 7807144315, vincent.agyapong@nshealth.ca %K email messaging %K text messaging %K supportive %K major depressive disorder %K randomized trial %K mental health %K digital health %K mobile health %K mHealth %K patient care %K health policy %K decision-making %K health care resources %D 2021 %7 13.10.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Major depressive disorder (MDD) accounts for 40.5% of disability-adjusted life years caused by mental and substance use disorders. Barriers such as stigma and financial and physical access to care have been reported, highlighting the need for innovative, accessible, and cost-effective psychological interventions. The effectiveness of supportive SMS text messaging in alleviating depression symptoms has been proven in clinical trials, but this approach can only help those with mobile phones. Objective: This paper presents the protocol for a study that will aim to evaluate the feasibility, comparative effectiveness, and user satisfaction of daily supportive email messaging as an effective strategy compared to daily supportive text messaging as part of the treatment of patients with MDD. Methods: This trial will be carried out using a hybrid type II implementation-effectiveness design. This design evaluates the effectiveness of an implementation strategy or intervention, while also evaluating the implementation context associated with the intervention. Patients with MDD receiving usual care will be randomized to receive either daily supportive email messaging or daily supportive text messaging of the same content for 6 months. The Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the 5-item World Health Organization Well-Being Index will be used to evaluate the effectiveness of both strategies. The implementation evaluation will be guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, as well as the Consolidated Framework for Implementation Research. All outcome measures will be analyzed using descriptive and inferential statistics. Qualitative data will be analyzed using thematic analysis. Results: Data collection for this trial began in April 2021. We expect the study results to be available within 18 months of study commencement. The results will shed light on the feasibility, acceptability, and effectiveness of using automated emails as a strategy for delivering supportive messages to patients with MDD in comparison to text messaging. Conclusions: The outcome of this trial will have translational impact on routine patient care and access to mental health, as well as potentially support mental health policy decision-making for health care resource allocation. Trial Registration: ClinicalTrials.gov NCT04638231; https://clinicaltrials.gov/ct2/show/NCT04638231 International Registered Report Identifier (IRRID): DERR1-10.2196/29495 %M 34643541 %R 10.2196/29495 %U https://www.researchprotocols.org/2021/10/e29495 %U https://doi.org/10.2196/29495 %U http://www.ncbi.nlm.nih.gov/pubmed/34643541 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 10 %P e25772 %T The Use of Task Shifting to Improve Treatment Engagement in an Internet-Based Mindfulness Intervention Among Chinese University Students: Randomized Controlled Trial %A Rodriguez,Marcus %A Eisenlohr-Moul,Tory A %A Weisman,Jared %A Rosenthal,M Zachary %+ Pitzer College, 1050 N Mills Ave, BN 205, Claremont, CA, 91711, United States, 1 9784605088, jweisman@pitzer.edu %K mindfulness %K mental health %K social support %K internet-based intervention %K treatment outcome %K university students %K smartphone %K mobile phone %D 2021 %7 13.10.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Traditional in-person psychotherapies are incapable of addressing global mental health needs. Use of computer-based interventions is one promising solution for closing the gap between the amount of global mental health treatment needed and received. Objective: Although many meta-analyses have provided evidence supporting the efficacy of self-guided, computer-based interventions, most report low rates of treatment engagement (eg, high attrition and low adherence). The aim of this study is to investigate the efficacy of an adjunctive treatment component that uses task shifting, wherein mental health care is provided by nonspecialist peer counselors to enhance engagement in an internet-based, self-directed, evidence-based mindfulness intervention among Chinese university students. Methods: From 3 universities across China, 54 students who reported at least mild stress, anxiety, or depression were randomly assigned to a 4-week internet-based mindfulness intervention (MIND) or to the intervention plus peer counselor support (MIND+), respectively. Be Mindful delivers all the elements of mindfulness-based cognitive therapy in an internet-based, 4-week course. Participants completed daily monitoring of mindfulness practice and mood, as well as baseline and posttreatment self-reported levels of depression, anxiety, stress, and trait mindfulness. We screened 56 volunteer peer counselor candidates who had no former training in the delivery of mental health services. Of these, 10 were invited to participate in a day-long training, and 4 were selected. Peer counselors were instructed to provide 6 brief (15-20 minute) sessions each week, to help encouraging participants to complete the internet-based intervention. Peer counselors received weekly web-based group supervision. Results: For both conditions, participation in the internet-based intervention was associated with significant improvements in mindfulness and mental health outcomes. The pre-post effect sizes (Cohen d) for mindfulness, depression, anxiety, and stress were 0.55, 0.95, 0.89, and 1.13, respectively. Participants assigned to the MIND+ (vs MIND) condition demonstrated significantly less attrition and more adherence, as indicated by a greater likelihood of completing posttreatment assessments (16/27, 59% vs 7/27, 26%; χ21=6.1; P=.01) and a higher percentage of course completion (72.6/100, 72.6% vs 50.7/100, 50.7%; t52=2.10; P=.04), respectively. No significant between-group differences in daily frequency and duration of mindfulness practice were observed. Multilevel logistic growth models showed that MIND+ participants reported significantly greater pre-post improvements in daily stress ratings (interaction estimate 0.39, SE 0.18; t317=2.29; P=.02) and depression (interaction estimate 0.38, SE 0.16; t330=2.37; P=.02) than those in the MIND condition. Conclusions: This study provides new insights into effective ways of leveraging technology and task shifting to implement large-scale mental health initiatives that are financially feasible, easily transportable, and quickly scalable in low-resource settings. The findings suggest that volunteer peer counselors receiving low-cost, low-intensity training and supervision may significantly improve participants’ indices of treatment engagement and mental health outcomes in an internet-based mindfulness intervention among Chinese university students. %M 34643532 %R 10.2196/25772 %U https://formative.jmir.org/2021/10/e25772 %U https://doi.org/10.2196/25772 %U http://www.ncbi.nlm.nih.gov/pubmed/34643532 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 10 %P e26164 %T A Mobile Health Intervention for Patients With Depressive Symptoms: Protocol for an Economic Evaluation Alongside Two Randomized Trials in Brazil and Peru %A Vera Cruz dos Santos,Daniela %A Coelho de Soárez,Patrícia %A Cavero,Victoria %A U Rocha,Thaís I %A Aschar,Suzana %A Daley,Kate Louise %A Garcia Claro,Heloísa %A Abud Scotton,George %A Fernandes,Ivan %A Diez-Canseco,Francisco %A Brandt,Lena Rebeca %A Toyama,Mauricio %A Martins Castro,Hellen Carolina %A Miranda,J Jaime %A Araya,Ricardo %A Quayle,Julieta %A Rossi Menezes,Paulo %+ Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, Av Dr Arnaldo, 455 2º andar sala 2228, São Paulo, 01246-903, Brazil, 55 1130617444, patricia.soarez@usp.br %K cost-effectiveness %K depression %K diabetes %K hypertension %K noncommunicable diseases %K randomized trials %K low- and middle-income countries %K mHealth %K task shifting %K behavioral activation %D 2021 %7 13.10.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mobile health interventions provide significant strategies for improving access to health services, offering a potential solution to reduce the mental health treatment gap. Economic evaluation of this intervention is needed to help inform local mental health policy and program development. Objective: This paper presents the protocol for an economic evaluation conducted alongside 2 randomized controlled trials (RCTs) to evaluate the cost-effectiveness of a psychological intervention delivered through a technological platform (CONEMO) to treat depressive symptoms in people with diabetes, hypertension, or both. Methods: The economic evaluation uses a within-trial analysis to evaluate the incremental costs and health outcomes of CONEMO plus enhanced usual care in comparison with enhanced usual care from public health care system and societal perspectives. Participants are patients of the public health care services for hypertension, diabetes, or both conditions in São Paulo, Brazil (n=880) and Lima, Peru (n=432). Clinical effectiveness will be measured by reduction in depressive symptoms and gains in health-related quality of life. We will conduct cost-effectiveness and cost-utility analyses, providing estimates of the cost per at least 50% reduction in 9-item Patient Health Questionnaire scores, and cost per quality-adjusted life year gained. The measurement of clinical effectiveness and resource use will take place over baseline, 3-month follow-up, and 6-month follow-up in the intervention and control groups. We will use a mixed costing methodology (ie, a combination of top–down and bottom–up approaches) considering 4 cost categories: intervention (CONEMO related) costs, health care costs, patient and family costs, and productivity costs. We will collect unit costs from the RCTs and national administrative databases. The multinational economic evaluations will be fully split analyses with a multicountry costing approach. We will calculate incremental cost-effectiveness ratios and present 95% CIs from nonparametric bootstrapping (1000 replicates). We will perform deterministic and probabilistic sensitivity analyses. Finally, we will present cost-effectiveness acceptability curves to compare a range of possible cost-effectiveness thresholds. Results: The economic evaluation project had its project charter in June 2018 and is expected to be completed in September 2021. The final results will be available in the second half of 2021. Conclusions: We expect to assess whether CONEMO plus enhanced usual care is a cost-effective strategy to improve depressive symptoms in this population compared with enhanced usual care. This study will contribute to the evidence base for health managers and policy makers in allocating additional resources for mental health initiatives. It also will provide a basis for further research on how this emerging technology and enhanced usual care can improve mental health and well-being in low- and middle-income countries. Trial Registration: ClinicalTrials.gov NCT12345678 (Brazil) and NCT03026426 (Peru); https://clinicaltrials.gov/ct2/show/NCT02846662 and https://clinicaltrials.gov/ct2/show/NCT03026426 International Registered Report Identifier (IRRID): DERR1-10.2196/26164 %M 34643538 %R 10.2196/26164 %U https://www.researchprotocols.org/2021/10/e26164 %U https://doi.org/10.2196/26164 %U http://www.ncbi.nlm.nih.gov/pubmed/34643538 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 10 %P e32544 %T Effectiveness of Telehealth Interventions for Women With Postpartum Depression: Systematic Review and Meta-analysis %A Zhao,Liuhong %A Chen,Jingfen %A Lan,Liuying %A Deng,Ni %A Liao,Yan %A Yue,Liqun %A Chen,Innie %A Wen,Shi Wu %A Xie,Ri-hua %+ Department of Nursing, The Seventh Affiliated Hospital, Southern Medical University, 28 Liguan Road, Lishui, Foshan, 528244, China, 86 189 2869 7126, xierihua928@hotmail.com %K telehealth %K postpartum depression %K anxiety %K meta-analysis %D 2021 %7 7.10.2021 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Postpartum depression (PPD) is a prevalent mental health problem with serious adverse consequences for affected women and their infants. Clinical trials have found that telehealth interventions for women with PPD result in increased accessibility and improved treatment effectiveness. However, no comprehensive synthesis of evidence from clinical trials by systematic review has been conducted. Objective: The aim of this study is to evaluate the effectiveness of telehealth interventions in reducing depressive symptoms and anxiety in women with PPD. To enhance the homogeneity and interpretability of the findings, this systematic review focuses on PPD measured by the Edinburgh Postnatal Depression Scale (EPDS). Methods: PubMed, The Cochrane Library, CINAHL, PsycINFO, CNKI, and Wanfang were electronically searched to identify randomized controlled trials (RCTs) on the effectiveness of telehealth interventions for women with PPD from inception to February 28, 2021. Data extraction and quality assessment were performed independently by two researchers. The quality of included studies was assessed using the Cochrane risk-of-bias tool, and meta-analysis was performed using RevMan 5.4 software. Results: Following the search, 9 RCTs with a total of 1958 women with PPD were included. The EPDS (mean difference=–2.99, 95% CI –4.52 to –1.46; P<.001) and anxiety (standardized mean difference=–0.39, 95% CI –0.67 to –0.12; P=.005) scores were significantly lower in the telehealth group compared with the control group. Significant subgroup differences were found in depressive symptoms according to the severity of PPD, telehealth technology, specific therapy, and follow-up time (P<.001). Conclusions: Telehealth interventions could effectively reduce the symptoms of depression and anxiety in women with PPD. However, better designed and more rigorous large-scale RCTs targeting specific therapies are needed to further explore the potential of telehealth interventions for PPD. Trial Registration: PROSPERO CRD42021258541; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=258541 %M 34617909 %R 10.2196/32544 %U https://mhealth.jmir.org/2021/10/e32544 %U https://doi.org/10.2196/32544 %U http://www.ncbi.nlm.nih.gov/pubmed/34617909 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 10 %P e32216 %T Evaluation of Novel Concentrated Interdisciplinary Group Rehabilitation for Patients With Chronic Illnesses: Protocol for a Nonrandomized Clinical Intervention Study %A Kvale,Gerd %A Frisk,Bente %A Jürgensen,Marte %A Børtveit,Tore %A Ødegaard-Olsen,Øystein Theodor %A Wilhelmsen-Langeland,Ane %A Aarli,Bernt Bøgvald %A Sandnes,Kristina %A Rykken,Sidsel %A Haugstvedt,Anne %A Hystad,Sigurd William %A Søfteland,Eirik %+ Division of Psychiatry, Haukeland University Hospital, PO Box 1400, Bergen, 5021, Norway, 47 55975000, gerd.kvale@helse-bergen.no %K COVID-19 %K chronic illnesses %K concentrated rehabilitation %K low back pain %K post–COVID-19 symptoms %K post–COVID-19 syndrome %K long COVID %K fatigue %K type 2 diabetes %K anxiety %K depression %D 2021 %7 7.10.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: An aging population with a growing burden of chronic complex illnesses will seriously challenge the public health care system. Consequently, novel and efficacious treatment approaches are highly warranted. Based on our experiences with concentrated treatment formats for other health challenges, we developed a highly concentrated interdisciplinary group rehabilitation approach for chronic illnesses. Objective: We aim to explore the acceptability of the intervention and describe potential changes in functional impairment at follow-up. Methods: The cornerstones of the intervention are as follows: (1) prepare the patient for change prior to treatment, (2) focus on health promoting microchoices instead of symptoms, and (3) expect the patient to integrate the changes in everyday living with limited hands-on follow-up. The intervention will be delivered to patients with highly diverse primary symptoms, namely patients with low back pain, post–COVID-19 symptoms, anxiety and depression, and type 2 diabetes. Results: Recruitment started between August 2020 and January 2021 (according to the illness category). For initial 3-month results, recruitment is expected to be completed by the end of 2021. Conclusions: If successful, this study may have a substantial impact on the treatment of low back pain, post–COVID-19 symptoms, anxiety and depression, and type 2 diabetes, which together constitute a major socioeconomic cost. Further, the study may widen the evidence base for the use of the concentrated treatment format in a diverse group of medical conditions. International Registered Report Identifier (IRRID): DERR1-10.2196/32216 %M 34505838 %R 10.2196/32216 %U https://www.researchprotocols.org/2021/10/e32216 %U https://doi.org/10.2196/32216 %U http://www.ncbi.nlm.nih.gov/pubmed/34505838 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 10 %P e30757 %T The COVID-19 Study of Healthcare and Support Personnel (CHAMPS): Protocol for a Longitudinal Observational Study %A Kaufmann,Peter G %A Havens,Donna S %A Mensinger,Janell L %A Bradley,Patricia K %A Brom,Heather M %A Copel,Linda C %A Costello,Alexander %A D'Annunzio,Christine %A Dean Durning,Jennifer %A Maldonado,Linda %A Barrow McKenzie,Ann %A Smeltzer,Suzanne C %A Yost,Jennifer %A , %+ M. Louise Fitzapatrick College of Nursing, Villanova University, 800 Lancaster Ave, Villanova, PA, 19085, United States, 1 6105195972, peter.kaufmann@villanova.edu %K COVID-19 %K SARS-CoV-2 %K stress %K depression %K anxiety %K sleep %K social support %K resilience %K mental health %K physical health %D 2021 %7 7.10.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Early in the development of the COVID-19 pandemic, it was evident that health care workers, first responders, and other essential workers would face significant stress and workplace demands related to equipment shortages and rapidly growing infections in the general population. Although the effects of other sources of stress on health have been documented, the effects of these unique conditions of the COVID-19 pandemic on the long-term health and well-being of the health care workforce are not known. Objective: The COVID-19 Study of Healthcare and Support Personnel (CHAMPS) was designed to document early and longitudinal effects of the pandemic on the mental and physical health of essential workers engaged in health care. We will investigate mediators and moderators of these effects and evaluate the influence of exposure to stress, including morbidity and mortality, over time. We will also examine the effect of protective factors and resilience on health outcomes. Methods: The study cohort is a convenience sample recruited nationally through communities, professional organizations, networks, social media, and snowball sampling. Recruitment took place for 13 months to obtain an estimated sample of 2762 adults who provided self-reported information administered on the web through structured questionnaires about their work environment, mental and physical health, and psychosocial factors. Follow-up questionnaires will be administered after 6 months and annually thereafter to ascertain changes in health, well-being, and lifestyle. Participants who consented to be recontacted form the longitudinal cohort and the CHAMPS Registry may be contacted to ascertain their interest in ancillary studies for which they may be eligible. Results: The study was approved by the Institutional Review Board and launched in May 2020, with grants from Travere Therapeutics Inc, McKesson Corporation, anonymous donors, and internal funding from the M. Louise Fitzpatrick College of Nursing at Villanova University. Recruitment ended in June 2021 after enrolling 2762 participants, 1534 of whom agreed to participate in the longitudinal study and the registry as well as to be contacted about eligibility for future studies. Conclusions: The CHAMPS Study and Registry will enable the acquisition of detailed data on the effects of extended psychosocial and workplace stress on morbidity and mortality and serve as a platform for ancillary studies related to the COVID-19 pandemic. Trial Registration: ClinicalTrials.gov NCT04370821; https://clinicaltrials.gov/ct2/show/NCT04370821 International Registered Report Identifier (IRRID): DERR1-10.2196/30757 %M 34582354 %R 10.2196/30757 %U https://www.researchprotocols.org/2021/10/e30757 %U https://doi.org/10.2196/30757 %U http://www.ncbi.nlm.nih.gov/pubmed/34582354 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 10 %P e31273 %T Supporting Mental Health During the COVID-19 Pandemic Using a Digital Behavior Change Intervention: An Open-Label, Single-Arm, Pre-Post Intervention Study %A Summers,Charlotte %A Wu,Philip %A Taylor,Alisdair J G %+ DDM Health, Technology House, Science Park, University of Warwick, Coventry, CV4 7EZ, United Kingdom, 44 7969091134, charlotte@ddm.health %K stress %K mental health %K COVID-19 %K digital therapy %K mHealth %K support %K behavior %K intervention %K online intervention %K outcome %K wellbeing %K sleep %K activity %K nutrition %D 2021 %7 6.10.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The COVID-19 pandemic is taking a toll on people’s mental health, particularly as people are advised to adhere to social distancing, self-isolation measures, and government-imposed national lockdowns. Digital health technologies have an important role to play in keeping people connected and in supporting their mental health and well-being. Even before the COVID-19 pandemic, mental health and social services were already strained. Objective: Our objective was to evaluate the 12-week outcomes of the digitally delivered Gro Health intervention, a holistic digital behavior change app designed for self-management of mental well-being, sleep, activity, and nutrition. Methods: The study used a quasi-experimental research design consisting of an open-label, single-arm, pre-post intervention engagement using a convenience sample. Adults who had joined the Gro Health app (intervention) and had a complete baseline dataset (ie, 7-item Generalized Anxiety Disorder scale, Perceived Stress Scale, and 9-item Patient Health Questionnaire) were followed up at 12 weeks (n=273), including 33 (12.1%) app users who reported a positive COVID-19 diagnosis during the study period. User engagement with the Gro Health platform was tracked by measuring total minutes of app engagement. Paired t tests were used to compare pre-post intervention scores. Linear regression analysis was performed to assess the relationship between minutes of active engagement with the Gro Health app and changes in scores across the different mental health measures. Results: Of the 347 study participants, 273 (78.67%) completed both the baseline and follow-up surveys. Changes in scores for anxiety, perceived stress, and depression were predicted by app engagement, with the strongest effect observed for changes in perceived stress score (F1,271=251.397; R2=0.479; P<.001). Conclusions: A digital behavior change platform that provides remote mental well-being support can be effective in managing depression, anxiety, and perceived stress during times of crisis such as the current COVID-19 pandemic. The outcomes of this study may also support the implementation of remote digital health apps supporting behavior change and providing support for low levels of mental health within the community. %M 34459740 %R 10.2196/31273 %U https://formative.jmir.org/2021/10/e31273 %U https://doi.org/10.2196/31273 %U http://www.ncbi.nlm.nih.gov/pubmed/34459740 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 4 %N 4 %P e29953 %T The Association of Delayed Care With Depression Among US Middle-Aged and Older Adults During the COVID-19 Pandemic: Cross-sectional Analysis %A Luo,Yan %+ The University of Alabama, 2106 Forest Lake Dr., Tuscaloosa, AL, 35401, United States, 1 2058868781, yluo30@crimson.ua.edu %K depression %K COVID-19 %K delayed care %K middle-aged adults %K older adults %D 2021 %7 5.10.2021 %9 Original Paper %J JMIR Aging %G English %X Background: During the COVID-19 pandemic, the depression level among US adults has significantly increased. Age disparity in depression during the pandemic has been reported in recent studies. Delay or avoidance of medical care is one of the collateral damages associated with the COVID-19 pandemic, and it can lead to increased morbidity and mortality. Objective: This study aimed to assess the prevalence of depression and delayed care among US middle-aged adults and older adults during the pandemic, as well as investigate the association of delayed care with depression among those 2 age groups. Methods: This cross-sectional study used data from the 2020 Health and Retirement Study (HRS) COVID-19 Project (Early, Version 1.0). Univariate analyses, bivariate analyses, and binary logistic regression were applied. US adults older than 46 years were included. Depression was measured by the Composite International Diagnostic Interview-Short Form (CIDI-SF). Delayed care was measured by the following 4 items: delayed surgery, delayed seeing a doctor, delayed dental care, and other delayed care. Results: A total of 3246 participants were identified. More than half of the participants were older than 65 years (n=1890, 58.2%), and 274 (8.8%) participants had depression during the pandemic. Delayed dental care was positively associated with depression among both middle-aged adults (OR 2.05, 95% CI 1.04-4.03; P=.04) and older adults (OR 3.08, 95% CI 1.07-8.87; P=.04). Delayed surgery was positively associated with depression among older adults (OR 3.69, 95% CI 1.06-12.90; P=.04). Self-reported pain was positively related to depression among both age groups. Middle-aged adults who reported higher education levels (some college or above) or worse self-reported health had a higher likelihood of having depression. While perceived more loneliness was positively associated with depression among older adults, financial difficulty was positively associated with depression among middle-aged adults. Conclusions: This study found that depression was prevalent among middle-aged and older adults during the pandemic. The study highlighted the collateral damage of the COVID-19 pandemic by identifying the association of delayed surgery and dental care with depression during the pandemic. Although surgery and dental care cannot be delivered by telehealth, telehealth services can still be provided to address patients’ concerns on delayed surgery and dental care. Moreover, the implementation of telemental health services is needed to address mental health symptoms among US middle-aged and older adults during the pandemic. Future research that uses more comprehensive measurements for delayed care is needed to decipher the path through which delayed care is associated with depression. %M 34524964 %R 10.2196/29953 %U https://aging.jmir.org/2021/4/e29953 %U https://doi.org/10.2196/29953 %U http://www.ncbi.nlm.nih.gov/pubmed/34524964 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 10 %P e31722 %T Practical and Emotional Problems Reported by Users of a Self-guided Digital Problem-solving Intervention During the COVID-19 Pandemic: Content Analysis %A Hentati,Amira %A Forsell,Erik %A Ljótsson,Brjánn %A Kraepelien,Martin %+ Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Norra Stationsgatan 69, Stockholm, 11364, Sweden, 46 704411425, amira.hentati@ki.se %K digital intervention %K COVID-19 %K problem-solving %K self-guided intervention %K content analysis %K public health %K mental health %K depression %K anxiety %K pandemic %D 2021 %7 4.10.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: To better direct assessments and interventions toward the general population during both the ongoing COVID-19 pandemic and future crises with societal restrictions, data on the types of practical and emotional problems that people are experiencing are needed. Objective: The aim of this study was to examine the types of practical and emotional problems that the general population is experiencing during the COVID-19 pandemic and to construct an empirically derived inventory based on the findings. Methods: A total of 396 participants, recruited among members of the general public in Sweden who were experiencing practical and/or emotional problems during the pandemic, accessed a self-guided digital problem-solving intervention for a period of 1 week to report and solve the problems they experienced. Prior to accessing the intervention, the participants completed a short self-assessment regarding symptoms of depression and anxiety. Content analysis was used to account for the types of problems participants reported. A set of items for an inventory was later proposed based on the problem categories derived from the analysis. Results: A majority of participants had clinically relevant symptoms of either depression or anxiety. The problems reported were categorized as 13 distinct types of problems. The most common problem was difficulty managing daily activities. Based on the categories, a 13-item inventory was proposed. Conclusions: The 13 types of problems, and the proposed inventory, could be valuable when composing assessments and interventions for the general population during the ongoing pandemic or similar crises with societal restrictions. The most common problem was of a practical nature, indicating the importance of including examples of such problems within assessments and interventions. Trial Registration: ClinicalTrials.gov NCT04677270; https://clinicaltrials.gov/ct2/show/NCT04677270 %M 34559670 %R 10.2196/31722 %U https://formative.jmir.org/2021/10/e31722 %U https://doi.org/10.2196/31722 %U http://www.ncbi.nlm.nih.gov/pubmed/34559670 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e28765 %T Finding Relevant Psychoeducation Content for Adolescents Experiencing Symptoms of Depression: Content Analysis of User-Generated Online Texts %A Dysthe,Kim K %A Haavet,Ole R %A Røssberg,Jan I %A Brandtzaeg,Petter B %A Følstad,Asbjørn %A Klovning,Atle %+ Department of General Practice/Family Medicine, University of Oslo, Kirkeveien 166, Oslo, 0450, Norway, 47 22 85 05 50, k.k.dysthe@medisin.uio.no %K adolescent %K depression %K internet %K education %K preventive psychiatry %K early medical intervention %K self-report %K psychoeducation %K information content %K online %K digital health %K e-health %D 2021 %7 30.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Symptoms of depression are frequent in youth and may develop into more severe mood disorders, suggesting interventions should take place during adolescence. However, young people tend not to share mental problems with friends, family, caregivers, or professionals. Many receive misleading information when searching the internet. Among several attempts to create mental health services for adolescents, technological information platforms based on psychoeducation show promising results. Such development rests on established theories and therapeutic models. To fulfill the therapeutic potential of psychoeducation in health technologies, we lack data-driven research on young peoples’ demand for information about depression. Objective: Our objective is to gain knowledge about what information is relevant to adolescents with symptoms of depression. From this knowledge, we can develop a population-specific psychoeducation for use in different technology platforms. Methods: We conducted a qualitative, constructivist-oriented content analysis of questions submitted by adolescents aged 16-20 years to an online public information service. A sample of 100 posts containing questions on depression were randomly selected from a total of 870. For analysis, we developed an a priori codebook from the main information topics of existing psychoeducational programs on youth depression. The distribution of topic prevalence in the total volume of posts containing questions on depression was calculated. Results: With a 95% confidence level and a ±9.2% margin of error, the distribution analysis revealed the following categories to be the most prevalent among adolescents seeking advice about depression: self-management (33%, 61/180), etiology (20%, 36/180), and therapy (20%, 36/180). Self-management concerned subcategories on coping in general and how to open to friends, family, and caregivers. The therapy topic concerned therapy options, prognosis, where to seek help, and how to open up to a professional. We also found young people dichotomizing therapy and self-management as opposite entities. The etiology topic concerned stressors and risk factors. The diagnosis category was less frequently referred to (9%, 17/180). Conclusions: Self-management, etiology, and therapy are the most prevalent categories among adolescents seeking advice about depression. Young people also dichotomize therapy and self-management as opposite entities. Future research should focus on measures to promote self-management, measures to stimulate expectations of self-efficacy, information about etiology, and information about diagnosis to improve self-monitoring skills, enhancing relapse prevention. %M 34591021 %R 10.2196/28765 %U https://www.jmir.org/2021/9/e28765 %U https://doi.org/10.2196/28765 %U http://www.ncbi.nlm.nih.gov/pubmed/34591021 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e24560 %T Prevention of Suicidal Relapses in Adolescents With a Smartphone Application: Bayesian Network Analysis of a Preclinical Trial Using In Silico Patient Simulations %A Mouchabac,Stephane %A Leray,Philippe %A Adrien,Vladimir %A Gollier-Briant,Fanny %A Bonnot,Olivier %+ Department of Child and Adolescent Psychiatry, Centre hospitalier universitaire de Nantes, 30 boulevard Jean Monnet, Nantes, 44000, France, 33 4323232, olivier.bonnot@chu-nantes.fr %K suicide %K bayesian network %K smartphone application %K digital psychiatry %K artificial intelligence %D 2021 %7 30.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Recently, artificial intelligence technologies and machine learning methods have offered attractive prospects to design and manage crisis response processes, especially in suicide crisis management. In other domains, most algorithms are based on big data to help diagnose and suggest rational treatment options in medicine. But data in psychiatry are related to behavior and clinical evaluation. They are more heterogeneous, less objective, and incomplete compared to other fields of medicine. Consequently, the use of psychiatric clinical data may lead to less accurate and sometimes impossible-to-build algorithms and provide inefficient digital tools. In this case, the Bayesian network (BN) might be helpful and accurate when constructed from expert knowledge. Medical Companion is a government-funded smartphone application based on repeated questions posed to the subject and algorithm-matched advice to prevent relapse of suicide attempts within several months. Objective: Our paper aims to present our development of a BN algorithm as a medical device in accordance with the American Psychiatric Association digital healthcare guidelines and to provide results from a preclinical phase. Methods: The experts are psychiatrists working in university hospitals who are experienced and trained in managing suicidal crises. As recommended when building a BN, we divided the process into 2 tasks. Task 1 is structure determination, representing the qualitative part of the BN. The factors were chosen for their known and demonstrated link with suicidal risk in the literature (clinical, behavioral, and psychometrics) and therapeutic accuracy (advice). Task 2 is parameter elicitation, with the conditional probabilities corresponding to the quantitative part. The 4-step simulation (use case) process allowed us to ensure that the advice was adapted to the clinical states of patients and the context. Results: For task 1, in this formative part, we defined clinical questions related to the mental state of the patients, and we proposed specific factors related to the questions. Subsequently, we suggested specific advice related to the patient’s state. We obtained a structure for the BN with a graphical representation of causal relations between variables. For task 2, several runs of simulations confirmed the a priori model of experts regarding mental state, refining the precision of our model. Moreover, we noticed that the advice had the same distribution as the previous state and was clinically relevant. After 2 rounds of simulation, the experts found the exact match. Conclusions: BN is an efficient methodology to build an algorithm for a digital assistant dedicated to suicidal crisis management. Digital psychiatry is an emerging field, but it needs validation and testing before being used with patients. Similar to psychotropics, any medical device requires a phase II (preclinical) trial. With this method, we propose another step to respond to the American Psychiatric Association guidelines. Trial Registration: ClinicalTrials.gov NCT03975881; https://clinicaltrials.gov/ct2/show/NCT03975881 %M 34591030 %R 10.2196/24560 %U https://www.jmir.org/2021/9/e24560 %U https://doi.org/10.2196/24560 %U http://www.ncbi.nlm.nih.gov/pubmed/34591030 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 9 %P e30305 %T Effectiveness of an Internet-Based Machine-Guided Stress Management Program Based on Cognitive Behavioral Therapy for Improving Depression Among Workers: Protocol for a Randomized Controlled Trial %A Kawakami,Norito %A Imamura,Kotaro %A Watanabe,Kazuhiro %A Sekiya,Yuki %A Sasaki,Natsu %A Sato,Nana %A , %+ Department of Mental Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan, 81 358413521, nkawakami@m.u-tokyo.ac.jp %K deep learning %K unguided intervention %K universal prevention %K workplace %K depression %K machine learning %D 2021 %7 29.9.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The effect of an unguided internet-based cognitive behavioral therapy (iCBT) stress management program on depression may be enhanced by applying artificial intelligence (AI) technologies to guide participants adopting the program. Objective: The aim of this study is to describe a research protocol to investigate the effect of a newly developed iCBT stress management program adopting AI technologies on improving depression among healthy workers during the COVID-19 pandemic. Methods: This study is a two-arm, parallel, randomized controlled trial. Participants (N=1400) will be recruited, and those who meet the inclusion criteria will be randomly allocated to the intervention or control (treatment as usual) group. A 6-week, six-module, internet-based stress management program, SMART-CBT, has been developed that includes machine-guided exercises to help participants acquire CBT skills, and it applies machine learning and deep learning technologies. The intervention group will participate in the program for 10 weeks. The primary outcome, depression, will be measured using the Beck Depression Inventory II at baseline and 3- and 6-month follow-ups. A mixed model repeated measures analysis will be used to test the intervention effect (group × time interactions) in the total sample (universal prevention) on an intention-to-treat basis. Results: The study was at the stage of recruitment of participants at the time of submission. The data analysis related to the primary outcome will start in January 2022, and the results might be published in 2022 or 2023. Conclusions: This is the first study to investigate the effectiveness of a fully automated machine-guided iCBT program for improving subthreshold depression among workers using a randomized controlled trial design. The study will explore the potential of a machine-guided stress management program that can be disseminated online to a large number of workers with minimal cost in the post–COVID-19 era. Trial Registration: UMIN Clinical Trials Registry（UMIN-CTR) UMIN000043897; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000050125 International Registered Report Identifier (IRRID): PRR1-10.2196/30305 %M 34460414 %R 10.2196/30305 %U https://www.researchprotocols.org/2021/9/e30305 %U https://doi.org/10.2196/30305 %U http://www.ncbi.nlm.nih.gov/pubmed/34460414 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e29412 %T Just-in-Time Adaptive Mechanisms of Popular Mobile Apps for Individuals With Depression: Systematic App Search and Literature Review %A Teepe,Gisbert W %A Da Fonseca,Ashish %A Kleim,Birgit %A Jacobson,Nicholas C %A Salamanca Sanabria,Alicia %A Tudor Car,Lorainne %A Fleisch,Elgar %A Kowatsch,Tobias %+ Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Weinbergstrasse 56/58, Zurich, 8092, Switzerland, 41 76 419 09 91, gteepe@ethz.ch %K depression %K digital mental health %K smartphone applications %K just-in-time adaptive interventions %K effectiveness %K mobile phone %D 2021 %7 28.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The number of smartphone apps that focus on the prevention, diagnosis, and treatment of depression is increasing. A promising approach to increase the effectiveness of the apps while reducing the individual’s burden is the use of just-in-time adaptive intervention (JITAI) mechanisms. JITAIs are designed to improve the effectiveness of the intervention and reduce the burden on the person using the intervention by providing the right type of support at the right time. The right type of support and the right time are determined by measuring the state of vulnerability and the state of receptivity, respectively. Objective: The aim of this study is to systematically assess the use of JITAI mechanisms in popular apps for individuals with depression. Methods: We systematically searched for apps addressing depression in the Apple App Store and Google Play Store, as well as in curated lists from the Anxiety and Depression Association of America, the United Kingdom National Health Service, and the American Psychological Association in August 2020. The relevant apps were ranked according to the number of reviews (Apple App Store) or downloads (Google Play Store). For each app, 2 authors separately reviewed all publications concerning the app found within scientific databases (PubMed, Cochrane Register of Controlled Trials, PsycINFO, Google Scholar, IEEE Xplore, Web of Science, ACM Portal, and Science Direct), publications cited on the app’s website, information on the app’s website, and the app itself. All types of measurements (eg, open questions, closed questions, and device analytics) found in the apps were recorded and reviewed. Results: None of the 28 reviewed apps used JITAI mechanisms to tailor content to situations, states, or individuals. Of the 28 apps, 3 (11%) did not use any measurements, 20 (71%) exclusively used self-reports that were insufficient to leverage the full potential of the JITAIs, and the 5 (18%) apps using self-reports and passive measurements used them as progress or task indicators only. Although 34% (23/68) of the reviewed publications investigated the effectiveness of the apps and 21% (14/68) investigated their efficacy, no publication mentioned or evaluated JITAI mechanisms. Conclusions: Promising JITAI mechanisms have not yet been translated into mainstream depression apps. Although the wide range of passive measurements available from smartphones were rarely used, self-reported outcomes were used by 71% (20/28) of the apps. However, in both cases, the measured outcomes were not used to tailor content and timing along a state of vulnerability or receptivity. Owing to this lack of tailoring to individual, state, or situation, we argue that the apps cannot be considered JITAIs. The lack of publications investigating whether JITAI mechanisms lead to an increase in the effectiveness or efficacy of the apps highlights the need for further research, especially in real-world apps. %M 34309569 %R 10.2196/29412 %U https://www.jmir.org/2021/9/e29412 %U https://doi.org/10.2196/29412 %U http://www.ncbi.nlm.nih.gov/pubmed/34309569 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 9 %P e28538 %T Health Care Provider Perspectives on the Use of a Digital Behavioral Health App to Support Patients: Qualitative Study %A Silfee,Valerie %A Williams,Kelly %A Leber,Brett %A Kogan,Jane %A Nikolajski,Cara %A Szigethy,Eva %A Serio,Catherine %+ UPMC Health Plan, U.S. Steel Tower, 600 Grant Street, Pittsburgh, PA, 15219, United States, 1 4124549008, silfeev@upmc.edu %K digital health %K mHealth %K implementation %K cognitive behavioral therapy %K anxiety %K depression %K smartphone %K mobile phone %D 2021 %7 28.9.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Despite the growing evidence indicating the efficacy of digital cognitive behavioral interventions (dCBIs) for behavioral health (BH) treatment, broad and consistent use of such interventions has been limited by knowledge obtained in real-world settings, including factors that impact provider uptake/referral. Engaging providers early in the implementation process offers an opportunity to explore their needs and behaviors, integrate interventions into workflows, and better understand provider setting capabilities. Objective: This study assessed providers’ views on the feasibility and acceptability of delivering a cognitive behavioral therapy (CBT)-based mobile app in multiple care settings. Methods: Participating providers included BH and physical health (PH) providers from a women’s health center, an outpatient BH clinic, and both rural/urban primary care settings. All participating providers cocreated workflows through facilitated workshops, including establishing feedback loops between the project team and providers and identifying clinical champions at each site. Over a 12-week period, the providers referred adult patients experiencing anxiety or depression to a mobile app-based dCBI, RxWell, and provided other indicated treatments as part of usual care. Referrals were completed by the providers through the electronic medical record. To better understand facilitators of and challenges in integrating RxWell into routine practice and perceptions of sustainability, a series of qualitative interviews was conducted. Interview data were analyzed to identify major themes using an inductive content analysis approach. Results: A total of 19 provider interviews were conducted to discover motivators and barriers for referring RxWell. The providers benefited from a focused discussion on how to incorporate the referral process into their workflow, and knowing the app content was rooted in evidence. Although the providers believed engaging in experiential learning was important, they indicated that more education on the digital health coach role and how to monitor patient progress is needed. The providers thought patient engagement may be impacted by motivation, a lack of comfort using a smartphone, or preference for in-person therapy. The providers also expressed enthusiasm in continuing to refer the app. They liked the ability to provide patients with support between sessions, to have an extra treatment option that teaches BH exercises, and to have a CBT treatment option that overcomes barriers (eg, wait times, copays, travel) to traditional therapy modalities. Conclusions: Digital intervention success in health care settings relies heavily on engagement of key stakeholders, such as providers, in both design and implementation of the intervention and focused evaluation within intended care setting(s). Scaling digital interventions to meet the mental health needs of patients in usual care settings leans on thoughtfully constructed and streamlined workflows to enable seamless referral of patients by providers. Our findings strongly suggest that providers are supportive of digital tool integration to support the mental health of patients and endorse its use within their routine workflow. %M 34529583 %R 10.2196/28538 %U https://formative.jmir.org/2021/9/e28538 %U https://doi.org/10.2196/28538 %U http://www.ncbi.nlm.nih.gov/pubmed/34529583 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e28700 %T Longitudinal Relationships Among Fear of COVID-19, Smartphone Online Self-Disclosure, Happiness, and Psychological Well-being: Survey Study %A Matthes,Jörg %A Koban,Kevin %A Neureiter,Ariadne %A Stevic,Anja %+ Department of Communication, University of Vienna, Währinger Straße 29, R. 7.45, Vienna, 1090, Austria, 43 1 4277 493 39, kevin.koban@univie.ac.at %K COVID-19 pandemic %K fear %K self-disclosure %K happiness, well-being %K panel study %K smartphones %K online platform %K social media %D 2021 %7 27.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Given that governmental prevention measures restricted most face-to-face communications, online self-disclosure via smartphones emerged as an alternative coping strategy that aimed at reducing the impact of the COVID-19 pandemic on people’s psychological health. Prepandemic research demonstrated that online self-disclosure benefits people’s psychological health by establishing meaningful relationships, obtaining social support, and achieving self-acceptance, particularly in times of crisis. However, it is unclear whether these dynamics transition well to lockdown conditions where online self-disclosure must stand almost entirely on its own. Longitudinal investigations are needed to gain insights into the psychological functionalities of online self-disclosure during the COVID-19 pandemic. Objective: This study aimed to determine the temporal associations between smartphone online self-disclosure (as a communicative behavior) and critical indicators of psychological health (including psychopathological, as well as hedonic and eudaimonic states) during the first COVID-19 lockdown in Austria. Methods: We conducted a representative 2-wave panel survey between late March/April 2020 and May 2020. A total of 416 participants completed both waves (43.1% attrition rate, given n=731 participants who completed the first wave). A partially metric measurement invariant overtime structural equation model was used to determine the temporal associations among online self-disclosure, fear of COVID-19, happiness, and psychological well-being. Results: The analysis revealed that fear of COVID-19 significantly predicted online self-disclosure over time (b=0.24, P=.003) and happiness over time (b=−0.14, P=.04), but not psychological well-being (b=0.03, P=.48), that is, stronger COVID-19 fears at T1 prompted more online self-disclosure and less happiness at T2. Online self-disclosure, on the other hand, significantly predicted happiness (b=0.09, P=.02), but neither fear of COVID-19 (b=−0.01, P=.57) nor psychological well-being (b=−0.01, P=.57) over time. Participants who engaged more strongly in online self-disclosure at T1 felt happier at T2, but they did not differ from less-disclosing participants concerning COVID-19 fears and psychological well-being at T2. Importantly, happiness and psychological well-being were significantly related over time (happiness T1 → psychological well-being T2: b=0.11, P<.001; psychological well-being T1 → happiness T2: b=0.42, P<.001). Conclusions: Our findings suggest that online self-disclosure might play a pivotal role in coping with pandemic stressors. With restrictions on their options, individuals increasingly turn to their smartphones and social media to disclose their feelings, problems, and concerns during lockdown. While online self-disclosure might not alleviate fears or improve psychological well-being, our results demonstrate that it made people experience more happiness during this crisis. This psychological resource may help them withstand the severe psychological consequences of the COVID-19 crisis over longer timeframes. %M 34519657 %R 10.2196/28700 %U https://www.jmir.org/2021/9/e28700 %U https://doi.org/10.2196/28700 %U http://www.ncbi.nlm.nih.gov/pubmed/34519657 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 9 %P e32663 %T Exploring the Well-being of Health Care Workers During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Study %A Liu,Jenny J W %A Nazarov,Anthony %A Plouffe,Rachel A %A Forchuk,Callista A %A Deda,Erisa %A Gargala,Dominic %A Le,Tri %A Bourret-Gheysen,Jesse %A Soares,Vanessa %A Nouri,Maede S %A Hosseiny,Fardous %A Smith,Patrick %A Roth,Maya %A MacDougall,Arlene G %A Marlborough,Michelle %A Jetly,Rakesh %A Heber,Alexandra %A Albuquerque,Joy %A Lanius,Ruth %A Balderson,Ken %A Dupuis,Gabrielle %A Mehta,Viraj %A Richardson,J Don %+ MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, St. Joseph's Health Care London, Parkwood Institute Research, Mental Health Building RM F4-367, 550 Wellington Road, London, ON, N6C 0A7, Canada, 1 519 685 4292 ext 48211, jenny.liu@sjhc.london.on.ca %K COVID-19 %K health care worker %K pandemic %K mental health %K wellbeing %K survey %K design %K longitudinal %K prospective %K protocol %K challenge %K impact %K distress %K perception %D 2021 %7 27.9.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Health care workers (HCWs) have experienced several stressors associated with the COVID-19 pandemic. Structural stressors, including extended work hours, redeployment, and changes in organizational mandates, often intersect with interpersonal and personal stressors, such as caring for those with COVID-19 infections; worrying about infection of self, family, and loved ones; working despite shortages of personal protective equipment; and encountering various difficult moral-ethical dilemmas. Objective: The paper describes the protocol for a longitudinal study seeking to capture the unique experiences, challenges, and changes faced by HCWs during the COVID-19 pandemic. The study seeks to explore the impact of COVID-19 on the mental well-being of HCWs with a particular focus on moral distress, perceptions of and satisfaction with delivery of care, and how changes in work structure are tolerated among HCWs providing clinical services. Methods: A prospective longitudinal design is employed to assess HCWs’ experiences across domains of mental health (depression, anxiety, posttraumatic stress, and well-being), moral distress and moral reasoning, work-related changes and telehealth, organizational responses to COVID-19 concerns, and experiences with COVID-19 infections to self and to others. We recruited HCWs from across Canada through convenience snowball sampling to participate in either a short-form or long-form web-based survey at baseline. Respondents to the baseline survey are invited to complete a follow-up survey every 3 months, for a total of 18 months. Results: A total of 1926 participants completed baseline surveys between June 26 and December 31, 2020, and 1859 participants provided their emails to contact them to participate in follow-up surveys. As of July 2021, data collection is ongoing, with participants nearing the 6- or 9-month follow-up periods depending on their initial time of self-enrollment. Conclusions: This protocol describes a study that will provide unique insights into the immediate and longitudinal impact of the COVID-19 pandemic on the dimensions of mental health, moral distress, health care delivery, and workplace environment of HCWs. The feasibility and acceptability of implementing a short-form and long-form survey on participant engagement and data retention will also be discussed. International Registered Report Identifier (IRRID): DERR1-10.2196/32663 %M 34477557 %R 10.2196/32663 %U https://www.researchprotocols.org/2021/9/e32663 %U https://doi.org/10.2196/32663 %U http://www.ncbi.nlm.nih.gov/pubmed/34477557 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e29681 %T Virtual Reality for Supporting the Treatment of Depression and Anxiety: Scoping Review %A Baghaei,Nilufar %A Chitale,Vibhav %A Hlasnik,Andrej %A Stemmet,Lehan %A Liang,Hai-Ning %A Porter,Richard %+ Department of Natural and Computational Sciences, Massey University, Oteha Rohe Albany Highway, Albany, Auckland, 0632, New Zealand, 64 800 627 739, n.baghaei@massey.ac.nz %K virtual reality %K mental health %K depression %K anxiety %K CBT %D 2021 %7 23.9.2021 %9 Review %J JMIR Ment Health %G English %X Background: Mental health conditions pose a major challenge to health care providers and society at large. The World Health Organization predicts that by 2030, mental health conditions will be the leading cause of disease burden worldwide. The current need for mental health care is overwhelming. In New Zealand, 1 in 6 adults has been diagnosed with common mental disorders, such as depression and anxiety disorders, according to a national survey. Cognitive behavioral therapy (CBT) has been shown to effectively help patients overcome a wide variety of mental health conditions. Virtual reality exposure therapy (VRET) might be one of the most exciting technologies emerging in the clinical setting for the treatment of anxiety and depression. Objective: This study aims to investigate the virtual reality (VR) technologies currently being used to help support the treatment of depression and anxiety. We also aim to investigate whether and how CBT is included as part of VRET and look at the VR technologies and interventions that have been used in recent studies on depression and anxiety. Methods: We performed a scoping review. To identify significant studies, we decided to use already aggregated sources from the Google Scholar database. Overall, the goal of our search strategy was to limit the number of initial results related to VR in mental health to only a relevant minimum. Results: Using our defined keywords, Google Scholar identified >17,300 articles. After applying all the inclusion and exclusion criteria, we identified a total of 369 articles for further processing. After manual evaluation, 34 articles were shortlisted; of the 34 articles, 9 (26%) reported the use of CBT with VR. All of the articles were published between 2017 and 2021. Out of the 9 studies, CBT was conducted within a VR environment in 5 (56%) studies, whereas in the remaining 4 (44%) studies, CBT was used as an addition to VRET. All 9 studies reported the use of CBT either in vivo or in a virtual environment to be effective in supporting the treatment of anxiety or depression. Conclusions: Most studies demonstrated the use of VR to be effective for supporting the treatment of anxiety or depression in a range of settings and recommended its potential as a tool for use in a clinical environment. Even though standalone headsets are much easier to work with and more suitable for home use, the shift from tethered VR headsets to standalone headsets in the mental health environment was not observed. All studies that looked at the use of CBT either in vivo or in a virtual environment found it to be effective in supporting the treatment of anxiety or depression. %M 34554097 %R 10.2196/29681 %U https://mental.jmir.org/2021/9/e29681 %U https://doi.org/10.2196/29681 %U http://www.ncbi.nlm.nih.gov/pubmed/34554097 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 9 %P e28002 %T “Skip the Small Talk” Virtual Event Intended to Promote Social Connection During a Global Pandemic: Online Survey Study %A Mote,Jasmine %A Gill,Kathryn %A Fulford,Daniel %+ Department of Occupational Therapy, Tufts University, 574 Boston Ave, Medford, MA, 02155, United States, 1 617 627 3781, jasmine.mote@tufts.edu %K COVID-19 %K depression %K digital group %K loneliness %K social connection %K virtual social interaction %K community %K mental health %K connection %K virtual health %D 2021 %7 23.9.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Social distancing measures meant to prevent the spread of COVID-19 in the past year have exacerbated loneliness and depression in the United States. While virtual tools exist to improve social connections, there have been limited attempts to assess community-based, virtual methods to promote new social connections. Objective: In this proof-of-concept study, we examined the extent to which Skip the Small Talk (STST)—a business dedicated to hosting events to facilitate structured, vulnerable conversations between strangers—helped reduce loneliness in a virtual format in the early months of the 2020 COVID-19 pandemic. We predicted that participants who attended STST virtual events would show a reduction in loneliness, improvement in positive affect, and reduction in negative affect after attending an event. We were also interested in exploring the role of depression symptoms on these results as well as the types of goals participants accomplished by attending STST events. Methods: Adult participants who registered for an STST virtual event between March 25 and June 30, 2020, completed a survey before attending the event (pre-event survey; N=64) and a separate survey after attending the event (postevent survey; n=25). Participants reported on their depression symptoms, loneliness, and positive and negative affect. Additionally, participants reported the goals they wished to accomplish as well as those they actually accomplished by attending the STST event. Results: The four most cited goals that participants hoped to accomplish before attending the STST event included the following: “to make new friends,” “to have deeper/better conversations with other people,” “to feel less lonely,” and “to practice social skills.” A total of 34% (20/58) of participants who completed the pre-event survey reported depression symptoms that indicated a high risk of a major depressive episode in the preceding 2 weeks. Of the 25 participants who completed the pre- and postevent surveys, participants reported a significant reduction in loneliness (P=.03, Cohen d=0.48) and negative affect (P<.001, Cohen d=1.52) after attending the STST event compared to before the event. Additionally, depressive symptoms were significantly positively correlated with change in negative affect (P=.03), suggesting that the higher the depression score was prior to attending the STST event, the higher the reduction in negative affect was following the event. Finally, 100% of the participants who wished to reduce their loneliness (11/11) or feel less socially anxious (5/5) prior to attending the STST event reported that they accomplished those goals after the event. Conclusions: Our preliminary assessment suggests that the virtual format of STST was helpful for reducing loneliness and negative affect for participants, including those experiencing depression symptoms, during the COVID-19 pandemic. While encouraging, additional research is necessary to demonstrate whether STST has benefits when compared to other social events and interventions and whether such benefits persist beyond the events themselves. %M 34468326 %R 10.2196/28002 %U https://formative.jmir.org/2021/9/e28002 %U https://doi.org/10.2196/28002 %U http://www.ncbi.nlm.nih.gov/pubmed/34468326 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e25922 %T Facilitator Contact, Discussion Boards, and Virtual Badges as Adherence Enhancements to a Web-Based, Self-guided, Positive Psychological Intervention for Depression: Randomized Controlled Trial %A Moskowitz,Judith Tedlie %A Addington,Elizabeth L %A Shiu,Eva %A Bassett,Sarah M %A Schuette,Stephanie %A Kwok,Ian %A Freedman,Melanie E %A Leykin,Yan %A Saslow,Laura R %A Cohn,Michael A %A Cheung,Elaine O %+ Department of Medical Social Sciences, Osher Center for Integrative Medicine, Northwestern University Feinberg School of Medicine, 625 N Michigan Ave, Suite 2700, Chicago, IL, 60611, United States, 1 3125037712, judith.moskowitz@northwestern.edu %K mHealth %K adherence %K depression %K discussion board %K gamification %K positive psychological intervention %K mobile phone %D 2021 %7 22.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Adherence to self-guided interventions tends to be very low, especially in people with depression. Prior studies have demonstrated that enhancements may increase adherence, but little is known about the efficacy of various enhancements in comparison to, or in combination with, one another. Objective: The aim of our study is to test whether 3 enhancements—facilitator contact (FC), an online discussion board, and virtual badges (VB)—alone, or in combination, improve adherence to a self-guided, web-based intervention for depression. We also examined whether age, gender, race, ethnicity, comfort with technology, or baseline depression predicted adherence or moderated the effects that each enhancement had on adherence. Methods: Participants were recruited through web-based sources and, after completing at least 4 out of 7 daily emotion reports, were sequentially assigned to 1 of 9 conditions—the intervention alone; the intervention plus 1, 2, or all 3 enhancements; or an emotion reporting control condition. The intervention was a positive psychological program consisting of 8 skills that specifically targeted positive emotions, and it was delivered over 5 weeks in a self-guided, web-based format. We operationalized adherence as the number of skills accessed. Results: A total of 602 participants were enrolled in this study. Participants accessed, on average, 5.61 (SD 2.76) of 8 skills. The total number of enhancements participants received (0-3) did not predict the number of skills accessed. Participants who were assigned to the VB+FC condition accessed significantly more skills than those in the intervention only conditions. Furthermore, participants in arms that received the combination of both the VB and FC enhancements (VB+FC and VB+FC+online discussion board) accessed a greater number of skills relative to the number of skills accessed by participants who received either VB or FC without the other. Moderation analyses revealed that the receipt of VB (vs no VB) predicted higher adherence among participants with moderately severe depression at baseline. Conclusions: The results suggested that the VB+FC combination significantly increased the number of skills accessed in a self-guided, web-based intervention for elevated depression. We have provided suggestions for refinements to these enhancements, which may further improve adherence. Trial Registration: ClinicalTrials.gov NCT02861755; http://clinicaltrials.gov/ct2/show/NCT02861755 %M 34550076 %R 10.2196/25922 %U https://www.jmir.org/2021/9/e25922 %U https://doi.org/10.2196/25922 %U http://www.ncbi.nlm.nih.gov/pubmed/34550076 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 9 %P e31439 %T The Safety and Efficacy of Microbial Ecosystem Therapeutic-2 in People With Major Depression: Protocol for a Phase 2, Double-Blind, Placebo-Controlled Study %A Chinna Meyyappan,Arthi %A Sgarbossa,Cassandra %A Vazquez,Gustavo %A Bond,David J %A Müller,Daniel J %A Milev,Roumen %+ Centre for Neuroscience Studies, Queen's University, 752 King St. West, Kingston, ON, K7L4X3, Canada, 1 6135444900, 14acm@queensu.ca %K gut-brain axis %K depression %K microbiome %K probiotics %K fecal transplant %K MET-2 %D 2021 %7 22.9.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The gut-brain axis is a bidirectional signaling pathway between the gastrointestinal tract and the brain; it is being studied because of its potential influence in mediating mood, anxiety, and other neuropsychiatric symptoms. Previous research examining the effects of gut microbiota on neuropsychiatric disorders suggests that gut repopulation treatments such as probiotics, microbe therapy, and fecal microbiota transplantation show promising results in treating symptoms of anxiety and depression. This study explores the use of an alternative gut repopulation treatment to fecal microbiota transplantation, known as Microbial Ecosystem Therapeutic (MET)-2, as an intervention against symptoms of depression. MET-2 is a daily, orally administered capsule containing 40 bacterial strains purified from a single healthy donor. Objective: The primary aim of this study is to assess changes in mood in people with major depression that occur pre-, post-, and during the administration of MET-2. The secondary aims are to assess changes in anxiety symptoms, blood biomarker concentrations, and the level of repopulation of healthy gut bacteria as a response to treatment. Methods: In this study, we will recruit 60 adults aged between 18 and 45 years old with major depression and randomly assign them to treatment or placebo groups. Patients in the treatment group will receive MET-2 once a day for 6 weeks, whereas patients in the placebo group will receive a matching placebo for 6 weeks. Participants will complete biweekly visits during the treatment period and a follow-up visit at 2 weeks post treatment. As a primary outcome measure, participants’ mood will be assessed using the Montgomery-Asberg Depression Rating Scale. Secondary outcome measures include changes in mood, anxiety, early stress, gastrointestinal symptoms, and tolerability of MET-2 treatment using a series of clinical scales and changes in blood markers, particularly immunoglobulins (Igs; IgA, IgG, and IgM) and inflammatory markers (C-reactive protein, tumor necrosis factor-α, transforming growth factor-β, interleukin-6, and interleukin-10). Changes in the relative abundance, diversity, and level of engraftment in fecal samples will be assessed using 16S rRNA sequencing. All data will be integrated to identify biomarkers that could indicate disease state or predict improvement in depressive symptoms in response to MET-2 treatment. Results: Given the association between the gut microbiome and depression, we hypothesized that participants receiving MET-2 would experience greater improvement in depressive symptoms than those receiving placebo owing to the recolonization of the gut microbiome with healthy bacteria modulating the gut-brain axis connection. Conclusions: This study is the first of its kind to evaluate the safety and efficacy of a microbial therapy such as MET-2 in comparison with placebo for major depressive disorder. We hope that this study will also reveal the potential capabilities of microbial therapies to treat other psychiatric illnesses and mood disorders. Trial Registration: ClinicalTrials.gov NCT04602715; https://clinicaltrials.gov/ct2/show/NCT04602715 International Registered Report Identifier (IRRID): DERR1-10.2196/31439 %M 34550085 %R 10.2196/31439 %U https://www.researchprotocols.org/2021/9/e31439 %U https://doi.org/10.2196/31439 %U http://www.ncbi.nlm.nih.gov/pubmed/34550085 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 9 %P e27570 %T Evaluation of a Commercial Mobile Health App for Depression and Anxiety (AbleTo Digital+): Retrospective Cohort Study %A Anton,Margaret T %A Greenberger,Heidi Mochari %A Andreopoulos,Evie %A Pande,Reena L %+ AbleTo, Inc, 320 W, 37th Street, 5th floor, New York, NY, 10018, United States, 1 (347) 926 5527, margaret.anton@ableto.com %K digital mental health %K mHealth %K iCBT %K coaching %K depression %K generalized anxiety %K social anxiety %K mobile phone %D 2021 %7 21.9.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital solutions, such as web-based and mobile interventions, have the potential to streamline pathways to mental health services and improve access to mental health care. Although a growing number of randomized trials have established the efficacy of digital interventions for common mental health problems, less is known about the real-world impact of these tools. AbleTo Digital+, a commercially available mental health app for depression and anxiety, offers a unique opportunity to understand the clinical impact of such tools delivered in a real-world context. Objective: The primary aim of this study is to examine the magnitude of change in depression and anxiety symptoms among individuals who used AbleTo Digital+ programs. The secondary aim is to evaluate Digital+ module completion, including the use of 1:1 coaching. Methods: In this retrospective cohort study, we analyzed previously collected and permanently deidentified data from a consecutive cohort of 1896 adults who initiated using one of the three Digital+ eight-module programs (depression, generalized anxiety, or social anxiety) between January 1 and June 30, 2020. Depression, generalized anxiety, and social anxiety symptoms were assessed within each program using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the Social Phobia Inventory, respectively. Linear mixed effects models were built to assess the association between module completion and symptom change among users who completed at least four modules and had at least mild baseline symptom elevations, controlling for age, gender, and baseline symptom severity. Digital+ use, including module completion, 1:1 coaching calls, and in-app coach messaging, was also evaluated. Results: Significant effects were observed among depression (Cohen d=1.5), generalized anxiety (Cohen d=1.2), and social anxiety (Cohen d=1.0) program participants who completed at least four modules and had mild baseline elevations (n=470). Associations between module completion and change in depression (β=−1.2; P<.001), generalized anxiety (β=−1.1; P<.001), and social anxiety (β=−2.4; P<.001) symptom scores retained significance with covariate adjustment. Participants completed an average of 2.6 (SD 2.7) modules. The average total length of app use was 52.2 (SD 83.5) days. Approximately two-thirds of the users engaged in at least 1 coaching call (66.82%, 1267/1896) or in-app text messaging (66.09%, 1253/1896). Participants who completed at least four modules participated in significantly more coaching calls per module (mean 1.1, SD 0.7) than users who completed fewer than four modules (mean 1.0, SD 1.2; t1407=−2.1; P=.03). Conclusions: This study demonstrated that AbleTo Digital+ users experienced significant reductions in depression, generalized anxiety, and social anxiety symptoms throughout the program. %M 34546170 %R 10.2196/27570 %U https://formative.jmir.org/2021/9/e27570 %U https://doi.org/10.2196/27570 %U http://www.ncbi.nlm.nih.gov/pubmed/34546170 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e21316 %T Roles of Psychosocial Factors on the Association Between Online Social Networking Use Intensity and Depressive Symptoms Among Adolescents: Prospective Cohort Study %A Li,Ji-Bin %A Feng,Li-Fen %A Wu,Anise M S %A Mai,Jin-Chen %A Chen,Yu-Xia %A Mo,Phoenix K H %A Lau,Joseph T F %+ Center for Health Behaviours Research, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, 5/F, School of Public Health, Prince of Wales Hospital, Hong Kong, China, 86 26376606, jlau@cuhk.edu.hk %K online social networking use intensity %K depressive symptoms %K psychosocial factors %K mediation and suppression %K longitudinal study %D 2021 %7 21.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The potential mechanisms underlying the association between online social networking use intensity and depressive symptoms are unclear and underresearched. Objective: We aimed to investigate the potential roles of interpersonal psychosocial factors on the association between online social networking use intensity and depressive symptoms among early adolescents. Methods: A total of 4237 adolescents from a 9-month longitudinal study were included. Score changes (indicated as △) for the social function use intensity (SFUI) and entertainment function use intensity (EFUI) subscales of the Online Social Networking Activity Intensity Scale and for friendship quality, perceived family support, perceived friend support, parent–adolescent conflict, social nonconfidence, and depressive symptoms were analyzed. The potential mediation effects of unfavorable psychosocial factors and suppression effects of favorable psychosocial factors on the association of △SFUI with △CES-D and the association of △EFUI with △CES-D were tested using hierarchical regression models. Results: The association between △SFUI and △CES-D was partially mediated by △mother–adolescent conflict (mediation effect size 5.11%, P=.02) and △social nonconfidence (mediation effect size 20.97%, P<.001) but partially suppressed by △friendship quality, △perceived family support, and △perceived friend support, with suppression effects of –0.011 (P=.003), –0.009 (P=.003), and –0.022 (P<.001), respectively. The association between △EFUI and △CES-D was partially mediated by △social nonconfidence (mediation effect size 30.65%, P<.001) but partially suppressed by △perceived family support and △perceived friend support, with suppression effects of –0.036 (P<.001) and –0.039 (P<.001), respectively. Conclusions: The association between online social networking use intensity and depressive symptoms was partially mediated through the indirect increase in social nonconfidence and mother–adolescent conflict; however, better perceived social support and friendship quality would partially compensate for the harmful impact of online social networking use intensity on depressive symptoms among early adolescents. %M 34546173 %R 10.2196/21316 %U https://www.jmir.org/2021/9/e21316 %U https://doi.org/10.2196/21316 %U http://www.ncbi.nlm.nih.gov/pubmed/34546173 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e29454 %T School-Based Suicide Risk Assessment Using eHealth for Youth: Systematic Scoping Review %A Exner-Cortens,Deinera %A Baker,Elizabeth %A Gray,Shawna %A Fernandez Conde,Cristina %A Rivera,Rocio Ramirez %A Van Bavel,Marisa %A Vezina,Elisabeth %A Ambrose,Aleta %A Pawluk,Chris %A Schwartz,Kelly D %A Arnold,Paul D %+ Department of Psychology, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N1N4, Canada, 1 4032208871, deinera.exner2@ucalgary.ca %K suicide %K risk assessment %K youth %K eHealth %K school mental health %K mobile phone %D 2021 %7 21.9.2021 %9 Review %J JMIR Ment Health %G English %X Background: Suicide is a leading cause of death among youth and a prominent concern for school mental health providers. Indeed, schools play a key role in suicide prevention, including participating in risk assessments with students expressing suicidal ideation. In the context of the COVID-19 pandemic, many schools now need to offer mental health services, including suicide risk assessment, via eHealth platforms. Post pandemic, the use of eHealth risk assessments will support more accessible services for youth living in rural and remote areas. However, as the remote environment is a new context for many schools, guidance is needed on best practices for eHealth suicide risk assessment among youth. Objective: This study aims to conduct a rapid, systematic scoping review to explore promising practices for conducting school-based suicide risk assessment among youth via eHealth (ie, information technologies that allow for remote communication). Methods: This review included peer-reviewed articles and gray literature published in English between 2000 and 2020. Although we did not find studies that specifically explored promising practices for school-based suicide risk assessment among youth via eHealth platforms, we found 12 peer-reviewed articles and 23 gray literature documents that contained relevant information addressing our broader study purpose; thus, these 35 sources were included in this review. Results: We identified five key recommendation themes for school-based suicide risk assessment among youth via eHealth platforms in the 12 peer-reviewed studies. These included accessibility, consent procedures, session logistics, safety planning, and internet privacy. Specific recommendation themes from the 23 gray literature documents substantially overlapped with and enhanced three of the themes identified in the peer-reviewed literature—consent procedures, session logistics, and safety planning. In addition, based on findings from the gray literature, we expanded the accessibility theme to a broader theme termed youth engagement, which included information on accessibility and building rapport, establishing a therapeutic space, and helping youth prepare for remote sessions. Finally, a new theme was identified in the gray literature findings, specifically concerning school mental health professional boundaries. A second key difference between the gray and peer-reviewed literature was the former’s focus on issues of equity and access and how technology can reinforce existing inequalities. Conclusions: For school mental health providers in need of guidance, we believe that these six recommendation themes (ie, youth engagement, school mental health professional boundaries, consent procedures, session logistics, safety planning, and internet privacy) represent the most promising directions for school-based suicide risk assessment among youth using eHealth tools. However, suicide risk assessment among youth via eHealth platforms in school settings represents a critical research gap. On the basis of the findings of this review, we provide specific recommendations for future research, including the need to focus on the needs of diverse youth. %M 34546178 %R 10.2196/29454 %U https://mental.jmir.org/2021/9/e29454 %U https://doi.org/10.2196/29454 %U http://www.ncbi.nlm.nih.gov/pubmed/34546178 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 9 %P e24352 %T Using Acoustic Speech Patterns From Smartphones to Investigate Mood Disorders: Scoping Review %A Flanagan,Olivia %A Chan,Amy %A Roop,Partha %A Sundram,Frederick %+ Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Building 507, Level 3, 28 Park Avenue, Grafton, Auckland, 1023, New Zealand, 64 9 923 7521, f.sundram@auckland.ac.nz %K smartphone %K data science %K speech patterns %K mood disorders %K diagnosis %K monitoring %D 2021 %7 17.9.2021 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Mood disorders are commonly underrecognized and undertreated, as diagnosis is reliant on self-reporting and clinical assessments that are often not timely. Speech characteristics of those with mood disorders differs from healthy individuals. With the wide use of smartphones, and the emergence of machine learning approaches, smartphones can be used to monitor speech patterns to help the diagnosis and monitoring of mood disorders. Objective: The aim of this review is to synthesize research on using speech patterns from smartphones to diagnose and monitor mood disorders. Methods: Literature searches of major databases, Medline, PsycInfo, EMBASE, and CINAHL, initially identified 832 relevant articles using the search terms “mood disorders”, “smartphone”, “voice analysis”, and their variants. Only 13 studies met inclusion criteria: use of a smartphone for capturing voice data, focus on diagnosing or monitoring a mood disorder(s), clinical populations recruited prospectively, and in the English language only. Articles were assessed by 2 reviewers, and data extracted included data type, classifiers used, methods of capture, and study results. Studies were analyzed using a narrative synthesis approach. Results: Studies showed that voice data alone had reasonable accuracy in predicting mood states and mood fluctuations based on objectively monitored speech patterns. While a fusion of different sensor modalities revealed the highest accuracy (97.4%), nearly 80% of included studies were pilot trials or feasibility studies without control groups and had small sample sizes ranging from 1 to 73 participants. Studies were also carried out over short or varying timeframes and had significant heterogeneity of methods in terms of the types of audio data captured, environmental contexts, classifiers, and measures to control for privacy and ambient noise. Conclusions: Approaches that allow smartphone-based monitoring of speech patterns in mood disorders are rapidly growing. The current body of evidence supports the value of speech patterns to monitor, classify, and predict mood states in real time. However, many challenges remain around the robustness, cost-effectiveness, and acceptability of such an approach and further work is required to build on current research and reduce heterogeneity of methodologies as well as clinical evaluation of the benefits and risks of such approaches. %M 34533465 %R 10.2196/24352 %U https://mhealth.jmir.org/2021/9/e24352 %U https://doi.org/10.2196/24352 %U http://www.ncbi.nlm.nih.gov/pubmed/34533465 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e28369 %T Mental Health Screening in General Practices as a Means for Enhancing Uptake of Digital Mental Health Interventions: Observational Cohort Study %A Whitton,Alexis E %A Hardy,Rebecca %A Cope,Kate %A Gieng,Chilin %A Gow,Leanne %A MacKinnon,Andrew %A Gale,Nyree %A O'Moore,Kathleen %A Anderson,Josephine %A Proudfoot,Judith %A Cockayne,Nicole %A O'Dea,Bridianne %A Christensen,Helen %A Newby,Jill Maree %+ Black Dog Institute, Hospital Road, Randwick, 2031, Australia, 61 293828507, a.whitton@unsw.edu.au %K depression %K anxiety %K general practice %K screening %K digital mental health %D 2021 %7 16.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital mental health interventions stand to play a critical role in managing the mental health impact of the COVID-19 pandemic. Thus, enhancing their uptake is a key priority. General practitioners (GPs) are well positioned to facilitate access to digital interventions, but tools that assist GPs in identifying suitable patients are lacking. Objective: This study aims to evaluate the suitability of a web-based mental health screening and treatment recommendation tool (StepCare) for improving the identification of anxiety and depression in general practice and, subsequently, uptake of digital mental health interventions. Methods: StepCare screens patients for symptoms of depression (9-item Patient Health Questionnaire) and anxiety (7-item Generalized Anxiety Disorder scale) in the GP waiting room. It provides GPs with stepped treatment recommendations that include digital mental health interventions for patients with mild to moderate symptoms. Patients (N=5138) from 85 general practices across Australia were invited to participate in screening. Results: Screening identified depressive or anxious symptoms in 43.09% (1428/3314) of patients (one-quarter were previously unidentified or untreated). The majority (300/335, 89.6%) of previously unidentified or untreated patients had mild to moderate symptoms and were candidates for digital mental health interventions. Although less than half were prescribed a digital intervention by their GP, when a digital intervention was prescribed, more than two-thirds of patients reported using it. Conclusions: Implementing web-based mental health screening in general practices can provide important opportunities for GPs to improve the identification of symptoms of mental illness and increase patient access to digital mental health interventions. Although GPs prescribed digital interventions less frequently than in-person psychotherapy or medication, the promising rates of uptake by GP-referred patients suggest that GPs can play a critical role in championing digital interventions and maximizing the associated benefits. %M 34528896 %R 10.2196/28369 %U https://www.jmir.org/2021/9/e28369 %U https://doi.org/10.2196/28369 %U http://www.ncbi.nlm.nih.gov/pubmed/34528896 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 9 %P e31052 %T Associations Between the Perceived Severity of the COVID-19 Pandemic, Cyberchondria, Depression, Anxiety, Stress, and Lockdown Experience: Cross-sectional Survey Study %A Han,Lei %A Zhan,Yanru %A Li,Weizi %A Xu,Yuqing %A Xu,Yan %A Zhao,Jinzhe %+ Faculty of Psychology, Beijing Normal University, 19 Xinjiekouwai Street Haidian District, Beijing, 100875, China, 86 19800356013, sszbjz@163.com %K COVID-19 %K cyberchondria %K depression %K anxiety %K stress %K ABC theory of emotions %K lockdown experience %K perceived severity %K cross-sectional %K online health information %D 2021 %7 16.9.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The outbreak of the COVID-19 pandemic has caused great panic among the public, with many people suffering from adverse stress reactions. To control the spread of the pandemic, governments in many countries have imposed lockdown policies. In this unique pandemic context, people can obtain information about pandemic dynamics on the internet. However, searching for health-related information on the internet frequently increases the possibility of individuals being troubled by the information that they find, and consequently, experiencing symptoms of cyberchondria. Objective: We aimed to examine the relationships between people’s perceived severity of the COVID-19 pandemic and their depression, anxiety, and stress to explore the role of cyberchondria, which, in these relationship mechanisms, is closely related to using the internet. In addition, we also examined the moderating role of lockdown experiences. Methods: In February 2020, a total of 486 participants were recruited through a web-based platform from areas in China with a large number of infections. We used questionnaires to measure participants’ perceived severity of the COVID-19 pandemic, to measure the severity of their cyberchondria, depression, anxiety, and stress symptoms, and to assess their lockdown experiences. Confirmatory factor analysis, exploratory factor analysis, common method bias, descriptive statistical analysis, and correlation analysis were performed, and moderated mediation models were examined. Results: There was a positive association between perceived severity of the COVID-19 pandemic and depression (β=0.36, t=8.51, P<.001), anxiety (β=0.41, t=9.84, P<.001), and stress (β=0.46, t=11.45, P<.001), which were mediated by cyberchondria (β=0.36, t=8.59, P<.001). The direct effects of perceived severity of the COVID-19 pandemic on anxiety (β=0.07, t=2.01, P=.045) and stress (β=0.09, t=2.75, P=.006) and the indirect effects of cyberchondria on depression (β=0.10, t=2.59, P=.009) and anxiety (β=0.10, t=2.50, P=.01) were moderated by lockdown experience. Conclusions: The higher the perceived severity of the COVID-19 pandemic, the more serious individuals’ symptoms of depression, anxiety, and stress. In addition, the associations were partially mediated by cyberchondria. Individuals with higher perceived severity of the COVID-19 pandemic were more likely to develop cyberchondria, which aggravated individuals’ depression, anxiety, and stress symptoms. Negative lockdown experiences exacerbated the COVID-19 pandemic’s impact on mental health. %M 34478402 %R 10.2196/31052 %U https://publichealth.jmir.org/2021/9/e31052 %U https://doi.org/10.2196/31052 %U http://www.ncbi.nlm.nih.gov/pubmed/34478402 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e28044 %T Testing the Differential Impact of an Internet-Based Mental Health Intervention on Outcomes of Well-being and Psychological Distress During COVID-19: Uncontrolled Intervention Study %A van Agteren,Joep %A Ali,Kathina %A Fassnacht,Daniel B %A Iasiello,Matthew %A Furber,Gareth %A Howard,Alexis %A Woodyatt,Lydia %A Musker,Michael %A Kyrios,Mike %+ Wellbeing and Resilience Centre, South Australian Health and Medical Research Institute, North Terrace, Adelaide, 5000, Australia, 61 881284944, joep.vanagteren@sahmri.com %K COVID-19 %K internet-based interventions %K mental health %K well-being %K intervention %K study %K impact %K internet %K online intervention %K distress %K resilience %K depression %K anxiety %K stress %D 2021 %7 15.9.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: During COVID-19, the psychological distress and well-being of the general population has been precarious, increasing the need to determine the impact of complementary internet-based psychological interventions on both positive mental health as well as distress states. Psychological distress and mental well-being represent distinct dimensions of our mental health, and congruent changes in outcomes of distress and well-being do not necessarily co-occur within individuals. When testing intervention impact, it is therefore important to assess change in both outcomes at the individual level, rather than solely testing group differences in average scores at the group level. Objective: This study set out to investigate the differential impact of an internet-based group mental health intervention on outcomes of positive mental health (ie, well-being, life satisfaction, resilience) and indicators of psychological distress (ie, depression, anxiety, stress). Methods: A 5-week mental health intervention was delivered to 89 participants using the Zoom platform during 2020. Impact on outcomes of distress, well-being, and resilience was assessed at the start and end of the program with multiple analysis of variance (MANOVA) and reliable change indices (RCIs) being used to determine program impact at the group and individual levels, respectively. Results: The intervention significantly improved all mental health outcomes measured, (F6,83=5.60, P<.001; Wilks Λ=.71; partial η2=.29) showing small to moderate effect sizes on individual outcomes. The largest effect sizes were observed for life satisfaction and overall well-being (η2=.22 and η2=.2, respectively). Larger effect sizes were noted for those with problematic mental health scores at baseline. A total of 92% (82/89) of participants demonstrated reliable change in at least one mental health outcome. Differential response patterns using RCI revealed that more than one-half of the participants showed improvement in both mental well-being and psychological distress, over one-quarter in outcomes of well-being only, and almost one-fifth in distress only. Conclusions: The results provide evidence for the significant impact of an internet-based mental health intervention during COVID-19 and indicate the importance of assessing dimensions of both well-being and distress when determining mental health intervention effectiveness. %M 34357876 %R 10.2196/28044 %U https://mental.jmir.org/2021/9/e28044 %U https://doi.org/10.2196/28044 %U http://www.ncbi.nlm.nih.gov/pubmed/34357876 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e29318 %T Adolescent Health on Social Media and the Mentorship of Youth Investigators: Five Content Analysis Studies Conducted by Youth Investigators %A Bushman,Maggie %A Godishala,Shreya %A Hyzer,Reese %A Jerisha,Joshua %A Jolliff,Anna %A Kaji,Ethan %A Kerr,Bradley %A Mathur,Anjali %A Tsao,Owen %+ Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin - Madison, 2870 University Avenue, Suite 200, Madison, WI, 53705, United States, 1 5035539361, ajolliff@wisc.edu %K social media %K anxiety %K depression %K self-esteem %K Instagram %K Reddit %K Twitter %K YouTube %K content analysis %K adolescent %D 2021 %7 15.9.2021 %9 Original Paper %J JMIR Ment Health %G English %X Although the literature on adolescent health includes studies that incorporate youth perspectives via a participatory design, research that is designed, conducted, and presented by youth remains absent. This paper presents the work of 5 youth investigators on the intersecting topics of adolescent health and social media. Each of these youths was equipped with tools, knowledge, and mentorship for scientifically evaluating a research question. The youths developed a research question that aligned with their interests and filled a gap that they identified in the literature. The youths, whose projects are featured in this paper, designed and conducted their own research project, drafted their own manuscript, and revised and resubmitted a draft based on reviewer input. Each youth worked with a research mentor; however, the research questions, study designs, and suggestions for future research were their own. %M 34524099 %R 10.2196/29318 %U https://mental.jmir.org/2021/9/e29318 %U https://doi.org/10.2196/29318 %U http://www.ncbi.nlm.nih.gov/pubmed/34524099 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e26207 %T Young Sexual Minority Adolescent Experiences of Self-expression and Isolation on Social Media: Cross-sectional Survey Study %A Charmaraman,Linda %A Hodes,Rachel %A Richer,Amanda M %+ Wellesley Centers for Women, Wellesley College, 106 Central Street, Wellesley, MA, 02481, United States, 1 7812832542, lcharmar@wellesley.edu %K social media %K social networking sites %K sexual minorities %K cyberbullying %K depression %K loneliness %K self-harm %K social support %K adolescents %D 2021 %7 15.9.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Early adolescent years are marked by pervasive self- and peer-regulation regarding gender and sexuality norms, which can affect the mental well-being of sexual minority youth. During this developmental period, social media use is also emerging as a dominant mode of communication with peers, allowing for both risk and resilient behaviors that can impact well-being. Objective: This exploratory study aims to examine how sexual minorities in middle school use social media, who they are connected to and for what purposes, and the associations between these behaviors and mental well-being compared with their heterosexual peers. Methods: In our cross-sectional survey study of 1033 early adolescents aged between 10 and 16 years (average age 12.7, SD 1.21 years) from 4 middle school sites in the Northeastern United States, we conducted an exploratory study comparing sexual minorities (212/873, 24.3% of sample with known sexual orientation) with their heterosexual peers (n=661), obtaining an 84.46% (1033/1223; total possible) response rate. Results: Sexual minorities reported having smaller networks on their favorite social media website (β=−.57; P<.001), less often responded positively when friends shared good news (β=−.35; P=.002), and less often tried to make friends feel better when they shared bad news (β=−.30; P=.01). However, sexual minorities more often reported joining a group or web-based community to make themselves feel less alone (β=.28; P=.003), unlike heterosexual youth. Sexual minorities had higher averages of loneliness and social isolation (β=.19; P<.001) than heterosexual students. Sexual minorities were also twice as likely to have tried to harm themselves in the past (β=.81; odds ratio [OR] 2.24, 95% CI 1.64-3.06; P<.001) and were more likely to have symptoms that reached the Center for Epidemiological Studies-Depression definition of depression (β=.15; OR 1.16, 95% CI 1.08-1.25; P<.001). About 39.1% (83/212) of sexual minorities had no one to talk to about their sexual orientation. Sexual minorities were 1.5 times more likely to have joined a social media website their parents would disapprove (β=.41; OR 1.50, 95% CI 1.14-1.97; P=.004) and more likely to report seeing videos related to self-harm (β=.33; OR 1.39, 95% CI 1.06-1.83; P=.02) on the web than heterosexual youth. Conclusions: Given previous reports of supportive and safe web-based spaces for sexual minority youth, our findings demonstrated that sexual minority youth prefer to maintain small, close-knit web-based communities (apart from their families) to express themselves, particularly when reaching out to web-based communities to reduce loneliness. Future longitudinal studies could determine any bidirectional influences of mental well-being and social media use in sexual minorities during this difficult developmental period. %M 34524107 %R 10.2196/26207 %U https://mental.jmir.org/2021/9/e26207 %U https://doi.org/10.2196/26207 %U http://www.ncbi.nlm.nih.gov/pubmed/34524107 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e26188 %T A Social Media Group Cognitive Behavioral Therapy Intervention to Prevent Depression in Perinatal Youth: Stakeholder Interviews and Intervention Design %A Gewali,Anupa %A Lopez,Alana %A Dachelet,Kristin %A Healy,Elise %A Jean-Baptiste,Marimirca %A Harridan,Holly %A Evans,Yolanda %A Unger,Jennifer A %A Bhat,Amritha %A Tandon,Darius %A Ronen,Keshet %+ Department of Global Health, University of Washington, 3980 15th Ave NE, Seattle, WA, , United States, 1 206 685 4363, keshet@uw.edu %K depression %K mental health %K perinatal %K pregnancy %K postpartum %K adolescent %K youth %K social media %K group %K mobile phone %D 2021 %7 15.9.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Adolescents and young adults aged <25 years (youth) are at a higher risk of perinatal depression than older adults, and they experience elevated barriers to in-person care. Digital platforms such as social media offer an accessible avenue to deliver group cognitive behavioral therapy (CBT) to perinatal youth. Objective: We aim to develop the Interactive Maternal Group for Information and Emotional Support (IMAGINE) intervention, a facilitated social media group CBT intervention to prevent perinatal depression in youth in the United States, by adapting the Mothers and Babies (MB) course, an evidence-based in-person group CBT intervention. In this study, we report perspectives of youth and health care providers on perinatal youths’ mental health needs and document how they informed IMAGINE design. Methods: We conducted 21 semistructured in-depth individual interviews with 10 pregnant or postpartum youths aged 14-24 years and 6 health care workers. All interviews were recorded, transcribed, and analyzed using deductive and inductive approaches to characterize perceptions of challenges and facilitators of youth perinatal mental health. Using a human-centered design approach, stakeholder perspectives were incorporated into the IMAGINE design. We classified MB adaptations to develop IMAGINE according to the Framework for Modification and Adaptation, reporting the nature, timing, reason, and goal of the adaptations. Results: Youth and health care workers described stigma associated with young pregnancy and parenting, social isolation, and lack of material resources as significant challenges to youth mental wellness. They identified nonjudgmental support, peer companionship, and access to step-by-step guidance as facilitators of youth mental wellness. They endorsed the use of a social media group to prevent perinatal depression and recommended that IMAGINE facilitate peer support, deliver content asynchronously to accommodate varied schedules, use a confidential platform, and facilitate the discussion of topics beyond the MB curriculum, such as navigating support resources or asking medical questions. IMAGINE was adapted from MB to accommodate stakeholder recommendations and facilitate the transition to web-based delivery. Content was tailored to be multimodal (text, images, and video), and the language was shortened and simplified. All content was designed for asynchronous engagement, and redundancy was added to accommodate intermittent access. The structure was loosened to allow the intervention facilitator to respond in real time to topics of interest for youth. A social media platform was selected that allows multiple conversation channels and conceals group member identity. All adaptations sought to preserve the fidelity of the MB core components. Conclusions: Our findings highlight the effect of stigmatization of young pregnancy and social determinants of health on youth perinatal mental health. Stakeholders supported the use of a social media group to create a supportive community and improve access to evidence-based depression prevention. This study demonstrates how a validated intervention can be tailored to this unique group. %M 34524086 %R 10.2196/26188 %U https://mental.jmir.org/2021/9/e26188 %U https://doi.org/10.2196/26188 %U http://www.ncbi.nlm.nih.gov/pubmed/34524086 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e26134 %T Social Media Use, Physical Activity, and Internalizing Symptoms in Adolescence: Cross-sectional Analysis %A Rutter,Lauren A %A Thompson,Holly M %A Howard,Jacqueline %A Riley,Tennisha N %A De Jesús-Romero,Robinson %A Lorenzo-Luaces,Lorenzo %+ Department of Psychological and Brain Sciences, Indiana University Bloomington, 1101 E Tenth Street, Bloomington, IN, 47405, United States, 1 8128569953, larutter@iu.edu %K social media %K depression %K anxiety %K physical activity %K adolescence %K mobile phone %D 2021 %7 15.9.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Most American adolescents have access to smartphones, and recent estimates suggest that they spend considerable time on social media compared with other physical and leisure activities. A large body of literature has established that social media use is related to poor mental health, but the complicated relationship between social media and symptoms of depression and anxiety in adolescents is yet to be fully understood. Objective: We aim to investigate the relationship between social media use and depression and anxiety symptoms in adolescents by exploring physical activity as a mediator. Methods: A Qualtrics survey manager recruited adult panel participants between February and March 2019, who indicated that they had adolescent children who spoke English. A total of 4592 adolescent-parent dyads completed the survey that took approximately 39 minutes. The survey entailed completing web-based questionnaires assessing various aspects of social media use, psychological symptoms, and psychosocial factors. The average age of the adolescent participants was 14.62 (SD 1.68; range 12-17) years, and the majority of the adolescent sample was male (2392/4592, 52.09%). Results: Total social media use was associated with more depressive symptoms (multiple R2=0.12; F3,4480=207.1; P<.001), anxiety (multiple R2=0.09; F3,4477=145.6; P<.001), and loneliness (multiple R2=0.06; F3,4512=98.06; P<.001), controlling for age and gender. Physical activity was associated with decreased depression and anxiety symptoms after controlling for other extracurricular activities and social media use (multiple R2=0.24; F5,4290=266.0; P<.001). There were significant differences in symptoms based on gender: female adolescents reported higher rates of social media use and males reported higher rates of depression. Nonbinary and transgender adolescents had higher rates of depression, anxiety, and loneliness than the female and male adolescents in the sample. Conclusions: In a nationally representative sample of adolescents, more social media use was associated with more severe symptoms of depression, anxiety, and loneliness. Increased physical activity was associated with decreased depression and anxiety symptoms. Physical activity partially mediated the relationship between social media use and depression and anxiety. As this was a cross-sectional study, we cannot conclude that social media use causes internalizing symptoms or that physical activity leads to decreased internalizing symptoms—there may be additional confounding variables producing the relationships we observed. Physical activity may protect against the potentially harmful effect of social media on some adolescents. The effect sizes were small to medium, and the results should be interpreted with caution. Other limitations of this study include our reliance on self-reporting. Future work should examine social media use beyond how much time adolescents spend using social media and instead focus on the nature of social media activity. %M 34524096 %R 10.2196/26134 %U https://mental.jmir.org/2021/9/e26134 %U https://doi.org/10.2196/26134 %U http://www.ncbi.nlm.nih.gov/pubmed/34524096 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e26035 %T Perceived Facilitators of and Barriers to Implementation of a Decision Support Tool for Adolescent Depression and Suicidality Screening: Focus Group and Interview Study %A Radovic,Ana %A Anderson,Nathan %A Hamm,Megan %A George-Milford,Brandie %A Fascetti,Carrie %A Engster,Stacey %A Lindhiem,Oliver %+ Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, 120 Lytton Avenue, Pittsburgh, PA, 15213, United States, 1 4126927227, ana.radovic@chp.edu %K depression %K adolescent %K suicidality %K screening %D 2021 %7 15.9.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Screening Wizard (SW) is a technology-based decision support tool aimed at guiding primary care providers (PCPs) to respond to depression and suicidality screens in adolescents. Separate screens assess adolescents’ and parents’ reports on mental health symptoms, treatment preferences, and potential treatment barriers. A detailed summary is provided to PCPs, also identifying adolescent-parent discrepancies. The goal of SW is to enhance decision-making to increase the utilization of evidence-based treatments. Objective: This qualitative study aims to describe multi-stakeholder perspectives of adolescents, parents, and providers to understand the potential barriers to the implementation of SW. Methods: We interviewed 11 parents and 11 adolescents and conducted two focus groups with 18 health care providers (PCPs, nurses, therapists, and staff) across 2 pediatric practices. Participants described previous experiences with screening for depression and were shown a mock-up of SW and asked for feedback. Interviews and focus groups were transcribed verbatim, and codebooks were inductively developed based on content. Transcripts were double coded, and disagreements were adjudicated to full agreement. Completed coding was used to produce thematic analyses of the interviews and focus groups. Results: We identified five main themes across the interviews and focus groups: parents, adolescents, and pediatric PCPs agree that depression screening should occur in pediatric primary care; there is concern that accurate self-disclosure does not always occur during depression screening; SW is viewed as a tool that could facilitate depression screening and that might encourage more honesty in screening responses; parents, adolescents, and providers do not want SW to replace mental health discussions with providers; and providers want to maintain autonomy in treatment decisions. Conclusions: We identified that providers, parents, and adolescents are all concerned with current screening practices, mainly regarding inaccurate self-disclosure. They recognized value in SW as a computerized tool that may elicit more honest responses and identify adolescent-parent discrepancies. Surprisingly, providers did not want the SW report to include treatment recommendations, and all groups did not want the SW report to replace conversations with the PCP about depression. Although SW was originally developed as a treatment decision algorithm, this qualitative study has led us to remove this component, and instead, SW focuses on aspects identified as most useful by all groups. We hope that this initial qualitative work will improve the future implementation of SW. %M 34524090 %R 10.2196/26035 %U https://mental.jmir.org/2021/9/e26035 %U https://doi.org/10.2196/26035 %U http://www.ncbi.nlm.nih.gov/pubmed/34524090 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e26031 %T Automated Monitoring of Suicidal Adolescents’ Digital Media Use: Qualitative Study Exploring Acceptability Within Clinical Care %A Biernesser,Candice %A Zelazny,Jamie %A Brent,David %A Bear,Todd %A Mair,Christina %A Trauth,Jeanette %+ Department of Psychiatry, University of Pittsburgh, BFT 313, 3811 O'Hara St., Pittsburgh, PA, 15229, United States, 1 586 9064, lubbertcl@upmc.edu %K adolescents %K parents %K digital media %K social media %K technology %K monitoring %K suicide prevention %K implementation in clinical care %K natural language processing %K qualitative %D 2021 %7 15.9.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Monitoring linguistic cues from adolescents’ digital media use (DMU; ie, digital content transmitted on the web, such as through text messages or social media) that could denote suicidal risk offers a unique opportunity to protect adolescents vulnerable to suicide, the second leading cause of death among youth. Adolescents communicate through digital media in high volumes and frequently express emotionality. In fact, web-based disclosures of suicidality are more common than in-person disclosures. The use of automated methods of digital media monitoring triggered by a natural language processing algorithm offers the potential to detect suicidal risk from subtle linguistic units (eg, negatively valanced words, phrases, or emoticons known to be associated with suicidality) present within adolescents’ digital media content and to use this information to respond to alerts of suicidal risk. Critical to the implementation of such an approach is the consideration of its acceptability in the clinical care of adolescents at high risk of suicide. Objective: Through data collection among recently suicidal adolescents, parents, and clinicians, this study examines the current context of digital media monitoring for suicidal adolescents seeking clinical care to inform the need for automated monitoring and the factors that influence the acceptance of automated monitoring of suicidal adolescents’ DMU within clinical care. Methods: A total of 15 recently suicidal adolescents (aged 13-17 years), 12 parents, and 10 clinicians participated in focus groups, qualitative interviews, and a group discussion, respectively. Data were recorded, transcribed, and analyzed using thematic analysis. Results: Participants described important challenges to the current strategies for monitoring the DMU of suicidal youth. They felt that automated monitoring would have advantages over current monitoring approaches, namely, by protecting web-based environments and aiding adolescent disclosure and support seeking about web-based suicidal risk communication, which may otherwise go unnoticed. However, they identified barriers that could impede implementation within clinical care, namely, adolescents’ and parents’ concerns about unintended consequences of automated monitoring, that is, the potential for loss of privacy or false alerts, and clinicians’ concerns about liability to respond to alerts of suicidal risk. On the basis of the needs and preferences of adolescents, parents, and clinicians, a model for automated digital media monitoring is presented that aims to optimize acceptability within clinical care for suicidal youth. Conclusions: Automated digital media monitoring offers a promising means to augment detection and response to suicidal risk within the clinical care of suicidal youth when strategies that address the preferences of adolescents, parents, and clinicians are in place. %M 34524104 %R 10.2196/26031 %U https://mental.jmir.org/2021/9/e26031 %U https://doi.org/10.2196/26031 %U http://www.ncbi.nlm.nih.gov/pubmed/34524104 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e25782 %T Investigating Viewership of Season 3 of “13 Reasons Why” and the Mental Wellness of Adolescents: Partially Randomized Preference Trial %A Uhls,Yalda T %A Felt,Laurel %A Wartella,Ellen %A Sanders,Andrew %+ University of California, Los Angeles, Franz Hall, Los Angeles, CA, 90095, United States, 1 3102101244, yaldatuhls@gmail.com %K media %K adolescence %K mental health %K narrative %K 13 Reasons Why %K conversation %K television %K depression %K sexual assault %D 2021 %7 15.9.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: A conflicting body of research suggests that additional investigation is needed to understand how globally watched television shows featuring social and mental health issues, such as 13 Reasons Why, might affect adolescents’ mental wellness. Objective: This study aims to investigate adolescents’ viewership of the third season of the Netflix drama 13 Reasons Why (13RW-3) and their engagement with show-related content, paying special attention to mental health outcomes and conversational partners. Methods: A panel-based research platform operated by the National Opinion Research Center at the University of Chicago recruited 157 adolescents aged 13 to 17 years from its nationally representative pool of participants. Participants answered questions about how they discussed and learned about social and mental health issues portrayed in 13RW-3 (eg, masculine role pressure and sexual assault) and questions about mental wellness (eg, mental health self-efficacy and depression). After the participants completed the survey (T1), they were directed to either watch 13RW-3 as it aired for the first time (intervention group) or not watch 13RW-3 (control group). Approximately one month later (T2), all the participants were asked to complete the postsurvey. Additional survey questions about conversational partners, information seeking because of watching the show, and use of show-related content were included in the intervention postsurvey. Results: Our sample (N=157) was 52.2% (n=82) female and 54.8% (n=86) White, with a mean age of 14.99 (SD 1.4) years. At T2, viewers of 13RW-3 spoke about suicide significantly more frequently than nonviewers (P=.007). From T1 to T2, viewers increasingly discussed issues explored by 13RW-3 (P=.002), especially suicide, mental health, and bullying. Adolescent viewers were most likely to speak with friends, and parents were the second most commonly named. Two variables emerged as consistent moderators of conversational choices—having depressive symptoms and being impacted by sexual assault. There was no association between conversational frequency and information seeking around social and mental health issues, and neither mental health self-efficacy scores nor masculine role pressure scores significantly differed between viewers and nonviewers at T2. Conclusions: Viewing 13RW-3, a globally watched television show featuring social and mental health issues, led to adolescent conversations and information searches about topics explored by the show. Depressive symptoms and the impact of sexual assault moderated several relationships, guiding participants toward engaging with certain issues and seeking out specific conversational partners. As 13RW-3’s stories drove conversations—and story-driven conversations can raise awareness, reduce stigma, shift attitudes, normalize certain behaviors, and strengthen supportive relationships—potential wellness implications for television shows featuring social and mental health issues are considerable. %M 34524097 %R 10.2196/25782 %U https://mental.jmir.org/2021/9/e25782 %U https://doi.org/10.2196/25782 %U http://www.ncbi.nlm.nih.gov/pubmed/34524097 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 9 %P e25017 %T The Effects of 3D Immersion Technology (3Scape) on Mental Health in Outpatients From a Short-Term Assessment, Rehabilitation, and Treatment Program: Feasibility Protocol for a Randomized Controlled Trial %A Miguel-Cruz,Antonio %A Ladurner,Anna-Maria %A Kohls-Wiebe,Megan %A Rawani,David %+ University of Alberta, 8205 114 St NW, 3-48 Corbett Hall, Edmonton, AB, T6G 2G4, Canada, 1 7802246641, miguelcr@ualberta.ca %K technology assessment %K mental health %K technology for rehabilitation %K clinical engineering %K biomedical engineering %D 2021 %7 14.9.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mental health conditions are prevalent among Canadians and are a leading cause of disability. Each year, 1 in 5 Canadians experiences a mental health issue. A total of 5% of people aged ≥65 years perceive their mental health as fair or poor, and 6.3% of them have mood disorders. Regarding older adults with cognitive impairments such as dementia, up to 40%-50% of them experience depression at some point. We believe that older adults can benefit significantly from information and telecommunication technologies as a strategy for improving mental health conditions such as depression and anxiety, while simultaneously improving their quality of life. 3Scape Systems Inc is an Alberta-based private company that has produced a series of specialized 3D videos designed to simulate real-life events and engage individuals living with mental health disorders and cognitive impairments such as dementia. Objective: This study aims to explore the trial design and effects of 3Scape videos on older adults’ symptoms of depression and anxiety and the efficacy of this technology in improving the quality of life of patients attending the Short-Term Assessment, Rehabilitation, and Treatment Psychiatry Day Hospital program at Glenrose Rehabilitation Hospital and to provide data to estimate the parameters required to design a definitive randomized controlled trial. Methods: The trial will use a randomized controlled design comprising 15 intervention participants and 15 control group participants. The participants will be adults aged ≥65 years who are cognitively intact or have minimal cognitive impairment (ie, Montreal Cognitive Assessment score ≥18), and are clients of the Short-Term Assessment, Rehabilitation, and Treatment Psychiatry Day Hospital program at Glenrose Rehabilitation Hospital. This study’s primary outcome variables are related to clients’ depressive and anxiety symptoms and their quality of life. The control group will receive the standard of care (ie, the Short-Term Assessment, Rehabilitation, and Treatment Psychiatry Day Hospital program at Glenrose Rehabilitation Hospital). The intervention group will receive the same standard of care as the control group and will use 3Scape Systems videos for therapeutic activities. Results: Our study is currently on hold because of the COVID-19 pandemic. The recruitment process is expected to resume by November 2021, and the primary impact analysis is expected to be conducted by February 2022. Conclusions: This study will provide valuable information such as the measurement of comparative intervention effects, perception of older adults and mental health therapists about the 3Scape Systems, the associated costs of treatment, and product costs. This will contribute to the evidence planning process, which will be crucial for the future adoption of 3Scape Systems. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 93685907; https://www.isrctn.com/ISRCTN93685907. International Registered Report Identifier (IRRID): PRR1-10.2196/25017 %M 34519669 %R 10.2196/25017 %U https://www.researchprotocols.org/2021/9/e25017 %U https://doi.org/10.2196/25017 %U http://www.ncbi.nlm.nih.gov/pubmed/34519669 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e28349 %T Acceptability of a Brief Web-Based Theory-Based Intervention to Prevent and Reduce Self-harm: Mixed Methods Evaluation %A Keyworth,Chris %A O'Connor,Rory %A Quinlivan,Leah %A Armitage,Christopher J %+ School of Psychology, University of Leeds, Woodhouse, Leeds, LS2 9JT, United Kingdom, 44 01133433738, c.keyworth@leeds.ac.uk %K self-harm %K implementation intentions %K acceptability %K online %K volitional help sheet %K digital health %K mental health %D 2021 %7 14.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The volitional help sheet (VHS) for self-harm equips people with a means of responding automatically to triggers for self-harm with coping strategies. Although there is some evidence of its efficacy, improving acceptability and making the intervention available in a web-based format may be crucial to increasing effectiveness and reach. Objective: This study aims to use the Theoretical Framework of Acceptability (TFA) to explore the acceptability of the VHS, examine for whom and under what circumstances this intervention is more or less acceptable, and develop a series of recommendations for how the VHS can be used to support people in reducing repeat self-harm. Methods: We explored acceptability in two phases. First, our patient and public involvement partners evaluated the original VHS from a lived experience perspective, which was subsequently translated into a web-based format. Second, a representative sample of adults in the United Kingdom who had previously self-harmed were recruited via a YouGov survey (N=514) and were asked to rate the acceptability of the VHS based on the seven constructs of the TFA, namely, affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy. Data were analyzed using descriptive statistics, one-tailed t tests, and binary logistic regression. A directed content analysis approach was used to analyze qualitative data. Results: Participants in the web-based survey rated the VHS as positive (affective attitude; t457=4.72; P<.001); were confident using it (self-efficacy; t457=9.54; P<.001); felt they did not have to give up any benefits, profits, or values when using it (opportunity costs; t439=−15.51; P<.001); understood it and how it worked (intervention coherence; t464=11.90; P<.001); and were confident that it would achieve its purpose (perceived effectiveness; t466=2.04; P=.04). The TFA domain burden appeared to be an important indicator of acceptability. Lower levels of perceived burden when using the VHS tool were more prevalent among younger adults aged 18-24 years (OR 3.63, 95% CI 1.50-8.78), people of White ethnic background (OR 3.02, 95% CI 1.06-8.613), and people without a long-term health condition (OR 1.53, 95% CI 1.01-2.30). Perceived modifications to further improve acceptability included improved formatting (burden), the feature to add new situations and responses or amend existing ones (ethicality), and clearer instructions and further detail about the purpose of the VHS (intervention coherence). Conclusions: Our findings show high levels of acceptability among some people who have previously self-harmed, particularly among younger adults, people of White ethnic backgrounds, and people without long-term health conditions. Future research should aim to improve acceptability among older adults, people from minority ethnic groups, and people with long-term health conditions. %M 34518153 %R 10.2196/28349 %U https://www.jmir.org/2021/9/e28349 %U https://doi.org/10.2196/28349 %U http://www.ncbi.nlm.nih.gov/pubmed/34518153 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 9 %P e31211 %T Implementation of an Internet-Based Acceptance and Commitment Therapy for Promoting Mental Health Among Migrant Live-in Caregivers in Canada: Protocol %A Fung,Kenneth Po-Lun %A Vahabi,Mandana %A Moosapoor,Masoomeh %A Akbarian,Abdolreza %A Jing-Wen Liu,Jenny %A Wong,Josephine Pui-Hing %+ Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria St, Toronto, ON, M5B 2K3, Canada, 1 416 979 5000 ext 552725, mvahabi@ryerson.ca %K migrant live-in caregiver %K women %K mental health %K acceptance commitment therapy %K resiliency %K empowerment %D 2021 %7 13.9.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Psychological distress, isolation, feelings of powerlessness, and limited social support are realities faced by temporary migrant live-in caregivers in Canada. Furthermore, they experience multiple barriers in accessing mental health services due to their long work hours, limited knowledge of health resources, precarious employment, and immigration status. Objective: The Women Empowerment - Caregiver Acceptance & Resilience E-Learning (WE2CARE) project is a pilot intervention research project that aims to promote the mental well-being and resiliency of migrant live-in caregivers. The objectives include exploring the effectiveness of this program in achieving the following: (1) reducing psychological distress (depression, anxiety, and stress); (2) promoting committed actions of self-care; and (3) building mutual support social networks. Further, participants’ satisfaction with the intervention and their perceived barriers to and facilitators of practicing the self-care strategies embedded in WE2CARE will be examined. Methods: A total of 36 live-in caregivers residing in the Greater Toronto Area will be recruited and randomly assigned to either the intervention or waitlist control group. The intervention group will receive a 6-week web-based psychosocial intervention that will be based on Acceptance and Commitment Therapy (ACT). Standardized self-reported surveys will be administered online preintervention, postintervention, and at 6 weeks postintervention to assess mental distress (Depression, Anxiety and Stress Scale), psychological flexibility (Acceptance and Action Questionnaire), mindfulness (Cognitive and Affective Mindfulness Scale – Revised), and resilience (Multi-System Model of Resilience Inventory). In addition, two focus groups will be held with a subset of participants to explore their feedback on the utility of the WE2CARE program. Results: WE2CARE was funded in January 2019 for a year. The protocol was approved by the research ethics boards of Ryerson University (REB 2019-036) and the University of Toronto (RIS37623) in February and May 2019, respectively. Data collection started upon ethics approval and was completed by May 2020. A total of 29 caregivers completed the study and 20 participated in the focus groups. Data analyses are in progress and results will be published in 2021. Conclusions: WE2CARE could be a promising approach to reducing stress, promoting resilience, and providing a virtual space for peer emotional support and collaborative learning among socially isolated and marginalized women. The results of this pilot study will inform the adaptation of an ACT-based psychological intervention for online delivery and determine its utility in promoting mental health among disadvantaged and vulnerable populations. International Registered Report Identifier (IRRID): DERR1-10.2196/31211 %M 34515642 %R 10.2196/31211 %U https://www.researchprotocols.org/2021/9/e31211 %U https://doi.org/10.2196/31211 %U http://www.ncbi.nlm.nih.gov/pubmed/34515642 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 9 %P e21348 %T Investigation of the Effects of an Online Support Group for Mental Health Problems on Stigma and Help-Seeking Among Japanese Adults: Cross-sectional Study %A Kobori,Osamu %A Yoshinaga,Naoki %+ Department of Psychology, International University of Health and Welfare, 4-1-26 Akasaka, Minato-ku, Tokyo, 1078402, Japan, 81 3 5574 3900, O.Kobori@iuhw.ac.jp %K online support group %K mental health %K depression %K stigma %K help-seeking %D 2021 %7 7.9.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Online support groups vary widely in both goals and structures owing to the rapid development of social networking services. Several studies have shown the potential effectiveness of online support groups, such as reducing psychological distress (eg, depression) among individuals with mental health problems. However, online support groups often do not aim at effectiveness regarding distress relief–related outcomes. Objective: This study aims to examine whether the use frequency of online support group platform functions (U2plus) is associated with lower stigma and higher consumer activation. Methods: A total of 350 U2plus users participated in a web-based survey. They were asked what therapy they had received in the past and how often they logged on to it, used each of its functions, and completed the following questionnaires: the Patient Health Questionnaire-9, the Devaluation-Discrimination Scale, and the General Help-Seeking Questionnaire. Results: Regarding the therapy received, 88% (308/350) of participants had taken medication for mental health problems, and 66.6% (233/350) had received psychotherapy or mental health counseling. Regarding use frequency, 21.7% (74/341) of the participants signed in to U2plus and used its functions more than once a week. The use frequency of U2plus functions was not correlated with perceived stigma, but the use frequency of some functions was weakly correlated with help-seeking intentions from formal sources (eg, doctors and psychologists). However, multiple regression analyses revealed that the use frequency of those functions did not uniquely predict help-seeking intentions. Conclusions: It was suggested that online support groups may serve as an alternative treatment option for those who are already undergoing pharmacological treatment and are willing to seek help from whatever source they deem helpful. %M 34491206 %R 10.2196/21348 %U https://formative.jmir.org/2021/9/e21348 %U https://doi.org/10.2196/21348 %U http://www.ncbi.nlm.nih.gov/pubmed/34491206 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e22844 %T Evaluation of Changes in Depression, Anxiety, and Social Anxiety Using Smartphone Sensor Features: Longitudinal Cohort Study %A Meyerhoff,Jonah %A Liu,Tony %A Kording,Konrad P %A Ungar,Lyle H %A Kaiser,Susan M %A Karr,Chris J %A Mohr,David C %+ Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University, 750 N Lake Shore Dr, 10th Floor, Chicago, IL, 60611, United States, 1 312 503 1403, d-mohr@northwestern.edu %K mHealth %K personal sensing %K digital phenotyping %K passive sensing %K ecological momentary assessment %K depression %K anxiety %K digital biomarkers %K digital phenotyping %K mental health assessment %K mobile device %K mobile phone %K internet technology %K psychiatric disorders %K mobile phone %D 2021 %7 3.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The assessment of behaviors related to mental health typically relies on self-report data. Networked sensors embedded in smartphones can measure some behaviors objectively and continuously, with no ongoing effort. Objective: This study aims to evaluate whether changes in phone sensor–derived behavioral features were associated with subsequent changes in mental health symptoms. Methods: This longitudinal cohort study examined continuously collected phone sensor data and symptom severity data, collected every 3 weeks, over 16 weeks. The participants were recruited through national research registries. Primary outcomes included depression (8-item Patient Health Questionnaire), generalized anxiety (Generalized Anxiety Disorder 7-item scale), and social anxiety (Social Phobia Inventory) severity. Participants were adults who owned Android smartphones. Participants clustered into 4 groups: multiple comorbidities, depression and generalized anxiety, depression and social anxiety, and minimal symptoms. Results: A total of 282 participants were aged 19-69 years (mean 38.9, SD 11.9 years), and the majority were female (223/282, 79.1%) and White participants (226/282, 80.1%). Among the multiple comorbidities group, depression changes were preceded by changes in GPS features (Time: r=−0.23, P=.02; Locations: r=−0.36, P<.001), exercise duration (r=0.39; P=.03) and use of active apps (r=−0.31; P<.001). Among the depression and anxiety groups, changes in depression were preceded by changes in GPS features for Locations (r=−0.20; P=.03) and Transitions (r=−0.21; P=.03). Depression changes were not related to subsequent sensor-derived features. The minimal symptoms group showed no significant relationships. There were no associations between sensor-based features and anxiety and minimal associations between sensor-based features and social anxiety. Conclusions: Changes in sensor-derived behavioral features are associated with subsequent depression changes, but not vice versa, suggesting a directional relationship in which changes in sensed behaviors are associated with subsequent changes in symptoms. %M 34477562 %R 10.2196/22844 %U https://www.jmir.org/2021/9/e22844 %U https://doi.org/10.2196/22844 %U http://www.ncbi.nlm.nih.gov/pubmed/34477562 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e30827 %T Characteristics of Dimensional Psychopathology in Suicidal Patients With Major Psychiatric Disorders and Its Association With the Length of Hospital Stay: Algorithm Validation Study %A Lee,Dong Yun %A Park,Jimyung %A Noh,Jai Sung %A Roh,Hyun Woong %A Ha,Jae Ho %A Lee,Eun Young %A Son,Sang Joon %A Park,Rae Woong %+ Department of Biomedical Informatics, Ajou University School of Medicine, Gyeonggi-do, Suwon, 16499, Republic of Korea, 82 31 219 4471, rwpark99@gmail.com %K suicide %K computed phenotype %K natural language processing %K research domain criteria %K electronic health record %D 2021 %7 3.9.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide has emerged as a serious concern for public health; however, only few studies have revealed the differences between major psychiatric disorders and suicide. Recent studies have attempted to quantify research domain criteria (RDoC) into numeric scores to systematically use them in computerized methods. The RDoC scores were used to reveal the characteristics of suicide and its association with major psychiatric disorders. Objective: We intended to investigate the differences in the dimensional psychopathology among hospitalized suicidal patients and the association between the dimensional psychopathology of psychiatric disorders and length of hospital stay. Methods: This retrospective study enrolled hospitalized suicidal patients diagnosed with major psychiatric disorders (depression, schizophrenia, and bipolar disorder) between January 2010 and December 2020 at a tertiary hospital in South Korea. The RDoC scores were calculated using the patients’ admission notes. To measure the differences between psychiatric disorder cohorts, analysis of variance and the Cochran Q test were conducted and post hoc analysis for RDoC domains was performed with the independent two-sample t test. A linear regression model was used to analyze the association between the RDoC scores and sociodemographic features and comorbidity index. To estimate the association between the RDoC scores and length of hospital stay, multiple logistic regression models were applied to each psychiatric disorder group. Results: We retrieved 732 admissions for 571 patients (465 with depression, 73 with schizophrenia, and 33 with bipolar disorder). We found significant differences in the dimensional psychopathology according to the psychiatric disorders. The patient group with depression showed the highest negative RDoC domain scores. In the cognitive and social RDoC domains, the groups with schizophrenia and bipolar disorder scored higher than the group with depression. In the arousal RDoC domain, the depression and bipolar disorder groups scored higher than the group with schizophrenia. We identified significant associations between the RDoC scores and length of stay for the depression and bipolar disorder groups. The odds ratios (ORs) of the length of stay were increased because of the higher negative RDoC domain scores in the group with depression (OR 1.058, 95% CI 1.006-1.114) and decreased by higher arousal RDoC domain scores in the group with bipolar disorder (OR 0.537, 95% CI 0.285-0.815). Conclusions: This study showed the association between the dimensional psychopathology of major psychiatric disorders related to suicide and the length of hospital stay and identified differences in the dimensional psychopathology of major psychiatric disorders. This may provide new perspectives for understanding suicidal patients. %M 34477555 %R 10.2196/30827 %U https://mental.jmir.org/2021/9/e30827 %U https://doi.org/10.2196/30827 %U http://www.ncbi.nlm.nih.gov/pubmed/34477555 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 9 %P e24377 %T Designing a Clinical Decision Support Tool That Leverages Machine Learning for Suicide Risk Prediction: Development Study in Partnership With Native American Care Providers %A Haroz,Emily E %A Grubin,Fiona %A Goklish,Novalene %A Pioche,Shardai %A Cwik,Mary %A Barlow,Allison %A Waugh,Emma %A Usher,Jason %A Lenert,Matthew C %A Walsh,Colin G %+ Center for American Indian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 415 N Washington St, Baltimore, MD, 21231, United States, 1 410 449 0051, eharoz1@jhu.edu %K suicide prevention %K machine learning %K Native American health %K implementation %D 2021 %7 2.9.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Machine learning algorithms for suicide risk prediction have been developed with notable improvements in accuracy. Implementing these algorithms to enhance clinical care and reduce suicide has not been well studied. Objective: This study aims to design a clinical decision support tool and appropriate care pathways for community-based suicide surveillance and case management systems operating on Native American reservations. Methods: Participants included Native American case managers and supervisors (N=9) who worked on suicide surveillance and case management programs on 2 Native American reservations. We used in-depth interviews to understand how case managers think about and respond to suicide risk. The results from interviews informed a draft clinical decision support tool, which was then reviewed with supervisors and combined with appropriate care pathways. Results: Case managers reported acceptance of risk flags based on a predictive algorithm in their surveillance system tools, particularly if the information was available in a timely manner and used in conjunction with their clinical judgment. Implementation of risk flags needed to be programmed on a dichotomous basis, so the algorithm could produce output indicating high versus low risk. To dichotomize the continuous predicted probabilities, we developed a cutoff point that favored specificity, with the understanding that case managers’ clinical judgment would help increase sensitivity. Conclusions: Suicide risk prediction algorithms show promise, but implementation to guide clinical care remains relatively elusive. Our study demonstrates the utility of working with partners to develop and guide the operationalization of risk prediction algorithms to enhance clinical care in a community setting. %M 34473065 %R 10.2196/24377 %U https://publichealth.jmir.org/2021/9/e24377 %U https://doi.org/10.2196/24377 %U http://www.ncbi.nlm.nih.gov/pubmed/34473065 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 8 %P e26223 %T Factors That Help and Hinder the Implementation of Digital Depression Prevention Programs: School-Based Cross-sectional Study %A Beames,Joanne R %A Johnston,Lara %A O'Dea,Bridianne %A Torok,Michelle %A Christensen,Helen %A Boydell,Katherine M %A Werner-Seidler,Aliza %+ Black Dog Institute, University of New South Wales, Hospital Road, Randwick, 2031, Australia, 61 2 9382 ext 8776, j.beames@blackdog.org.au %K secondary school %K depression %K prevention %K digital %K barrier %K facilitator %K teacher %K counselor %K principal %K student %D 2021 %7 27.8.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital prevention programs that are delivered in a school environment can inoculate young people against depression. However, little is known about the school-based factors that help and hinder the implementation of these programs. Staff members are integral for supporting mental health programs in schools and are likely to have a wealth of expertise and knowledge about the factors that affect implementation. Objective: The primary objective of this study was to explore the barriers and facilitators to implementing a digital depression prevention program in Australian secondary schools with teachers, counselors, and principals. The secondary objective was to explore variations in these factors across different school contexts, including the school type (government or nongovernment), location (capital city, regional/or rural areas), and socioeconomic status (SES) (low, medium, high). Methods: This quantitative cross-sectional survey study assessed the barriers and facilitators to implementing a hypothetical digital prevention program in Australian schools. The survey was taken by 97 teachers (average age 38.3 years), 93 counselors (average age 39.5 years), and 11 principals (average age 50.9 years) across Australia between November 2017 and July 2018. Results: A range of barriers and facilitators relating to logistics and resources, staff support, and program factors were endorsed by the surveyed staff. Consistent with prior research, common barriers included a lack of time and resources (ie, staff and rooms). These barriers were particularly evident in government, rural/regional, and low socioeconomic schools. Other barriers were specific to digital delivery, including privacy issues and a lack of clarity around staff roles and responsibilities. Facilitators included upskilling staff through training, embedding the program into the curriculum, and other program factors including universal delivery, screening of students’ mental health, and clear referral pathways. Knowledge about the program efficacy was also perceived as important by a large proportion of the respondents. Conclusions: The digital depression prevention program was perceived as suitable for use within different schools in Australia, although certain factors need to be considered to enable effective implementation. Logistics and resources, support, and program factors were identified as particularly important for school-based implementation. To maximize the effectiveness in delivering digital programs, implementation may need to be tailored to the staff roles and school types. %M 34448701 %R 10.2196/26223 %U https://www.jmir.org/2021/8/e26223 %U https://doi.org/10.2196/26223 %U http://www.ncbi.nlm.nih.gov/pubmed/34448701 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 8 %P e26119 %T Distant Supervision for Mental Health Management in Social Media: Suicide Risk Classification System Development Study %A Fu,Guanghui %A Song,Changwei %A Li,Jianqiang %A Ma,Yue %A Chen,Pan %A Wang,Ruiqian %A Yang,Bing Xiang %A Huang,Zhisheng %+ School of Health Sciences, Wuhan University, Wuchang District, Wuhan, 430072, China, 86 15902731922, 00009312@whu.edu.cn %K deep learning %K distant supervision %K mental health %K crisis prevention %D 2021 %7 26.8.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based social media provides common people with a platform to express their emotions conveniently and anonymously. There have been nearly 2 million messages in a particular Chinese social media data source, and several thousands more are generated each day. Therefore, it has become impossible to analyze these messages manually. However, these messages have been identified as an important data source for the prevention of suicide related to depression disorder. Objective: We proposed in this paper a distant supervision approach to developing a system that can automatically identify textual comments that are indicative of a high suicide risk. Methods: To avoid expensive manual data annotations, we used a knowledge graph method to produce approximate annotations for distant supervision, which provided a basis for a deep learning architecture that was built and refined by interactions with psychology experts. There were three annotation levels, as follows: free annotations (zero cost), easy annotations (by psychology students), and hard annotations (by psychology experts). Results: Our system was evaluated accordingly and showed that its performance at each level was promising. By combining our system with several important psychology features from user blogs, we obtained a precision of 80.75%, a recall of 75.41%, and an F1 score of 77.98% for the hardest test data. Conclusions: In this paper, we proposed a distant supervision approach to develop an automatic system that can classify high and low suicide risk based on social media comments. The model can therefore provide volunteers with early warnings to prevent social media users from committing suicide. %M 34435964 %R 10.2196/26119 %U https://www.jmir.org/2021/8/e26119 %U https://doi.org/10.2196/26119 %U http://www.ncbi.nlm.nih.gov/pubmed/34435964 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e30610 %T Psychosomatic Rehabilitation Patients and the General Population During COVID-19: Online Cross-sectional and Longitudinal Study of Digital Trainings and Rehabilitation Effects %A Keller,Franziska Maria %A Dahmen,Alina %A Derksen,Christina %A Kötting,Lukas %A Lippke,Sonia %+ Department of Psychology & Methods, Jacobs University Bremen gGmbH, Campus Ring 1, Bremen, 28759, Germany, 49 421200 ext 4730, s.lippke@jacobs-university.de %K mental health %K COVID-19 %K medical rehabilitation %K psychosomatic rehabilitation %K internet-delivered digital trainings %D 2021 %7 26.8.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic has largely affected people’s mental health and psychological well-being. Specifically, individuals with a pre-existing mental health disorder seem more impaired by lockdown measures posing as major stress factors. Medical rehabilitation treatment can help people cope with these stressors. The internet and digital apps provide a platform to contribute to regular treatment and to conduct research on this topic. Objective: Making use of internet-based assessments, this study investigated individuals from the general population and patients from medical, psychosomatic rehabilitation clinics. Levels of depression, anxiety, loneliness, and perceived stress during the COVID-19 pandemic, common COVID-19–related worries, and the intention to use digital apps were compared. Furthermore, we investigated whether participating in internet-delivered digital trainings prior to and during patients’ rehabilitation stay, as well as the perceived usefulness of digital trainings, were associated with improved mental health after rehabilitation. Methods: A large-scale, online, cross-sectional study was conducted among a study sample taken from the general population (N=1812) in Germany from May 2020 to April 2021. Further, a longitudinal study was conducted making use of the internet among a second study sample of psychosomatic rehabilitation patients at two measurement time points—before (N=1719) and after (n=738) rehabilitation—between July 2020 and April 2021. Validated questionnaires and adapted items were used to assess mental health and COVID-19–related worries. Digital trainings were evaluated. Propensity score matching, multivariate analyses of covariance, an exploratory factor analysis, and hierarchical regression analyses were performed. Results: Patients from the psychosomatic rehabilitation clinics reported increased symptoms with regard to depression, anxiety, loneliness, and stress (F4,2028=183.74, P<.001, η2p=0.27) compared to the general population. Patients perceived greater satisfaction in communication with health care professionals (F1,837=31.67, P<.001, η2p=0.04), had lower financial worries (F1,837=38.96, P<.001, η2p=0.04), but had higher household-related worries (F1,837=5.34, P=.02, η2p=0.01) compared to the general population. Symptoms of depression, anxiety, loneliness, and perceived stress were lower postrehabilitation (F1,712=23.21, P<.001, η2p=0.04) than prior to rehabilitation. Psychosomatic patients reported a higher intention to use common apps and digital trainings (F3,2021=51.41, P<.001, η2p=0.07) than the general population. With regard to digital trainings offered prior to and during the rehabilitation stay, the perceived usefulness of digital trainings on rehabilitation goals was associated with decreased symptoms of depression (β=–.14, P<.001), anxiety (β=–.12, P<.001), loneliness (β=–.18, P<.001), and stress postrehabilitation (β=–.19, P<.001). Participation in digital group therapy for depression was associated with an overall change in depression (F1,725=4.82, P=.03, η2p=0.01) and anxiety (F1,725=6.22, P=.01, η2p=0.01) from pre- to postrehabilitation. Conclusions: This study validated the increased mental health constraints of psychosomatic rehabilitation patients in comparison to the general population and the effects of rehabilitation treatment. Digital rehabilitation components are promising tools that could prepare patients for their rehabilitation stay, could integrate well with face-to-face therapy during rehabilitation treatment, and could support aftercare. Trial Registration: ClinicalTrials.gov NCT04453475; https://clinicaltrials.gov/ct2/show/NCT04453475 and ClinicalTrials.gov NCT03855735; https://clinicaltrials.gov/ct2/show/NCT03855735 %M 34270444 %R 10.2196/30610 %U https://mental.jmir.org/2021/8/e30610 %U https://doi.org/10.2196/30610 %U http://www.ncbi.nlm.nih.gov/pubmed/34270444 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e29419 %T The Persistence of the Impact of COVID-19–Related Distress, Mood Inertia, and Loneliness on Mental Health During a Postlockdown Period in Germany: An Ecological Momentary Assessment Study %A Haucke,Matthias %A Liu,Shuyan %A Heinzel,Stephan %+ Department of Psychiatry and Psychotherapy, Charité – Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, Berlin, Germany, 49 30450517002, siyan908@hotmail.com %K COVID-19 %K outbreaks %K epidemics %K pandemics %K psychological responses and emotional well-being %K ecological momentary assessment %K risk and protective factors %K low incidence and restrictions %D 2021 %7 26.8.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The first wave of the COVID-19 pandemic in early 2020 increased mental health problems globally. However, little is known about mental health problems during a low-incidence period of the pandemic without strict public health measures. Objective: We aim to investigate whether COVID-19–related risk factors for mental health problems persist beyond lockdown measures. We targeted a vulnerable population that is at risk of developing low mental health and assessed their daily dynamics of mood and emotion regulation after a strict lockdown. Methods: During a postlockdown period in Germany (between August 8, 2020, and November 1, 2020), we conducted an ecological momentary assessment with 131 participants who experienced at least mild COVID-19–related distress and loneliness. To estimate negative mood inertia, we built a lag-1 three-level autoregressive model. Results: We found that information exposure and active daily COVID-19 cases did not have an impact on negative mood amid a postlockdown period. However, there was a day-to-day carryover effect of negative mood. In addition, worrying about COVID-19, feeling restricted by COVID-19, and feeling lonely increased negative mood. Conclusions: The mental health of a vulnerable population is still challenged by COVID-19–related stressors after the lifting of a strict lockdown. This study highlights the need to protect mental health during postpandemic periods. %M 34347622 %R 10.2196/29419 %U https://mental.jmir.org/2021/8/e29419 %U https://doi.org/10.2196/29419 %U http://www.ncbi.nlm.nih.gov/pubmed/34347622 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 8 %P e30617 %T Psychoeducational Interventions for Caregivers of Persons With Multiple Sclerosis: Protocol for a Randomized Trial %A Douglas,Sara L %A Plow,Matthew %A Packer,Tanya %A Lipson,Amy R %A Lehman,Michelle J %+ School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, United States, 1 216 368 0702, sld4@case.edu %K multiple sclerosis %K caregivers %K distress %K anxiety %K depression %K psycho-education %K website %K coaching %K mobile phone %D 2021 %7 26.8.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Of the approximately 1 million people living with multiple sclerosis in the United States, more than half receive informal, unpaid care or support from family or friends (caregivers). These caregivers report high levels of stress, anxiety, and negative emotions. Few researchers have conducted psychoeducational interventions for these caregivers. Objective: This paper presents a protocol for a randomized clinical trial that aims to test the efficacy of two interventions for improving stress, anxiety, depression, and negative emotions for caregivers of persons with multiple sclerosis. Methods: Participants included any self-identified family or friend caregiver of a person with multiple sclerosis. Data collection began in April 2021 and is expected to continue until November 2021. Participants will be randomized to receive either a website-only or a website-coaching intervention delivered for 6 weeks. Data will be collected at baseline, 6 weeks after baseline (after delivery of intervention), and 6 weeks later. Results: The protocol was approved by the institutional review board of the Case Western Reserve University on January 21, 2021 (protocol 20201484). As of May 2021, 66 participants were enrolled. Conclusions: Our findings will have implications for identifying the efficacy of two types of interventions developed for caregivers of persons with multiple sclerosis to reduce negative psychological outcomes associated with caregiving. Trial Registration: ClinicalTrials.gov NCT04662008; http://clinicaltrials.gov/ct2/show/NCT04662008 International Registered Report Identifier (IRRID): DERR1-10.2196/30617 %M 34435971 %R 10.2196/30617 %U https://www.researchprotocols.org/2021/8/e30617 %U https://doi.org/10.2196/30617 %U http://www.ncbi.nlm.nih.gov/pubmed/34435971 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e28736 %T Factors Associated With Psychological Disturbances During the COVID-19 Pandemic: Multicountry Online Study %A Plomecka,Martyna %A Gobbi,Susanna %A Neckels,Rachael %A Radzinski,Piotr %A Skorko,Beata %A Lazzeri,Samuel %A Almazidou,Kristina %A Dedic,Alisa %A Bakalovic,Asja %A Hrustic,Lejla %A Ashraf,Zainab %A Es Haghi,Sarvin %A Rodriguez-Pino,Luis %A Waller,Verena %A Jabeen,Hafsa %A Alp,A Beyza %A Behnam,Mehdi %A Shibli,Dana %A Baranczuk-Turska,Zofia %A Haq,Zeeshan %A Qureshi,Salah %A Strutt,Adriana M %A Jawaid,Ali %+ Center of Excellence for Neural Plasticity and Brain Disorders: BRAINCITY, Nencki Institute of Experimental Biology, Ludwika Pasteura 3, Warsaw, 02-093, Poland, 48 518892048, a.jawaid@nencki.edu.pl %K COVID-19 %K pandemic %K mental health %K depression %K posttraumatic stress disorder %K general psychological disturbance %K global %D 2021 %7 19.8.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Accumulating evidence suggests that the COVID-19 pandemic has negatively impacted the mental health of individuals. However, the susceptibility of individuals to be impacted by the pandemic is variable, suggesting potential influences of specific factors related to participants’ demographics, attitudes, and practices. Objective: We aimed to identify the factors associated with psychological symptoms related to the effects of the first wave of the pandemic in a multicountry cohort of internet users. Methods: This study anonymously screened 13,332 internet users worldwide for acute psychological symptoms related to the COVID-19 pandemic from March 29 to April 14, 2020, during the first wave of the pandemic amidst strict lockdown conditions. A total of 12,817 responses were considered valid. Moreover, 1077 participants from Europe were screened a second time from May 15 to May 30, 2020, to ascertain the presence of psychological effects after the ease down of restrictions. Results: Female gender, pre-existing psychiatric conditions, and prior exposure to trauma were identified as notable factors associated with increased psychological symptoms during the first wave of COVID-19 (P<.001). The same factors, in addition to being related to someone who died due to COVID-19 and using social media more than usual, were associated with persistence of psychological disturbances in the limited second assessment of European participants after the restrictions had relatively eased (P<.001). Optimism, ability to share concerns with family and friends like usual, positive prediction about COVID-19, and daily exercise were related to fewer psychological symptoms in both assessments (P<.001). Conclusions: This study highlights the significant impact of the COVID-19 pandemic at the worldwide level on the mental health of internet users and elucidates prominent associations with their demographics, history of psychiatric disease risk factors, household conditions, certain personality traits, and attitudes toward COVID-19. %M 34254939 %R 10.2196/28736 %U https://mental.jmir.org/2021/8/e28736 %U https://doi.org/10.2196/28736 %U http://www.ncbi.nlm.nih.gov/pubmed/34254939 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 8 %P e31072 %T Optimizing Social-Emotional-Communication Development in Infants of Mothers With Depression: Protocol for a Randomized Controlled Trial of a Mobile Intervention Targeting Depression and Responsive Parenting %A Baggett,Kathleen M %A Davis,Betsy %A Sheeber,Lisa %A Miller,Katy %A Leve,Craig %A Mosley,Elizabeth A %A Landry,Susan H %A Feil,Edward G %+ Georgia State University, 14 Marietta St NW, Atlanta, GA, 30303, United States, 1 404 413 1571, kbaggett@gsu.edu %K maternal depression %K parenting %K infant social-emotional and social-communication development %K mobile intervention %K remote coaching %K trial protocol %K mobile phone %D 2021 %7 18.8.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Postpartum depression interferes with maternal engagement in interventions that are effective in improving infant social-emotional and social-communication outcomes. There is an absence of integrated interventions with demonstrated effectiveness in both reducing maternal depression and promoting parent-mediated practices that optimize infant social-emotional and social-communication competencies. Interventions targeting maternal depression are often separate from parent-mediated interventions. To address the life course needs of depressed mothers and their infants, we need brief, accessible, and integrated interventions that target both maternal depression and specific parent practices shown to improve infant social-emotional and social-communication trajectories. Objective: The aim of this study is to evaluate the efficacy of a mobile internet intervention, Mom and Baby Net, with remote coaching to improve maternal mood and promote parent practices that optimize infant social-emotional and social-communication development. Methods: This is a two-arm, randomized controlled intent-to-treat trial. Primary outcomes include maternal depression symptoms and observed parent and infant behaviors. Outcomes are measured via direct observational assessments and standardized questionnaires. The sample is being recruited from the urban core of a large southern city in the United States. Study enrollment was initiated in 2017 and concluded in 2020. Participants are biological mothers with elevated depression symptoms, aged 18 years or older, and who have custody of an infant less than 12 months of age. Exclusion criteria at the time of screening include maternal homelessness or shelter residence, inpatient mental health or substance abuse treatment, or maternal or infant treatment of a major mental or physical illness that would hinder meaningful study participation. Results: The start date of this grant-funded randomized controlled trial (RCT) was September 1, 2016. Data collection is ongoing. Following the institutional review board (IRB)–approved pilot work, the RCT was approved by the IRB on November 17, 2017. Recruitment was initiated immediately following IRB approval. Between February 15, 2018, and March 11, 2021, we successfully recruited a sample of 184 women and their infants into the RCT. The sample is predominantly African American and socioeconomically disadvantaged. Conclusions: Data collection is scheduled to be concluded in March 2022. We anticipate that relative to the attention control condition, which is focused on education around maternal depression and infant developmental milestones with matching technology and coaching structure, mothers in the Mom and Baby Net intervention will experience greater reductions in depression and gains in sensitive and responsive parent practices and that their infants will demonstrate greater gains in social-emotional and social-communication behavior. Trial Registration: ClinicalTrials.gov NCT03464630; https://clinicaltrials.gov/ct2/show/NCT03464630 International Registered Report Identifier (IRRID): DERR1-10.2196/31072 %M 34406122 %R 10.2196/31072 %U https://www.researchprotocols.org/2021/8/e31072 %U https://doi.org/10.2196/31072 %U http://www.ncbi.nlm.nih.gov/pubmed/34406122 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e32475 %T Acceptability of Using Social Media Content in Mental Health Research: A Reflection. Comment on “Twitter Users’ Views on Mental Health Crisis Resolution Team Care Compared With Stakeholder Interviews and Focus Groups: Qualitative Analysis” %A Morant,Nicola %A Chilman,Natasha %A Lloyd-Evans,Brynmor %A Wackett,Jane %A Johnson,Sonia %+ Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7NF, United Kingdom, 44 7969688554, n.morant@ucl.ac.uk %K Twitter %K social media %K qualitative %K crisis resolution team %K home treatment team %K mental health %K acute care %K severe mental illness %D 2021 %7 17.8.2021 %9 Letter to the Editor %J JMIR Ment Health %G English %X %M 34402799 %R 10.2196/32475 %U https://mental.jmir.org/2021/8/e32475 %U https://doi.org/10.2196/32475 %U http://www.ncbi.nlm.nih.gov/pubmed/34402799 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 8 %P e24393 %T Development of a Mobile App to Support Self-management of Anxiety and Depression in African American Women: Usability Study %A McCall,Terika %A Ali,Muhammad Osama %A Yu,Fei %A Fontelo,Paul %A Khairat,Saif %+ Center for Medical Informatics, Yale School of Medicine, 300 George Street, Suite 501, New Haven, CT, 06511, United States, 1 203 737 5379, terika.mccall@yale.edu %K African Americans %K women %K mental health %K anxiety %K depression %K telemedicine %K mHealth %K mobile applications %K digital health %K user-centered design %K mobile phone %D 2021 %7 17.8.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Anxiety and depressive disorders are the most common mental health conditions among African American women. Despite the need for mental health care, African American women significantly underuse mental health services. Previous mobile health studies revealed significant improvements in anxiety or depressive symptoms after intervention. The use of mobile apps offers the potential to eliminate or mitigate barriers for African American women who are seeking access to mental health services and resources. Objective: This study aims to evaluate the usability of the prototype of an app that is designed for supporting the self-management of anxiety and depression in African American women. Methods: Individual usability testing sessions were conducted with 15 participants in Chapel Hill, North Carolina. Cognitive walkthrough and think-aloud protocols were used to evaluate the user interface. Eye-tracking glasses were used to record participants’ visual focus and gaze path as they performed the tasks. The Questionnaire for User Interface Satisfaction was administered after each session to assess the participants’ acceptance of the app. Results: Participants rated the usability of the prototype positively and provided recommendations for improvement. The average of the mean scores for usability assessments (ie, overall reactions to the software, screen, terminology and app information, learning, and app capabilities) ranged from 7.2 to 8.8 on a scale of 0-9 (low to high rating) for user tasks. Most participants were able to complete each task with limited or no assistance. Design recommendations included improving the user interface by adding graphics and color, adding a tutorial for first-time users, curating a list of Black women therapists within the app, adding details about tracking anxiety and depression in the checkup graphs, informing users that they can use the talk-to-text feature for journal entries to reduce burden, relabeling the mental health information icon, monitoring for crisis support, and improving clickthrough sequencing. Conclusions: This study provides a better understanding of user experience with an app tailored to support the management of anxiety and depression for African American women, which is an underserved group. As African American women have high rates of smartphone ownership, there is a great opportunity to use mobile technology to provide access to needed mental health services and resources. Future work will include incorporating feedback from usability testing and focus group sessions to refine and develop the app further. The updated app will undergo iterative usability testing before launching the pilot study to evaluate the feasibility and acceptability of the prototype. %M 34133313 %R 10.2196/24393 %U https://formative.jmir.org/2021/8/e24393 %U https://doi.org/10.2196/24393 %U http://www.ncbi.nlm.nih.gov/pubmed/34133313 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 8 %P e28918 %T Automated Screening for Social Anxiety, Generalized Anxiety, and Depression From Objective Smartphone-Collected Data: Cross-sectional Study %A Di Matteo,Daniel %A Fotinos,Kathryn %A Lokuge,Sachinthya %A Mason,Geneva %A Sternat,Tia %A Katzman,Martin A %A Rose,Jonathan %+ The Edward S Rogers Sr Department of Electrical and Computer Engineering, University of Toronto, 10 King's College Road, Toronto, ON, Canada, 1 416 978 6992, daniel.dimatteo@utoronto.ca %K mobile sensing %K passive EMA %K passive sensing %K psychiatric assessment %K mood and anxiety disorders %K mobile apps %K mhealth %K mobile phone %K digital health %K digital phenotyping %D 2021 %7 13.8.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The lack of access to mental health care could be addressed, in part, through the development of automated screening technologies for detecting the most common mental health disorders without the direct involvement of clinicians. Objective smartphone-collected data may contain sufficient information about individuals’ behaviors to infer their mental states and therefore screen for anxiety disorders and depression. Objective: The objective of this study is to compare how a single set of recognized and novel features, extracted from smartphone-collected data, can be used for predicting generalized anxiety disorder (GAD), social anxiety disorder (SAD), and depression. Methods: An Android app was designed, together with a centralized server system, to collect periodic measurements of objective smartphone data. The types of data included samples of ambient audio, GPS location, screen state, and light sensor data. Subjects were recruited into a 2-week observational study in which the app was run on their personal smartphones. The subjects also completed self-report severity measures of SAD, GAD, and depression. The participants were 112 Canadian adults from a nonclinical population. High-level features were extracted from the data of 84 participants, and predictive models of SAD, GAD, and depression were built and evaluated. Results: Models of SAD and depression achieved a significantly greater screening accuracy than uninformative models (area under the receiver operating characteristic means of 0.64, SD 0.13 and 0.72, SD 0.12, respectively), whereas models of GAD failed to be predictive. Investigation of the model coefficients revealed key features that were predictive of SAD and depression. Conclusions: We demonstrate the ability of a common set of features to act as predictors in the models of both SAD and depression. This suggests that the types of behaviors that can be inferred from smartphone-collected data are broad indicators of mental health, which can be used to study, assess, and track psychopathology simultaneously across multiple disorders and diagnostic boundaries. %M 34397386 %R 10.2196/28918 %U https://www.jmir.org/2021/8/e28918 %U https://doi.org/10.2196/28918 %U http://www.ncbi.nlm.nih.gov/pubmed/34397386 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 8 %P e20678 %T Artificial Intelligence–Based Chatbot for Anxiety and Depression in University Students: Pilot Randomized Controlled Trial %A Klos,Maria Carolina %A Escoredo,Milagros %A Joerin,Angela %A Lemos,Viviana Noemí %A Rauws,Michiel %A Bunge,Eduardo L %+ Interdisciplinary Center for Research in Health and Behavioral Sciences (CIICSAC), Universidad Adventista del Plata (UAP)., National Scientific and Technical Research Council (CONICET)., 25 de Mayo 99, Libertador San Martín, Entre Ríos, 3103, Argentina, 54 3435064263, mcarolinaklos@gmail.com %K artificial intelligence %K chatbots %K conversational agents %K mental health %K anxiety %K depression %K college students %D 2021 %7 12.8.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Artificial intelligence–based chatbots are emerging as instruments of psychological intervention; however, no relevant studies have been reported in Latin America. Objective: The objective of the present study was to evaluate the viability, acceptability, and potential impact of using Tess, a chatbot, for examining symptoms of depression and anxiety in university students. Methods: This was a pilot randomized controlled trial. The experimental condition used Tess for 8 weeks, and the control condition was assigned to a psychoeducation book on depression. Comparisons were conducted using Mann-Whitney U and Wilcoxon tests for depressive symptoms, and independent and paired sample t tests to analyze anxiety symptoms. Results: The initial sample consisted of 181 Argentinian college students (158, 87.2% female) aged 18 to 33. Data at week 8 were provided by 39 out of the 99 (39%) participants in the experimental condition and 34 out of the 82 (41%) in the control group. On an average, 472 (SD 249.52) messages were exchanged, with 116 (SD 73.87) of the messages sent from the users in response to Tess. A higher number of messages exchanged with Tess was associated with positive feedback (F2,36=4.37; P=.02). No significant differences between the experimental and control groups were found from the baseline to week 8 for depressive and anxiety symptoms. However, significant intragroup differences demonstrated that the experimental group showed a significant decrease in anxiety symptoms; no such differences were observed for the control group. Further, no significant intragroup differences were found for depressive symptoms. Conclusions: The students spent a considerable amount of time exchanging messages with Tess and positive feedback was associated with a higher number of messages exchanged. The initial results show promising evidence for the usability and acceptability of Tess in the Argentinian population. Research on chatbots is still in its initial stages and further research is needed. %M 34092548 %R 10.2196/20678 %U https://formative.jmir.org/2021/8/e20678 %U https://doi.org/10.2196/20678 %U http://www.ncbi.nlm.nih.gov/pubmed/34092548 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e29368 %T Understanding People’s Use of and Perspectives on Mood-Tracking Apps: Interview Study %A Schueller,Stephen M %A Neary,Martha %A Lai,Jocelyn %A Epstein,Daniel A %+ Department of Psychological Science, University of California, Irvine, 4201 Social and Behavioral Sciences Gateway, Irvine, CA, 92697, United States, 1 9498243850, s.schueller@uci.edu %K mental health %K mobile apps %K mHealth %K emotions %K affect %K self-tracking %D 2021 %7 11.8.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Supporting mental health and wellness is of increasing interest due to a growing recognition of the prevalence and burden of mental health issues. Mood is a central aspect of mental health, and several technologies, especially mobile apps, have helped people track and understand it. However, despite formative work on and dissemination of mood-tracking apps, it is not well understood how mood-tracking apps used in real-world contexts might benefit people and what people hope to gain from them. Objective: To address this gap, the purpose of this study was to understand motivations for and experiences in using mood-tracking apps from people who used them in real-world contexts. Methods: We interviewed 22 participants who had used mood-tracking apps using a semistructured interview and card sorting task. The interview focused on their experiences using a mood-tracking app. We then conducted a card sorting task using screenshots of various data entry and data review features from mood-tracking apps. We used thematic analysis to identify themes around why people use mood-tracking apps, what they found useful about them, and where people felt these apps fell short. Results: Users of mood-tracking apps were primarily motivated by negative life events or shifts in their own mental health that prompted them to engage in tracking and improve their situation. In general, participants felt that using a mood-tracking app facilitated self-awareness and helped them to look back on a previous emotion or mood experience to understand what was happening. Interestingly, some users reported less inclination to document their negative mood states and preferred to document their positive moods. There was a range of preferences for personalization and simplicity of tracking. Overall, users also liked features in which their previous tracked emotions and moods were visualized in figures or calendar form to understand trends. One gap in available mood-tracking apps was the lack of app-facilitated recommendations or suggestions for how to interpret their own data or improve their mood. Conclusions: Although people find various features of mood-tracking apps helpful, the way people use mood-tracking apps, such as avoiding entering negative moods, tracking infrequently, or wanting support to understand or change their moods, demonstrate opportunities for improvement. Understanding why and how people are using current technologies can provide insights to guide future designs and implementations. %M 34383678 %R 10.2196/29368 %U https://mental.jmir.org/2021/8/e29368 %U https://doi.org/10.2196/29368 %U http://www.ncbi.nlm.nih.gov/pubmed/34383678 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 8 %P e28931 %T Perceptions of Alerts Issued by Social Media Platforms in Response to Self-injury Posts Among Latinx Adolescents: Qualitative Analysis %A Laestadius,Linnea I %A Craig,Katherine A %A Campos-Castillo,Celeste %+ Zilber School of Public Health, University of Wisconsin-Milwaukee, P O Box 413, Milwaukee, WI, 53201, United States, 1 414 251 5607, llaestad@uwm.edu %K adolescents %K social media %K mental health %K NSSI %K race and ethnicity %K mobile phone %D 2021 %7 10.8.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: There is growing interest in using social media data to detect and address nonsuicidal self-injury (NSSI) among adolescents. Adolescents often do not seek clinical help for NSSI and may adopt strategies to obscure detection; therefore, social media platforms may be able to facilitate early detection and treatment by using machine learning models to screen posts for harmful content and subsequently alert adults. However, such efforts have raised privacy and ethical concerns among health researchers. Little is currently known about how adolescents perceive these efforts. Objective: The aim of this study is to examine perceptions of automated alerts for NSSI posts on social media among Latinx adolescents, who are at risk for NSSI yet are underrepresented in both NSSI and health informatics research. In addition, we considered their perspectives on preferred recipients of automated alerts. Methods: We conducted semistructured, qualitative interviews with 42 Latinx adolescents between the ages of 13 and 17 years who were recruited from a nonprofit organization serving the Latinx community in Milwaukee, Wisconsin. The Latinx population in Milwaukee is largely of Mexican descent. All interviews were conducted between June and July 2019. Transcripts were analyzed using framework analysis to discern their perceptions of automated alerts sent by social media platforms and potential alert recipients. Results: Participants felt that automated alerts would make adolescents safer and expedite aid before the situation escalated. However, some worried that hyperbolic statements would generate false alerts and instigate conflicts. Interviews revealed strong opinions about ideal alert recipients. Parents were most commonly endorsed, but support was conditional on perceptions that the parent would respond appropriately. Emergency services were judged as safer but inappropriate for situations considered lower risk. Alerts sent to school staff generated the strongest privacy concerns. Altogether, the preferred alert recipients varied by individual adolescents and perceived risks in the situation. None raised ethical concerns about the collection, analysis, or storage of personal information regarding their mental health status. Conclusions: Overall, Latinx adolescents expressed broad support for automated alerts for NSSI on social media, which indicates opportunities to address NSSI. However, these efforts should be co-constructed with adolescents to ensure that preferences and needs are met, as well as embedded within broader approaches for addressing structural and cultural barriers to care. %M 34383683 %R 10.2196/28931 %U https://www.jmir.org/2021/8/e28931 %U https://doi.org/10.2196/28931 %U http://www.ncbi.nlm.nih.gov/pubmed/34383683 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e27589 %T Toward a Mobile Platform for Real-world Digital Measurement of Depression: User-Centered Design, Data Quality, and Behavioral and Clinical Modeling %A Nickels,Stefanie %A Edwards,Matthew D %A Poole,Sarah F %A Winter,Dale %A Gronsbell,Jessica %A Rozenkrants,Bella %A Miller,David P %A Fleck,Mathias %A McLean,Alan %A Peterson,Bret %A Chen,Yuanwei %A Hwang,Alan %A Rust-Smith,David %A Brant,Arthur %A Campbell,Andrew %A Chen,Chen %A Walter,Collin %A Arean,Patricia A %A Hsin,Honor %A Myers,Lance J %A Marks Jr,William J %A Mega,Jessica L %A Schlosser,Danielle A %A Conrad,Andrew J %A Califf,Robert M %A Fromer,Menachem %+ Verily Life Sciences, 269 E Grand Ave, South San Francisco, CA, 94080, United States, 1 833 391 8633, stefnickels@verily.com %K mental health %K mobile sensing %K mobile phone %K mHealth %K depression %K location %K GPS %K app usage %K voice diaries %K adherence %K engagement %K mobility %K sleep %K physical activity %K digital phenotyping %K user-centered design %D 2021 %7 10.8.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Although effective mental health treatments exist, the ability to match individuals to optimal treatments is poor, and timely assessment of response is difficult. One reason for these challenges is the lack of objective measurement of psychiatric symptoms. Sensors and active tasks recorded by smartphones provide a low-burden, low-cost, and scalable way to capture real-world data from patients that could augment clinical decision-making and move the field of mental health closer to measurement-based care. Objective: This study tests the feasibility of a fully remote study on individuals with self-reported depression using an Android-based smartphone app to collect subjective and objective measures associated with depression severity. The goals of this pilot study are to develop an engaging user interface for high task adherence through user-centered design; test the quality of collected data from passive sensors; start building clinically relevant behavioral measures (features) from passive sensors and active inputs; and preliminarily explore connections between these features and depression severity. Methods: A total of 600 participants were asked to download the study app to join this fully remote, observational 12-week study. The app passively collected 20 sensor data streams (eg, ambient audio level, location, and inertial measurement units), and participants were asked to complete daily survey tasks, weekly voice diaries, and the clinically validated Patient Health Questionnaire (PHQ-9) self-survey. Pairwise correlations between derived behavioral features (eg, weekly minutes spent at home) and PHQ-9 were computed. Using these behavioral features, we also constructed an elastic net penalized multivariate logistic regression model predicting depressed versus nondepressed PHQ-9 scores (ie, dichotomized PHQ-9). Results: A total of 415 individuals logged into the app. Over the course of the 12-week study, these participants completed 83.35% (4151/4980) of the PHQ-9s. Applying data sufficiency rules for minimally necessary daily and weekly data resulted in 3779 participant-weeks of data across 384 participants. Using a subset of 34 behavioral features, we found that 11 features showed a significant (P<.001 Benjamini-Hochberg adjusted) Spearman correlation with weekly PHQ-9, including voice diary–derived word sentiment and ambient audio levels. Restricting the data to those cases in which all 34 behavioral features were present, we had available 1013 participant-weeks from 186 participants. The logistic regression model predicting depression status resulted in a 10-fold cross-validated mean area under the curve of 0.656 (SD 0.079). Conclusions: This study finds a strong proof of concept for the use of a smartphone-based assessment of depression outcomes. Behavioral features derived from passive sensors and active tasks show promising correlations with a validated clinical measure of depression (PHQ-9). Future work is needed to increase scale that may permit the construction of more complex (eg, nonlinear) predictive models and better handle data missingness. %M 34383685 %R 10.2196/27589 %U https://mental.jmir.org/2021/8/e27589 %U https://doi.org/10.2196/27589 %U http://www.ncbi.nlm.nih.gov/pubmed/34383685 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e26348 %T Validity of the Aktibipo Self-rating Questionnaire for the Digital Self-assessment of Mood and Relapse Detection in Patients With Bipolar Disorder: Instrument Validation Study %A Anýž,Jiří %A Bakštein,Eduard %A Dally,Andrea %A Kolenič,Marián %A Hlinka,Jaroslav %A Hartmannová,Tereza %A Urbanová,Kateřina %A Correll,Christoph U %A Novák,Daniel %A Španiel,Filip %+ National Insitute of Mental Health, Topolová 748, Klecany, 250 67, Czech Republic, 420 283 088 409, jiri.anyz@nudz.cz %K bipolar disorder %K symptom monitoring %K ecological mood assessment %K relapse detection %K mobile application %K mobile phone %D 2021 %7 9.8.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Self-reported mood is a valuable clinical data source regarding disease state and course in patients with mood disorders. However, validated, quick, and scalable digital self-report measures that can also detect relapse are still not available for clinical care. Objective: In this study, we aim to validate the newly developed ASERT (Aktibipo Self-rating) questionnaire—a 10-item, mobile app–based, self-report mood questionnaire consisting of 4 depression, 4 mania, and 2 nonspecific symptom items, each with 5 possible answers. The validation data set is a subset of the ongoing observational longitudinal AKTIBIPO400 study for the long-term monitoring of mood and activity (via actigraphy) in patients with bipolar disorder (BD). Patients with confirmed BD are included and monitored with weekly ASERT questionnaires and monthly clinical scales (Montgomery-Åsberg Depression Rating Scale [MADRS] and Young Mania Rating Scale [YMRS]). Methods: The content validity of the ASERT questionnaire was assessed using principal component analysis, and the Cronbach α was used to assess the internal consistency of each factor. The convergent validity of the depressive or manic items of the ASERT questionnaire with the MADRS and YMRS, respectively, was assessed using a linear mixed-effects model and linear correlation analyses. In addition, we investigated the capability of the ASERT questionnaire to distinguish relapse (YMRS≥15 and MADRS≥15) from a nonrelapse (interepisode) state (YMRS<15 and MADRS<15) using a logistic mixed-effects model. Results: A total of 99 patients with BD were included in this study (follow-up: mean 754 days, SD 266) and completed an average of 78.1% (SD 18.3%) of the requested ASERT assessments (completion time for the 10 ASERT questions: median 24.0 seconds) across all patients in this study. The ASERT depression items were highly associated with MADRS total scores (P<.001; bootstrap). Similarly, ASERT mania items were highly associated with YMRS total scores (P<.001; bootstrap). Furthermore, the logistic mixed-effects regression model for scale-based relapse detection showed high detection accuracy in a repeated holdout validation for both depression (accuracy=85%; sensitivity=69.9%; specificity=88.4%; area under the receiver operating characteristic curve=0.880) and mania (accuracy=87.5%; sensitivity=64.9%; specificity=89.9%; area under the receiver operating characteristic curve=0.844). Conclusions: The ASERT questionnaire is a quick and acceptable mood monitoring tool that is administered via a smartphone app. The questionnaire has a good capability to detect the worsening of clinical symptoms in a long-term monitoring scenario. %M 34383689 %R 10.2196/26348 %U https://mental.jmir.org/2021/8/e26348 %U https://doi.org/10.2196/26348 %U http://www.ncbi.nlm.nih.gov/pubmed/34383689 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e19824 %T Deep Learning With Anaphora Resolution for the Detection of Tweeters With Depression: Algorithm Development and Validation Study %A Wongkoblap,Akkapon %A Vadillo,Miguel A %A Curcin,Vasa %+ DIGITECH, Suranaree University of Technology, 111 University Avenue, Muang, Nakhon Ratchasima, 30000, Thailand, 66 44224336, wongkoblap@sut.ac.th %K depression %K mental health %K Twitter %K social media %K deep learning %K anaphora resolution %K multiple-instance learning %K depression markers %D 2021 %7 6.8.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental health problems are widely recognized as a major public health challenge worldwide. This concern highlights the need to develop effective tools for detecting mental health disorders in the population. Social networks are a promising source of data wherein patients publish rich personal information that can be mined to extract valuable psychological cues; however, these data come with their own set of challenges, such as the need to disambiguate between statements about oneself and third parties. Traditionally, natural language processing techniques for social media have looked at text classifiers and user classification models separately, hence presenting a challenge for researchers who want to combine text sentiment and user sentiment analysis. Objective: The objective of this study is to develop a predictive model that can detect users with depression from Twitter posts and instantly identify textual content associated with mental health topics. The model can also address the problem of anaphoric resolution and highlight anaphoric interpretations. Methods: We retrieved the data set from Twitter by using a regular expression or stream of real-time tweets comprising 3682 users, of which 1983 self-declared their depression and 1699 declared no depression. Two multiple instance learning models were developed—one with and one without an anaphoric resolution encoder—to identify users with depression and highlight posts related to the mental health of the author. Several previously published models were applied to our data set, and their performance was compared with that of our models. Results: The maximum accuracy, F1 score, and area under the curve of our anaphoric resolution model were 92%, 92%, and 90%, respectively. The model outperformed alternative predictive models, which ranged from classical machine learning models to deep learning models. Conclusions: Our model with anaphoric resolution shows promising results when compared with other predictive models and provides valuable insights into textual content that is relevant to the mental health of the tweeter. %M 34383688 %R 10.2196/19824 %U https://mental.jmir.org/2021/8/e19824 %U https://doi.org/10.2196/19824 %U http://www.ncbi.nlm.nih.gov/pubmed/34383688 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 4 %N 3 %P e29021 %T Ecological Momentary Assessment of Depression in People With Advanced Dementia: Longitudinal Pilot Study %A Niculescu,Iulia %A Quirt,Hannah %A Arora,Twinkle %A Borsook,Terry %A Green,Robin %A Ford,Brett %A Iaboni,Andrea %+ KITE, Toronto Rehabilitation Institute, University Health Network, 550 University Avenue, Toronto, ON, M5G 2A2, Canada, 1 (416) 597 3422 ext 3027, andrea.iaboni@uhn.ca %K dementia %K depression %K ecological momentary assessment %K tool performance %D 2021 %7 4.8.2021 %9 Original Paper %J JMIR Aging %G English %X Background: Barriers to assessing depression in advanced dementia include the presence of informant and patient recall biases. Ecological momentary assessment provides an improved approach for mood assessment by collecting observations in intervals throughout the day, decreasing recall bias, and increasing ecological validity. Objective: This study aims to evaluate the feasibility, reliability, and validity of the modified 4-item Cornell Scale for Depression in Dementia for Momentary Assessment (mCSDD4-MA) tool to assess depression in patients with advanced dementia. Methods: A intensive longitudinal pilot study design was used. A total of 12 participants with advanced dementia were enrolled from an inpatient psychogeriatric unit. Participants were assessed using clinical depression assessments at admission and discharge. Research staff recorded observations four times a day for 6 weeks on phones with access to the mCSDD4-MA tool. Descriptive data related to feasibility were reported (ie, completion rates). Statistical models were used to examine the interrater reliability and construct and predictive validity of the data. Results: Overall, 1923 observations were completed, representing 55.06% (1923/3496) of all rating opportunities with 2 raters and 66.01% (1923/2913) with at least one rater. Moderate interrater reliability was demonstrated for all items, except for lack of interest. Moderate correlations were observed between observers and patient-reported outcomes, where observers reported fewer symptoms relative to participants’ self-reports. Several items were associated with and able to predict depression. Conclusions: The mCSDD4-MA tool was feasible to use, and most items in the tool showed moderate reliability and validity for assessing depression in dementia. Repeated and real-time depression assessment in advanced dementia holds promise for the identification of clinical depression and depressive symptoms. %M 34346884 %R 10.2196/29021 %U https://aging.jmir.org/2021/3/e29021 %U https://doi.org/10.2196/29021 %U http://www.ncbi.nlm.nih.gov/pubmed/34346884 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 8 %P e30813 %T Smartphone Delivery of Cognitive Behavioral Therapy for Postintensive Care Syndrome-Family: Protocol for a Pilot Study %A Petrinec,Amy B %A Hughes,Joel W %A Zullo,Melissa D %A Wilk,Cindy %A George,Richard L %+ College of Nursing, Kent State University, Henderson Hall, 1375 University Esplanade, Kent, OH, 44242, United States, 1 3307152987, apetrine@kent.edu %K postintensive care syndrome-family %K mobile health app %K cognitive behavioral therapy %K mobile phone %D 2021 %7 4.8.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Family members of critically ill patients experience symptoms of postintensive care syndrome-family (PICS-F), including anxiety, depression, and posttraumatic stress disorder. Postintensive care syndrome-family reduces the quality of life of the families of critically ill patients and may impede the recovery of such patients. Cognitive behavioral therapy has become a first-line nonpharmacological treatment of many psychological symptoms and disorders, including anxiety, depression, and posttraumatic stress. With regard to managing mild-to-moderate symptoms, the delivery of cognitive behavioral therapy via mobile technology without input from a clinician has been found to be feasible and well accepted, and its efficacy rivals that of face-to-face therapy. Objective: The purpose of our pilot study is to examine the efficacy of using a smartphone mobile health (mHealth) app to deliver cognitive behavioral therapy and diminish the severity and prevalence of PICS-F symptoms in family members of critically ill patients. Methods: For our pilot study, 60 family members of critically ill patients will be recruited. A repeated-measures longitudinal study design that involves the randomization of participants to 2 groups (the control and intervention groups) will be used. The intervention group will receive cognitive behavioral therapy, which will be delivered via a smartphone mHealth app. Bandura’s social cognitive theory and an emphasis on mental health self-efficacy form the theoretical framework of the study. Results: Recruitment for the study began in August 2020. Data collection and analysis are expected to be completed by March 2022. Conclusions: The proposed study represents a novel approach to the treatment of PICS-F symptoms and is an extension of previous work conducted by the research team. The study will be used to plan a fully powered randomized controlled trial. Trial Registration: ClinicalTrials.gov NCT04316767; https://clinicaltrials.gov/ct2/show/NCT04316767 International Registered Report Identifier (IRRID): DERR1-10.2196/30813 %M 34346900 %R 10.2196/30813 %U https://www.researchprotocols.org/2021/8/e30813 %U https://doi.org/10.2196/30813 %U http://www.ncbi.nlm.nih.gov/pubmed/34346900 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e27619 %T Self-guided Cognitive Behavioral Therapy Apps for Depression: Systematic Assessment of Features, Functionality, and Congruence With Evidence %A Martinengo,Laura %A Stona,Anne-Claire %A Griva,Konstadina %A Dazzan,Paola %A Pariante,Carmine Maria %A von Wangenheim,Florian %A Car,Josip %+ Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Clinical Sciences Building, Level 18, 11 Mandalay Road, Singapore, Singapore, 65 6904 7005, josip.car@ntu.edu.sg %K cognitive behavioral therapy %K CBT %K depression %K mobile applications %K apps %K telemedicine %K mHealth %K self-guided CBT-based apps %K self-management %K mobile phone %D 2021 %7 30.7.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health disorders affect 1 in 10 people globally, of whom approximately 300 million are affected by depression. At least half of the people affected by depression remain untreated. Although cognitive behavioral therapy (CBT) is an effective treatment, access to mental health specialists, habitually challenging, has worsened because of the COVID-19 pandemic. Internet-based CBT is an effective and feasible strategy to increase access to treatment for people with depression. Mental health apps may further assist in facilitating self-management for people affected by depression; however, accessing the correct app may be cumbersome given the large number and wide variety of apps offered by public app marketplaces. Objective: This study aims to systematically assess the features, functionality, data security, and congruence with evidence of self-guided CBT-based apps targeting users affected by depression that are available in major app stores. Methods: We conducted a systematic assessment of self-guided CBT-based apps available in Google Play and the Apple App Store. Apps launched or updated since August 2018 were identified through a systematic search in the 42matters database using CBT-related terms. Apps meeting the inclusion criteria were downloaded and assessed using a Samsung Galaxy J7 Pro (Android 9) and iPhone 7 (iOS 13.3.1). Apps were appraised using a 182-question checklist developed by the research team, assessing their general characteristics, technical aspects and quality assurance, and CBT-related features, including 6 evidence-based CBT techniques (ie, psychoeducation, behavioral activation, cognitive restructuring, problem solving, relaxation, and exposure for comorbid anxiety) as informed by a CBT manual, CBT competence framework, and a literature review of internet-based CBT clinical trial protocols. The results were reported as a narrative review using descriptive statistics. Results: The initial search yielded 3006 apps, of which 98 met the inclusion criteria and were systematically assessed. There were 20 well-being apps; 65 mental health apps, targeting two or more common mental health disorders, including depression; and 13 depression apps. A total of 28 apps offered at least four evidence-based CBT techniques, particularly depression apps. Cognitive restructuring was the most common technique, offered by 79% (77/98) of the apps. Only one-third of the apps offered suicide risk management resources, whereas 17% (17/98) of the apps offered COVID-19–related information. Although most apps included a privacy policy, only a third of the apps presented it before account creation. In total, 82% (74/90) of privacy policies stated sharing data with third-party service providers. Half of the app development teams included academic institutions or health care providers. Conclusions: Only a few self-guided CBT-based apps offer comprehensive CBT programs or suicide risk management resources. Sharing of users’ data is widespread, highlighting shortcomings in health app market governance. To fulfill their potential, self-guided CBT-based apps should follow evidence-based clinical guidelines, be patient centered, and enhance users’ data security. %M 34328431 %R 10.2196/27619 %U https://www.jmir.org/2021/7/e27619 %U https://doi.org/10.2196/27619 %U http://www.ncbi.nlm.nih.gov/pubmed/34328431 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 7 %P e29840 %T Predicting Depressive Symptom Severity Through Individuals’ Nearby Bluetooth Device Count Data Collected by Mobile Phones: Preliminary Longitudinal Study %A Zhang,Yuezhou %A Folarin,Amos A %A Sun,Shaoxiong %A Cummins,Nicholas %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Conde,Pauline %A Stewart,Callum %A Laiou,Petroula %A Matcham,Faith %A Oetzmann,Carolin %A Lamers,Femke %A Siddi,Sara %A Simblett,Sara %A Rintala,Aki %A Mohr,David C %A Myin-Germeys,Inez %A Wykes,Til %A Haro,Josep Maria %A Penninx,Brenda W J H %A Narayan,Vaibhav A %A Annas,Peter %A Hotopf,Matthew %A Dobson,Richard J B %A , %+ Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, SGDP Centre, IoPPN, Box PO 80, De Crespigny Park, Denmark Hill, London, SE5 8AF, United Kingdom, 44 20 7848 0473, richard.j.dobson@kcl.ac.uk %K mental health %K depression %K digital biomarkers %K digital phenotyping %K digital health %K Bluetooth %K hierarchical Bayesian model %K mobile health %K mHealth %K monitoring %D 2021 %7 30.7.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Research in mental health has found associations between depression and individuals’ behaviors and statuses, such as social connections and interactions, working status, mobility, and social isolation and loneliness. These behaviors and statuses can be approximated by the nearby Bluetooth device count (NBDC) detected by Bluetooth sensors in mobile phones. Objective: This study aimed to explore the value of the NBDC data in predicting depressive symptom severity as measured via the 8-item Patient Health Questionnaire (PHQ-8). Methods: The data used in this paper included 2886 biweekly PHQ-8 records collected from 316 participants recruited from three study sites in the Netherlands, Spain, and the United Kingdom as part of the EU Remote Assessment of Disease and Relapse-Central Nervous System (RADAR-CNS) study. From the NBDC data 2 weeks prior to each PHQ-8 score, we extracted 49 Bluetooth features, including statistical features and nonlinear features for measuring the periodicity and regularity of individuals’ life rhythms. Linear mixed-effect models were used to explore associations between Bluetooth features and the PHQ-8 score. We then applied hierarchical Bayesian linear regression models to predict the PHQ-8 score from the extracted Bluetooth features. Results: A number of significant associations were found between Bluetooth features and depressive symptom severity. Generally speaking, along with depressive symptom worsening, one or more of the following changes were found in the preceding 2 weeks of the NBDC data: (1) the amount decreased, (2) the variance decreased, (3) the periodicity (especially the circadian rhythm) decreased, and (4) the NBDC sequence became more irregular. Compared with commonly used machine learning models, the proposed hierarchical Bayesian linear regression model achieved the best prediction metrics (R2=0.526) and a root mean squared error (RMSE) of 3.891. Bluetooth features can explain an extra 18.8% of the variance in the PHQ-8 score relative to the baseline model without Bluetooth features (R2=0.338, RMSE=4.547). Conclusions: Our statistical results indicate that the NBDC data have the potential to reflect changes in individuals’ behaviors and statuses concurrent with the changes in the depressive state. The prediction results demonstrate that the NBDC data have a significant value in predicting depressive symptom severity. These findings may have utility for the mental health monitoring practice in real-world settings. %M 34328441 %R 10.2196/29840 %U https://mhealth.jmir.org/2021/7/e29840 %U https://doi.org/10.2196/29840 %U http://www.ncbi.nlm.nih.gov/pubmed/34328441 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 7 %P e26796 %T A Mobile Peer Intervention for Preventing Mental Health and Substance Use Problems in Adolescents: Protocol for a Randomized Controlled Trial (The Mind Your Mate Study) %A Birrell,Louise %A Furneaux-Bate,Ainsley %A Chapman,Cath %A Newton,Nicola C %+ The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Level 6, Jane Foss Russell Building, G02, Camperdown, Sydney, 2006, Australia, 61 8627 6904, ainsley.furneaux-bate@sydney.edu.au %K prevention %K mental health %K substance use %K peer support %K depression %K anxiety %K help-seeking %K mobile phone %D 2021 %7 30.7.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Anxiety, mood, and substance use disorders have significant social and economic impacts, which are largely attributable to their early age of onset and chronic disabling course. Therefore, it is critical to intervene early to prevent chronic and debilitating trajectories. Objective: This paper describes the study protocol of a CONSORT (Consolidated Standards of Reporting Trials)-compliant randomized controlled trial for evaluating the effectiveness of the Mind your Mate program, a mobile health (mHealth) peer intervention that aims to prevent mental health (focusing on anxiety and depression) and substance use problems in adolescents. Methods: Participants will consist of approximately 840 year 9 or year 10 students (60 students per grade per school) from 14 New South Wales high schools in Sydney, Australia. Schools will be recruited from a random selection of independent and public schools across the New South Wales Greater Sydney Area by using publicly available contact details. The intervention will consist of 1 introductory classroom lesson and a downloadable mobile app that will be available for use for 12 months. Schools will be randomly allocated to receive either the mHealth peer intervention or a waitlist control (health education as usual). All students will be given web-based self-assessments at baseline and at 6- and 12-month follow-ups. The primary outcomes of the trial will be the self-reported use of alcohol and drugs, anxiety and depression symptoms, knowledge about mental health and substance use, motives for not drinking, and willingness to seek help. Secondary outcomes will include positive well-being, the quality of life, and the impact of the COVID-19 pandemic. Analyses will be conducted using mixed-effects linear regression analyses for normally distributed data and mixed-effects logistic regression analyses for categorical data. Results: The Mind your Mate study was funded by an Australian Rotary Health Bruce Edwards Postdoctoral Research Fellowship from 2019 to 2022. Some of the development costs for the Mind your Mate intervention came from a seed funding grant from the Brain and Mind Centre of the University of Sydney. The enrollment of schools began in July 2020; 12 of 14 schools were enrolled at the time of submission. Baseline assessments are currently underway, and the first results are expected to be submitted for publication in 2022. Conclusions: The Mind your Mate study will generate vital new knowledge about the effectiveness of a peer support prevention strategy in real-world settings for the most common mental disorders in youth. If effective, this intervention will constitute a scalable, low-cost prevention strategy that has significant potential to reduce the impact of mental and substance use disorders. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620000753954; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379738&isReview=true International Registered Report Identifier (IRRID): DERR1-10.2196/26796 %M 34328426 %R 10.2196/26796 %U https://www.researchprotocols.org/2021/7/e26796 %U https://doi.org/10.2196/26796 %U http://www.ncbi.nlm.nih.gov/pubmed/34328426 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 7 %P e26187 %T Tele–Mental Health for Reaching Out to Patients in a Time of Pandemic: Provider Survey and Meta-analysis of Patient Satisfaction %A Mazziotti,Raffaele %A Rutigliano,Grazia %+ Department of Pathology, University of Pisa, via Savi, 10, Pisa, 56126, Italy, 39 3496117744, grazia.rutigliano.gr@gmail.com %K telepsychiatry %K telepsychology %K e-mental health %K document clustering %K survey %K COVID-19 %K access to care %K patient satisfaction %K mental health %K tele–mental health %K review %K telemedicine %K satisfaction %K access %D 2021 %7 29.7.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic threatened to impact mental health by disrupting access to care due to physical distance measures and the unexpected pressure on public health services. Tele–mental health was rapidly implemented to deliver health care services. Objective: The aims of this study were (1) to present state-of-the-art tele–mental health research, (2) to survey mental health providers about care delivery during the pandemic, and (3) to assess patient satisfaction with tele–mental health. Methods: Document clustering was applied to map research topics within tele–mental health research. A survey was circulated among mental health providers. Patient satisfaction was investigated through a meta-analysis of studies that compared satisfaction scores between tele–mental health and face-to-face interventions for mental health disorders, retrieved from Web of Knowledge and Scopus. Hedges g was used as the effect size measure, and effect sizes were pooled using a random-effect model. Sources of heterogeneity and bias were examined. Results: Evidence on tele–mental health has been accumulating since 2000, especially regarding service implementation, depressive or anxiety disorders, posttraumatic stress disorder, and special populations. Research was concentrated in a few countries. The survey (n=174 respondents from Italy, n=120 international) confirmed that, after the onset of COVID-19 outbreak, there was a massive shift from face-to-face to tele–mental health delivery of care. However, respondents held skeptical views about tele–mental health and did not feel sufficiently trained and satisfied. Meta-analysis of 29 studies (n=2143) showed that patients would be equally satisfied with tele–mental health as they are with face-to-face interventions (Hedges g=−0.001, 95% CI −0.116 to 0.114, P=.98, Q=43.83, I2=36%, P=.03) if technology-related issues were minimized. Conclusions: Mental health services equipped with tele–mental health will be better able to cope with public health crises. Both providers and patients need to be actively engaged in digitization, to reshape their reciprocal trust around technological innovations. %M 34114956 %R 10.2196/26187 %U https://mental.jmir.org/2021/7/e26187 %U https://doi.org/10.2196/26187 %U http://www.ncbi.nlm.nih.gov/pubmed/34114956 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e23029 %T A Brief Intervention to Increase Uptake and Adherence of an Internet-Based Program for Depression and Anxiety (Enhancing Engagement With Psychosocial Interventions): Randomized Controlled Trial %A Batterham,Philip J %A Calear,Alison L %A Sunderland,Matthew %A Kay-Lambkin,Frances %A Farrer,Louise M %A Christensen,Helen %A Gulliver,Amelia %+ Centre for Mental Health Research, Research School of Population Health, The Australian National University, 63 Eggleston Rd, Acton, Canberra, 2601, Australia, 61 02612 ext 51031, philip.batterham@anu.edu.au %K implementation %K mental health %K adherence %K uptake %K engagement-facilitation intervention %K internet %K randomized controlled trial %D 2021 %7 27.7.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Psychosocial, self-guided, internet-based programs are effective in treating depression and anxiety. However, the community uptake of these programs is poor. Recent approaches to increasing engagement (defined as both uptake and adherence) in internet-based programs include brief engagement facilitation interventions (EFIs). However, these programs require evaluation to assess their efficacy. Objective: The aims of this hybrid implementation effectiveness trial are to examine the effects of a brief internet-based EFI presented before an internet-based cognitive behavioral therapy self-help program (myCompass 2) in improving engagement (uptake and adherence) with that program (primary aim), assess the relative efficacy of the myCompass 2 program, and determine whether greater engagement was associated with improved efficacy (greater reduction in depression or anxiety symptoms) relative to the control (secondary aim). Methods: A 3-arm randomized controlled trial (N=849; recruited via social media) assessed the independent efficacy of the EFI and myCompass 2. The myCompass 2 program was delivered with or without the EFI; both conditions were compared with an attention control condition. The EFI comprised brief (5 minutes), tailored audio-visual content on a series of click-through linear webpages. Results: Uptake was high in all groups; 82.8% (703/849) of participants clicked through the intervention following the pretest survey. However, the difference in uptake between the EFI + myCompass 2 condition (234/280, 83.6%) and the myCompass 2 alone condition (222/285, 77.9%) was not significant (n=565; χ21=29.2; P=.09). In addition, there was no significant difference in the proportion of participants who started any number of modules (1-14 modules) versus those who started none between the EFI + myCompass 2 (214/565, 37.9%) and the myCompass 2 alone (210/565, 37.2%) conditions (n=565; χ21<0.1; P=.87). Finally, there was no significant difference between the EFI + myCompass 2 and the myCompass 2 alone conditions in the number of modules started (U=39366.50; z=−0.32; P=.75) or completed (U=39494.0; z=−0.29; P=.77). The myCompass 2 program was not found to be efficacious over time for symptoms of depression (F4,349.97=1.16; P=.33) or anxiety (F4,445.99=0.12; P=.98). However, planned contrasts suggested that myCompass 2 may have been effective for participants with elevated generalized anxiety disorder symptoms (F4,332.80=3.50; P=.01). Conclusions: This brief internet-based EFI did not increase the uptake of or adherence to an existing internet-based program for depression and anxiety. Individuals’ motivation to initiate and complete internet-based self-guided interventions is complex and remains a significant challenge for self-guided interventions. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618001565235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375839 %M 34313595 %R 10.2196/23029 %U https://www.jmir.org/2021/7/e23029 %U https://doi.org/10.2196/23029 %U http://www.ncbi.nlm.nih.gov/pubmed/34313595 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 7 %P e29159 %T Use of Telemedicine in Depression Care by Physicians: Scoping Review %A Echelard,Jean-François %+ Faculty of Medicine, Université de Montréal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1J4, Canada, 1 (514) 343 6111, jfechelard@hotmail.com %K telemedicine %K telepsychiatry %K depression %K mental health %K videoconferencing %D 2021 %7 26.7.2021 %9 Review %J JMIR Form Res %G English %X Background: Depression is a common disorder, and it creates burdens on people’s mental and physical health as well as societal costs. Although traditional in-person consultations are the usual mode of caring for patients with depression, telemedicine may be well suited to psychiatric assessment and management. Telepsychiatry can be defined as the use of information and communication technologies such as videoconferencing and telephone calls for the care of psychopathologies. Objective: This review aims to evaluate the extent and nature of the existing literature on the use of telemedicine for the care of depression by physicians. This review also aims to examine the effects and perceptions regarding this virtual care and determine how it compares to traditional in-person care. Methods: The Arksey and O’Malley framework and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines were followed. Relevant articles were identified through a search of three databases (MEDLINE, Cochrane Database of Systematic Reviews, and PsycArticles) on October 11, 2020. The search terms were “(virtual OR telemedicine OR teleconsultation* OR telehealth OR phone* OR webcam* OR telepsychiatry) AND (depress*)”. Eligibility criteria were applied to select studies about the use of telemedicine for the care of patients with depression specifically by physicians. An Excel file (Microsoft Corporation) was used to chart data from all included articles. Results: The search resulted in the identification of 28 articles, and all 13 nonreview studies were analyzed in detail. Most nonreview studies were conducted in the United States during the last decade. Most telemedicine programs were led by psychiatrists, and the average study population size was 135. In all applicable studies, telepsychiatry tended to perform at least as well as in-person care regarding improvement in depression severity, patient satisfaction, quality of life, functioning, cost-effectiveness, and most other perceptions and variables. Cultural sensitivity and collaborative care were part of the design of some telemedicine programs. Conclusions: Additional randomized, high-quality studies are recommended to evaluate various outcomes of the use of telemedicine for depression care, including depression variables, perceptions, health care outcomes and other outcomes. Studies should be conducted in various clinical contexts, including primary care. Telepsychiatry is a promising modality of care for patients suffering from depression. %M 34309571 %R 10.2196/29159 %U https://formative.jmir.org/2021/7/e29159 %U https://doi.org/10.2196/29159 %U http://www.ncbi.nlm.nih.gov/pubmed/34309571 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 7 %P e26183 %T Experience of Peer Bloggers Using a Social Media Website for Adolescents With Depression or Anxiety: Proof-of-Concept Study %A Karim,Sana %A Hsiung,Kimberly %A Symonds,Maria %A Radovic,Ana %+ Children's Hospital of Pittsburgh, University of Pittsburgh, 120 Lytton Ave, Pittsburgh, PA, United States, 1 4126247000, sana.karim3@chp.edu %K adolescent %K social media %K blogging %K depression %K anxiety %D 2021 %7 22.7.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Supporting Our Valued Adolescents (SOVA) is a moderated and anonymous social media website intervention. SOVA ambassadors are adolescents and young adults (AYA) asked to write monthly blog posts and comments on others’ posts on topics surrounding mental health. Objective: This study aims to understand the feasibility and acceptability of peer blogging for a moderated mental health intervention website and explore whether bloggers—AYA who self-report symptoms of depression and anxiety—experience potential benefits. Methods: AYA aged 14 to 26 years with a self-reported history of depression or anxiety were recruited to the SOVA Peer Ambassador Program. Participants were asked to write one blog post a month and comment at least four times a month on other blog posts, for which they were compensated for up to US $15 monthly. Outcome variables measured at baseline and 3 months after intervention included website usability and feasibility, depressive symptoms, anxiety symptoms, mental health treatment history, cybercoping, personal blogging style, self-esteem, loneliness, mental health stigma, social support, and positive youth development characteristics. Open-ended questions were asked about their blogging acceptability and usability. Results: Of 66 AYA showing interest and completing onboarding, 71% (47/66) wrote at least one blog post, with an average of 3 posts per person. A sample of 51% (34/66) of participants completed a 3-month survey for the full analysis. Almost all 34 participants were satisfied with the experience of blogging (32/34, 94%) and rated the website usability as good (80.1, SD 14.9). At 3 months, self-esteem scores increased by 2.1, with a small-medium effect size (P=.01; Cohen d=0.45), and youth competence and confidence increased by 0.7 (P=.002) and 1.3 (P=.002), with medium effect sizes (Cohen d=0.62 and 0.60), respectively. Conclusions: A blogging intervention for AYA with a history of depression or anxiety was feasible with regular and active engagement and shows evidence in a one-sample design for positive changes in strength-based assets—self-esteem, competence, and confidence—which map onto resilience. %M 34292161 %R 10.2196/26183 %U https://formative.jmir.org/2021/7/e26183 %U https://doi.org/10.2196/26183 %U http://www.ncbi.nlm.nih.gov/pubmed/34292161 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 7 %P e30845 %T Delivering an Online Cognitive Behavioral Therapy Program to Address Mental Health Challenges Faced by Correctional Workers and Other Public Safety Personnel: Protocol for a Mixed Methods Study %A Alavi,Nazanin %A Stephenson,Callum %A Omrani,Mohsen %A Gerritsen,Cory %A Martin,Michael S %A Knyahnytskyi,Alex %A Zhu,Yiran %A Kumar,Anchan %A Jagayat,Jasleen %A Shirazi,Amirhossein %A Moghimi,Elnaz %A Patel,Charmy %A Knyahnytska,Yuliya %A Simpson,Alexander I F %A Zaheer,Juveria %A Andersen,Judith %A Munshi,Alpna %A Groll,Dianne %+ Department of Psychiatry, Faculty of Health Sciences, Queen's University, Hotel Dieu Hospital, 166 Brock Street, Kingston, ON, K7L 5G2, Canada, 1 613 544 3310, nazanin.alavi@queensu.ca %K mental health %K correctional workers %K public safety personnel %K depression %K anxiety %K psychotherapy %K cognitive behavioral therapy %K online %K internet %K treatment %D 2021 %7 22.7.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Public safety personnel have regular and often intense exposure to potentially traumatic events at work, especially workplace violence in the case of correctional workers. Subsequently, correctional workers are at higher risk of developing mental health problems such as posttraumatic stress disorder. Public safety personnel are up to 4 times more likely to experience suicidal ideation, suicidal attempts, and death by suicide compared to the general population. Despite this high prevalence, help-seeking behaviors from public safety personnel are low due to stigma and irregular work hours limiting access to care. Innovative treatments are needed to address these challenges. Objective: This study will investigate the efficacy of an electronically delivered cognitive behavioral therapy (e-CBT) program tailored to correctional workers’ mental health problems. Methods: This study is composed of 4 phases. In phase 1, we will interview correctional workers individually and in focus groups to identify personal, social, and cultural factors affecting their mental health and barriers to care. Phase 2 will use the information gathered from the interviews to develop gender- and diagnosis-specific e-CBT modules. These will be presented to a new group of participants who will provide further feedback on their usability and accessibility. In phase 3, we will randomly assign participants to either an e-CBT or treatment as usual arm. The program will be evaluated with validated symptomatology questionnaires and interviews. Phase 4 will use this additional information to fine-tune the e-CBT modules for a larger-scale randomized controlled trial design comparing the e-CBT program to in-person CBT. All e-CBT modules will be delivered through a secure online platform. Results: The study received ethics approval in December 2020, and participant recruitment began in March 2021. Participant recruitment has been conducted through targeted advertisements and physician referrals. To date, there have been 15 participants recruited for Phase 1, and it is expected to conclude in July 2021, with phase 2 beginning in September 2021. Complete data collection and analysis from all phases are expected to conclude by July 2023. Linear and binomial regression (for continuous and categorical outcomes, respectively) will be conducted along with interpretive qualitative methods. Conclusions: If proven efficacious and feasible, this e-CBT program can provide a high-quality and clinically validated resource to address the mental health problems of correctional workers. Additionally, findings can contribute to the development of innovative treatments for other public safety professions. Trial Registration: ClinicalTrials.gov NCT04666974; https://www.clinicaltrials.gov/ct2/show/NCT04666974 International Registered Report Identifier (IRRID): DERR1-10.2196/30845 %M 34088656 %R 10.2196/30845 %U https://www.researchprotocols.org/2021/7/e30845 %U https://doi.org/10.2196/30845 %U http://www.ncbi.nlm.nih.gov/pubmed/34088656 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e29312 %T Risk Factors of Psychological Responses of Chinese University Students During the COVID-19 Outbreak: Cross-sectional Web-Based Survey Study %A Zhang,Xudong %A Shi,Xin %A Wang,Yang %A Jing,Huiquan %A Zhai,Qingqing %A Li,Kunhang %A Zhao,Dan %A Zhong,Shiyu %A Song,Yuequn %A Zhang,Feng %A Bao,Yijun %+ Department of Neurosurgery, The Fourth Hospital of China Medical University, No 4 Chongshandong, Huanggu, Shenyang, 110084, China, 86 15840150493, yjbao@cmu.edu.cn %K university students %K depressive symptoms %K anxiety symptoms %K mental health status %K COVID-19 %K pandemic %K mental health %K anxiety %K psychological health %D 2021 %7 21.7.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: COVID-19 is a highly contagious and highly pathogenic disease caused by a novel coronavirus, SARS-CoV-2, and it has become a pandemic. As a vulnerable population, university students are at high risk during the epidemic, as they have high mobility and often overlook the severity of the disease because they receive incomplete information about the epidemic. In addition to the risk of death from infection, the epidemic has placed substantial psychological pressure on the public. In this respect, university students are more prone to psychological problems induced by the epidemic compared to the general population because for most students, university life is their first time outside the structure of the family, and their mental development is still immature. Internal and external expectations and academic stress lead to excessive pressure on students, and unhealthy lifestyles also deteriorate their mental health. The outbreak of COVID-19 was a significant social event, and it could potentially have a great impact on the life and the mental health of university students. Therefore, it is of importance to investigate university students’ mental health status during the outbreak of COVID-19. Objective: The principal objective of this study was to investigate the influencing factors of the psychological responses of Chinese university students during the COVID-19 outbreak. Methods: This study used data from a survey conducted in China between February 21 and 24, 2020, and the data set contains demographic information and psychological measures including the Self-Rating Anxiety Scale, the Self-Rating Depression Scale, and the compulsive behaviors portion of the Yale-Brown Obsessive-Compulsive Scale. A total of 2284 questionnaires were returned, and 2270 of them were valid and were used for analysis. The Mann-Whitney U test for two independent samples and binary logistic regression models were used for statistical analysis. Results: Our study surveyed 563 medical students and 1707 nonmedical students. Among them, 251/2270 students (11.06%) had mental health issues. The results showed that contact history of similar infectious disease (odds ratio [OR] 3.363, P=.02), past medical history (OR 3.282, P<.001), and compulsive behaviors (OR 3.525, P<.001) contributed to the risk of mental health issues. Older students (OR 0.928, P=.02), regular daily life during the epidemic outbreak (OR 0.410, P<.001), exercise during the epidemic outbreak (OR 0.456, P<.001), and concern related to COVID-19 (OR 0.638, P=.002) were protective factors for mental health issues. Conclusions: According to the study results, mental health issues have seriously affected university students, and our results are beneficial for identifying groups of university students who are at risk for possible mental health issues so that universities and families can prevent or intervene in the development of potential mental health issues at the early stage of their development. %M 34156961 %R 10.2196/29312 %U https://www.jmir.org/2021/7/e29312 %U https://doi.org/10.2196/29312 %U http://www.ncbi.nlm.nih.gov/pubmed/34156961 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e24047 %T Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial %A Yellowlees,Peter M %A Parish,Michelle Burke %A Gonzalez,Alvaro D %A Chan,Steven R %A Hilty,Donald M %A Yoo,Byung-Kwang %A Leigh,J Paul %A McCarron,Robert M %A Scher,Lorin M %A Sciolla,Andres F %A Shore,Jay %A Xiong,Glen %A Soltero,Katherine M %A Fisher,Alice %A Fine,Jeffrey R %A Bannister,Jennifer %A Iosif,Ana-Maria %+ Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, CA, United States, 1 916 734 0849, pmyellowlees@ucdavis.edu %K asynchronous telepsychiatry %K synchronous telepsychiatry %K psychiatrist %K primary care physician %K psychiatric consultation %K Spanish-speaking %K collaborative care %K workforce %K depression %K telehealth %D 2021 %7 20.7.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking. Objective: This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method. Methods: Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients’ self-reported physical and mental health and depression) outcomes were assessed every 6 months. Results: For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI −0.2 to 0.6; P=.28; and GAF: −0.6, 95% CI −3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI −0.04 to 0.8; P=.07; and GAF: −0.5, 95% CI −3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention. Conclusions: This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care. Trial Registration: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979. %M 33993104 %R 10.2196/24047 %U https://www.jmir.org/2021/7/e24047 %U https://doi.org/10.2196/24047 %U http://www.ncbi.nlm.nih.gov/pubmed/33993104 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 7 %P e16643 %T A Gamified Smartphone-Based Intervention for Depression: Randomized Controlled Pilot Trial %A Lukas,Christian Aljoscha %A Eskofier,Bjoern %A Berking,Matthias %+ Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nuremberg, Naegelsbachstr 25a, Erlangen, 91052, Germany, 49 176 80526686, christian.aljoscha.lukas@fau.de %K smartphone technology %K depression %K cognitive behavioral therapy %K approach/avoidance %K gamification %D 2021 %7 20.7.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Available smartphone-based interventions for depression predominantly use evidence-based strategies from cognitive-behavioral therapy (CBT), but patient engagement and reported effect sizes are small. Recently, studies have demonstrated that smartphone-based interventions combining CBT with gamified approach-avoidance bias modification training (AAMT) can foster patient engagement and reduce symptoms of several mental health problems. Objective: Based on these findings, we developed a gamified smartphone-based intervention, mentalis Phoenix (MT-Phoenix), and hypothesized the program would both engage patients and produce preliminary evidence for the reduction of depressive symptoms. Methods: To test this hypothesis, we evaluated MT-Phoenix in a randomized controlled pilot trial including 77 individuals with elevated depression scores (Patient Health Questionnaire-9 scores ≥5). Participants were either instructed to train for 14 days with MT-Phoenix or assigned to a waitlist control condition. Engagement with the intervention was measured by assessing usage data. The primary outcome was reduction in depressive symptom severity at postassessment. Results: Data from this pilot trial shows that participants in the intervention group used the smartphone-based intervention for 46% of all days (6.4/14) and reported a significantly greater reduction of depressive symptoms than did participants in the control condition (F1,74=19.34; P=.001), with a large effect size (d=1.02). Effects were sustained at a 3-month follow-up. Conclusions: A gamified smartphone-based intervention combining CBT with AAMT may foster patient engagement and effectively target depressive symptoms. Future studies should evaluate the effectiveness of this intervention in a phase 3 trial using clinical samples. Moreover, the intervention should be compared to active control conditions. Trial Registration: German Clinical Trial Registry DRKS00012769; https://tinyurl.com/47mw8du7 %M 34283037 %R 10.2196/16643 %U https://mental.jmir.org/2021/7/e16643 %U https://doi.org/10.2196/16643 %U http://www.ncbi.nlm.nih.gov/pubmed/34283037 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 7 %P e28168 %T New Evidence in the Booming Field of Online Mindfulness: An Updated Meta-analysis of Randomized Controlled Trials %A Sommers-Spijkerman,Marion %A Austin,Judith %A Bohlmeijer,Ernst %A Pots,Wendy %+ Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, Netherlands, 31 652783025, m.p.j.spijkerman-6@umcutrecht.nl %K mindfulness %K mental health %K intervention %K online %K meta-analysis %K mobile phone %D 2021 %7 19.7.2021 %9 Review %J JMIR Ment Health %G English %X 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. %M 34279240 %R 10.2196/28168 %U https://mental.jmir.org/2021/7/e28168 %U https://doi.org/10.2196/28168 %U http://www.ncbi.nlm.nih.gov/pubmed/34279240 %0 Journal Article %@ 2564-1891 %I JMIR Publications %V 1 %N 1 %P e26769 %T Monitoring Depression Trends on Twitter During the COVID-19 Pandemic: Observational Study %A Zhang,Yipeng %A Lyu,Hanjia %A Liu,Yubao %A Zhang,Xiyang %A Wang,Yu %A Luo,Jiebo %+ University of Rochester, 500 Joseph C Wilson Blvd, Rochester, NY, United States, 1 585 276 5784, jluo@cs.rochester.edu %K mental health %K depression %K social media %K Twitter %K data mining %K natural language processing %K transformers %K COVID-19 %D 2021 %7 18.7.2021 %9 Original Paper %J JMIR Infodemiology %G English %X Background: The COVID-19 pandemic has affected people’s daily lives and has caused economic loss worldwide. Anecdotal evidence suggests that the pandemic has increased depression levels among the population. However, systematic studies of depression detection and monitoring during the pandemic are lacking. Objective: This study aims to develop a method to create a large-scale depression user data set in an automatic fashion so that the method is scalable and can be adapted to future events; verify the effectiveness of transformer-based deep learning language models in identifying depression users from their everyday language; examine psychological text features’ importance when used in depression classification; and, finally, use the model for monitoring the fluctuation of depression levels of different groups as the disease propagates. Methods: To study this subject, we designed an effective regular expression-based search method and created the largest English Twitter depression data set containing 2575 distinct identified users with depression and their past tweets. To examine the effect of depression on people’s Twitter language, we trained three transformer-based depression classification models on the data set, evaluated their performance with progressively increased training sizes, and compared the model’s tweet chunk-level and user-level performances. Furthermore, inspired by psychological studies, we created a fusion classifier that combines deep learning model scores with psychological text features and users’ demographic information, and investigated these features’ relations to depression signals. Finally, we demonstrated our model’s capability of monitoring both group-level and population-level depression trends by presenting two of its applications during the COVID-19 pandemic. Results: Our fusion model demonstrated an accuracy of 78.9% on a test set containing 446 people, half of which were identified as having depression. Conscientiousness, neuroticism, appearance of first person pronouns, talking about biological processes such as eat and sleep, talking about power, and exhibiting sadness were shown to be important features in depression classification. Further, when used for monitoring the depression trend, our model showed that depressive users, in general, responded to the pandemic later than the control group based on their tweets (n=500). It was also shown that three US states—New York, California, and Florida—shared a similar depression trend as the whole US population (n=9050). When compared to New York and California, people in Florida demonstrated a substantially lower level of depression. Conclusions: This study proposes an efficient method that can be used to analyze the depression level of different groups of people on Twitter. We hope this study can raise awareness among researchers and the public of COVID-19’s impact on people’s mental health. The noninvasive monitoring system can also be readily adapted to other big events besides COVID-19 and can be useful during future outbreaks. %M 34458682 %R 10.2196/26769 %U https://infodemiology.jmir.org/2021/1/e26769 %U https://doi.org/10.2196/26769 %U http://www.ncbi.nlm.nih.gov/pubmed/34458682 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 9 %N 7 %P e28754 %T Depression Detection on Reddit With an Emotion-Based Attention Network: Algorithm Development and Validation %A Ren,Lu %A Lin,Hongfei %A Xu,Bo %A Zhang,Shaowu %A Yang,Liang %A Sun,Shichang %+ Dalian University of Technology, No. 2 Linggong Road, Dalian, , China, 86 041184706009, liang@dlut.edu.cn %K depression detection %K attention network %K emotional semantic information %K dynamic fusion strategy %K natural language processing %K social media %K emotion %K mental health %K algorithm %K deep learning %D 2021 %7 16.7.2021 %9 Original Paper %J JMIR Med Inform %G English %X Background: As a common mental disease, depression seriously affects people’s physical and mental health. According to the statistics of the World Health Organization, depression is one of the main reasons for suicide and self-harm events in the world. Therefore, strengthening depression detection can effectively reduce the occurrence of suicide or self-harm events so as to save more people and families. With the development of computer technology, some researchers are trying to apply natural language processing techniques to detect people who are depressed automatically. Many existing feature engineering methods for depression detection are based on emotional characteristics, but these methods do not consider high-level emotional semantic information. The current deep learning methods for depression detection cannot accurately extract effective emotional semantic information. Objective: In this paper, we propose an emotion-based attention network, including a semantic understanding network and an emotion understanding network, which can capture the high-level emotional semantic information effectively to improve the depression detection task. Methods: The semantic understanding network module is used to capture the contextual semantic information. The emotion understanding network module is used to capture the emotional semantic information. There are two units in the emotion understanding network module, including a positive emotion understanding unit and a negative emotion understanding unit, which are used to capture the positive emotional information and the negative emotional information, respectively. We further proposed a dynamic fusion strategy in the emotion understanding network module to fuse the positive emotional information and the negative emotional information. Results: We evaluated our method on the Reddit data set. The experimental results showed that the proposed emotion-based attention network model achieved an accuracy, precision, recall, and F-measure of 91.30%, 91.91%, 96.15%, and 93.98%, respectively, which are comparable results compared with state-of-the-art methods. Conclusions: The experimental results showed that our model is competitive with the state-of-the-art models. The semantic understanding network module, the emotion understanding network module, and the dynamic fusion strategy are effective modules for depression detection. In addition, the experimental results verified that the emotional semantic information was effective in depression detection. %M 34269683 %R 10.2196/28754 %U https://medinform.jmir.org/2021/7/e28754 %U https://doi.org/10.2196/28754 %U http://www.ncbi.nlm.nih.gov/pubmed/34269683 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 7 %P e28321 %T Intervention Use and Symptom Change With Unguided Internet-Based Cognitive Behavioral Therapy for Depression During the COVID-19 Pandemic: Log Data Analysis of a Convenience Sample %A Oehler,Caroline %A Scholze,Katharina %A Reich,Hanna %A Sander,Christian %A Hegerl,Ulrich %+ Forschungszentrum Depression, Stiftung Deutsche Depressionshilfe, Goerdelerring 9, Leipzig, 04109, Germany, 49 34122387420, caroline.oehler@medizin.uni-leipzig.de %K iCBT %K internet-based cognitive behavioral therapy %K internet-based treatment %K internet- and mobile-based intervention %K depression %K guidance %K unguided %K COVID-19 %D 2021 %7 16.7.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Internet- and mobile-based interventions are most efficacious in the treatment of depression when they involve some form of guidance, but providing guidance requires resources such as trained personnel, who might not always be available (eg, during lockdowns to contain the COVID-19 pandemic). Objective: The current analysis focuses on changes in symptoms of depression in a guided sample of patients with depression who registered for an internet-based intervention, the iFightDepression tool, as well as the extent of intervention use, compared to an unguided sample. The objective is to further understand the effects of guidance and adherence on the intervention’s potential to induce symptom change. Methods: Log data from two convenience samples in German routine care were used to assess symptom change after 6-9 weeks of intervention as well as minimal dose (finishing at least two workshops). A linear regression model with changes in Patient Health Questionnaire (PHQ-9) score as a dependent variable and guidance and minimal dose as well as their interaction as independent variables was specified. Results: Data from 1423 people with symptoms of depression (n=940 unguided, 66.1%) were included in the current analysis. In the linear regression model predicting symptom change, a significant interaction of guidance and minimal dose revealed a specifically greater improvement for patients who received guidance and also worked with the intervention content (β=–1.75, t=–2.37, P=.02), while there was little difference in symptom change due to guidance in the group that did not use the intervention. In this model, the main effect of guidance was only marginally significant (β=–.53, t=–1.78, P=.08). Conclusions: Guidance in internet-based interventions for depression is not only an important factor to facilitate adherence, but also seems to further improve results for patients adhering to the intervention compared to those who do the same but without guidance. %M 34115604 %R 10.2196/28321 %U https://mental.jmir.org/2021/7/e28321 %U https://doi.org/10.2196/28321 %U http://www.ncbi.nlm.nih.gov/pubmed/34115604 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e25537 %T A Digital Intervention for Primary Care Practitioners to Support Antidepressant Discontinuation (Advisor for Health Professionals): Development Study %A Bowers,Hannah %A Kendrick,Tony %A van Ginneken,Nadja %A Glowacka,Marta %A Williams,Samantha %A Leydon,Geraldine M %A May,Carl %A Dowrick,Christopher %A Moncrieff,Joanna %A Johnson,Chris F %A Moore,Michael %A Laine,Rebecca %A Geraghty,Adam W A %+ Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor, Southampton, SO15 5HT, United Kingdom, 44 2380591743, h.m.bowers@soton.ac.uk %K antidepressant discontinuation %K intervention development %K depression %K primary care %K digital intervention %D 2021 %7 16.7.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The number of people receiving antidepressants has increased in the past 3 decades, mainly because of people staying on them longer. However, in many cases long-term treatment is not evidence based and risks increasing side effects. Additionally, prompting general practitioners (GPs) to review medication does not improve the rate of appropriate discontinuation. Therefore, GPs and other health professionals may need help to support patients discontinuing antidepressants in primary care. Objective: This study aims to develop a digital intervention to support practitioners in helping patients discontinue inappropriate long-term antidepressants (as part of a wider intervention package including a patient digital intervention and patient telephone support). Methods: A prototype digital intervention called Advisor for Health Professionals (ADvisor HP) was planned and developed using theory, evidence, and a person-based approach. The following elements informed development: a literature review and qualitative synthesis, an in-depth qualitative study, the development of guiding principles for design elements, and theoretical behavioral analyses. The intervention was then optimized through think-aloud qualitative interviews with health professionals while they were using the prototype intervention. Results: Think-aloud qualitative interviews with 19 health professionals suggested that the digital intervention contained useful information and was readily accessible to practitioners. The development work highlighted a need for further guidance on drug tapering schedules for practitioners and clarity about who is responsible for broaching the subject of discontinuation. Practitioners highlighted the need to have information in easily and quickly accessible formats because of time constraints in day-to-day practice. Some GPs felt that some information was already known to them but understood why this was included. Practitioners differed in their ideas about how they would use ADvisor HP in practice, with some preferring to read the resource in its entirety and others wanting to dip in and out as needed. Changes were made to the wording and structure of the intervention in response to the feedback provided. Conclusions: ADvisor HP is a digital intervention that has been developed using theory, evidence, and a person-based approach. The optimization work suggests that practitioners may find this tool to be useful in supporting the reduction of long-term antidepressant use. Further quantitative and qualitative evaluation through a randomized controlled trial is needed to examine the feasibility, effectiveness, and cost-effectiveness of the intervention. %M 34269688 %R 10.2196/25537 %U https://www.jmir.org/2021/7/e25537 %U https://doi.org/10.2196/25537 %U http://www.ncbi.nlm.nih.gov/pubmed/34269688 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 7 %P e16949 %T Barriers to the Use of Web-Based Mental Health Programs for Preventing Depression: Qualitative Study %A Eccles,Heidi %A Nannarone,Molly %A Lashewicz,Bonnie %A Attridge,Mark %A Marchand,Alain %A Aiken,Alice %A Ho,Kendall %A Wang,JianLi %+ The Institute of Mental Health Research, University of Ottawa, Room 5404, 1145 Carling Ave, Ottawa, ON, K1Z 7K4, Canada, 1 6137226521 ext 6057, jlwang@ucalgary.ca %K prevention %K mental health %K depression %K problem solving therapy %K barriers %K web-based program %K qualitative study %D 2021 %7 15.7.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression has a profound impact on population health. Although using web-based mental health programs to prevent depression has been found to be effective in decreasing depression incidence, there are obstacles preventing their use, as reflected by the low rates of use and adherence. Objective: The aims of the study are to understand the barriers to using web-based mental health programs for the prevention of depression and the possible dangers or concerns regarding the use of such programs. Methods: BroMatters and HardHat were two randomized controlled trials (RCTs) that evaluated the effectiveness of e–mental health programs for preventing workplace depression. In the BroMatters RCT, only working men who were at high risk of having a major depressive episode were included. The participants were assigned to either the control group or 1 of 2 intervention groups. The control participants had access to the general depression information on the BroMatters website. Intervention group 1 had access to BroMatters and BroHealth—the depression prevention program. Intervention group 2 had access to BroMatters and BroHealth along with weekly access to a qualified coach through telephone calls. The HardHat trial targeted both men and women at high risk of having a major depressive episode. The participants in the intervention group were given access to the HardHat depression prevention program (which included a web-based coach), whereas HardHat access was only granted to the control group once the study was completed. This qualitative study recruited male participants from the intervention groups of the two RCTs. A total of 2 groups of participants were recruited from the BroMatters study (after a baseline interview: n=41; 1 month after the RCT: n=20; 61/744, 8.2%), and 1 group was recruited from the HardHat RCT 1 month after the initial quantitative interview (9/103, 8.7%). Semistructured interviews were performed with the participants (70/847, 8.3%) and analyzed using content analysis. Results: There were both personal and program-level barriers to program use. The three personal barriers included time, stress level, and the perception of depression prevention. Content, functionality, and dangers were the program-level barriers to the use of web-based mental health programs. Large amounts of text and functionality issues within the programs decreased participants’ engagement. The dangers associated with web-based mental health programs included privacy breaches and inadequate help for severe symptoms. Conclusions: There are personal and program-level barriers to the use of web-based mental health programs. The stigmatization of help seeking for depression symptoms affects the time spent on the program, as does the public perception of depression. Certain barriers may be mitigated by program updates, whereas others may require a complete shift in the perception of depression prevention. %M 34264195 %R 10.2196/16949 %U https://formative.jmir.org/2021/7/e16949 %U https://doi.org/10.2196/16949 %U http://www.ncbi.nlm.nih.gov/pubmed/34264195 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e28244 %T Behavioral Activation and Depression Symptomatology: Longitudinal Assessment of Linguistic Indicators in Text-Based Therapy Sessions %A Burkhardt,Hannah A %A Alexopoulos,George S %A Pullmann,Michael D %A Hull,Thomas D %A Areán,Patricia A %A Cohen,Trevor %+ Department of Biomedical Informatics and Medical Education, University of Washington, 850 Republican St, Seattle, WA, 98109, United States, 1 206 897 4636, haalbu@uw.edu %K natural language processing %K text analysis %K behavioral activation %K depression %K digital interventions %K mental health %D 2021 %7 14.7.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Behavioral activation (BA) is rooted in the behavioral theory of depression, which states that increased exposure to meaningful, rewarding activities is a critical factor in the treatment of depression. Assessing constructs relevant to BA currently requires the administration of standardized instruments, such as the Behavioral Activation for Depression Scale (BADS), which places a burden on patients and providers, among other potential limitations. Previous work has shown that depressed and nondepressed individuals may use language differently and that automated tools can detect these differences. The increasing use of online, chat-based mental health counseling presents an unparalleled resource for automated longitudinal linguistic analysis of patients with depression, with the potential to illuminate the role of reward exposure in recovery. Objective: This work investigated how linguistic indicators of planning and participation in enjoyable activities identified in online, text-based counseling sessions relate to depression symptomatology over time. Methods: Using distributional semantics methods applied to a large corpus of text-based online therapy sessions, we devised a set of novel BA-related categories for the Linguistic Inquiry and Word Count (LIWC) software package. We then analyzed the language used by 10,000 patients in online therapy chat logs for indicators of activation and other depression-related markers using LIWC. Results: Despite their conceptual and operational differences, both previously established LIWC markers of depression and our novel linguistic indicators of activation were strongly associated with depression scores (Patient Health Questionnaire [PHQ]-9) and longitudinal patient trajectories. Emotional tone; pronoun rates; words related to sadness, health, and biology; and BA-related LIWC categories appear to be complementary, explaining more of the variance in the PHQ score together than they do independently. Conclusions: This study enables further work in automated diagnosis and assessment of depression, the refinement of BA psychotherapeutic strategies, and the development of predictive models for decision support. %M 34259637 %R 10.2196/28244 %U https://www.jmir.org/2021/7/e28244 %U https://doi.org/10.2196/28244 %U http://www.ncbi.nlm.nih.gov/pubmed/34259637 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 7 %P e30735 %T Developing and Implementing a Web-Based Psychotherapy Program to Address Mental Health Challenges Among Patients Receiving Oncologic and Palliative Care: Protocol for an Open-Label Randomized Controlled Trial %A Alavi,Nazanin %A Stephenson,Callum %A Miller,Shadé %A Khalafi,Payam %A Sinan,Israa %A Kain,Danielle %A McDougall,Maggie %A Davies,Julia %A Stark,Debora %A Tompkins,Erin %A Jagayat,Jasleen %A Omrani,Mohsen %A Shirazi,Amirhossein %A Groll,Dianne %A Soares,Claudio %+ Department of Psychiatry, Faculty of Health Sciences, Queen's University, Hotel Dieu Hospital, 166 Brock Street, Kingston, ON, K7L 5G2, Canada, 1 613 544 3310, nazanin.alavi@queensu.ca %K anxiety %K cognitive behavioral therapy %K depression %K eHealth %K electronic care %K internet %K mental health treatment %K oncology %K palliative care %K psychotherapy %D 2021 %7 14.7.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The demand for mental health care, particularly for depression and anxiety, is 3-fold greater among patients receiving oncologic and palliative care than for the general population. This population faces unique barriers, making them more susceptible to mental health challenges. Various forms of psychotherapy have been deemed effective in addressing mental health challenges in this population, including supportive psychotherapy, cognitive behavioral therapy, problem-based therapy, and mindfulness; however, their access to traditional face-to-face psychotherapy resources is limited owing to their immunocompromised status, making frequent hospital visits dangerous. Additionally, patients can face hospital fatigue from numerous appointments and investigations or may live in remote areas, which makes commutes both physically and financially challenging. Web-based psychotherapy is a promising solution to address these accessibility barriers. Moreover, web-based psychotherapy has been proven effective in addressing depression and anxiety in other populations and may be implementable among patients receiving oncologic and palliative care. Objective: The study will investigate the feasibility and effectiveness of web-based psychotherapy among patients receiving oncologic and palliative care, who have comorbid depression or anxiety. We hypothesized that this program will be a viable and efficacious treatment modality compared to current treatment modalities in addressing depression and anxiety symptoms in this population. Methods: Participants (n=60) with depression or anxiety will be recruited from oncology and palliative care settings in Kingston (Ontario, Canada). Participants will be randomly allocated to receive either 8 weeks of web-based psychotherapy plus treatment as usual (treatment arm) or treatment as usual exclusively (control arm). The web-based psychotherapy program will incorporate cognitive behavioral therapy, mindfulness, and problem-solving skills, and homework assignments with personalized feedback from a therapist. All web-based programs will be delivered through a secure platform specifically designed for web-based psychotherapy delivery. To evaluate treatment efficacy, all participants will complete standardized symptomology questionnaires at baseline, midpoint (week 4), and posttreatment. Results: The study received ethics approval in February 2021 and began recruiting participants in April 2021. Participant recruitment has been conducted through social media advertisements, physical advertisements, and physician referrals. To date, 11 participants (treatment, n=5; control, n=4; dropout, n=2) have been recruited. Data collection and analysis are expected to conclude by December 2021 and January 2022, respectively. Linear regression (for continuous outcomes) will be conducted with interpretive qualitative methods. Conclusions: Our findings can be incorporated into clinical policy and help develop more accessible mental health treatment options for patients receiving oncologic and palliative care. Asynchronous and web-based psychotherapy delivery is a more accessible, scalable, and financially feasible treatment that could have major implications on the health care system. Trial Registration: ClinicalTrials.gov NCT04664270; https://clinicaltrials.gov/ct2/show/NCT04664270 International Registered Report Identifier (IRRID): DERR1-10.2196/30735 %M 34259164 %R 10.2196/30735 %U https://www.researchprotocols.org/2021/7/e30735 %U https://doi.org/10.2196/30735 %U http://www.ncbi.nlm.nih.gov/pubmed/34259164 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 7 %P e27018 %T User Engagement and Usability of Suicide Prevention Apps: Systematic Search in App Stores and Content Analysis %A Wilks,Chelsey R %A Chu,Carol %A Sim,DongGun %A Lovell,Josh %A Gutierrez,Peter %A Joiner,Thomas %A Kessler,Ronald C %A Nock,Matthew K %+ Department of Psychological Sciences, University of Missouri-St. Louis, 1 University Way, St Louis, MO, 63121, United States, 1 (314) 516 5383, chelseywilks@umsl.edu %K suicide %K mHealth %K usability %K engagement %K mobile phone %D 2021 %7 14.7.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: People with suicidal thoughts are more inclined to seek technology-delivered interventions than in-person forms of treatment, making mobile apps for suicide prevention an ideal platform for treatment delivery. This review examines apps designed for suicide prevention, with a specific focus on user engagement. Objective: This study aims to update the literature and broadly evaluate the landscape of mobile health apps for suicide prevention; examine apps with key features and primary approaches to suicide prevention; and systematically evaluate the engagement, functionality, aesthetics, and information of the apps. Methods: All apps related to suicidal thoughts and behaviors were identified in the Google Play and iOS app stores and were systematically reviewed for their content and quality. The mobile app rating scale (MARS) was used to evaluate app usability and engagement. Results: Of the 66 apps identified, 42 (64%) were specifically designed for people with suicidal ideation, and 59 (89%) had at least one best practice feature for suicide risk reduction. The mean overall MARS score of all apps was 3.5 (range 2.1-4.5), with 83% (55/66) of apps having a minimum acceptability score of 3. The total MARS score was not associated with the user app rating (r=−0.001; P=.99) or the number of features (r=0.24; P=.09). Conclusions: This study identified many usable and engaging apps in app stores designed for suicide prevention. However, there are only limited apps for clinicians. Thus, mobile apps for suicide prevention should be carefully developed and clinically evaluated. %M 34259163 %R 10.2196/27018 %U https://formative.jmir.org/2021/7/e27018 %U https://doi.org/10.2196/27018 %U http://www.ncbi.nlm.nih.gov/pubmed/34259163 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 7 %P e20969 %T Designing Asynchronous Remote Support for Behavioral Activation in Teenagers With Depression: Formative Study %A Bhattacharya,Arpita %A Nagar,Ria %A Jenness,Jessica %A Munson,Sean A %A Kientz,Julie A %+ Department of Informatics, University of California, Irvine, 6210 Donald Bren Hall, Irvine, CA, 92697, United States, 1 (949) 824 2901, arpitab@uci.edu %K teens %K mental health %K behavioral activation %K asynchronous remote communities %D 2021 %7 13.7.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Many teenagers in the United States experience challenges with symptoms of depression, and they lack adequate resources for accessing in-person mental health care. Involving teens and clinicians in designing technologies that use evidence-based practices that reduce barriers to accessing mental health care is crucial. Interventions based on behavioral activation (BA) help teens understand the relationship between mood and activity, help them practice goal-directed behaviors to improve mood, and may be particularly well-suited to delivery via internet-based platforms. Objective: This study aims to understand the needs and challenges that teens and mental health clinicians face in depression management and involve them in the design process of a remote intervention that uses asynchronous remote communities. Our goal is to understand the benefits and challenges of adapting BA to an internet-based platform that supports the asynchronous remote community approach as a delivery tool for teen depression management. Methods: We enrolled mental health clinicians (n=10) and teens (n=8) in separate, private, internet-based groups on Slack (Slack Technologies Inc). They participated in 20-minute design activities for 10 weeks and were then invited to interviews about their experiences in the study. Results: Both teen and clinician participants wanted internet-based support for BA as a supplement to in-person therapy. Although participants perceived the asynchronous format as conducive to supporting accessible care, teens and clinicians raised concerns about safety, privacy, and the moderating of the internet-based group. Design decisions that address these concerns need to be balanced with the potential benefits of learning coping skills, increasing access to mental health care, and promoting asynchronous human connection to support teens. Conclusions: We discuss considerations for balancing tensions in privacy and safety while designing and selecting internet-based platforms to support remote care and integrating evidence-based support when designing digital technologies for the treatment of teens with depression. %M 34255665 %R 10.2196/20969 %U https://formative.jmir.org/2021/7/e20969 %U https://doi.org/10.2196/20969 %U http://www.ncbi.nlm.nih.gov/pubmed/34255665 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e25917 %T A Newly Developed Online Peer Support Community for Depression (Depression Connect): Qualitative Study %A Smit,Dorien %A Vrijsen,Janna N %A Groeneweg,Bart %A Vellinga-Dings,Amber %A Peelen,Janneke %A Spijker,Jan %+ Depression Expertise Center, Pro Persona Mental Health Care, PO Box 2167, Nijmegen, 6500 WC, Netherlands, 31 647074551, d.smit@propersona.nl %K depression %K online peer support community %K internet support group %K experiential knowledge %K self-management %K empowerment %K qualitative research %K patients’ perspectives %K participation style %D 2021 %7 12.7.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet support groups enable users to provide peer support by exchanging knowledge about and experiences in coping with their illness. Several studies exploring the benefits of internet support groups for depression have found positive effects on recovery-oriented values, including empowerment. However, to date, little attention has been paid to user narratives. Objective: This study aims to capture the user perspective on an online peer support community for depression with a focus on the modes of user engagement and the benefits users derive from participation in the forum. Methods: In this qualitative study, we conducted 15 semistructured interviews with users of Depression Connect, a newly developed online peer support community for individuals with depression. Combining a concept-driven and a data-driven approach, we aimed to gain insight into what users value in our Depression Connect platform and whether and how the platform promotes empowerment. We performed a thematic analysis to explore the merits and demerits reported by users by using theoretical concepts widely used in internet support group research. In the subsequent data-driven analysis, we sought to understand the relationship between different styles of user engagement and the participants’ experiences with the use of Depression Connect. Data analysis consisted of open, axial, and selective coding. To include as diverse perspectives as possible, we opted for purposive sampling. To verify and validate the (interim) results, we included negative cases and performed member checks. Results: We found participation in Depression Connect contributes to a sense of belonging, emotional growth, self-efficacy, and empowerment. “Getting too caught up” was the most frequently reported negative aspect of using Depression Connect. The deployment and development of three participation styles (ie, reading, posting, and responding) affected the perceived benefits of Depression Connect use differentially, where the latter style was central to enhancing empowerment. “Being of value to others” boosted the users’ belief in their personal strength. Finally, Depression Connect was predominantly used to supplement offline support and care for depression, and it mainly served as a safe environment where members could freely reflect on their coping mechanisms for depression and exchange and practice coping strategies. Conclusions: Our findings shed new light on user engagement processes on which internet support groups rely. The online community primarily served as a virtual meeting place to practice (social) skills for deployment in the offline world. It also allowed the members to learn from each other’s knowledge and experiences and explore newly gained insights and coping skills. %M 34255659 %R 10.2196/25917 %U https://www.jmir.org/2021/7/e25917 %U https://doi.org/10.2196/25917 %U http://www.ncbi.nlm.nih.gov/pubmed/34255659 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 7 %P e26498 %T A Mobile-Based Intervention to Increase Self-esteem in Students With Depressive Symptoms: Randomized Controlled Trial %A Bruhns,Alina %A Lüdtke,Thies %A Moritz,Steffen %A Bücker,Lara %+ University Medical Center Hamburg-Eppendorf (UKE), Martinistraße 52, Hamburg, 20251, Germany, 49 40741055868, l.buecker@uke.de %K mHealth %K depression %K depressive symptoms %K students’ mental health %K self-help smartphone app %K mobile phone %K self-esteem %D 2021 %7 12.7.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depressive symptoms are one of the most common and ever-increasing mental health problems among students worldwide. Conventional treatment options, particularly psychotherapy, do not reach all students in need of help. Internet- and mobile-based interventions are promising alternatives for narrowing the treatment gap. Objective: In the framework of a randomized controlled trial, we aim to investigate the effectiveness, acceptance, and side effects of a self-help smartphone app (MCT & More) based on cognitive behavioral therapy, mindfulness, acceptance and commitment therapy, and metacognitive training in a sample of students with self-reported depressive symptoms. Furthermore, we were interested in examining the influence of treatment expectations and attitudes toward internet- and mobile-based interventions on treatment adherence and effectiveness. Methods: A total of 400 students were recruited via open access websites and randomized to either the intervention group (n=200), who received access to the self-help smartphone app MCT & More for a period of 4 weeks, or to a wait-list control group (n=200). The Patient Health Questionnaire-9 (depression) served as the primary outcome parameter, and the Rosenberg Self-esteem Scale (self-esteem) and the global item of the World Health Organization Quality of Life-abbreviated version (quality of life) served as the secondary outcome parameters. The Attitudes Towards Psychological Online Interventions was used to measure attitudes toward internet- and mobile-based interventions. Outcome expectations were assessed using the Patient Questionnaire on Therapy Expectation and Evaluation, and side effects were assessed using the Inventory for Assessing Negative Effects of Psychotherapy. Results: Per-protocol (PP), complete-case, and intention-to-treat analyses showed a significantly higher reduction in depressive symptoms (PP: F1,222=3.98; P=.047; d=0.26) and a significantly higher increase in self-esteem (PP: F1,220=8.79; P=.003; d=0.40) in the intervention group than in the wait-list control group. Most participants regularly used the self-help smartphone app (91/120, 75.8%, at least once a week). The more positive the attitude toward internet- and mobile-based interventions (r=0.260; P=.004) and the more positive the outcome expectation (r=0.236; P=.009), the more frequently the self-help smartphone app was used. Conclusions: The effectiveness of the self-help smartphone app MCT & More was demonstrated among students with depressive symptoms compared with a wait-list control group. The app could be offered regularly as a low-threshold intervention to enhance students’ health. Trial Registration: German Clinical Trials Register DRKS00020941; https://tinyurl.com/pr84w6er %M 34255711 %R 10.2196/26498 %U https://mhealth.jmir.org/2021/7/e26498 %U https://doi.org/10.2196/26498 %U http://www.ncbi.nlm.nih.gov/pubmed/34255711 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 7 %P e24512 %T Understanding the Role of Social Media–Based Mental Health Support Among College Students: Survey and Semistructured Interviews %A Vornholt,Piper %A De Choudhury,Munmun %+ School of Interactive Computing, College of Computing, Georgia Institute of Technology, 756 W Peachtree St NW, Atlanta, GA, 30308, United States, 1 4043858603, munmund@gatech.edu %K college mental health %K social media %K social support %K mobile phone %D 2021 %7 12.7.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental illness is a growing concern within many college campuses. Limited access to therapy resources, along with the fear of stigma, often prevents students from seeking help. Introducing supportive interventions, coping strategies, and mitigation programs might decrease the negative effects of mental illness among college students. Objective: Many college students find social support for a variety of needs through social media platforms. With the pervasive adoption of social media sites in college populations, in this study, we examine whether and how these platforms may help meet college students’ mental health needs. Methods: We first conducted a survey among 101 students, followed by semistructured interviews (n=11), of a large public university in the southeast region of the United States to understand whether, to what extent, and how students appropriate social media platforms to suit their struggle with mental health concerns. The interviews were intended to provide comprehensive information on students’ attitudes and their perceived benefits and limitations of social media as platforms for mental health support. Results: Our survey revealed that a large number of participating students (71/101, 70.3%) had recently experienced some form of stress, anxiety, or other mental health challenges related to college life. Half of them (52/101, 51.5%) also reported having appropriated some social media platforms for self-disclosure or help, indicating the pervasiveness of this practice. Through our interviews, we obtained deeper insights into these initial observations. We identified specific academic, personal, and social life stressors; motivations behind social media use for mental health needs; and specific platform affordances that helped or hindered this use. Conclusions: Students recognized the benefits of social media in helping connect with peers on campus and promoting informal and candid disclosures. However, they argued against complete anonymity in platforms for mental health help and advocated the need for privacy and boundary regulation mechanisms in social media platforms supporting this use. Our findings bear implications for informing campus counseling efforts and in designing social media–based mental health support tools for college students. %M 34255701 %R 10.2196/24512 %U https://mental.jmir.org/2021/7/e24512 %U https://doi.org/10.2196/24512 %U http://www.ncbi.nlm.nih.gov/pubmed/34255701 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 9 %N 7 %P e28227 %T Multifeature Fusion Attention Network for Suicide Risk Assessment Based on Social Media: Algorithm Development and Validation %A Li,Jiacheng %A Zhang,Shaowu %A Zhang,Yijia %A Lin,Hongfei %A Wang,Jian %+ College of Computer Science and Technology, Dalian University of Technology, No 2 Linggong Road, Ganjingzi District, Dalian, 116023, China, 86 13384118909, zhangyijia1979@gmail.com %K suicide risk assessment %K social media %K infodemiology %K attention mechanism %K neural networks %D 2021 %7 9.7.2021 %9 Original Paper %J JMIR Med Inform %G English %X Background: Suicide has become the fifth leading cause of death worldwide. With development of the internet, social media has become an imperative source for studying psychological illnesses such as depression and suicide. Many methods have been proposed for suicide risk assessment. However, most of the existing methods cannot grasp the key information of the text. To solve this problem, we propose an efficient method to extract the core information from social media posts for suicide risk assessment. Objective: We developed a multifeature fusion recurrent attention model for suicide risk assessment. Methods: We used the bidirectional long short-term memory network to create the text representation with context information from social media posts. We further introduced a self-attention mechanism to extract the core information. We then fused linguistic features to improve our model. Results: We evaluated our model on the dataset delivered by the Computational Linguistics and Clinical Psychology 2019 shared task. The experimental results showed that our model improves the risk-F1, urgent-F1, and existence-F1 by 3.3%, 0.9%, and 3.7%, respectively. Conclusions: We found that bidirectional long short-term memory performs well for long text representation, and the attention mechanism can identify the key information in the text. The external features can complete the semantic information lost by the neural network during feature extraction and further improve the performance of the model. The experimental results showed that our model performs better than the state-of-the-art method. Our work has theoretical and practical value for suicidal risk assessment. %M 34255687 %R 10.2196/28227 %U https://medinform.jmir.org/2021/7/e28227 %U https://doi.org/10.2196/28227 %U http://www.ncbi.nlm.nih.gov/pubmed/34255687 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 7 %P e28677 %T User Perspectives on a Resilience-Building App (JoyPop): Qualitative Study %A Mushquash,Aislin R %A Pearson,Erin S %A Waddington,Kayla %A MacIsaac,Angela %A Mohammed,Shakira %A Grassia,Elizabeth %A Smith,Savanah %A Wekerle,Christine %+ Department of Psychology, Lakehead University, 955 Oliver Road, Thunder Bay, ON, , Canada, 1 807 343 8771, aislin.mushquash@lakeheadu.ca %K resilience %K smartphone %K app %K innovation %K qualitative %K perspective %K mHealth %K emotion %K mental health %D 2021 %7 8.7.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Resilience is the capability, resources, and processes that are available to a person or system to adapt successfully in the face of stress or adversity. Given that resilience can be enhanced, using advances in technology to deliver and evaluate the impact of resilience interventions is warranted. Evidence supports the effectiveness of the resilience-building JoyPop app in improving resilience-related outcomes after use; however, experiential data from users is also needed to provide a more comprehensive account of its utility. Objective: The aim of this study was to explore users’ experiences with the JoyPop app and their perspectives on its utility. Methods: This qualitative description study involved a combination of group and one-on-one semistructured interviews with a subset of first-year undergraduate students who participated in a larger evaluation of the JoyPop app. Participants used the app for a 4-week period and were subsequently asked about their frequency of app use, most and least used features (and associated reasons), most and least helpful features (and associated reasons), barriers to use, facilitators of use and continuation, and recommendations for improvement. Data were coded and categorized through inductive content analysis. Results: The sample of 30 participants included 24 females and 6 males, with a mean age of 18.77 years (SD 2.30). App use ranged from 1 to 5 times daily (mean 2.11, SD 0.74), with the majority indicating that they used the app at least twice daily. The Rate My Mood, Journal, and SquareMoves features were reported to be used most often, while the Rate My Mood, Journal, and Breathing Exercises features were identified as the most helpful. A number of themes and subthemes pertaining to facilitators of app use (prompts, creating routine, self-monitoring opportunities, expressive opportunities), barriers to app use (editing, lack of variety, student lifestyle), outcomes of app use (increased awareness, checking in with oneself, helpful distraction, emotional control), and recommendations for app improvement (adding more features, enhancing existing features, enhancing tracking abilities, providing personalization) were identified. Conclusions: This study provides insight into the aspects of the JoyPop app that motivated and benefitted users, as well as measures that can be taken to improve user experiences and promote longer-term uptake. Users were willing to engage with the app and incorporate it into their routine, and they valued the ability to self-monitor, express emotion, and engage in distraction. %M 34255696 %R 10.2196/28677 %U https://mhealth.jmir.org/2021/7/e28677 %U https://doi.org/10.2196/28677 %U http://www.ncbi.nlm.nih.gov/pubmed/34255696 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 7 %P e23091 %T Acceptability of Computerized Cognitive Behavioral Therapy for Adults: Umbrella Review %A Treanor,Charlene J %A Kouvonen,Anne %A Lallukka,Tea %A Donnelly,Michael %+ Centre for Public Health, Queen's University Belfast, School of Medicine, Dentistry and Biomedical Sciences, Royal Victoria Hospital, Grosvenor Road, Belfast, BT16 6BJ, United Kingdom, 44 28 90978993, michael.donnelly@qub.ac.uk %K computerized/internet cognitive behavioral therapy %K cCBT %K iCBT %K acceptability %K mental health %K umbrella review %D 2021 %7 6.7.2021 %9 Review %J JMIR Ment Health %G English %X Background: Mental ill-health presents a major public health problem. A potential part solution that is receiving increasing attention is computer-delivered psychological therapy, particularly during the COVID-19 pandemic as health care systems moved to remote service delivery. However, computerized cognitive behavioral therapy (cCBT) requires active engagement by service users, and low adherence may minimize treatment effectiveness. Therefore, it is important to investigate the acceptability of cCBT to understand implementation issues and maximize potential benefits. Objective: This study aimed to produce a critical appraisal of published reviews about the acceptability of cCBT for adults. Methods: An umbrella review informed by the Joanna Briggs Institute (JBI) methodology identified systematic reviews about the acceptability of cCBT for common adult mental disorders. Acceptability was operationalized in terms of uptake of, dropping out from, or completion of cCBT treatment; factors that facilitated or impeded adherence; and reports about user, carer, and health care professional experience and satisfaction with cCBT. Databases were searched using search terms informed by relevant published research. Review selection and quality appraisal were guided by the JBI methodology and the AMSTAR tool and undertaken independently by 2 reviewers. Results: The systematic searches of databases identified 234 titles, and 9 reviews (covering 151 unique studies) met the criteria. Most studies were comprised of service users with depression, anxiety, or specifically, panic disorder or phobia. Operationalization of acceptability varied across reviews, thereby making it difficult to synthesize results. There was a similar number of guided and unguided cCBT programs; 34% of guided and 36% of unguided users dropped out; and guidance included email, telephone, face-to-face, and discussion forum support. Guided cCBT was completed in full by 8%-74% of the participants, while 94% completed one module and 67%-84% completed some modules. Unguided cCBT was completed in full by 16%-66% of participants, while 95% completed one module and 54%-93% completed some modules. Guided cCBT appeared to be associated with adherence (sustained via telephone). A preference for face-to-face CBT compared to cCBT (particularly for users who reported feeling isolated), internet or computerized delivery problems, negative perceptions about cCBT, low motivation, too busy or not having enough time, and personal circumstances were stated as reasons for dropping out. Yet, some users favored the anonymous nature of cCBT, and the capacity to undertake cCBT in one’s own time was deemed beneficial but also led to avoidance of cCBT. There was inconclusive evidence for an association between sociodemographic variables, mental health status, and cCBT adherence or dropping out. Users tended to be satisfied with cCBT, reported improvements in mental health, and recommended cCBT. Overall, the results indicated that service users’ preferences were important considerations regarding the use of cCBT. Conclusions: The review indicated that “one size did not fit all” regarding the acceptability of cCBT and that individual tailoring of cCBT is required in order to increase population reach, uptake, and adherence and therefore, deliver treatment benefits and improve mental health. %M 34255714 %R 10.2196/23091 %U https://mental.jmir.org/2021/7/e23091 %U https://doi.org/10.2196/23091 %U http://www.ncbi.nlm.nih.gov/pubmed/34255714 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e22075 %T Advancing Mental Health and Psychological Support for Health Care Workers Using Digital Technologies and Platforms %A Ye,Jiancheng %+ Feinberg School of Medicine, Northwestern University, 633 N Saint Clair St, Chicago, IL, United States, 1 312 503 3690, jiancheng.ye@u.northwestern.edu %K mental health %K health care workers %K health informatics %K digital intervention %K health technology %K mobile health %K COVID-19 %D 2021 %7 30.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The COVID-19 pandemic is a global public health crisis that has not only endangered the lives of patients but also resulted in increased psychological issues among medical professionals, especially frontline health care workers. As the crisis caused by the pandemic shifts from acute to protracted, attention should be paid to the devastating impacts on health care workers’ mental health and social well-being. Digital technologies are being harnessed to support the responses to the pandemic, which provide opportunities to advance mental health and psychological support for health care workers. Objective: The aim of this study is to develop a framework to describe and organize the psychological and mental health issues that health care workers are facing during the COVID-19 pandemic. Based on the framework, this study also proposes interventions from digital health perspectives that health care workers can leverage during and after the pandemic. Methods: The psychological problems and mental health issues that health care workers have encountered during the COVID-19 pandemic were reviewed and analyzed based on the proposed MEET (Mental Health, Environment, Event, and Technology) framework, which also demonstrated the interactions among mental health, digital interventions, and social support. Results: Health care workers are facing increased risk of experiencing mental health issues due to the COVID-19 pandemic, including burnout, fear, worry, distress, pressure, anxiety, and depression. These negative emotional stressors may cause psychological problems for health care workers and affect their physical and mental health. Digital technologies and platforms are playing pivotal roles in mitigating psychological issues and providing effective support. The proposed framework enabled a better understanding of how to mitigate the psychological effects during the pandemic, recover from associated experiences, and provide comprehensive institutional and societal infrastructures for the well-being of health care workers. Conclusions: The COVID-19 pandemic presents unprecedented challenges due to its prolonged uncertainty, immediate threat to patient safety, and evolving professional demands. It is urgent to protect the mental health and strengthen the psychological resilience of health care workers. Given that the pandemic is expected to exist for a long time, caring for mental health has become a “new normal” that needs a strengthened multisector collaboration to facilitate support and reduce health disparities. The proposed MEET framework could provide structured guidelines for further studies on how technology interacts with mental and psychological health for different populations. %M 34106874 %R 10.2196/22075 %U https://formative.jmir.org/2021/6/e22075 %U https://doi.org/10.2196/22075 %U http://www.ncbi.nlm.nih.gov/pubmed/34106874 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 6 %P e25742 %T Twitter Users’ Views on Mental Health Crisis Resolution Team Care Compared With Stakeholder Interviews and Focus Groups: Qualitative Analysis %A Chilman,Natasha %A Morant,Nicola %A Lloyd-Evans,Brynmor %A Wackett,Jane %A Johnson,Sonia %+ Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7BN, United Kingdom, 44 7969688554, n.morant@ucl.ac.uk %K Twitter %K social media %K qualitative %K crisis resolution team %K home treatment team %K mental health %K acute care %K severe mental illness %D 2021 %7 29.6.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Analyzing Twitter posts enables rapid access to how issues and experiences are socially shared and constructed among communities of health service users and providers, in ways that traditional qualitative methods may not. Objective: To enrich the understanding of mental health crisis care in the United Kingdom, this study explores views on crisis resolution teams (CRTs) expressed on Twitter. We aim to identify the similarities and differences among views expressed on Twitter compared with interviews and focus groups. Methods: We used Twitter’s advanced search function to retrieve public tweets on CRTs. A thematic analysis was conducted on 500 randomly selected tweets. The principles of refutational synthesis were applied to compare themes with those identified in a multicenter qualitative interview study. Results: The most popular hashtag identified was #CrisisTeamFail, where posts were principally related to poor quality of care and access, particularly for people given a personality disorder diagnosis. Posts about CRTs giving unhelpful self-management advice were common, as were tweets about resource strains on mental health services. This was not identified in the research interviews. Although each source yielded unique themes, there were some overlaps with themes identified via interviews and focus groups, including the importance of rapid access to care. Views expressed on Twitter were generally more critical than those obtained via face-to-face methods. Conclusions: Traditional qualitative studies may underrepresent the views of more critical stakeholders by collecting data from participants accessed via mental health services. Research on social media content can complement traditional or face-to-face methods and ensure that a broad spectrum of viewpoints can inform service development and policy. %M 34185017 %R 10.2196/25742 %U https://mental.jmir.org/2021/6/e25742 %U https://doi.org/10.2196/25742 %U http://www.ncbi.nlm.nih.gov/pubmed/34185017 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e25808 %T Effects of Mobile App–Based Intervention for Depression in Middle-Aged and Older Adults: Mixed Methods Feasibility Study %A Gould,Christine E %A Carlson,Chalise %A Ma,Flora %A Forman-Hoffman,Valerie %A Ranta,Kristian %A Kuhn,Eric %+ Geriatric Research, Education, and Clinical Center, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA, 94304, United States, 1 6504935000 ext 68899, cegould@stanford.edu %K aging %K depression %K digital health %K digital therapeutics %K mHealth %K mobile phone %D 2021 %7 29.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital mental health interventions may help middle-aged and older adults with depression overcome barriers to accessing traditional care, but few studies have investigated their use in this population. Objective: This pilot study examines the feasibility, acceptability, and potential efficacy of the Meru Health Program, an 8-week mobile app–delivered intervention. Methods: A total of 20 community-dwelling middle-aged and older adults (age: mean 61.7 years, SD 11.3) with elevated depressive symptoms participated in a single-arm pilot study investigating the Meru Health Program, an app-delivered intervention supported by remote therapists. The program primarily uses mindfulness and cognitive behavioral skills to target depressive symptoms. A semistructured interview was completed at the baseline to establish current psychiatric diagnoses. Depressive symptoms were measured using the Patient Health Questionnaire and Patient-Reported Outcomes Measurement Information System (PROMIS) depression measures. Anxiety symptoms were measured using the Generalized Anxiety Disorder Scale and the PROMIS Anxiety measure. User experience and acceptability were examined through surveys and qualitative interviews. Results: In total, 90% (18/20) of the participants completed the program, with 75% (15/20) completing at least 7 of the 8 introductory weekly lessons. On average, participants completed 60 minutes of practice and exchanged 5 messages with their therapists every week. The app was rated as helpful by 89% (17/19) participants. Significant decreases in depressive (P=.03) and anxiety symptom measures (P=.01) were found; 45% (9/20) of participants showed clinically significant improvement in either depressive symptoms or anxiety symptoms. Conclusions: The findings suggest that the commercially available Meru Health Program may be feasible, acceptable, and potentially beneficial to middle-aged and older adults. Although larger controlled trials are needed to demonstrate efficacy, these findings suggest that digital health interventions may benefit adults of all ages. %M 34185000 %R 10.2196/25808 %U https://formative.jmir.org/2021/6/e25808 %U https://doi.org/10.2196/25808 %U http://www.ncbi.nlm.nih.gov/pubmed/34185000 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e24584 %T Effectiveness and Acceptance of Technology-Based Psychological Interventions for the Acute Treatment of Unipolar Depression: Systematic Review and Meta-analysis %A Köhnen,Moritz %A Kriston,Levente %A Härter,Martin %A Baumeister,Harald %A Liebherz,Sarah %+ Department of Medical Psychology, University Medical Center Hamburg–Eppendorf, Martinistr 52, Building West 26, Hamburg, , Germany, 49 40 7410 57705, m.koehnen@uke.de %K internet %K digital health %K digital mental health %K telephone %K psychotherapy %K depressive disorder %K systematic review %K meta-analysis %K technology-based psychological interventions %D 2021 %7 13.6.2021 %9 Review %J J Med Internet Res %G English %X Background: Evidence on technology-based psychological interventions (TBIs) for the acute treatment of depression is rapidly growing. Despite extensive research in this field, there is a lack of research determining effectiveness and acceptance of TBIs considering different application formats in people with a formally diagnosed depressive disorder. Objective: The goal of the review was to investigate the effectiveness and acceptance of TBIs in people with diagnosed depression with particular focus on application formats (stand-alone interventions, blended treatments, collaborative and/or stepped care interventions). Methods: Studies investigating adults with diagnosed unipolar depressive disorders receiving any kind of psychotherapeutic treatment delivered (at least partly) by a technical medium and conducted as randomized controlled trials (RCTs) were eligible for inclusion. We searched CENTRAL (Cochrane Central Register of Controlled Trials; August 2020), MEDLINE, PsycINFO, PSYNDEX, CINAHL (January 2018), clinical trial registers, and sources of grey literature (January 2019). Two independent authors decided about study inclusion and extracted data. We performed random effects meta-analyses to synthesize the data. Results: Database searches resulted in 15,546 records of which 78 completed studies were included. TBIs delivered as stand-alone interventions showed positive effects on posttreatment depression severity when compared to treatment as usual (SMD –0.44, 95% CI –0.73 to –0.15, k=10; I²=86%), attention placebo (SMD –0.51, 95% CI –0.73 to –0.30; k=12; I²=66%), and waitlist controls (SMD –1.01, 95% CI –1.23 to –0.79; k=19; I²=73%). Superior long-term effects on depression severity were shown when TBIs were compared to treatment as usual (SMD –0.24, 95% CI –0.41 to –0.07; k=6; I²=48%) attention placebo (SMD –0.23, 95% CI –0.40 to –0.07; k=7; I²=21%) and waitlist controls (SMD –0.74, 95% CI –1.31 to –0.18; k=3; I²=79%). TBIs delivered as blended treatments (providing a TBI as an add-on to face-to-face treatment) yielded beneficial effects on posttreatment depression severity (SMD –0.27, 95% CI –0.48 to –0.05; k=8; I²=53%) compared to face-to-face treatments only. Additionally, TBIs delivered within collaborative care trials were more effective in reducing posttreatment (SMD –0.20, 95% CI –0.36 to –0.04; k=2; I²=0%) and long-term (SMD –0.23, 95% CI –0.39 to –0.07; k=2; I²=0%) depression severity than usual care. Dropout rates did not differ between the intervention and control groups in any comparison (all P≥.09). Conclusions: We found that TBIs are effective not only when delivered as stand-alone interventions but also when they are delivered as blended treatments or in collaborative care trials for people with diagnosed depression. Our results may be useful to inform routine care, since we focused specifically on different application formats, formally diagnosed patients, and the long-term effectiveness of TBIs. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2018-028042 %M 36260395 %R 10.2196/24584 %U https://www.jmir.org/2021/6/e24584/ %U https://doi.org/10.2196/24584 %U http://www.ncbi.nlm.nih.gov/pubmed/36260395 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e27344 %T Discovery of Depression-Associated Factors From a Nationwide Population-Based Survey: Epidemiological Study Using Machine Learning and Network Analysis %A Nam,Sang Min %A Peterson,Thomas A %A Seo,Kyoung Yul %A Han,Hyun Wook %A Kang,Jee In %+ Department of Psychiatry, Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2 2228 1620, jeeinkang@yuhs.ac %K depression %K epidemiology %K machine learning %K network %K prediction model %K XGBoost %D 2021 %7 24.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: In epidemiological studies, finding the best subset of factors is challenging when the number of explanatory variables is large. Objective: Our study had two aims. First, we aimed to identify essential depression-associated factors using the extreme gradient boosting (XGBoost) machine learning algorithm from big survey data (the Korea National Health and Nutrition Examination Survey, 2012-2016). Second, we aimed to achieve a comprehensive understanding of multifactorial features in depression using network analysis. Methods: An XGBoost model was trained and tested to classify “current depression” and “no lifetime depression” for a data set of 120 variables for 12,596 cases. The optimal XGBoost hyperparameters were set by an automated machine learning tool (TPOT), and a high-performance sparse model was obtained by feature selection using the feature importance value of XGBoost. We performed statistical tests on the model and nonmodel factors using survey-weighted multiple logistic regression and drew a correlation network among factors. We also adopted statistical tests for the confounder or interaction effect of selected risk factors when it was suspected on the network. Results: The XGBoost-derived depression model consisted of 18 factors with an area under the weighted receiver operating characteristic curve of 0.86. Two nonmodel factors could be found using the model factors, and the factors were classified into direct (P<.05) and indirect (P≥.05), according to the statistical significance of the association with depression. Perceived stress and asthma were the most remarkable risk factors, and urine specific gravity was a novel protective factor. The depression-factor network showed clusters of socioeconomic status and quality of life factors and suggested that educational level and sex might be predisposing factors. Indirect factors (eg, diabetes, hypercholesterolemia, and smoking) were involved in confounding or interaction effects of direct factors. Triglyceride level was a confounder of hypercholesterolemia and diabetes, smoking had a significant risk in females, and weight gain was associated with depression involving diabetes. Conclusions: XGBoost and network analysis were useful to discover depression-related factors and their relationships and can be applied to epidemiological studies using big survey data. %M 34184998 %R 10.2196/27344 %U https://www.jmir.org/2021/6/e27344/ %U https://doi.org/10.2196/27344 %U http://www.ncbi.nlm.nih.gov/pubmed/34184998 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 4 %N 2 %P e26475 %T Trends in Positive, Negative, and Neutral Themes of Popular Music From 1998 to 2018: Observational Study %A Kwon,Lois %A Medina,Daniela %A Ghattas,Fady %A Reyes,Lilia %+ Pennsylvania State University College of Medicine, Pennsylvania State University, 500 University Drive, Hershey, PA, 17033, United States, 1 347 585 7279, lkwon@pennstatehealth.psu.edu %K music %K adolescent %K themes %K trends %K primary care provider %K social media %K mental health %K depression %K anxiety %K pop culture %D 2021 %7 24.6.2021 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Across the United States, the incidence of adolescent depression and suicide cases has risen in the past 10 years. Despite the risk factors and causes being multifactorial, the influence of popular culture on society and adolescents in this media-driven generation cannot be mitigated. Although the impact of social media and its effect on shaping self-identity in adolescents have been observed, the impact of music and its potential for subliminal negative messages to adolescents remains unclear. Objective: This study analyzes the lyrics and music videos of the most popular music of multiple genres to quantify the frequencies of varying music theme trends. Methods: The frequencies of themes of 1052 total American and Latin songs were collected from the Nielsen Music and Billboard’s top 100 chart performance from 1998 to 2018 for hip hop/rhythm and blues (R&B), pop, Latin, country, and rock/metal genres. Themes from songs were identified, quantified, and categorized with a rubric into negative, neutral, and positive themes by 3 different reviewers. Analysis was performed using 2-tailed t tests and a generalized linear model. Results: Popular songs were reviewed for positive, negative, and neutral themes in the following 3-year intervals for ease of analysis purposes: 1998 to 2000 (n=148), 2001 to 2003 (n=150), 2004 to 2006 (n=148), 2007 to 2009 (n=156), 2010 to 2012 (n= 150), 2013 to 2015 (n=150), and 2016 to 2018 (n=150). There was a significant 180% increase in the percentage of songs with negative themes between all the interval years and across all genres (P<.001), while there was no significant difference in the frequency of songs with positive (P=.54) or neutral (P=.26) themes by year. There were significant differences in the number of negative themes found across genres (P<.001), with hip hop/R&B having the highest frequency of 130 out of 208 (62.5%) of the negative themes when compared to each of the individual genres (P<.001). Conclusions: This study shows there is an increase in the frequency of negative themes over the span of 20 years across all genres, with hip hop/R&B having the highest frequency among the genres. These findings point to the potential impact that music may have in popular culture and on society. Furthermore, these results can help shape discussions between caregivers and their adolescent dependents and between primary care providers and their adolescent patients. %M 34184999 %R 10.2196/26475 %U https://pediatrics.jmir.org/2021/2/e26475/ %U https://doi.org/10.2196/26475 %U http://www.ncbi.nlm.nih.gov/pubmed/34184999 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e26771 %T Acceptability and Effectiveness of Artificial Intelligence Therapy for Anxiety and Depression (Youper): Longitudinal Observational Study %A Mehta,Ashish %A Niles,Andrea Nicole %A Vargas,Jose Hamilton %A Marafon,Thiago %A Couto,Diego Dotta %A Gross,James Jonathan %+ Department of Psychology, Stanford University, Building 420, 450 Jane Stanford Way, Stanford, CA, 94305, United States, 1 650 724 5436, ashm@stanford.edu %K digital mental health treatment %K acceptability %K effectiveness %K anxiety %K depression %D 2021 %7 22.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Youper is a widely used, commercially available mobile app that uses artificial intelligence therapy for the treatment of anxiety and depression. Objective: Our study examined the acceptability and effectiveness of Youper. Further, we tested the cumulative regulation hypothesis, which posits that cumulative emotion regulation successes with repeated intervention engagement will predict longer-term anxiety and depression symptom reduction. Methods: We examined data from paying Youper users (N=4517) who allowed their data to be used for research. To characterize the acceptability of Youper, we asked users to rate the app on a 5-star scale and measured retention statistics for users’ first 4 weeks of subscription. To examine effectiveness, we examined longitudinal measures of anxiety and depression symptoms. To test the cumulative regulation hypothesis, we used the proportion of successful emotion regulation attempts to predict symptom reduction. Results: Youper users rated the app highly (mean 4.36 stars, SD 0.84), and 42.66% (1927/4517) of users were retained by week 4. Symptoms decreased in the first 2 weeks of app use (anxiety: d=0.57; depression: d=0.46). Anxiety improvements were maintained in the subsequent 2 weeks, but depression symptoms increased slightly with a very small effect size (d=0.05). A higher proportion of successful emotion regulation attempts significantly predicted greater anxiety and depression symptom reduction. Conclusions: Youper is a low-cost, completely self-guided treatment that is accessible to users who may not otherwise access mental health care. Our findings demonstrate the acceptability and effectiveness of Youper as a treatment for anxiety and depression symptoms and support continued study of Youper in a randomized clinical trial. %M 34155984 %R 10.2196/26771 %U https://www.jmir.org/2021/6/e26771 %U https://doi.org/10.2196/26771 %U http://www.ncbi.nlm.nih.gov/pubmed/34155984 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 6 %P e27140 %T Indications of Depressive Symptoms During the COVID-19 Pandemic in Germany: Comparison of National Survey and Twitter Data %A Cohrdes,Caroline %A Yenikent,Seren %A Wu,Jiawen %A Ghanem,Bilal %A Franco-Salvador,Marc %A Vogelgesang,Felicitas %+ Mental Health Research Unit, Department of Epidemiology and Health Monitoring, Robert Koch Institute, General-Pape-Str. 62-66, Berlin, 12101, Germany, 49 30 18754 2692, CohrdesC@rki.de %K depressive symptoms %K GEDA/EHIS survey %K Twitter %K COVID-19 %K pandemic %K social contact ban %K temporal progression %K data correspondence %K public mental health surveillance %K depression %K survey %K social media %K data %K infodemiology %K infoveillance %K twitter %K mental health %K public health %K surveillance %K monitoring %K symptom %D 2021 %7 18.6.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The current COVID-19 pandemic is associated with extensive individual and societal challenges, including challenges to both physical and mental health. To date, the development of mental health problems such as depressive symptoms accompanying population-based federal distancing measures is largely unknown, and opportunities for rapid, effective, and valid monitoring are currently a relevant matter of investigation. Objective: In this study, we aim to investigate, first, the temporal progression of depressive symptoms during the COVID-19 pandemic and, second, the consistency of the results from tweets and survey-based self-reports of depressive symptoms within the same time period. Methods: Based on a cross-sectional population survey of 9011 German adolescents and adults (n=4659, 51.7% female; age groups from 15 to 50 years and older) and a sample of 88,900 tweets (n=74,587, 83.9% female; age groups from 10 to 50 years and older), we investigated five depressive symptoms (eg, depressed mood and energy loss) using items from the Patient Health Questionnaire (PHQ-8) before, during, and after relaxation of the first German social contact ban from January to July 2020. Results: On average, feelings of worthlessness were the least frequently reported symptom (survey: n=1011, 13.9%; Twitter: n=5103, 5.7%) and fatigue or loss of energy was the most frequently reported depressive symptom (survey: n=4472, 51.6%; Twitter: n=31,005, 34.9%) among both the survey and Twitter respondents. Young adult women and people living in federal districts with high COVID-19 infection rates were at an increased risk for depressive symptoms. The comparison of the survey and Twitter data before and after the first contact ban showed that German adolescents and adults had a significant decrease in feelings of fatigue and energy loss over time. The temporal progression of depressive symptoms showed high correspondence between both data sources (ρ=0.76-0.93; P<.001), except for diminished interest and depressed mood, which showed a steady increase even after the relaxation of the contact ban among the Twitter respondents but not among the survey respondents. Conclusions: Overall, the results indicate relatively small differences in depressive symptoms associated with social distancing measures during the COVID-19 pandemic and highlight the need to differentiate between positive (eg, energy level) and negative (eg, depressed mood) associations and variations over time. The results also underscore previous suggestions of Twitter data’s potential to help identify hot spots of declining and improving public mental health and thereby help provide early intervention measures, especially for young and middle-aged adults. Further efforts are needed to investigate the long-term consequences of recurring lockdown phases and to address the limitations of social media data such as Twitter data to establish real-time public mental surveillance approaches. %M 34142973 %R 10.2196/27140 %U https://mental.jmir.org/2021/6/e27140 %U https://doi.org/10.2196/27140 %U http://www.ncbi.nlm.nih.gov/pubmed/34142973 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 6 %P e15551 %T Typology and Impact of YouTube Videos Posted in Response to a Student Suicide Crisis: Social Media Metrics and Content Analyses %A Cheng,Qijin %A Lui,Carrie %A Ip,Flora Wai Lam %A Yip,Paul Siu Fai %+ Hong Kong Jockey Club Centre for Suicide Research and Prevention, The University of Hong Kong, 2/F, 5 Sassoon Road, Pokfulam, Hong Kong, China (Hong Kong), 852 28315232, sfpyip@hku.hk %K suicide %K suicide prevention %K social media %K infodemiology %K internet %K digital health %K YouTube %K impact evaluation %K network visualization %D 2021 %7 18.6.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Videos relating to suicide are available on YouTube, but their characteristics and impacts have seldom been examined. Objective: This study aimed to examine YouTube videos posted in response to a sudden spate of student suicides in Hong Kong during the 2015-2016 school year and evaluate the impacts of those videos. Methods: Keyword search was performed on YouTube, and relevant videos were identified. Video typology was examined through content analysis, specifically grouping the videos by who uploaded the videos, what presentation formats were used in the videos, whether the videos were originally created by the uploaders, and whether the videos disclosed the uploaders’ personal experiences with suicide. Impacts of the videos were assessed in terms of reach (measured by view count), engagement (measured by comment count), and insights (measured as to what extent the comments to each video could reveal personal suicide risk and attitude toward help-seeking). Statistical analysis was conducted to compare the impacts of different types of videos. The 7 most impactful videos that were originally created by the YouTubers were selected for further analysis. They were compared with 7 videos uploaded by the same YouTubers right before the student suicide videos and 7 right after the student suicide videos. The comparison focused on their impacts and the network structure of the comments to those videos. Results: A total of 162 relevant YouTube videos were identified. They were uploaded by 7 types of stakeholders, and the most common format was one person talking to the camera. A total of 87.0% (141/162) of the videos were originally created by the uploaders and only 8.0% (13/162) of the videos disclosed uploader personal experiences with suicide. The uploader profiles being popular or top YouTubers and the video containing disclosure of the uploader’s personal experiences were found to be significantly correlated with greater impacts (P<.001). Focusing on the 7 most impactful original videos, it is found that those videos generated more engagement, especially more interactions between the viewers, and more insights than regular videos uploaded by the same YouTubers. Conclusions: When responding to a youth suicide crisis, videos made by key opinion leaders on YouTube sharing their own experiences of overcoming suicide risks could generate significant positive impacts. These types of videos offer a precious opportunity to craft online campaigns and activities to raise suicide prevention awareness and engage vulnerable youth. %R 10.2196/15551 %U https://mental.jmir.org/2021/6/e15551/ %U https://doi.org/10.2196/15551 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e26575 %T Gaming Your Mental Health: A Narrative Review on Mitigating Symptoms of Depression and Anxiety Using Commercial Video Games %A Kowal,Magdalena %A Conroy,Eoin %A Ramsbottom,Niall %A Smithies,Tim %A Toth,Adam %A Campbell,Mark %+ Lero, The Science Foundation Ireland Research Centre for Software, Physical Education and Sport Sciences Department, University of Limerick, p1041 PESS building, Castletroy, Limerick, Ireland, 353 061234944, mark.campbell@ul.ie %K commercial video games %K mobile phone %K clinical %K mental health disorders %K psychotherapy %K pandemic %K accessibility %K health care %D 2021 %7 16.6.2021 %9 Viewpoint %J JMIR Serious Games %G English %X Globally, depression and anxiety are the two most prevalent mental health disorders. They occur both acutely and chronically, with various symptoms commonly expressed subclinically. The treatment gap and stigma associated with such mental health disorders are common issues encountered worldwide. Given the economic and health care service burden of mental illnesses, there is a heightened demand for accessible and cost-effective methods that prevent occurrence of mental health illnesses and facilitate coping with mental health illnesses. This demand has been exacerbated post the advent of the COVID-19 pandemic and the subsequent increase in incidence of mental health disorders. To address these demands, a growing body of research is exploring alternative solutions to traditional mental health treatment methods. Commercial video games have been shown to impart cognitive benefits to those playing regularly (ie, attention control, cognitive flexibility, and information processing). In this paper, we specifically focus on the mental health benefits associated with playing commercial video games to address symptoms of depression and anxiety. In light of the current research, we conclude that commercial video games show great promise as inexpensive, readily accessible, internationally available, effective, and stigma-free resources for the mitigation of some mental health issues in the absence of, or in addition to, traditional therapeutic treatments. %M 34132648 %R 10.2196/26575 %U https://games.jmir.org/2021/2/e26575 %U https://doi.org/10.2196/26575 %U http://www.ncbi.nlm.nih.gov/pubmed/34132648 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 6 %P e27489 %T Feasibility and Efficacy of Delivering Cognitive Behavioral Therapy Through an Online Psychotherapy Tool for Depression: Protocol for a Randomized Controlled Trial %A Alavi,Nazanin %A Stephenson,Callum %A Yang,Megan %A Kumar,Anchan %A Shao,Yijia %A Miller,Shadé %A Yee,Caitlin S %A Stefatos,Anthi %A Gholamzadehmir,Maedeh %A Abbaspour,Zara %A Jagayat,Jasleen %A Shirazi,Amirhossein %A Omrani,Mohsen %A Patel,Archana %A Patel,Charmy %A Groll,Dianne %+ Department of Psychiatry, Queen's University, Hotel Dieu Hospital, 166 Brock Street, Kingston, ON, K7L 5G2, Canada, 1 6135443310, nalavi@gmail.com %K mental health %K depression %K psychotherapy %K cognitive behavioral therapy %K online %K internet %K electronic %K virtual %K mental health care %D 2021 %7 16.6.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Major depressive disorder (MDD) is a prevalent and debilitating mental health disorder. Among different therapeutic approaches (eg, medication and psychotherapy), psychotherapy in the form of cognitive behavioral therapy (CBT) is considered the gold standard treatment for MDD. However, although efficacious, CBT is not readily accessible to many patients in need because of hurdles such as stigma, long wait times, high cost, the large time commitment for health care providers, and cultural or geographic barriers. Electronically delivered cognitive behavioral therapy (e-CBT) can effectively address many of these accessibility barriers. Objective: This study aims to investigate the efficacy and feasibility of implementing an e-CBT program compared with in-person treatment for MDD. It is hypothesized that the e-CBT program will offer results comparable with those of the in-person treatment program, regarding symptom reduction and quality of life improvement. Methods: This nonrandomized controlled trial intervention will provide e-CBT for MDD through the Online Psychotherapy Tool, a secure, cloud-based, digital mental health platform. Participants (aged 18-65 years) will be offered 12 weekly sessions of an e-CBT program tailored to MDD to address their depressive symptoms. Participants (n=55) will complete predesigned modules and homework assignments while receiving personalized feedback and interacting with a therapist through the platform. Using clinically validated symptomology questionnaires, the efficacy of the e-CBT program will be compared with that of a group (n=55) receiving in-person CBT. Questionnaires will be completed at baseline, at week 6 and week 12, and at a 6-month follow-up. Focus groups will be conducted to investigate personal, cultural, and social factors impacting the accessibility and feasibility of implementing a web-based psychotherapy tool from a patient and care provider perspective. Inclusion criteria include diagnosis of MDD, competence to consent to participate, ability to speak and read English, and consistent and reliable access to the internet. Exclusion criteria include active psychosis, acute mania, severe alcohol or substance use disorder, and active suicidal or homicidal ideation. Results: Ethics approval was obtained in January 2019, and recruitment of participants began in June 2019. Recruitment has been conducted via social media, web-based communities, and physician referrals. To date, 52 participants have been recruited to the e-CBT group, and 48 patients have been recruited to the in-person CBT group. Data collection is expected to be completed by March 2021, and analyses are expected to be completed by June 2021, as linear regression (for continuous outcomes) and binomial regression analysis (for categorical outcomes) are still being conducted. Conclusions: The results of this study can provide valuable information for the development of more accessible and scalable mental health interventions with increased care capacity for MDD, without sacrificing the quality of care. Trial Registration: ClinicalTrials.gov NCT04478058; http://clinicaltrials.gov/ct2/show/NCT04478058 International Registered Report Identifier (IRRID): DERR1-10.2196/27489 %M 33990076 %R 10.2196/27489 %U https://www.researchprotocols.org/2021/6/e27489 %U https://doi.org/10.2196/27489 %U http://www.ncbi.nlm.nih.gov/pubmed/33990076 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e29036 %T Professional Social Media Usage and Work Engagement Among Professionals in Finland Before and During the COVID-19 Pandemic: Four-Wave Follow-Up Study %A Oksa,Reetta %A Kaakinen,Markus %A Savela,Nina %A Hakanen,Jari J %A Oksanen,Atte %+ Faculty of Social Sciences, Tampere University, Kalevantie 5, Tampere, 33100, Finland, 358 504377619, reetta.oksa@tuni.fi %K COVID-19 %K engagement %K mental health %K moderator %K predictor %K psychological distress %K social media %K social support %K support %K task resources %K usage %K work engagement %D 2021 %7 15.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has changed work life profoundly and concerns regarding the mental well-being of employees’ have arisen. Organizations have made rapid digital advancements and have started to use new collaborative tools such as social media platforms overnight. Objective: Our study aimed to investigate how professional social media communication has affected work engagement before and during the COVID-19 pandemic and the role of perceived social support, task resources, and psychological distress as predictors and moderators of work engagement. Methods: Nationally representative longitudinal survey data were collected in 2019-2020, and 965 respondents participated in all 4 surveys. Measures included work engagement, perceived social support and task resources, and psychological distress. The data were analyzed using a hybrid linear regression model.  Results: Work engagement remained stable and only decreased in autumn 2020. Within-person changes in social media communication at work, social support, task resources, and psychological distress were all associated with work engagement. The negative association between psychological distress and work engagement was stronger in autumn 2020 than before the COVID-19 outbreak. Conclusions: The COVID-19 pandemic has exerted pressure on mental health at work. Fostering social support and task resources at work is important in maintaining work engagement. Social media communication could help maintain a supportive work environment. %M 34048356 %R 10.2196/29036 %U https://www.jmir.org/2021/6/e29036 %U https://doi.org/10.2196/29036 %U http://www.ncbi.nlm.nih.gov/pubmed/34048356 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e20988 %T Digital Information Technology Use, Self-Rated Health, and Depression: Population-Based Analysis of a Survey Study on Older Migrants %A Kouvonen,Anne %A Kemppainen,Laura %A Ketonen,Eeva-Leena %A Kemppainen,Teemu %A Olakivi,Antero %A Wrede,Sirpa %+ Faculty of Social Sciences, University of Helsinki, PO Box 54, Helsinki, 00014, Finland, 358 504487113, anne.kouvonen@helsinki.fi %K digital information technology %K older adults %K migrants %K health %K depression %K mobile phone %D 2021 %7 14.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Previous studies have found that in general, poor health is associated with a lower likelihood of internet use in older adults, but it is not well known how different indicators of health are associated with different types of digital information technology (DIT) use. Moreover, little is known about the relationship between health and the types of DIT use in older ethnic minority and migrant populations. Objective: The aim of this study is to examine the associations among depressive symptoms and self-rated health (SRH) with different dimensions of DIT use in older migrants. Methods: We analyzed data from the Care, Health and Ageing of Russian-speaking Minority (CHARM) study, which is based on a nationally representative sample of community-dwelling, Russian-speaking adults aged 50 years or older residing permanently in Finland (men: 616/1082, 56.93%; age: mean 63.2 years, SD 8.4 years; response rate: 1082/3000, 36.07%). Data were collected in 2019 using a postal survey. Health was measured using depressive symptoms (measured using the Center for Epidemiologic Studies Depression Scale) and SRH. Binary logistic regression analyses were used to investigate the associations between the two health indicators and the following six outcomes: daily internet use, smartphone ownership, the use of the internet for messages and calls, social media use, the use of the internet for personal health data, and obtaining health information from the internet. A number of sociodemographic and socioeconomic factors were controlled for in the logistic regression regression analysis. Analyses were performed with weights accounting for the survey design and nonresponse. Results: After adjusting for sociodemographic and socioeconomic factors, depressive symptoms (odds ratio [OR] 2.68, 95% CI 1.37-5.24; P=.004) and poor SRH (OR 7.90, 95% CI 1.88-33.11; P=.005) were associated with a higher likelihood of not using the internet daily. Depressive symptoms (OR 1.88, 95% CI 1.06-3.35; P=.03) and poor SRH (OR 5.05, 95% CI 1.58-16.19; P=.006) also increased the likelihood of smartphone nonuse. Depressive symptoms were additionally associated with a lower likelihood of social media use, and poor SRH was associated with a lower likelihood of using the internet for messaging and calling. Conclusions: Poor SRH and depressive symptoms are associated with a lower likelihood of DIT use in older adults. Longitudinal studies are required to determine the directions of these relationships. %M 34125069 %R 10.2196/20988 %U https://www.jmir.org/2021/6/e20988 %U https://doi.org/10.2196/20988 %U http://www.ncbi.nlm.nih.gov/pubmed/34125069 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 6 %P e27526 %T Adaptation of a Live Video Mind–Body Program to a Web-Based Platform for English-Speaking Adults With Neurofibromatosis: Protocol for the NF-Web Study %A Lester,Ethan Gabriel %A Hopkins,Sarah Whitall %A Popok,Paula Jean %A Vranceanu,Ana-Maria %+ Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square,, 1st Floor, Suite 100, Boston, MA, 02114, United States, 1 617 724 4977, avranceanu@mgh.harvard.edu %K neurofibromatosis %K quality of life %K stress management %K mind–body %K asynchronous delivery %K resiliency %K mobile phone %D 2021 %7 10.6.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Neurofibromatosis (NF) is a rare genetic condition associated with lower but modifiable quality of life (QoL). Although a virtual live video program (Relaxation Response Resiliency Program for Neurofibromatosis [3RP-NF]; efficacy randomized controlled trial underway) that we created has been made available, ongoing barriers impede some patients from engaging in this intervention. A necessary next step is to develop a stand-alone web-based intervention that reduces barriers to accessing NF-specific psychosocial care. Objective: First, we aim to develop a web-based platform (Neurofibromatosis-Web [NF-Web]) of our mind–body resiliency program (3RP-NF) through qualitative interviews with participants from an adult efficacy randomized controlled trial. Second, we aim to iteratively optimize the feasibility, acceptability, credibility, and satisfaction of the NF-Web platform through open pilot trials with participant exit interviews and explore quantitative outcomes within this sample. Here, we describe the protocol and study design, intervention, and analysis plan. Methods: For aim 1, we will invite completers from our efficacy trial to participate in qualitative interviews. We will use data from these interviews to adapt the content of the live video program for asynchronous delivery and understand how to create a user-friendly format for an engaging web platform. For aim 2, we will enroll eligible participants recruited for the efficacy trial who could not enroll because of treatment barriers. Eligible participants will complete QoL, depression, anxiety, pain, treatment satisfaction, and program credibility measures at baseline and posttest. Inclusion criteria are identical to those for the efficacy trial, including stress and coping difficulties (self-report), no change in antidepressant medication in the past 3 months, no psychotherapy in the past 3 months, no major upcoming surgeries in the next 12 months, English speaking, ability to complete questionnaires on the web and participate in live video interventions, and consent before participation. The primary outcomes are feasibility, treatment satisfaction, and credibility. The secondary outcomes include physical, psychological, social, and environmental QoL; depression; anxiety; pain intensity; and pain interference. We will enroll at least two group cohorts and iteratively refine the program based on participant feedback after each cohort completes the open pilot trial. Results: This trial is ongoing. We have completed the interviews (n=23) and analyzed the data to construct the website. Afterward, we will recruit our cohorts for the trial (approximately n=15/cohort; total=30). Recruitment will end by May 2021, with plans to analyze the data by October 2021. Conclusions: We will develop the first web platform for people with NF with difficulties managing stress and NF symptoms and report on feasibility and preliminary effects in improving QoL and psychosocial functioning. NF-Web has potential to extend the reach of our 3RP-NF intervention by removing barriers to care, including lack of trained providers, scheduling difficulties, and appearance concerns. International Registered Report Identifier (IRRID): DERR1-10.2196/27526 %M 34110294 %R 10.2196/27526 %U https://www.researchprotocols.org/2021/6/e27526 %U https://doi.org/10.2196/27526 %U http://www.ncbi.nlm.nih.gov/pubmed/34110294 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 6 %P e24312 %T A Wake-up Call for Burnout in Portuguese Physicians During the COVID-19 Outbreak: National Survey Study %A Ferreira,Sónia %A Sousa,Mafalda Machado %A Moreira,Pedro Silva %A Sousa,Nuno %A Picó-Pérez,Maria %A Morgado,Pedro %+ Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Universidade do Minho, Campus de Gualtar, Braga, 4710-057, Portugal, 351 253 604928, pedromorgado@med.uminho.pt %K COVID-19 %K anxiety %K coronavirus %K depression %K frontline %K health care professionals %K health care staff %K obsessive compulsive disorder %K SARS-CoV-2 %K stress %D 2021 %7 9.6.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The COVID-19 outbreak has imposed physical and psychological pressure on health care professionals, including frontline physicians. Hence, evaluating the mental health status of physicians during the current pandemic is important to define future preventive guidelines among health care stakeholders. Objective: In this study, we intended to study alterations in the mental health status of Portuguese physicians working at the frontline during the COVID-19 pandemic and potential sociodemographic factors influencing their mental health status. Methods: A nationwide survey was conducted during May 4-25, 2020, to infer differences in mental health status (depression, anxiety, stress, and obsessive compulsive symptoms) between Portuguese physicians working at the frontline during the COVID-19 pandemic and other nonfrontline physicians. A representative sample of 420 participants stratified by age, sex, and the geographic region was analyzed (200 frontline and 220 nonfrontline participants). Moreover, we explored the influence of several sociodemographic factors on mental health variables including age, sex, living conditions, and household composition. Results: Our results show that being female (β=1.1; t=2.5; P=.01) and working at the frontline (β=1.4; t=2.9; P=.004) are potential risk factors for stress. In contrast, having a house with green space was a potentially beneficial factor for stress (β=–1.5; t=–2.5; P=.01) and anxiety (β=–1.1; t=–2.4; P=.02). Conclusions: It is important to apply protective mental health measures for physicians to avoid the long-term effects of stress, such as burnout. %M 33630744 %R 10.2196/24312 %U https://publichealth.jmir.org/2021/6/e24312 %U https://doi.org/10.2196/24312 %U http://www.ncbi.nlm.nih.gov/pubmed/33630744 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e25259 %T Coping Styles for Mediating the Effect of Resilience on Depression Among Medical Students in Web-Based Classes During the COVID-19 Pandemic: Cross-sectional Questionnaire Study %A Zhao,Lina %A Sznajder,Kristin %A Cheng,Dan %A Wang,Shimeng %A Cui,Can %A Yang,Xiaoshi %+ Department of Social Medicine, College of Health Management, China Medical University, No 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, 110122, China, 86 18900910796, xsyang@cmu.edu.cn %K resilience %K coping styles %K depression %K medical students %K COVID-19 %K coping %K mediation %K web-based education %K e-learning %K smartphone %K cross-sectional %D 2021 %7 7.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Due to strict, nationwide, comprehensive COVID-19 protective measures, including home quarantine, all Chinese medical students began taking web-based classes beginning in the spring semester of 2020. Home quarantine, web-based classes, and the stress surrounding the COVID-19 pandemic may have triggered an increased incidence of mental health problems among medical students. Although there have been increasing amounts of literature on depression among medical students, studies focusing on positive psychological resources, such as resilience during the COVID-19 pandemic, still need to be expanded. Objective: This study aims to assess depression among medical students who are taking web-based classes during the COVID-19 pandemic and to investigate the role of coping styles as mediators between resilience and depression. Methods: A cross-sectional study of 666 medical students involving stratified sampling in Shenyang, Liaoning Province, China, was completed between March 20 and April 10, 2020. The participants responded to a self-administered, smartphone-based questionnaire, which included the Patient Health Questionnaire-9, Simplified Coping Style Questionnaire, and Ego Resilience 89 Scale. Hierarchical linear regression and structural equation modeling were used in this study. Results: The prevalence of depression among the participants was 9.6% (64/666) in this study. The regression analysis revealed that grade (the year in which the medical student was in training) (P=.013), how well students adapted to web-based classes (P<.001), their levels of resilience (P=.04), and their coping styles were independent predictors for depression (P<.001). Resilience and positive coping styles were negatively related to depression (resilience: P=.04; positive coping styles: P<.001), and negative coping styles were positively related to depression (P<.001). The structural equation modeling analysis showed that the effect of resilience on depression was partially mediated by coping styles (P=.007). Conclusions: In this study, it was found that the prevalence of depression was slightly low and coping styles mediated the association between resilience and depression among medical students during the COVID-19 pandemic. These findings have significant implications for future studies. Future studies and interventions should aim to improve resilience and promote positive coping styles. %M 34033579 %R 10.2196/25259 %U https://www.jmir.org/2021/6/e25259 %U https://doi.org/10.2196/25259 %U http://www.ncbi.nlm.nih.gov/pubmed/34033579 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 6 %P e23986 %T Factors Predicting Trial Engagement, Treatment Satisfaction, and Health-Related Quality of Life During a Web-Based Treatment and Social Networking Trial for Binge Drinking and Depression in Young Adults: Secondary Analysis of a Randomized Controlled Trial %A Sanatkar,Samineh %A Heinsch,Milena %A Baldwin,Peter Andrew %A Rubin,Mark %A Geddes,Jenny %A Hunt,Sally %A Baker,Amanda L %A Woodcock,Kathryn %A Lewin,Terry J %A Brady,Kathleen %A Deady,Mark %A Thornton,Louise %A Teesson,Maree %A Kay-Lambkin,Frances %+ Centre for Brain and Mental Health Research, School of Medicine and Public Health, The University of Newcastle, University Drive, Callaghan, 2308, Australia, 61 02 9065 9179, samineh.sanatkar@uon.edu.au %K digital mental health %K personality %K negative affect %K study engagement %K life quality %D 2021 %7 7.6.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental health and alcohol use problems are among the most common causes of disease burden in young Australians, frequently co-occur (comorbidity), and lead to significant lifetime burden. However, comorbidities remain significantly underdetected and undertreated in health settings. Digital mental health tools designed to identify at-risk individuals, encourage help-seeking, or deliver treatment for comorbidity have the potential to address this service gap. However, despite a strong body of evidence that digital mental health programs provide an effective treatment option for a range of mental health and alcohol use problems in young adults, research shows that uptake rates can be low. Thus, it is important to understand the factors that influence treatment satisfaction and quality-of-life outcomes for young adults who access e–mental health interventions for comorbidity. Objective: In this study, we seek to understand the factors that influence treatment satisfaction and quality-of-life outcomes for young adults who access e–mental health interventions for comorbid alcohol and mood disorders. The aim is to determine the importance of personality (ie, Big Five personality traits and intervention attitudes), affective factors (ie, depression, anxiety, and stress levels), and baseline alcohol consumption in predicting intervention trial engagement at sign-up, satisfaction with the online tool, and quality of life at the end of the iTreAD (Internet Treatment for Alcohol and Depression) trial. Methods: Australian adults (N=411) aged between 18 and 30 years who screened positive for depression and alcohol use problems signed up for the iTreAD project between August 2014 and October 2015. During registration, participants provided information about their personality, current affective state, alcohol use, treatment expectations, and basic demographic information. Subsequent follow-up surveys were used to gauge the ongoing trial engagement. The last follow-up questionnaire, completed at 64 weeks, assessed participants’ satisfaction with web-based treatment and quality-of-life outcomes. Results: Multiple linear regression analyses were used to assess the relative influence of predictor variables on trial engagement, treatment satisfaction, and quality-of-life outcomes. The analyses revealed that the overall predictive effects of personality and affective factors were 20% or lower. Neuroticism constituted a unique predictor of engagement with the iTreAD study in that neuroticism facilitated the return of web-based self-assessments during the study. The return of incentivized follow-up assessments predicted treatment satisfaction, and state-based depression predicted variance in quality-of-life reports at study completion. Conclusions: Our findings suggest that traditional predictors of engagement observed in face-to-face research may not be easily transferable to digital health interventions, particularly those aimed at comorbid mental health concerns and alcohol misuse among young adults. More research is needed to identify what determines engagement in this population to optimally design and execute digital intervention studies with multiple treatment aims. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN): 12614000310662; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365137&isReview=true. International Registered Report Identifier (IRRID): RR2-10.1186/s12889-015-2365-2 %M 34096873 %R 10.2196/23986 %U https://mental.jmir.org/2021/6/e23986 %U https://doi.org/10.2196/23986 %U http://www.ncbi.nlm.nih.gov/pubmed/34096873 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e28055 %T Multimodule Web-Based COVID-19 Anxiety and Stress Resilience Training (COAST): Single-Cohort Feasibility Study With First Responders %A Heyen,Janna Marie %A Weigl,Noé %A Müller,Mario %A Müller,Stefan %A Eberle,Urs %A Manoliu,Andrei %A Vetter,Stefan %A Brown,Adam D %A Berger,Thomas %A Kleim,Birgit %+ Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Lenggstrasse 31, PO Box 1931, Zürich, CH-8032, Switzerland, 41 (0)44 384 21 11, birgit.kleim@pukzh.ch %K anxiety %K COVID-19 %K electronic mental health %K feasibility %K first responder %K mental health %K mindfulness %K resilience %K self-efficacy %K sleep quality %K stress %K training %D 2021 %7 7.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Since the emergence of COVID-19, health care workers and first responders have been at a high risk for mental health symptoms owing to their exposure to the virus and increased work stress during the pandemic. Although interventions exist to address mental health issues following exposure to disasters, emergencies, and humanitarian crises, considerably less is known about web-based unguided interventions to help mitigate the negative impacts of such events. Additionally, in contexts in which emergencies reduce access to in-person care, remote forms of support are critical, yet there are limited studies on the use of such interventions. Evidence-based, easy-to-use, scalable interventions are direly needed for this population. Objective: This study aimed to develop and test the feasibility of an unguided electronic mental health program, COVID-19 Anxiety and Stress Resilience Training (COAST), tailored to first responders and health care personnel, based on scientific evidence and empirically based techniques. Methods: We developed COVID-19–specific training modules focusing on several domains that are previously reported as key to resilience and stress recovery: self-efficacy, mindfulness, sleep quality, and positive thinking. The program was made available to 702 first responders between May and August 2020, during the COVID-19 pandemic. Sociodemographic, work-, and COVID-19–related information was collected, and psychometric questionnaires were completed. We examined user acceptance and user activity, including module choice and participant feedback. Results: In total, 52 of 702 (7%) first responders to whom we reached out used the program at least once. COAST use was independent of age, sex, or baseline levels of self-efficacy, mindful awareness, sleep quality, and positive thinking (for all, P>.39). First responders who had tested positive and those who had been quarantined were more likely to engage in the program. A click count analysis per module showed that participants used the self-efficacy and mindfulness modules most often, with 382 and 122 clicks, respectively, over 15 weeks. Overall, first responders expressed satisfaction with the program. Conclusions: Engagement of first responders in the multimodule web-based COAST program was feasible and the first responder cohort expressed overall satisfaction with the program. Those in more difficult circumstances, including those in quarantine and those who tested positive, may be more likely to engage in such programs. Further controlled studies could pave the way for efficacy studies and the development of additional modules, including just-in-time interventions or blended interventions combining individual use of an unguided self-help intervention, such as COAST, with subsequent individual psychotherapy for those who continue to experience stress and psychological symptoms. %M 33999835 %R 10.2196/28055 %U https://formative.jmir.org/2021/6/e28055 %U https://doi.org/10.2196/28055 %U http://www.ncbi.nlm.nih.gov/pubmed/33999835 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e28892 %T Mental Health and Behavior of College Students During the COVID-19 Pandemic: Longitudinal Mobile Smartphone and Ecological Momentary Assessment Study, Part II %A Mack,Dante L %A DaSilva,Alex W %A Rogers,Courtney %A Hedlund,Elin %A Murphy,Eilis I %A Vojdanovski,Vlado %A Plomp,Jane %A Wang,Weichen %A Nepal,Subigya K %A Holtzheimer,Paul E %A Wagner,Dylan D %A Jacobson,Nicholas C %A Meyer,Meghan L %A Campbell,Andrew T %A Huckins,Jeremy F %+ Department of Psychological and Brain Sciences, Dartmouth College, Moore Hall, 3 Maynard St, Hanover, NH, 03755, United States, 1 603 646 3181, f002vhk@dartmouth.edu %K anxiety %K college %K COVID-19 %K COVID fatigue %K depression %K George Floyd %K mobile sensing %K phone usage %K sleep %K digital phenotyping %D 2021 %7 4.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Since late 2019, the lives of people across the globe have been disrupted by COVID-19. Millions of people have become infected with the disease, while billions of people have been continually asked or required by local and national governments to change their behavioral patterns. Previous research on the COVID-19 pandemic suggests that it is associated with large-scale behavioral and mental health changes; however, few studies have been able to track these changes with frequent, near real-time sampling or compare these changes to previous years of data for the same individuals. Objective: By combining mobile phone sensing and self-reported mental health data in a cohort of college-aged students enrolled in a longitudinal study, we seek to understand the behavioral and mental health impacts associated with the COVID-19 pandemic, measured by interest across the United States in the search terms coronavirus and COVID fatigue. Methods: Behaviors such as the number of locations visited, distance traveled, duration of phone use, number of phone unlocks, sleep duration, and sedentary time were measured using the StudentLife mobile smartphone sensing app. Depression and anxiety were assessed using weekly self-reported ecological momentary assessments, including the Patient Health Questionnaire-4. The participants were 217 undergraduate students. Differences in behaviors and self-reported mental health collected during the Spring 2020 term, as compared to previous terms in the same cohort, were modeled using mixed linear models. Results: Linear mixed models demonstrated differences in phone use, sleep, sedentary time and number of locations visited associated with the COVID-19 pandemic. In further models, these behaviors were strongly associated with increased interest in COVID fatigue. When mental health metrics (eg, depression and anxiety) were added to the previous measures (week of term, number of locations visited, phone use, sedentary time), both anxiety and depression (P<.001) were significantly associated with interest in COVID fatigue. Notably, these behavioral and mental health changes are consistent with those observed around the initial implementation of COVID-19 lockdowns in the spring of 2020. Conclusions: In the initial lockdown phase of the COVID-19 pandemic, people spent more time on their phones, were more sedentary, visited fewer locations, and exhibited increased symptoms of anxiety and depression. As the pandemic persisted through the spring, people continued to exhibit very similar changes in both mental health and behaviors. Although these large-scale shifts in mental health and behaviors are unsurprising, understanding them is critical in disrupting the negative consequences to mental health during the ongoing pandemic. %M 33900935 %R 10.2196/28892 %U https://www.jmir.org/2021/6/e28892 %U https://doi.org/10.2196/28892 %U http://www.ncbi.nlm.nih.gov/pubmed/33900935 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e27132 %T Proof-of-Concept Support for the Development and Implementation of a Digital Assessment for Perinatal Mental Health: Mixed Methods Study %A Martin-Key,Nayra Anna %A Spadaro,Benedetta %A Schei,Thea Sofie %A Bahn,Sabine %+ Cambridge Centre for Neuropsychiatric Research, Department of Chemical Engineering and Biotechnology, University of Cambridge, Philippa Fawcett Drive, Cambridge, CB3 0AS, United Kingdom, 44 1223 334151, sb209@cam.ac.uk %K COM-B %K COVID-19 %K digital mental health %K maternal mental health %K paternal mental health %K perinatal mental health %K mental health %K support %K development %K implementation %K assessment %K mother %K women %D 2021 %7 4.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Perinatal mental health symptoms commonly remain underdiagnosed and undertreated in maternity care settings in the United Kingdom, with outbreaks of disease, like the COVID-19 pandemic, further disrupting access to adequate mental health support. Digital technologies may offer an innovative way to support the mental health needs of women and their families throughout the perinatal period, as well as assist midwives in the recognition of perinatal mental health concerns. However, little is known about the acceptability and perceived benefits and barriers to using such technologies. Objective: The aim of this study was to conduct a mixed methods evaluation of the current state of perinatal mental health care provision in the United Kingdom, as well as users’ (women and partners) and midwives’ interest in using a digital mental health assessment throughout the perinatal period. Methods: Women, partners, and midwives were recruited to participate in the study, which entailed completing an online survey. Quantitative data were explored using descriptive statistics. Open-ended response data were first investigated using thematic analysis. Resultant themes were then mapped onto the components of the Capability, Opportunity, and Motivation Behavior model and summarized using descriptive statistics. Results: A total of 829 women, 103 partners, and 90 midwives participated in the study. The provision of adequate perinatal mental health care support was limited, with experiences varying significantly across respondents. There was a strong interest in using a digital mental health assessment to screen, diagnose, and triage perinatal mental health concerns, particularly among women and midwives. The majority of respondents (n=781, 76.42%) expressed that they would feel comfortable or very comfortable using or recommending a digital mental health assessment. The majority of women and partners showed a preference for in-person consultations (n=417, 44.74%), followed by a blended care approach (ie, both in-person and online consultations) (n=362, 38.84%), with fewer participants preferring online-only consultations (n=120, 12.88%). Identified benefits and barriers mainly related to physical opportunity (eg, accessibility), psychological capability (eg, cognitive skills), and automatic motivation (eg, emotions). Conclusions: This study provides proof-of-concept support for the development and implementation of a digital mental health assessment to inform clinical decision making in the assessment of perinatal mental health concerns in the United Kingdom. %M 34033582 %R 10.2196/27132 %U https://www.jmir.org/2021/6/e27132 %U https://doi.org/10.2196/27132 %U http://www.ncbi.nlm.nih.gov/pubmed/34033582 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e29365 %T Meaning in Life Among Patients With Chronic Pain and Suicidal Ideation: Mixed Methods Study %A Costanza,Alessandra %A Chytas,Vasileios %A Piguet,Valérie %A Luthy,Christophe %A Mazzola,Viridiana %A Bondolfi,Guido %A Cedraschi,Christine %+ Department of Psychiatry, Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, Geneva, 1211, Switzerland, 41 223795900, alessandra.costanza@unige.ch %K suicide %K suicidal behavior %K suicidal ideation %K suicide attempt %K chronic pain %K meaning in life %K protective factors %K risk factors %K mental health %D 2021 %7 4.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Patients with chronic pain have elevated risk of suicidal ideation and behavior, including suicide attempts and completed suicides. In most studies, associations between chronic pain and suicidal ideation/suicidal behavior are robust even after adjusting for the effect of sociodemographics and psychiatric comorbidity. However, to refine the risk profile of these patients, further exploration of other possible risk and protective factors is necessary. Objective: There is a common clinical observation that experiencing chronic pain often requires a revision of life goals and expectations, and hence, it impacts the existential domain including one’s perception of the meaning in life (MiL). This study aimed to characterize the main domains that constitute the personal MiL, including the “presence of” and “search for” constructs, in a group of patients with chronic pain and suicidal ideation. Methods: Seventy participants were enlisted by ongoing recruitment through a larger project anchored in daily clinical practice at the Multidisciplinary Pain Center of the Geneva University Hospitals. It was an observational mixed method study. Data were recorded through both validated quantitative questionnaires and qualitative open-ended questions. Results: The total sample consisted of 70 patients. Responses to questionnaires showed a depressive episode in 68 (97%) patients and anxious disorders in 25 (36%) patients. With a score threshold for positive MiL of 24, the mean score for the “presence of” construct was 20.13 (SD 8.23), and 63% (44/70) of respondents had a score <24. The mean score for the “search for” construct was lower at 18.14 (SD 8.64), and 70% (49/70) of respondents had a score <24. The “presence of” and “search for” constructs were significantly positively correlated (R=0.402; P=.001). An open question addressed the “presence of” construct by inviting the respondents to cite domains they consider as providing meaning in their life at the present time. All patients responded to this question, citing one or more domains. The three main dimensions that emerged from content analysis of this qualitative section were as follows: the domain of relationships, the domain of personal activities, and pain and its consequences on MiL. Conclusions: The study results provide insights into patients with chronic pain and suicidal ideation, including the domains that provide them with meaning in their lives and the impact of pain on these domains with regard to suicidal ideation. The main clinical implications concern both prevention and supportive/psychotherapeutic interventions. They are based on a narrative approach aiming to explore with the patients the content of their suffering and the MiL domains that they could identify to mitigate it, in order to restructure/reinforce these domains and thus possibly reduce suicidal ideation. Specifically, a focus on maintaining the domains of interpersonal relationships and personal activities can allow patients to ultimately escape the biopsychosocial vicious cycle of chronic pain–induced deep moral suffering. %M 34003136 %R 10.2196/29365 %U https://formative.jmir.org/2021/6/e29365 %U https://doi.org/10.2196/29365 %U http://www.ncbi.nlm.nih.gov/pubmed/34003136 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e25199 %T Validation of Visual and Auditory Digital Markers of Suicidality in Acutely Suicidal Psychiatric Inpatients: Proof-of-Concept Study %A Galatzer-Levy,Isaac %A Abbas,Anzar %A Ries,Anja %A Homan,Stephanie %A Sels,Laura %A Koesmahargyo,Vidya %A Yadav,Vijay %A Colla,Michael %A Scheerer,Hanne %A Vetter,Stefan %A Seifritz,Erich %A Scholz,Urte %A Kleim,Birgit %+ Research and Development, AiCure, 19 W 24th St, 11th Floor, New York, NY, 10010, United States, 1 6463015037, vidya.koesmahargyo@aicure.com %K digital phenotyping %K digital biomarkers %K digital health %K depression %K suicidal ideation %K digital markers %K digital %K facial %K suicide %K suicide risk %K visual %K auditory %D 2021 %7 3.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Multiple symptoms of suicide risk have been assessed based on visual and auditory information, including flattened affect, reduced movement, and slowed speech. Objective quantification of such symptomatology from novel data sources can increase the sensitivity, scalability, and timeliness of suicide risk assessment. Objective: We aimed to examine measurements extracted from video interviews using open-source deep learning algorithms to quantify facial, vocal, and movement behaviors in relation to suicide risk severity in recently admitted patients following a suicide attempt. Methods: We utilized video to quantify facial, vocal, and movement markers associated with mood, emotion, and motor functioning from a structured clinical conversation in 20 patients admitted to a psychiatric hospital following a suicide risk attempt. Measures were calculated using open-source deep learning algorithms for processing facial expressivity, head movement, and vocal characteristics. Derived digital measures of flattened affect, reduced movement, and slowed speech were compared to suicide risk with the Beck Scale for Suicide Ideation controlling for age and sex, using multiple linear regression. Results: Suicide severity was associated with multiple visual and auditory markers, including speech prevalence (β=−0.68, P=.02, r2=0.40), overall expressivity (β=−0.46, P=.10, r2=0.27), and head movement measured as head pitch variability (β=−1.24, P=.006, r2=0.48) and head yaw variability (β=−0.54, P=.06, r2=0.32). Conclusions: Digital measurements of facial affect, movement, and speech prevalence demonstrated strong effect sizes and linear associations with the severity of suicidal ideation. %M 34081022 %R 10.2196/25199 %U https://www.jmir.org/2021/6/e25199 %U https://doi.org/10.2196/25199 %U http://www.ncbi.nlm.nih.gov/pubmed/34081022 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 5 %P e26989 %T Use of a Self-guided Computerized Cognitive Behavioral Tool During COVID-19: Evaluation Study %A Detweiler Guarino,Isadora %A Cowan,Devin R %A Fellows,Abigail M %A Buckey,Jay C %+ Space Medicine Innovations Laboratory, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH, 03756, United States, 1 603 650 6012, Jay.C.Buckey.Jr@dartmouth.edu %K computerized cognitive behavioral therapy %K interactive media %K COVID-19 %K computer-based therapy %K usability %K acceptability %K cognitive behavioral therapy %K therapy %K effectiveness %K digital health %K depression %K stress %D 2021 %7 31.5.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Internet-based programs can help provide accessible and inexpensive behavioral health care to those in need; however, the evaluation of these interventions has been mostly limited to controlled trials. Data regarding patterns of use and effectiveness of self-referred, open-access online interventions are lacking. We evaluated an online-based treatment designed to address stress, depression, and conflict management, the Dartmouth PATH Program, in a freely available and self-guided format during the COVID-19 pandemic. Objective: The primary aim is to determine users’ levels of stress and depression, and the nature of problems and triggers they reported during the COVID-19 pandemic. A secondary objective is to assess the acceptability and usability of the PATH content and determine whether such a program would be useful as a stand-alone open-access resource. The final objective is understanding the high dropout rates associated with online behavioral programs by contrasting the use pattern and program efficacy of individuals who completed session one and did not return to the program with those who came back to complete more sessions. Methods: Cumulative anonymous data from 562 individuals were analyzed. Stress triggers, stress responses, and reported problems were analyzed using qualitative analysis techniques. Scores on usability and acceptability questionnaires were evaluated using the sign test and Wilcoxon signed rank test. Mixed-effects linear modeling was used to evaluate changes in stress and depression over time. Results: A total of 2484 users registered from April through October 2020, most of whom created an account without initiating a module. A total of 562 individuals started the program and were considered in the data analysis. The most common stress triggers individuals reported involved either conflicts with family or spouses and work or workload. The most common problems addressed in the mood module were worry, anxiousness, or stress and difficulty concentrating or procrastination. The attrition rate was high with 13% (21/156) completing the conflict module, 17% (50/289) completing session one of the mood module, and 14% (16/117) completing session one of the stress module. Usability and acceptability scores for the mood and stress modules were significantly better than average. In those who returned to complete sessions, symptoms of stress showed a significant improvement over time (P=.03), and there was a significant decrease in depressive symptoms over all time points (P=.01). Depression severity decreased on average by 20% (SD 35.2%; P=.60) between sessions one and two. Conclusions: Conflicts with others, worry, and difficulty concentrating were some of the most common problems people used the programs to address. Individuals who completed the modules indicated improvements in self-reported stress and depression symptoms. Users also found the modules to be effective and rated the program highly for usability and acceptability. Nevertheless, the attrition rate was very high, as has been found with other freely available online-based interventions. Trial Registration: ClinicalTrials.gov NCT02726061; https://clinicaltrials.gov/ct2/show/NCT02726061 %M 33973856 %R 10.2196/26989 %U https://formative.jmir.org/2021/5/e26989 %U https://doi.org/10.2196/26989 %U http://www.ncbi.nlm.nih.gov/pubmed/33973856 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 5 %P e20179 %T Displayed Depression Symptoms on Facebook at Two Time Points: Content Analysis %A Moreno,Megan A %A Gaus,Quintin %A Wilt,Megan %A Arseniev-Koehler,Alina %A Ton,Adrienne %A Adrian,Molly %A VanderStoep,Ann %+ Department of Pediatrics, University of Wisconsin-Madison, 2870 University Ave, Suite 200, Madison, WI, 53705, United States, 1 (608) 262 4440, mamoreno@pediatrics.wisc.edu %K adolescents %K content analysis %K depression %K Facebook %K social media %D 2021 %7 31.5.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression is a prevalent and problematic mental disorder that often has an onset in adolescence. Previous studies have illustrated that depression disclosures on social media are common and may be linked to an individual’s experiences of depression. However, most studies have examined depression displays on social media at a single time point. Objective: This study aims to investigate displayed depression symptoms on Facebook at 2 developmental time points based on symptom type and gender. Methods: Participants were recruited from an ongoing longitudinal cohort study. The content analysis of text-based Facebook data over 1 year was conducted at 2 time points: time 1 (adolescence; age 17-18 years) and time 2 (young adulthood; ages 20-22 years). Diagnostic criteria for depression were applied to each post to identify the displayed depression symptoms. Data were extracted verbatim. The analysis included nonparametric tests for comparisons. Results: A total of 78 participants’ Facebook profiles were examined, of which 40 (51%) were male. At time 1, 62% (48/78) of the adolescents had a Facebook profile, and 54% (26/78) displayed depression symptom references with an average of 9.4 (SD 3.1) references and 3.3 (SD 2.3) symptom types. Of the 78 participants, 15 (19%) females and 12 (15%) males displayed depression symptom references; these prevalence estimates were not significantly different by gender (P=.59). At time 2, 35 young adults displayed symptoms of depression with an average of 4.6 (SD 2.3) references and 2.4 (SD 1.3) symptom types. There were no differences in the prevalence of symptoms of depression displayed between males (n=19) and females (n=16; P=.63). Conclusions: This content analysis study within an ongoing cohort study illustrates the differences in depression displays on Facebook by developmental stage and symptom. This study contributes to a growing body of literature by showing that using social media to observe and understand depression during the emerging adult developmental period may be a valuable approach. %M 34057422 %R 10.2196/20179 %U https://formative.jmir.org/2021/5/e20179 %U https://doi.org/10.2196/20179 %U http://www.ncbi.nlm.nih.gov/pubmed/34057422 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 5 %P e27400 %T A Web-Based Group Cognitive Behavioral Therapy Intervention for Symptoms of Anxiety and Depression Among University Students: Open-Label, Pragmatic Trial %A Bantjes,Jason %A Kazdin,Alan E %A Cuijpers,Pim %A Breet,Elsie %A Dunn-Coetzee,Munita %A Davids,Charl %A Stein,Dan J %A Kessler,Ronald C %+ Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Private Bag X1, Matieland, Stellenbosch, 7602, South Africa, 27 832345554, jbantjes@sun.ac.za %K anxiety %K cognitive behavioral therapy %K depression %K e-intervention %K group therapy %K web-based %K university students %K South Africa %D 2021 %7 27.5.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Anxiety and depression are common among university students, and university counseling centers are under pressure to develop effective, novel, and sustainable interventions that engage and retain students. Group interventions delivered via the internet could be a novel and effective way to promote student mental health. Objective: We conducted a pragmatic open trial to investigate the uptake, retention, treatment response, and level of satisfaction with a remote group cognitive behavioral therapy intervention designed to reduce symptoms of anxiety and depression delivered on the web to university students during the COVID-19 pandemic. Methods: Preintervention and postintervention self-reported data on anxiety and depression were collected using the Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9. Satisfaction was assessed postintervention using the Client Satisfaction with Treatment Questionnaire. Results: A total of 175 students were enrolled, 158 (90.3%) of whom initiated treatment. Among those initiating treatment, 86.1% (135/158) identified as female, and the mean age was 22.4 (SD 4.9) years. The mean number of sessions attended was 6.4 (SD 2.8) out of 10. Among participants with clinically significant symptoms at baseline, mean symptom scores decreased significantly for anxiety (t56=11.6; P<.001), depression (t61=7.8; P<.001), and composite anxiety and depression (t60=10.7; P<.001), with large effect sizes (d=1-1.5). Remission rates among participants with clinically significant baseline symptoms were 67.7%-78.9% and were not associated with baseline symptom severity. High overall levels of satisfaction with treatment were reported. Conclusions: The results of this study serve as a proof of concept for the use of web-based group cognitive behavioral therapy to promote the mental health of university students. %M 34042598 %R 10.2196/27400 %U https://mental.jmir.org/2021/5/e27400 %U https://doi.org/10.2196/27400 %U http://www.ncbi.nlm.nih.gov/pubmed/34042598 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 5 %P e24623 %T The Differential Effects of Social Media on Depressive Symptoms and Suicidal Ideation Among the Younger and Older Adult Population in Hong Kong During the COVID-19 Pandemic: Population-Based Cross-sectional Survey Study %A Yang,Xue %A Yip,Benjamin H K %A Mak,Arthur D P %A Zhang,Dexing %A Lee,Eric K P %A Wong,Samuel Y S %+ Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, School of Public Health Building, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong, Hong Kong, 852 2252 8488, yeungshanwong@cuhk.edu.hk %K social media %K depression %K suicidal ideation %K social loneliness %K posttraumatic stress %K suicide %K mental health %K COVID-19 %K loneliness %K age %K mediation %D 2021 %7 25.5.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Social media has become a ubiquitous part of daily life during the COVID-19 pandemic isolation. However, the role of social media use in depression and suicidal ideation of the general public remains unclear. Related empirical studies were limited and reported inconsistent findings. Little is known about the potential underlying mechanisms that may illustrate the relationship between social media use and depression and suicidal ideation during the COVID-19 pandemic. Objective: This study tested the mediation effects of social loneliness and posttraumatic stress disorder (PTSD) symptoms on the relationship between social media use and depressive symptoms and suicidal ideation, as well as the moderation effect of age on the mediation models. Methods: We administered a population-based random telephone survey in May and June 2020, when infection control measures were being vigorously implemented in Hong Kong. A total of 1070 adults (658 social media users and 412 nonusers) completed the survey. Structural equation modeling (SEM) and multigroup SEM were conducted to test the mediation and moderation effects. Results: The weighted prevalence of probable depression was 11.6%; 1.6% had suicidal ideation in the past 2 weeks. Both moderated mediation models of depressive symptoms (χ262=335.3; P<.05; comparative fit index [CFI]=0.94; nonnormed fit index [NNFI]=0.92; root mean square error of approximation [RMSEA]=0.06) and suicidal ideation (χ234=50.8; P<.05; CFI=0.99; NNFI=0.99; RMSEA=0.02) showed acceptable model fit. There was a significantly negative direct effect of social media use on depressive symptoms among older people (β=–.07; P=.04) but not among younger people (β=.04; P=.55). The indirect effect via PTSD symptoms was significantly positive among both younger people (β=.09; P=.02) and older people (β=.10; P=.01). The indirect effect via social loneliness was significant among older people (β=–.01; P=.04) but not among younger people (β=.01; P=.31). The direct effect of social media use on suicidal ideation was not statistically significant in either age group (P>.05). The indirect effects via PTSD symptoms were statistically significant among younger people (β=.02; P=.04) and older people (β=.03; P=.01). Social loneliness was not a significant mediator between social media use and suicidal ideation among either age group (P>.05). Conclusions: Social media may be a “double-edged sword” for psychosocial well-being during the COVID-19 pandemic, and its roles vary across age groups. The mediators identified in this study can be addressed by psychological interventions to prevent severe mental health problems during and after the COVID-19 pandemic. %M 33835937 %R 10.2196/24623 %U https://publichealth.jmir.org/2021/5/e24623 %U https://doi.org/10.2196/24623 %U http://www.ncbi.nlm.nih.gov/pubmed/33835937 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e25465 %T Internet-Based Cognitive Behavioral Therapy for Patients Reporting Symptoms of Anxiety and Depression After Myocardial Infarction: U-CARE Heart Randomized Controlled Trial Twelve-Month Follow-up %A Humphries,Sophia Monica %A Wallert,John %A Norlund,Fredrika %A Wallin,Emma %A Burell,Gunilla %A von Essen,Louise %A Held,Claes %A Olsson,Erik Martin Gustaf %+ Clinical Psychology in Healthcare, Department of Women's and Children's Health, Uppsala University, Akademiska Hospital, Uppsala, 75185, Sweden, 46 760341186, sophia.humphries@kbh.uu.se %K myocardial infarction %K iCBT %K psychological treatment %K cardiovascular health %K cognitive behavior therapy %K internet %K cardiovascular %K infarction %K treatment %K anxiety %K depression %D 2021 %7 24.5.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The U-CARE Heart trial was one of the first randomized controlled trials to evaluate the effect of internet-based cognitive behavioral therapy on self-reported symptoms of anxiety or depression for patients with a recent myocardial infarction. While the effects of internet-based cognitive behavioral therapy on Hospital Anxiety and Depression Scale (HADS) scores at 14 weeks postbaseline were not significant, in this study, we investigated possible long-term effects of treatment. Objective: The aim of this study was to evaluate the long-term effectiveness of internet-based cognitive behavioral therapy on self-reported symptoms of anxiety and depression in patients 12 months after a myocardial infarction and to explore subsequent occurrences of cardiovascular disease events. Methods: Shortly after acute myocardial infarction, 239 patients (33% female, mean age 59.6 years) reporting mild-to-moderate symptoms of anxiety or depression were randomized to 14 weeks of therapist-guided internet-based cognitive behavioral therapy (n=117) or treatment as usual (n=122). Data from national registries were used to explore group differences in clinical outcomes such as cardiovascular disease and cardiovascular-related mortality for a follow-up period of up to 5 years: group differences in HADS total score 1 year post–myocardial infarction, the primary outcome, was analyzed using multiple linear regression. Secondary outcomes, such as HADS anxiety and depression subscales and the Cardiac Anxiety Questionnaire total score (CAQ), which measures heart-focused anxiety, were analyzed in the same way. Multiple imputation was used to account for missing data, and a pooled treatment effect was estimated. Adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) for data pertaining to registry outcomes. Results: Both groups reported lower HADS total scores 1 year after myocardial infarction than those at baseline. HADS total scores were not significantly different between the treatment and control groups 1 year after myocardial infarction (β=–1.14, 95% CI –2.73 to 0.45, P=.16). CAQ was the only measure improved significantly by internet-based cognitive behavioral therapy when compared with treatment as usual (β=–2.58, 95% CI –4.75 to –0.42, P=.02) before adjusting for multiple comparisons. The composite outcome of nonfatal cardiovascular events and cardiovascular-related mortality did not differ between groups but was numerically higher in the internet-based cognitive behavioral therapy group, who were at slightly greater risk (HR 1.8, 95% CI 0.96 to 3.4, P=.07). Adjusting for previous myocardial infarction and diabetes attenuated this estimate (HR 1.5, 95% CI 0.8 to 2.8, P=.25). Conclusions: Internet-based cognitive behavioral therapy was not superior in reducing self-reported symptoms of depression or anxiety compared to treatment as usual at the 1-year follow-up after myocardial infarction. A reduction in cardiac-related anxiety was observed but was not significant after adjusting for multiple comparisons. There was no difference in risk of cardiovascular events between the treatment groups. Low treatment adherence, which might have affected treatment engagement and outcomes, should be considered when interpreting these results. Trial Registration: ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-015-0689-y %M 34028358 %R 10.2196/25465 %U https://www.jmir.org/2021/5/e25465 %U https://doi.org/10.2196/25465 %U http://www.ncbi.nlm.nih.gov/pubmed/34028358 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 5 %P e27818 %T The Impact of the COVID-19 Pandemic on Physical and Mental Health in China and Spain: Cross-sectional Study %A Wang,Cuiyan %A López-Núñez,María Inmaculada %A Pan,Riyu %A Wan,Xiaoyang %A Tan,Yilin %A Xu,Linkang %A Choo,Faith %A Ho,Roger %A Ho,Cyrus %A Aparicio García,Marta E %+ Department of Psychological Medicine, Institute of Health Innovation and Technology, National University of Singapore, Level 9, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore, 65 97321097, pcmrhcm@nus.edu.sg %K anxiety %K China %K coronavirus %K COVID-19 %K depression %K developing countries %K knowledge %K masks %K pandemic %K physical %K precaution %K psychological impact %K Spain %K stress %D 2021 %7 21.5.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Differences in physical and mental health impact across continents during the COVID-19 pandemic are unknown. Objective: This study compared the levels of impact of COVID-19 on mental health among people from Spain and China and correlated mental health parameters with variables relating to symptoms similar to COVID-19, COVID-19 knowledge, and precautionary measures. Methods: We collected information on demographic data, physical symptoms, contact history with persons with a confirmed COVID-19 diagnosis, COVID-19 knowledge, and precautionary measures. Participants completed the Impact of Event Scale-Revised (IES-R) and the Depression, Anxiety and Stress Scale–21 Items (DASS-21). To analyze the differences in the mental health parameters, the mean scores between Chinese and Spanish respondents were compared using the independent samples t test. The differences in categorical variables between the two samples were analyzed by the chi-square test. Linear regression was used to calculate the univariate associations between the independent variables and mental health parameters for both groups separately, with adjustments made for age, gender, and education. Results: A total of 1528 participants (Spain: n=687; China: n=841) were recruited. The mean age of the Chinese respondents was 24.73 years (SD 7.60; range 18-65 years), and the mean age of the Spanish respondents was 43.06 years (SD 11.95; range 18-76 years). Spanish participants reported significantly more symptoms similar to COVID-19 infection (eg, fever, sore throat, and breathing difficulties), contact history with COVID-19, higher perceived risk of contracting COVID-19, frequent use of medical services, and less confidence in medical services compared with their Chinese counterparts (P<.001). Spanish participants reported significantly higher DASS-21 stress and depression scores, while Chinese participants reported significantly higher IES-R scores (P<.001). Chinese participants encountered more discrimination from other countries (P<.001). Significantly more Chinese participants reported using face masks than Spanish ones (P<.001). More exposure to health information was associated with adverse mental health in Spain (depression: P=.02; anxiety: P=.02; stress: P=.001). Conclusions: Our study found that Spanish respondents reported higher levels of stress and depression as well as more symptoms and use of medical services. In preparation for the next pandemic, Spain needs to establish a prompt policy to implement rapid response and enhance medical services to safeguard physical and mental health. %M 33900933 %R 10.2196/27818 %U https://formative.jmir.org/2021/5/e27818 %U https://doi.org/10.2196/27818 %U http://www.ncbi.nlm.nih.gov/pubmed/33900933 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 5 %P e26716 %T A Nurse Case Management HIV Prevention Intervention (Come As You Are) for Youth Experiencing Homelessness: Protocol for a Randomized Wait-list Controlled Trial %A Santa Maria,Diane %A Lightfoot,Marguerita %A Nyamathi,Adey %A Businelle,Michael %A Paul,Mary %A Quadri,Yasmeen %A Padhye,Nikhil %A Jones,Jennifer %A Calvo Armijo,Margarita %+ Cizik School of Nursing, University of Texas Health Science Center at Houston, 6901 Bertner Ave, Houston, TX, 77030, United States, 1 713 500 2190, diane.m.santamaria@uth.tmc.edu %K HIV prevention %K nurse case management %K motivational interviewing %K homelessness %K youth %K just-in-time-adaptive intervention %K ecological momentary assessment %D 2021 %7 21.5.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Youth experiencing homelessness are more likely than housed youth to experience premature death, suicide, drug overdose, pregnancy, substance use, and mental illness. Yet while youth experiencing homelessness are 6 to 12 times more likely to become infected with HIV than housed youth, with HIV prevalence as high as 16%, many do not access the prevention services they need. Despite adversities, youth experiencing homelessness are interested in health promotion programs, can be recruited and retained in interventions and research studies, and demonstrate improved outcomes when programs are tailored and relevant to them. Objective: The study aims to compare the efficacy of a nurse case management HIV prevention and care intervention, titled Come As You Are, with that of usual care among youth experiencing homelessness aged 16 to 25 years. Methods: The study is designed as a 2-armed randomized wait-list controlled trial. Participants (n=450) will be recruited and followed up for 9 months after the intervention for a total study period of 12 months. Come As You Are combines nurse case management with a smartphone-based daily ecological momentary assessment to develop participant-driven HIV prevention behavioral goals that can be monitored in real-time. Youth in the city of Houston, Texas will be recruited from drop-in centers, shelters, street outreach programs, youth-serving organizations, and clinics. Results: Institutional review board approval (Committee for the Protection of Human Subjects, University of Texas Health Science Center at Houston) was obtained in November 2018. The first participant was enrolled in November 2019. Data collection is ongoing. To date, 123 participants have consented to participate in the study, 89 have been enrolled, and 15 have completed their final follow-up. Conclusions: There is a paucity of HIV prevention research regarding youth experiencing homelessness. Novel and scalable interventions that address the full continuum of behavioral and biomedical HIV prevention are needed. This study will determine whether a personalized and mobile HIV prevention approach can reduce HIV risk among a hard-to-reach, transient population of youth at high risk. International Registered Report Identifier (IRRID): DERR1-10.2196/26716 %M 34018967 %R 10.2196/26716 %U https://www.researchprotocols.org/2021/5/e26716 %U https://doi.org/10.2196/26716 %U http://www.ncbi.nlm.nih.gov/pubmed/34018967 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e25656 %T Digitization of Measurement-Based Care Pathways in Mental Health Through REDCap and Electronic Health Record Integration: Development and Usability Study %A Hawley,Steve %A Yu,Joanna %A Bogetic,Nikola %A Potapova,Natalia %A Wakefield,Chris %A Thompson,Mike %A Kloiber,Stefan %A Hill,Sean %A Jankowicz,Damian %A Rotenberg,David %+ Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, 250 College St., Toronto, ON, M5T 1L8, Canada, 1 416 535 8501, steve.hawley@camh.ca %K REDCap %K electronic health record %K systems integration %K measurement-based care %K hospital information systems %D 2021 %7 20.5.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The delivery of standardized self-report assessments is essential for measurement-based care in mental health. Paper-based methods of measurement-based care data collection may result in transcription errors, missing data, and other data quality issues when entered into patient electronic health records (EHRs). Objective: This study aims to help address these issues by using a dedicated instance of REDCap (Research Electronic Data Capture; Vanderbilt University)—a free, widely used electronic data capture platform—that was established to enable the deployment of digitized self-assessments in clinical care pathways to inform clinical decision making. Methods: REDCap was integrated with the primary clinical information system to facilitate the real-time transfer of discrete data and PDF reports from REDCap into the EHR. Both technical and administrative components were required for complete implementation. A technology acceptance survey was also administered to capture physicians’ and clinicians’ attitudes toward the new system. Results: The integration of REDCap with the EHR transitioned clinical workflows from paper-based methods of data collection to electronic data collection. This resulted in significant time savings, improved data quality, and valuable real-time information delivery. The digitization of self-report assessments at each appointment contributed to the clinic-wide implementation of the major depressive disorder integrated care pathway. This digital transformation facilitated a 4-fold increase in the physician adoption of this integrated care pathway workflow and a 3-fold increase in patient enrollment, resulting in an overall significant increase in major depressive disorder integrated care pathway capacity. Physicians’ and clinicians’ attitudes were overall positive, with almost all respondents agreeing that the system was useful to their work. Conclusions: REDCap provided an intuitive patient interface for collecting self-report measures and accessing results in real time to inform clinical decisions and an extensible backend for system integration. The approach scaled effectively and expanded to high-impact clinics throughout the hospital, allowing for the broad deployment of complex workflows and standardized assessments, which led to the accumulation of harmonized data across clinics and care pathways. REDCap is a flexible tool that can be effectively leveraged to facilitate the automatic transfer of self-report data to the EHR; however, thoughtful governance is required to complement the technical implementation to ensure that data standardization, data quality, patient safety, and privacy are maintained. %M 34014169 %R 10.2196/25656 %U https://www.jmir.org/2021/5/e25656 %U https://doi.org/10.2196/25656 %U http://www.ncbi.nlm.nih.gov/pubmed/34014169 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e24412 %T Factors Influencing Anxiety Among WeChat Users During the Early Stages of the COVID-19 Pandemic in Mainland China: Cross-sectional Survey Study %A Zou,Changqing %A Zhang,Weiyu %A Sznajder,Kristin %A Yang,Fengzhi %A Jia,Yajing %A Ma,Ruqing %A Cui,Can %A Yang,Xiaoshi %+ Department of Social Medicine, School of Public Health, China Medical University, No 77 Puhe Road, Shenyang North New Area, Liaoning Province, Shenyang, 110122, China, 86 18900910796, xsyang@cmu.edu.cn %K anxiety %K COVID-19 %K information seeking behavior %K positive psychological response %K health information %K public health emergency %K mental health %K online survey %K China %K cross-sectional study %D 2021 %7 17.5.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The rapid outbreak of COVID-19 around the world has adversely affected the mental health of the public. The prevalence of anxiety among the public has increased dramatically during the COVID-19 pandemic. However, there are few studies evaluating the effects of positive psychological responses and information-seeking behaviors on anxiety experienced among social media users during the COVID-19 pandemic. Objective: This study evaluated the prevalence of anxiety and its associated factors among WeChat users in mainland China during the early stages of the COVID-19 pandemic. Methods: From February 10 to February 24, 2020, a nationwide, web-based cross-sectional survey study was carried out using convenience sampling. Participants’ levels of anxiety, positive psychological responses, and information-seeking behaviors were assessed. The survey was distributed among WeChat users via the WeChat smartphone platform. Chi-square tests and multivariable logistic regression analyses were performed to examine the factors associated with anxiety. Results: This study found that the prevalence of anxiety (Generalized Anxiety Disorder 7-item [GAD-7] scale score ≥7) among WeChat users in China was 17.96% (446/2483) during the early stages of the COVID-19 pandemic. Results of multivariable logistic regression analysis showed that information-seeking behaviors such as cannot stop searching for information on COVID-19, being concerned about the COVID-19 pandemic, and spending more than 1 hour per day consuming information about the pandemic were found to be associated with increased levels of anxiety. Additionally, participants who chose social media and commercial media as the primary sources to obtain information about the COVID-19 pandemic were found more likely to report anxiety. Conversely, participants who were confident or rational about the COVID-19 pandemic were less likely to report anxiety. Conclusions: This study found that positive psychological responses and information-seeking behaviors were closely associated with anxiety among WeChat users during the COVID-19 pandemic in China. It might be paramount to enhance mental well-being by helping people respond to the COVID-19 pandemic more rationally and positively in order to decrease symptoms of anxiety. %M 33878025 %R 10.2196/24412 %U https://www.jmir.org/2021/5/e24412 %U https://doi.org/10.2196/24412 %U http://www.ncbi.nlm.nih.gov/pubmed/33878025 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 5 %P e26948 %T Suicide Prevention Among College Students Before and During the COVID-19 Pandemic: Protocol for a Systematic Review and Meta-analysis %A Xiao,Yunyu %A Hinrichs,Rachel %A Johnson,Nina %A McKinley,Amanda %A Carlson,Joan %A Agley,Jon %A Yip,Paul Siu Fai %+ School of Social Work, Indiana University–Purdue University Indianapolis, 902 W New York St, 4F, Education/Social Work Building, ES 4119, Indianapolis, IN, 46202, United States, 1 201 253 7264, yx18@iu.edu %K suicide %K suicidal prevention %K college %K university %K health disparities %K equity %K suicidal ideation %K suicide attempt %K COVID-19 %K college student %K young adult %K disparity %K review %D 2021 %7 17.5.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is the second leading cause of death for college-aged individuals worldwide and in the United States. Recent studies have identified preliminary evidence of widening disparities in suicidal behaviors across sex, sexual orientation, race/ethnicity, age, and socioeconomic status among college students. Few systematic reviews and meta-analyses offer a comprehensive understanding of on-campus and off-campus suicide interventions, nor is collated information available for different types of screening, assessment, treatment, and postvention plans. Further challenges have been identified since the COVID-19 pandemic, calling for cost-effective and innovative interventions to address increased rates of suicidal behaviors among college students facing unprecedented stressors. Objective: This research protocol describes the first systematic review and meta-analysis to identify the most effective and cost-effective intervention components for universal and targeted (indicated and selected) suicide prevention among college students in a global context. Special attention will be placed on disparities in suicide prevention across sociodemographic subgroups, inclusive interventions beyond campus, global context, and intervention responses to the COVID-19 pandemic. Methods: A sensitive search strategy will be executed across MEDLINE (Ovid), EMBASE, PsycINFO (EBSCO), ERIC (EBSCO), Cochrane Library, Dissertations and Theses Global (ProQuest), Scopus, Global Index Medicus, SciELO, African Journals Online, Global Health (CABI), and Google Scholar. Data extraction and evaluation will be conducted by three independent researchers. Risk of bias will be assessed. A multilevel meta-regression model and subgroup analysis will be used to analyze the data and estimate effect sizes. Results: The initial search was completed in December 2020 and updated with additional other-language studies in March 2020. We expect the results to be submitted for publication in mid-2021. Conclusions: Despite increasing rates of suicidal behaviors among college students, few preventative efforts have targeted this population, and fewer focus on factors that might place specific demographic groups at heightened risk. The impact of COVID-19 on suicidal behaviors among college students highlights and exacerbates the urgent need for rapid and effective interventions that might differ from traditional approaches. This equity-focused study will address these gaps and provide a valuable analysis of the effectiveness of suicide prevention programs and interventions. Findings will inform clinicians, researchers, policy makers, families, and organizations about evidence-based interventions for reducing the gaps in the suicide crisis among college students from different sociodemographic groups. Trial Registration: PROSPERO CRD42020225429; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=225429 International Registered Report Identifier (IRRID): DERR1-10.2196/26948 %M 33878016 %R 10.2196/26948 %U https://www.researchprotocols.org/2021/5/e26948 %U https://doi.org/10.2196/26948 %U http://www.ncbi.nlm.nih.gov/pubmed/33878016 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 5 %P e29014 %T Comparing the Effectiveness of Education Versus Digital Cognitive Behavioral Therapy for Adults With Sickle Cell Disease: Protocol for the Cognitive Behavioral Therapy and Real-time Pain Management Intervention for Sickle Cell via Mobile Applications (CaRISMA) Study %A Badawy,Sherif M %A Abebe,Kaleab Z %A Reichman,Charlotte A %A Checo,Grace %A Hamm,Megan E %A Stinson,Jennifer %A Lalloo,Chitra %A Carroll,Patrick %A Saraf,Santosh L %A Gordeuk,Victor R %A Desai,Payal %A Shah,Nirmish %A Liles,Darla %A Trimnell,Cassandra %A Jonassaint,Charles R %+ Center for Research on Media, Technology, and Health, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, United States, 1 412 586 9850, cjonassaint@pitt.edu %K sickle cell anemia %K sickle cell disease %K pain %K depression %K depressive symptoms %K quality of life %K digital %K mHealth %K eHealth %K CBT %K cognitive behavioral therapy %K education %K mobile phone %D 2021 %7 14.5.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Patients with sickle cell disease (SCD) experience significant medical and psychological stressors that affect their mental health, well-being, and disease outcomes. Digital cognitive behavioral therapy (CBT) has been used in other patient populations and has demonstrated clinical benefits. Although evidence-based, nonpharmacological interventions for pain management are widely used in other populations, these treatments have not been well studied in SCD. Currently, there are no adequately powered large-scale clinical trials to evaluate the effectiveness and dissemination potential of behavioral pain management for adults with SCD. Furthermore, some important details regarding behavioral therapies in SCD remain unclear—in particular, what works best for whom and when. Objective: Our primary goal is to compare the effectiveness of two smartphone–delivered programs for reducing SCD pain symptoms: digital CBT versus pain and SCD education (Education). Our secondary goal is to assess whether baseline depression symptoms moderate the effect of interventions on pain outcomes. We hypothesize that digital CBT will confer greater benefits on pain outcomes and depressive symptoms at 6 months and a greater reduction in health care use (eg, opioid prescriptions or refills or acute care visits) over 12 months. Methods: The CaRISMA (Cognitive Behavioral Therapy and Real-time Pain Management Intervention for Sickle Cell via Mobile Applications) study is a multisite comparative effectiveness trial funded by the Patient-Centered Outcomes Research Institute. CaRISMA is conducted at six clinical academic sites, in partnership with four community-based organizations. CaRISMA will evaluate the effectiveness of two 12-week health coach–supported digital health programs with a total of 350 participants in two groups: CBT (n=175) and Education (n=175). Participants will complete a series of questionnaires at baseline and at 3, 6, and 12 months. The primary outcome will be the change in pain interference between the study arms. We will also evaluate changes in pain intensity, depressive symptoms, other patient-reported outcomes, and health care use as secondary outcomes. We have 80% power to detect a difference of 0.37 SDs between study arms on 6-month changes in the outcomes with 15% expected attrition at 6 months. An exploratory analysis will examine whether baseline depression symptoms moderate the effect of the intervention on pain interference. Results: This study will be conducted from March 2021 through February 2022, with results expected to be available in February 2023. Conclusions: Patients with SCD experience significant disease burden, psychosocial stress, and impairment of their quality of life. CaRISMA proposes to leverage digital technology and overcome barriers to the routine use of behavioral treatments for pain and depressive symptoms in the treatment of adults with SCD. The study will provide data on the comparative effectiveness of digital CBT and Education approaches and evaluate the potential for implementing evidence-based behavioral interventions to manage SCD pain. Trial Registration: ClinicalTrials.gov NCT04419168; https://clinicaltrials.gov/ct2/show/NCT04419168. International Registered Report Identifier (IRRID): PRR1-10.2196/29014 %M 33988517 %R 10.2196/29014 %U https://www.researchprotocols.org/2021/5/e29014 %U https://doi.org/10.2196/29014 %U http://www.ncbi.nlm.nih.gov/pubmed/33988517 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 5 %P e26654 %T Assessing Suicide Reporting in Top Newspaper Social Media Accounts in China: Content Analysis Study %A Lai,Kaisheng %A Li,Dan %A Peng,Huijuan %A Zhao,Jingyuan %A He,Lingnan %+ School of Communication and Design, Sun Yat-Sen University, No. 132 Waihuan East Road, Higher Education Mega Center, Guangzhou, , China, 86 020 3933 1935, heln3@mail.sysu.edu.cn %K suicide %K suicide reporting %K mainstream publishers %K social media %K WHO guidelines %D 2021 %7 13.5.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Previous studies have shown that suicide reporting in mainstream media has a significant impact on suicidal behaviors (eg, irresponsible suicide reporting can trigger imitative suicide). Traditional mainstream media are increasingly using social media platforms to disseminate information on public-related topics, including health. However, there is little empirical research on how mainstream media portrays suicide on social media platforms and the quality of their coverage. Objective: This study aims to explore the characteristics and quality of suicide reporting by mainstream publishers via social media in China. Methods: Via the application programming interface of the social media accounts of the top 10 Chinese mainstream publishers (eg, People’s Daily and Beijing News), we obtained 2366 social media posts reporting suicide. This study conducted content analysis to demonstrate the characteristics and quality of the suicide reporting. According to the World Health Organization (WHO) guidelines, we assessed the quality of suicide reporting by indicators of harmful information and helpful information. Results: Chinese mainstream publishers most frequently reported on suicides stated to be associated with conflict on their social media (eg, 24.47% [446/1823] of family conflicts and 16.18% [295/1823] of emotional frustration). Compared with the suicides of youth (730/1446, 50.48%) and urban populations (1454/1588, 91.56%), social media underreported suicides in older adults (118/1446, 8.16%) and rural residents (134/1588, 8.44%). Harmful reporting practices were common (eg, 54.61% [1292/2366] of the reports contained suicide-related words in the headline and 49.54% [1172/2366] disclosed images of people who died by suicide). Helpful reporting practices were very limited (eg, 0.08% [2/2366] of reports provided direct information about support programs). Conclusions: The suicide reporting of mainstream publishers on social media in China broadly had low adherence to the WHO guidelines. Considering the tremendous information dissemination power of social media platforms, we suggest developing national suicide reporting guidelines that apply to social media. By effectively playing their separate roles, we believe that social media practitioners, health institutions, social organizations, and the general public can endeavor to promote responsible suicide reporting in the Chinese social media environment. %M 33983127 %R 10.2196/26654 %U https://mental.jmir.org/2021/5/e26654 %U https://doi.org/10.2196/26654 %U http://www.ncbi.nlm.nih.gov/pubmed/33983127 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e27410 %T Guided Internet-Based Cognitive Behavioral Therapy for Depression: Implementation Cost-Effectiveness Study %A Piera-Jiménez,Jordi %A Etzelmueller,Anne %A Kolovos,Spyros %A Folkvord,Frans %A Lupiáñez-Villanueva,Francisco %+ Open Evidence Research Group, Universitat Oberta de Catalunya, Rambla del Poblenou 156, Barcelona, 08018, Spain, 34 651041515, jpieraj@uoc.edu %K digital health %K telemedicine %K eHealth %K e–mental health %K internet-based cognitive behavioral therapy %K depression %K iCBT %K implementation %K cost-effectiveness %K cognitive behavioral therapy %K CBT %K cost %D 2021 %7 11.5.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Major depressive disorder is a chronic condition; its prevalence is expected to grow with the aging trend of high-income countries. Internet-based cognitive-behavioral therapy has proven efficacy in treating major depressive disorder. Objective: The objective of this study was to assess the cost-effectiveness of implementing a community internet-based cognitive behavioral therapy intervention (Super@, the Spanish program for the MasterMind project) for treating major depressive disorder. Methods: The cost-effectiveness of the Super@ program was assessed with the Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing tool, using a 3-state Markov model. Data from the cost and effectiveness of the intervention were prospectively collected from the implementation of the program by a health care provider in Badalona, Spain; the corresponding data for usual care were gathered from the literature. The health states, transition probabilities, and utilities were computed using Patient Health Questionnaire–9 scores. Results: The analysis was performed using data from 229 participants using the Super@ program. Results showed that the intervention was more costly than usual care; the discounted (3%) and nondiscounted incremental cost-effectiveness ratios were €29,367 and €26,484 per quality-adjusted life-year, respectively (approximately US $35,299 and $31,833, respectively). The intervention was cost-effective based on the €30,000 willingness-to-pay threshold typically applied in Spain (equivalent to approximately $36,060). According to the deterministic sensitivity analyses, the potential reduction of costs associated with intervention scale-up would reduce the incremental cost-effectiveness ratio of the intervention, although it remained more costly than usual care. A discount in the incremental effects up to 5% exceeded the willingness-to-pay threshold of €30,000. Conclusions: The Super@ program, an internet-based cognitive behavioral therapy intervention for treating major depressive disorder, cost more than treatment as usual. Nevertheless, its implementation in Spain would be cost-effective from health care and societal perspectives, given the willingness-to-pay threshold of €30,000 compared with treatment as usual. %M 33973857 %R 10.2196/27410 %U https://www.jmir.org/2021/5/e27410 %U https://doi.org/10.2196/27410 %U http://www.ncbi.nlm.nih.gov/pubmed/33973857 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 5 %P e27868 %T Evidence of Human-Level Bonds Established With a Digital Conversational Agent: Cross-sectional, Retrospective Observational Study %A Darcy,Alison %A Daniels,Jade %A Salinger,David %A Wicks,Paul %A Robinson,Athena %+ Woebot Health, 650 Fifth Street, San Francisco, CA, , United States, 1 851694777, alison@woebothealth.com %K conversational agents %K mobile mental health %K chatbots %K depression %K anxiety %K digital health %D 2021 %7 11.5.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: There are far more patients in mental distress than there is time available for mental health professionals to support them. Although digital tools may help mitigate this issue, critics have suggested that technological solutions that lack human empathy will prevent a bond or therapeutic alliance from being formed, thereby narrowing these solutions’ efficacy. Objective: We aimed to investigate whether users of a cognitive behavioral therapy (CBT)–based conversational agent would report therapeutic bond levels that are similar to those in literature about other CBT modalities, including face-to-face therapy, group CBT, and other digital interventions that do not use a conversational agent. Methods: A cross-sectional, retrospective study design was used to analyze aggregate, deidentified data from adult users who self-referred to a CBT-based, fully automated conversational agent (Woebot) between November 2019 and August 2020. Working alliance was measured with the Working Alliance Inventory-Short Revised (WAI-SR), and depression symptom status was assessed by using the 2-item Patient Health Questionnaire (PHQ-2). All measures were administered by the conversational agent in the mobile app. WAI-SR scores were compared to those in scientific literature abstracted from recent reviews. Results: Data from 36,070 Woebot users were included in the analysis. Participants ranged in age from 18 to 78 years, and 57.48% (20,734/36,070) of participants reported that they were female. The mean PHQ-2 score was 3.03 (SD 1.79), and 54.67% (19,719/36,070) of users scored over the cutoff score of 3 for depression screening. Within 5 days of initial app use, the mean WAI-SR score was 3.36 (SD 0.8) and the mean bond subscale score was 3.8 (SD 1.0), which was comparable to those in recent studies from the literature on traditional, outpatient, individual CBT and group CBT (mean bond subscale scores of 4 and 3.8, respectively). PHQ-2 scores at baseline weakly correlated with bond scores (r=−0.04; P<.001); however, users with depression and those without depression had high bond scores of 3.45. Conclusions: Although bonds are often presumed to be the exclusive domain of human therapeutic relationships, our findings challenge the notion that digital therapeutics are incapable of establishing a therapeutic bond with users. Future research might investigate the role of bonds as mediators of clinical outcomes, since boosting the engagement and efficacy of digital therapeutics could have major public health benefits. %M 33973854 %R 10.2196/27868 %U https://formative.jmir.org/2021/5/e27868 %U https://doi.org/10.2196/27868 %U http://www.ncbi.nlm.nih.gov/pubmed/33973854 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 5 %P e26186 %T Using Multimodal Assessments to Capture Personalized Contexts of College Student Well-being in 2020: Case Study %A Lai,Jocelyn %A Rahmani,Amir %A Yunusova,Asal %A Rivera,Alexander P %A Labbaf,Sina %A Hu,Sirui %A Dutt,Nikil %A Jain,Ramesh %A Borelli,Jessica L %+ UCI THRIVE Lab, Department of Psychological Science, University of California, Irvine, 4201 Social and Behavioral Sciences Gateway, Irvine, CA, 92697, United States, 1 4086565508, jocelyn.lai@uci.edu %K COVID-19 %K emerging adulthood %K multimodal personal chronicles %K case study %K wearable internet of things %K individualized mHealth %K college students %K mental health %D 2021 %7 11.5.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The year 2020 has been challenging for many, particularly for young adults who have been adversely affected by the COVID-19 pandemic. Emerging adulthood is a developmental phase with significant changes in the patterns of daily living; it is a risky phase for the onset of major mental illness. College students during the pandemic face significant risk, potentially losing several protective factors (eg, housing, routine, social support, job, and financial security) that are stabilizing for mental health and physical well-being. Individualized multiple assessments of mental health, referred to as multimodal personal chronicles, present an opportunity to examine indicators of health in an ongoing and personalized way using mobile sensing devices and wearable internet of things. Objective: To assess the feasibility and provide an in-depth examination of the impact of the COVID-19 pandemic on college students through multimodal personal chronicles, we present a case study of an individual monitored using a longitudinal subjective and objective assessment approach over a 9-month period throughout 2020, spanning the prepandemic period of January through September. Methods: The individual, referred to as Lee, completed psychological assessments measuring depression, anxiety, and loneliness across 4 time points in January, April, June, and September. We used the data emerging from the multimodal personal chronicles (ie, heart rate, sleep, physical activity, affect, behaviors) in relation to psychological assessments to understand patterns that help to explicate changes in the individual’s psychological well-being across the pandemic. Results: Over the course of the pandemic, Lee’s depression severity was highest in April, shortly after shelter-in-place orders were mandated. His depression severity remained mildly severe throughout the rest of the months. Associations in positive and negative affect, physiology, sleep, and physical activity patterns varied across time periods. Lee’s positive affect and negative affect were positively correlated in April (r=0.53, P=.04) whereas they were negatively correlated in September (r=–0.57, P=.03). Only in the month of January was sleep negatively associated with negative affect (r=–0.58, P=.03) and diurnal beats per minute (r=–0.54, P=.04), and then positively associated with heart rate variability (resting root mean square of successive differences between normal heartbeats) (r=0.54, P=.04). When looking at his available contextual data, Lee noted certain situations as supportive coping factors and other situations as potential stressors. Conclusions: We observed more pandemic concerns in April and noticed other contextual events relating to this individual’s well-being, reflecting how college students continue to experience life events during the pandemic. The rich monitoring data alongside contextual data may be beneficial for clinicians to understand client experiences and offer personalized treatment plans. We discuss benefits as well as future directions of this system, and the conclusions we can draw regarding the links between the COVID-19 pandemic and college student mental health. %M 33882022 %R 10.2196/26186 %U https://formative.jmir.org/2021/5/e26186 %U https://doi.org/10.2196/26186 %U http://www.ncbi.nlm.nih.gov/pubmed/33882022 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 5 %P e25009 %T Promoting the Mental Health of University Students in China: Protocol for Contextual Assessment to Inform Intervention Design and Adaptation %A Wong,Josephine Pui-Hing %A Jia,Cun-Xian %A Vahabi,Mandana %A Liu,Jenny Jing Wen %A Li,Alan Tai-Wai %A Cong,Xiaofeng %A Poon,Maurice Kwong-Lai %A Yamada,Janet %A Ning,Xuan %A Gao,Jianguo %A Cheng,Shengli %A Sun,Guoxiao %A Wang,Xinting %A Fung,Kenneth Po-Lun %+ Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, ON, M5B2K3, Canada, 1 416 979 5000 ext 556303, jph.wong@ryerson.ca %K mental health %K mental illness %K stigma %K protocol %K acceptance and commitment therapy %K implementation science %K student mental health %D 2021 %7 11.5.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Chinese students are extremely vulnerable to developing mental illness. The stigma associated with mental illness presents a barrier to seeking help for their mental health. Objective: The Linking Hearts—Linking Youth and ‘Xin’ (hearts) project is an implementation science project that seeks to reduce mental illness stigma and promote the mental health of university students in Jinan, China. The Linking Hearts project consists of 3 components. In this paper, we outline the protocol for the first component, that is, the contextual assessment and analysis of the mental health needs of university students as the first step to inform the adaptation of an evidence-based intervention to be implemented in Jinan, China. Methods: Six local universities will participate in the Linking Hearts project. A total of 100 students from each university (n=600) will engage in the contextual assessment through self-report surveys on depression, anxiety, stress, mental health knowledge, and mental health stigma. Quantitative data will be analyzed using several descriptive and inferential analyses via SPSS. A small number of participants (144 students and 144 service providers) will also be engaged in focus groups to assess the socio-environmental contexts of university students’ health and availability of mental health resources. Qualitative data will be transcribed verbatim and NVivo will be used for data management. Social network analysis will also be performed using EgoNet. Results: Linking Hearts was funded in January 2018 for 5 years. The protocol of Linking Hearts and its 3 components was approved by the research ethics boards of all participating institutions in China in November 2018. Canadian institutions that gave approval were Ryerson University (REB2018-455) in January 2019, University of Alberta (Pro00089364), York University (e2019-162) in May 2019, and University of Toronto (RIS37724) in August 2019. Data collection took place upon ethics approval and was completed in January 2020. A total of 600 students were surveyed. An additional 147 students and 138 service providers took part in focus groups. Data analysis is ongoing. Results will be published in 2021. Conclusions: Findings from this contextual assessment and analysis will generate new knowledge on university students’ mental health status, mental health knowledge, and resources available for them. These findings will be used to adapt and refine the Acceptance and Commitment to Empowerment-Linking Youth N’ Xin intervention model. The results of this contextual assessment will be used to inform the adaptation and refinement of the mental health intervention to promote the mental health of Chinese university students in Jinan. International Registered Report Identifier (IRRID): RR1-10.2196/25009 %M 33973869 %R 10.2196/25009 %U https://www.researchprotocols.org/2021/5/e25009 %U https://doi.org/10.2196/25009 %U http://www.ncbi.nlm.nih.gov/pubmed/33973869 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 5 %P e27663 %T The Use of Closed-Circuit Television and Video in Suicide Prevention: Narrative Review and Future Directions %A Onie,Sandersan %A Li,Xun %A Liang,Morgan %A Sowmya,Arcot %A Larsen,Mark Erik %+ Black Dog Institute, University of New South Wales, Sydney, Hospital Road, Sydney, 2031, Australia, 61 432359134, sandy.onie@gmail.com %K suicide %K suicide prevention %K CCTV %K video %K computer vision %K machine learning %D 2021 %7 7.5.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide is a recognized public health issue, with approximately 800,000 people dying by suicide each year. Among the different technologies used in suicide research, closed-circuit television (CCTV) and video have been used for a wide array of applications, including assessing crisis behaviors at metro stations, and using computer vision to identify a suicide attempt in progress. However, there has been no review of suicide research and interventions using CCTV and video. Objective: The objective of this study was to review the literature to understand how CCTV and video data have been used in understanding and preventing suicide. Furthermore, to more fully capture progress in the field, we report on an ongoing study to respond to an identified gap in the narrative review, by using a computer vision–based system to identify behaviors prior to a suicide attempt. Methods: We conducted a search using the keywords “suicide,” “cctv,” and “video” on PubMed, Inspec, and Web of Science. We included any studies which used CCTV or video footage to understand or prevent suicide. If a study fell into our area of interest, we included it regardless of the quality as our goal was to understand the scope of how CCTV and video had been used rather than quantify any specific effect size, but we noted the shortcomings in their design and analyses when discussing the studies. Results: The review found that CCTV and video have primarily been used in 3 ways: (1) to identify risk factors for suicide (eg, inferring depression from facial expressions), (2) understanding suicide after an attempt (eg, forensic applications), and (3) as part of an intervention (eg, using computer vision and automated systems to identify if a suicide attempt is in progress). Furthermore, work in progress demonstrates how we can identify behaviors prior to an attempt at a hotspot, an important gap identified by papers in the literature. Conclusions: Thus far, CCTV and video have been used in a wide array of applications, most notably in designing automated detection systems, with the field heading toward an automated detection system for early intervention. Despite many challenges, we show promising progress in developing an automated detection system for preattempt behaviors, which may allow for early intervention. %M 33960952 %R 10.2196/27663 %U https://mental.jmir.org/2021/5/e27663 %U https://doi.org/10.2196/27663 %U http://www.ncbi.nlm.nih.gov/pubmed/33960952 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e27918 %T Perceived Utility and Characterization of Personal Google Search Histories to Detect Data Patterns Proximal to a Suicide Attempt in Individuals Who Previously Attempted Suicide: Pilot Cohort Study %A Areán,Patricia A %A Pratap,Abhishek %A Hsin,Honor %A Huppert,Tierney K %A Hendricks,Karin E %A Heagerty,Patrick J %A Cohen,Trevor %A Bagge,Courtney %A Comtois,Katherine Anne %+ Department of Biomedical Informatics and Medical Education, University of Washington, 850 Republican St, Seattle, WA, , United States, 1 206 543 2259, apratap@uw.edu %K real-world data %K web searches %K suicide risk factors %K suicide detection %K suicide %K eHealth %K internet %K website %K search history %K risk %K EHR %K social media %K behavior %K mental health %K personalized %K online seeking behavior %D 2021 %7 6.5.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite decades of research to better understand suicide risk and to develop detection and prevention methods, suicide is still one of the leading causes of death globally. While large-scale studies using real-world evidence from electronic health records can identify who is at risk, they have not been successful at pinpointing when someone is at risk. Personalized social media and online search history data, by contrast, could provide an ongoing real-world datastream revealing internal thoughts and personal states of mind. Objective: We conducted this study to determine the feasibility and acceptability of using personalized online information-seeking behavior in the identification of risk for suicide attempts. Methods: This was a cohort survey study to assess attitudes of participants with a prior suicide attempt about using web search data for suicide prevention purposes, dates of lifetime suicide attempts, and an optional one-time download of their past web searches on Google. The study was conducted at the University of Washington School of Medicine Psychiatry Research Offices. The main outcomes were participants’ opinions on internet search data for suicide prediction and intervention and any potential change in online information-seeking behavior proximal to a suicide attempt. Individualized nonparametric association analysis was used to assess the magnitude of difference in web search data features derived from time periods proximal (7, 15, 30, and 60 days) to the suicide attempts versus the typical (baseline) search behavior of participants. Results: A total of 62 participants who had attempted suicide in the past agreed to participate in the study. Internet search activity varied from person to person (median 2-24 searches per day). Changes in online search behavior proximal to suicide attempts were evident up to 60 days before attempt. For a subset of attempts (7/30, 23%) search features showed associations from 2 months to a week before the attempt. The top 3 search constructs associated with attempts were online searching patterns (9/30 attempts, 30%), semantic relatedness of search queries to suicide methods (7/30 attempts, 23%), and anger (7/30 attempts, 23%). Participants (40/59, 68%) indicated that use of this personalized web search data for prevention purposes was acceptable with noninvasive potential interventions such as connection to a real person (eg, friend, family member, or counselor); however, concerns were raised about detection accuracy, privacy, and the potential for overly invasive intervention. Conclusions: Changes in online search behavior may be a useful and acceptable means of detecting suicide risk. Personalized analysis of online information-seeking behavior showed notable changes in search behavior and search terms that are tied to early warning signs of suicide and are evident 2 months to 7 days before a suicide attempt. %M 33955838 %R 10.2196/27918 %U https://www.jmir.org/2021/5/e27918 %U https://doi.org/10.2196/27918 %U http://www.ncbi.nlm.nih.gov/pubmed/33955838 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e27610 %T Initial Outcomes of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy Tailored to Public Safety Personnel: Longitudinal Observational Study %A Hadjistavropoulos,Heather D %A McCall,Hugh C %A Thiessen,David L %A Huang,Ziyin %A Carleton,R Nicholas %A Dear,Blake F %A Titov,Nickolai %+ Department of Psychology, University of Regina, Administration-Humanities Building, AH 345, 3737 Wascana Parkway, Regina, SK, S4S 0A2, Canada, 1 306 585 5133, Heather.Hadjistavropoulos@uregina.ca %K internet %K cognitive behavior therapy %K anxiety %K depression %K posttraumatic stress disorder %K public safety personnel %K CBT %K internet-based cognitive behavioral therapy %K ICBT %K PTSD %K outcome %K diagnosis %K longitudinal %K observational %K literature %K effectiveness %D 2021 %7 5.5.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Canadian public safety personnel (PSP) experience high rates of mental health disorders and face many barriers to treatment. Internet-delivered cognitive behavioral therapy (ICBT) overcomes many such barriers, and is effective for treating depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms. Objective: This study was designed to fill a gap in the literature regarding the use of ICBT tailored specifically for PSP. We examined the effectiveness of a tailored ICBT program for treating depression, anxiety, and PTSD symptoms among PSP in the province of Saskatchewan. Methods: We employed a longitudinal single-group open-trial design (N=83) with outcome measures administered at screening and at 8 weeks posttreatment. Data were collected between December 5, 2019 and September 11, 2020. Primary outcomes included changes in depression, anxiety, and PTSD symptoms. Secondary outcomes included changes in functional impairment; symptoms of panic, social anxiety, and anger; as well as treatment satisfaction, working alliance, and program usage patterns. Results: Clients reported large symptom reductions on measures of depression and anxiety, as well as moderate reductions on measures of PTSD and secondary symptoms, except for social anxiety. Most clients who reported symptoms above clinical cut-offs on measures of depression, anxiety, and PTSD during screening experienced clinically significant symptom reductions. Results suggested good engagement, treatment satisfaction, and working alliance. Conclusions: Tailored, transdiagnostic ICBT demonstrated promising outcomes as a treatment for depression, anxiety, and PTSD among Saskatchewan PSP and warrants further investigation. Trial Registration: Clinicaltrials.gov NCT04127032; https://www.clinicaltrials.gov/ct2/show/NCT04127032 %M 33949959 %R 10.2196/27610 %U https://www.jmir.org/2021/5/e27610 %U https://doi.org/10.2196/27610 %U http://www.ncbi.nlm.nih.gov/pubmed/33949959 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e25288 %T Information and Communication Technology Use in Suicide Prevention: Scoping Review %A Rassy,Jessica %A Bardon,Cécile %A Dargis,Luc %A Côté,Louis-Philippe %A Corthésy-Blondin,Laurent %A Mörch,Carl-Maria %A Labelle,Réal %+ Department of Psychology, Université du Québec à Montréal, CP 8888, succ Centre-Ville, Montréal, QC, H3C 3P8, Canada, 1 514 987 4184, labelle.real@uqam.ca %K suicide prevention %K information and communication technology %K scoping review %K mobile phone %D 2021 %7 4.5.2021 %9 Review %J J Med Internet Res %G English %X Background: The use of information and communication technology (ICT) in suicide prevention has progressed rapidly over the past decade. ICT plays a major role in suicide prevention, but research on best and promising practices has been slow. Objective: This paper aims to explore the existing literature on ICT use in suicide prevention to answer the following question: what are the best and most promising ICT practices for suicide prevention? Methods: A scoping search was conducted using the following databases: PubMed, PsycINFO, Sociological Abstracts, and IEEE Xplore. These databases were searched for articles published between January 1, 2013, and December 31, 2018. The five stages of the scoping review process were as follows: identifying research questions; targeting relevant studies; selecting studies; charting data; and collating, summarizing, and reporting the results. The World Health Organization suicide prevention model was used according to the continuum of universal, selective, and indicated prevention. Results: Of the 3848 studies identified, 115 (2.99%) were selected. Of these, 10 regarded the use of ICT in universal suicide prevention, 53 referred to the use of ICT in selective suicide prevention, and 52 dealt with the use of ICT in indicated suicide prevention. Conclusions: The use of ICT plays a major role in suicide prevention, and many promising programs were identified through this scoping review. However, large-scale evaluation studies are needed to further examine the effectiveness of these programs and strategies. In addition, safety and ethics protocols for ICT-based interventions are recommended. %M 33820754 %R 10.2196/25288 %U https://www.jmir.org/2021/5/e25288 %U https://doi.org/10.2196/25288 %U http://www.ncbi.nlm.nih.gov/pubmed/33820754 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e26939 %T Exploring the Role of Persuasive Design in Unguided Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety Among Adults: Systematic Review, Meta-analysis, and Meta-regression %A McCall,Hugh C %A Hadjistavropoulos,Heather D %A Sundström,Christopher Richard Francis %+ Department of Psychology, University of Regina, 3737 Wascana Pkwy, Regina, SK, S4S 0A2, Canada, 1 306 585 4111, hugh.c.mccall@gmail.com %K ICBT %K internet %K depression %K anxiety %K persuasive design %K eHealth %D 2021 %7 29.4.2021 %9 Review %J J Med Internet Res %G English %X Background: Internet-delivered cognitive behavioral therapy (ICBT) is an effective treatment that can overcome barriers to mental health care. Various research groups have suggested that unguided ICBT (ie, ICBT without therapist support) and other eHealth interventions can be designed to enhance user engagement and thus outcomes. The persuasive systems design framework captures most design recommendations for eHealth interventions, but there is little empirical evidence that persuasive design is related to clinical outcomes in unguided ICBT. Objective: This study aims to provide an updated meta-analysis of randomized controlled trials of unguided ICBT for depression and anxiety, describe the frequency with which various persuasive design principles are used in such interventions, and use meta-regression to explore whether a greater number of persuasive design elements predicts efficacy in unguided ICBT for depression and anxiety. Methods: We conducted a systematic review of 5 databases to identify randomized controlled trials of unguided ICBT for depression and anxiety. We conducted separate random effects meta-analyses and separate meta-regressions for depression and anxiety interventions. Each meta-regression included 2 steps. The first step included, as a predictor, whether each intervention was transdiagnostic. For the meta-regression of ICBT for depression, the first step also included the type of control condition. The number of persuasive design principles identified for each intervention was added as a predictor in the second step to reveal the additional variance in effect sizes explained by persuasive design. Results: Of the 4471 articles we identified in our search, 46 (1.03%) were eligible for inclusion in our analyses. Our meta-analyses showed effect sizes (Hedges g) ranging from 0.22 to 0.31 for depression interventions, depending on the measures taken to account for bias in the results. We found a mean effect size of 0.45 (95% CI 0.33-0.56) for anxiety interventions, with no evidence that the results were inflated by bias. Included interventions were identified as using between 1 and 13 persuasive design principles, with an average of 4.95 (SD 2.85). The meta-regressions showed that a greater number of persuasive design principles predicted greater efficacy in ICBT for depression (R2 change=0.27; B=0.04; P=.02) but not anxiety (R2 change=0.05; B=0.03; P=.17). Conclusions: These findings show wide variability in the use of persuasive design in unguided ICBT for depression and anxiety and provide preliminary support for the proposition that more persuasively designed interventions are more efficacious, at least in the treatment of depression. Further research is needed to clarify the role of persuasive design in ICBT. %M 33913811 %R 10.2196/26939 %U https://www.jmir.org/2021/4/e26939 %U https://doi.org/10.2196/26939 %U http://www.ncbi.nlm.nih.gov/pubmed/33913811 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 4 %P e19163 %T An Implementation Strategy to Expand Mobile Health Use in HIV Care Settings: Rapid Evaluation Study Using the Consolidated Framework for Implementation Research %A Cohn,Wendy F %A Canan,Chelsea E %A Knight,Sarah %A Waldman,Ava Lena %A Dillingham,Rebecca %A Ingersoll,Karen %A Schexnayder,Julie %A Flickinger,Tabor E %+ Department of Public Health Sciences, University of Virginia Cancer Center, University of Virginia, 560 Ray C Hunt Dr, PO Box 800765, Charlottesville, VA, 22908, United States, 1 434 964 7811, wfc2r@virginia.edu %K mHealth %K smartphone %K mobile health %K implementation strategy %K implementation science %K Consolidated Framework for Implementation Research %K HIV care engagement %K viral suppression %D 2021 %7 28.4.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) apps can provide support to people living with a chronic disease by offering resources for communication, self-management, and social support. PositiveLinks (PL) is a clinic-deployed mHealth app designed to improve the health of people with HIV. In a pilot study, PL users experienced considerable improvements in care engagement and viral load suppression. To promote its expansion to other HIV clinics, we developed an implementation strategy consisting of training resources and on-demand program support. Objective: The objective of our study was to conduct an interim analysis of the barriers and facilitators to PL implementation at early adopting sites to guide optimization of our implementation strategy. Methods: Semistructured interviews with stakeholders at PL expansion sites were conducted. Analysis of interviews identified facilitators and barriers that were mapped to 22 constructs of the Consolidated Framework for Implementation Research (CFIR). The purpose of the analysis was to identify the facilitators and barriers to PL implementation in order to adapt the PL implementation strategy. Four Ryan White HIV clinics were included. Interviews were conducted with one health care provider, two clinic managers, and five individuals who coordinated site PL activities. Results: Ten common facilitators and eight common barriers were identified. Facilitators to PL implementation included PL’s fit with patient and clinic needs, PL training resources, and sites’ early engagement with their information technology personnel. Most barriers were specific to mHealth, including access to Wi-Fi networks, maintaining patient smartphone access, patient privacy concerns, and lack of clarity on how to obtain approvals for mHealth use. Conclusions: The CFIR is a useful framework for evaluating mHealth interventions. Although PL training resources were viewed favorably, we identified important barriers to PL implementation in a sample of Ryan White clinics. This enabled our team to expand guidance on identifying information technology stakeholders and procuring and managing mobile resources. Ongoing evaluation results continue to inform improvements to the PL implementation strategy, facilitating PL access for future expansion sites. %M 33908893 %R 10.2196/19163 %U https://mhealth.jmir.org/2021/4/e19163 %U https://doi.org/10.2196/19163 %U http://www.ncbi.nlm.nih.gov/pubmed/33908893 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 4 %P e25407 %T Protocol for the Pregnancy During the COVID-19 Pandemic (PdP) Study: A Longitudinal Cohort Study of Mental Health Among Pregnant Canadians During the COVID-19 Pandemic and Developmental Outcomes in Their Children %A Giesbrecht,Gerald F %A Bagshawe,Mercedes %A van Sloten,Melinda %A MacKinnon,Anna L %A Dhillon,Ashley %A van de Wouw,Marcel %A Vaghef-Mehrabany,Elnaz %A Rojas,Laura %A Cattani,Danielle %A Lebel,Catherine %A Tomfohr-Madsen,Lianne %+ Department of Pediatrics, University of Calgary, 2500 University Drive, Calgary, AB, T2N 1N4, Canada, 1 403 441 8469, ggiesbre@ucalgary.ca %K pregnancy %K anxiety %K depression %K stress %K social support %K resilience %K COVID-19 %K infant development %K pandemic %D 2021 %7 28.4.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The COVID-19 pandemic and countermeasures implemented by governments around the world have led to dramatically increased symptoms of depression and anxiety. Pregnant individuals may be particularly vulnerable to the negative psychological effects of COVID-19 public health measures because they represent a demographic that is most affected by disasters and because pregnancy itself entails significant life changes that require major psychosocial and emotional adjustments. Objective: The PdP study was designed to investigate the associations among exposure to objective hardship caused by the pandemic, perceived stress and psychological distress in pregnant individuals, and developmental outcomes in their offspring. Methods: The PdP study comprises a prospective longitudinal cohort of individuals who were pregnant at enrollment, with repeated follow-ups during pregnancy and the postpartum period. Participants were eligible if they were pregnant, ≥17 years old, at ≤35 weeks of gestation at study enrollment, living in Canada, and able to read and write in English or French. At enrollment, participants completed an initial survey that assessed demographic and socioeconomic characteristics, previous pregnancies and births, prepregnancy health, health conditions during pregnancy, medications, psychological distress, social support, and hardships experienced because of the COVID-19 pandemic (eg, lost employment or a loved one dying). For the first three months following the initial survey, participants received a monthly email link to complete a follow-up survey that asked about their experiences since the previous survey. After three months, follow-up surveys were sent every other month to reduce participant burden. For each of these surveys, participants were first asked if they were still pregnant and then routed either to the next prenatal survey or to the delivery survey. In the postpartum period, surveys were sent at 3, 6, and 12 months of infant age to assess maternal stress, psychological distress, and infant development. Results: Participant recruitment via social media (Facebook and Instagram) began on April 5, 2020, and is ongoing. As of April 2021, more than 11,000 individuals have started the initial survey. Follow-up data collection is ongoing. Conclusions: This longitudinal investigation seeks to elucidate the associations among hardships, maternal psychological distress, child development during the COVID-19 pandemic, and risk and resilience factors that amplify or ameliorate these associations. The findings of this study are intended to generate knowledge about the psychological consequences of pandemics on pregnant individuals and point toward prevention and intervention targets. International Registered Report Identifier (IRRID): DERR1-10.2196/25407 %M 33848971 %R 10.2196/25407 %U https://www.researchprotocols.org/2021/4/e25407 %U https://doi.org/10.2196/25407 %U http://www.ncbi.nlm.nih.gov/pubmed/33848971 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 4 %P e24760 %T Psychological and Coping Strategies Related to Home Isolation and Social Distancing in Children and Adolescents During the COVID-19 Pandemic: Cross-sectional Study %A Zainel,Abduljaleel Abdullatif %A Qotba,Hamda %A Al-Maadeed,Alyaa %A Al-Kohji,Sadriya %A Al Mujalli,Hanan %A Ali,Atif %A Al Mannai,Lolwa %A Aladab,Aisha %A AlSaadi,Hamda %A AlKarbi,Khalid Ali %A Al-Baghdadi,Tholfakhar %+ Primary Health Care Corporation, PO Box 55772, Doha, Qatar, 974 55087676, azainel@phcc.gov.qa %K COVID-19 %K coronavirus %K pandemic %K psychological %K coping strategies %K children %K adolescents %K Qatar %D 2021 %7 27.4.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: In December 2019, a novel coronavirus called SARS-CoV-2 was identified as the cause of a cluster of pneumonia cases in Wuhan, China. It rapidly spread due to human-to-human transmission, resulting in a global pandemic. Nearly every country, including Qatar, has established guidelines and regulations to limit the spread of the virus and to preserve public health. However, these procedures have been associated with negative effects on the psychological and intellectual well-being of individuals, including children and adolescents. Objective: The objective of this study was to determine the psychological influence of home isolation and social distancing on children and adolescents during the COVID-19 pandemic in Qatar, and the strategies used to cope with these measures. Methods: This cross-sectional study was undertaken using an online questionnaire administered through SMS text messaging. All home-isolated children and adolescents registered at the Primary Health Care Corporation aged 7-18 years were invited to participate in the study. Children and adolescents with intellectual disadvantages were excluded. A P value of .05 (two-tailed) was considered statistically significant. Results: Data were collected from 6608 participants from June 23 to July 18, 2020. Nearly all participants adhered to the official regulations during the period of home isolation and social distancing; however, 69.1% (n=4568) of parents believed their children were vulnerable to the virus compared to 25% (n=1652) who expressed they were not vulnerable at all. Higher levels of anger, depression, and general anxiety were prevalent among 1.3% (n=84), 3.9% (n=260), and 1.6% (n=104) of participants, respectively. The mean score for the emotional constructs anger and depression decreased with increased compliance with regulations (P=.04 and P=.11, respectively). The differences in mean score for all psychological and coping strategies used among participants across the 3 levels of vulnerability to SARS-CoV-2 were statistically significant. The mean score varied little with increasing reported vulnerability to the virus. This mild variation can make a difference when the sample size is large, as is the case in this study. Conclusions: Screening for psychological and social disruptions is important for the development of strategies by schools and health care providers to assess and monitor behavioral changes and negative psychological impact during post–COVID-19 reintegration. Participants experiencing higher levels of anxiety should be given more attention during reintegration and transitional phases in schools. Although electronic devices and social media platforms may have lowered anxiety levels in some cases, it is important to address how they are used and how content is tailored to children and adolescents. It is also important to maintain an active lifestyle for children and young persons, and encourage them not to neglect their physical health, as this promotes a better psychological state of mind. %M 33851577 %R 10.2196/24760 %U https://formative.jmir.org/2021/4/e24760 %U https://doi.org/10.2196/24760 %U http://www.ncbi.nlm.nih.gov/pubmed/33851577 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 4 %P e27106 %T Evaluation of Mood Check-in Feature for Participation in Meditation Mobile App Users: Retrospective Longitudinal Analysis %A Huberty,Jennifer %A Green,Jeni %A Puzia,Megan %A Stecher,Chad %+ College of Health Solutions, Arizona State University, 500 N 3rd St, Phoenix, AZ, 85004, United States, 1 8019278558, jeni.green@asu.edu %K adherence %K meditation %K mindfulness %K mood %K smartphone application %K app %K engagement %K mHealth %K mental health %K behavior %D 2021 %7 23.4.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mindfulness meditation smartphone apps may improve mental health but lack evidence-based behavioral strategies to encourage their regular use for attaining mental health benefits. In October 2019, the Calm mindfulness meditation app introduced a mood check-in feature, but its effects on participation in meditation have yet to be tested. Objective: The objective of this study was to investigate how a mood check-in feature impacts meditation behavior in Calm app subscribers. Methods: This was a retrospective longitudinal analysis of mobile app usage data from a random sample of first-time subscribers to the Calm app (n=2600) who joined in summer 2018 or summer 2019. The mood check-in feature allows users to rate their mood using an emoji after completing a meditation session and displays a monthly calendar of their past mood check-ins. Regression analyses were used to compare the rate of change in meditation behavior before and after the introduction of mood check-ins and to estimate how usage of mood check-ins was associated with individuals’ future meditation behavior (ie, intent-to-treat effects). Additional regression models examined the heterogenous effect of mood check-ins between subscribers who were active or inactive users prior to the introduction to mood check-ins (ie, above or below the median number of weeks with any meditation within their cohort). In order to confirm the specific associations between mood check-ins and meditation engagement, we modeled the direct relationship between the use of mood check-ins in previous weeks and subsequent meditation behavior (ie, treatment on the treated effects). Results: During the first 9 months of their subscription, the 2019 cohort completed an average of 0.482 more sessions per week (95% CI 0.309 to 0.655) than the 2018 cohort; however, across both cohorts, average weekly meditation declined (–0.033 sessions per week, 95% CI –0.035 to –0.031). Controlled for trends in meditation before mood check-ins and aggregate differences between the 2018 and 2019 samples, the time trend in the number of weekly meditation sessions increased by 0.045 sessions among the 2019 cohort after the introduction of mood check-ins (95% CI 0.039 to 0.052). This increase in meditation was most pronounced among the inactive subscribers (0.063 sessions, 95% CI 0.052 to 0.074). When controlled for past-week meditation, use of mood check-ins during the previous week was positively associated with the likelihood of meditating the following week (odds ratio 1.132, 95% CI 1.059 to 1.211); however, these associations were not sustained beyond 1 week. Conclusions: Using mood check-ins increases meditation participation in Calm app subscribers and may be especially beneficial for inactive subscribers. Mobile apps should consider incorporating mood check-ins to help better engage a wider range of users in app-based meditation, but more research is warranted. %M 33890865 %R 10.2196/27106 %U https://mhealth.jmir.org/2021/4/e27106 %U https://doi.org/10.2196/27106 %U http://www.ncbi.nlm.nih.gov/pubmed/33890865 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e23487 %T A Direct-to-Public Peer Support Program (Big White Wall) Versus Web-Based Information to Aid the Self-management of Depression and Anxiety: Results and Challenges of an Automated Randomized Controlled Trial %A Morriss,Richard %A Kaylor-Hughes,Catherine %A Rawsthorne,Matthew %A Coulson,Neil %A Simpson,Sandra %A Guo,Boliang %A James,Marilyn %A Lathe,James %A Moran,Paul %A Tata,Laila J %A Williams,Laura %+ Institute of Mental Health, University of Nottingham, Jubilee Campus, Triumph Road, Nottingham, NG7 2TU, United Kingdom, 44 1158230427, richard.morriss@nottingham.ac.uk %K peer support %K digital mental health %K depression %K anxiety %K population reach %K productivity %K mobile phone %D 2021 %7 23.4.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Effective help for depression and anxiety reaches a small proportion of people who might benefit from it. The scale of the problem suggests the need for effective, safe web-based public health services delivered directly to the public. One model, the Big White Wall (BWW), offers peer support at low cost. As these interventions are delivered digitally, we tested whether a randomized controlled trial (RCT) intervention could also be fully delivered and evaluated digitally. Objective: This study aims to determine the reach, feasibility, acceptability, baseline costs, and outcomes of a public health campaign for an automated RCT of the BWW, providing digital peer support and information, compared with a standard website used by the National Health Service Moodzone (MZ), to people with probable mild-to-moderate depression and anxiety disorder. The primary outcome was the change in self-rated well-being at 6 weeks, measured using the Warwick-Edinburgh Mental Well-Being Scale. Methods: An 18-month campaign was conducted across Nottinghamshire, the United Kingdom (target population 914,000) to advertise the trial directly to the public through general marketing, web-based and social media sources, health services, other public services, and third-sector groups. The population reach of this campaign was examined by the number of people accessing the study website and self-registering to the study. A pragmatic, parallel-group, single-blind RCT was then conducted using a fully automated trial website in which eligible participants were randomized to receive either 6 months of access to BWW or signposted to MZ. Those eligible for participation were aged >16 years with probable mild-to-moderate depression or anxiety disorders. Results: Of 6483 visitors to the study website, 1510 (23.29%) were eligible. Overall, 790 of 1510 (52.32%) visitors participated. Of 790 visitors, 397 (50.3%) were randomized to BWW and 393 (49.7%) to MZ. Their mean age was 38 (SD 13.8) years, 81.0% (640/790) were female, 93.4% (738/790) were White, and 47.4% (271/572) had no contact with health services in the previous 3 months. We estimated 3-month productivity losses of £1001.01 (95% CI 868.75-1133.27; US $1380.79; 95% CI 1198.35-1563.23) per person for those employed. Only 16.6% (131/790) participants completed the primary outcome assessment. There were no differences in the primary or secondary outcomes between the 2 groups. Conclusions: Most participants reached and those eligible for this trial of digital interventions were White women not in recent contact with health services and whose productivity losses represent a significant annual societal burden. A fully automated RCT recruiting directly from the public failed to recruit and retain sufficient participants to test the clinical effectiveness of this digital intervention, primarily because it did not personally engage participants and explain how these unfamiliar interventions might benefit them. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 12673428; https://www.isrctn.com/ISRCTN12673428 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.8061 %M 33890858 %R 10.2196/23487 %U https://www.jmir.org/2021/4/e23487 %U https://doi.org/10.2196/23487 %U http://www.ncbi.nlm.nih.gov/pubmed/33890858 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 4 %P e24605 %T Implementing a Peer Advocate Mental Health Digital Intervention Program for Ohio Youth: Descriptive Pilot Study %A Albritton,Tashuna %A Ford,Kelsey Lynett %A Elsbernd,Kira %A Santodomingo,Melodie %A Juzang,Ivan %A Weddington,Pam %A Bull,Sheana %+ CUNY School of Medicine, City College of New York, 160 Convent Ave, New York, NY, 10031, United States, 1 212 650 8224, talbritton@med.cuny.edu %K mental health %K adolescent %K digital health %K suicide prevention %K social support %K youth %D 2021 %7 23.4.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: In the United States, millions of adolescents report poor mental health, where 1 in 5 teenagers considers suicide. Reducing stigma and fostering peer support remains critical for positive mental health interventions and programs. Increasingly, digital mental health tools have emerged with great promise, leveraging social networks. Despite the potential, limited understanding of such comprehensive programs and their implementation exist. Objective: The objective of this study investigates a piloted digital mental health training program (Be Present) for youth, specifically describing the impact on youth behavioral outcomes and user engagement and identifying high-risk youth in the early phases of prevention. Methods: Eligibility included Ohio residents (aged 14 to 22 years) to be enrolled as either a Friend or a Peer Advocate. From May 1 to June 1, 2019, participants completed the Advocate training course, taking pretest and posttest surveys. Single-arm descriptive analyses measured youth outcomes (self-efficacy, intentions, behaviors, social support, knowledge, and sources of strength) and engagement and assessed risk based on survey responses. Results: A total of 65 adolescents participated, with 54 completing both pretest and posttest surveys. The majority of participants included non-Hispanic White females. Findings illustrated a significant increase in self-report of referrals for mental health services as well as in perceptions that youth had of experiencing social support; however, no significant differences were found for measures of self-efficacy, knowledge, and sources of strength between pretest and posttest surveys. Roughly two-thirds of the participants completed all of the Advocate training modules, and we observed a gradual decline in engagement. Most respondents who received escalated high-risk response messages identified as female. Conclusions: The pilot presented promise for implementing a digital mental health program focused on peer support, specifically observing reported youth behavioral outcomes and user engagement and identifying high-risk youth. Various limitations exist given the small nonrepresentative sample and lack of control group. All findings should be considered preliminary to a larger trial and underscore the feasibility of delivering online training programs to bolster adolescent mental health. Such formative evaluation proved critical for future implementation and research, offering opportunity for substantial improvements for real-world digital mental health programs. %M 33890868 %R 10.2196/24605 %U https://mental.jmir.org/2021/4/e24605 %U https://doi.org/10.2196/24605 %U http://www.ncbi.nlm.nih.gov/pubmed/33890868 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 4 %P e23432 %T A Mental Health–Informed Physical Activity Intervention for First Responders and Their Partners Delivered Using Facebook: Mixed Methods Pilot Study %A McKeon,Grace %A Steel,Zachary %A Wells,Ruth %A Newby,Jill %A Hadzi-Pavlovic,Dusan %A Vancampfort,Davy %A Rosenbaum,Simon %+ School of Psychiatry, University of New South Wales, Level 1, AGSM, Botany Street, Sydney, 2031, Australia, 61 9065 9097, g.mckeon@unsw.edu.au %K physical activity %K PTSD %K social media %K first responders %K mental health %K families %K online %K exercise %D 2021 %7 22.4.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: First responders (eg, police, firefighters, and paramedics) are at high risk of experiencing poor mental health. Physical activity interventions can help reduce symptoms and improve mental health in this group. More research is needed to evaluate accessible, low-cost methods of delivering programs. Social media may be a potential platform for delivering group-based physical activity interventions. Objective: This study aims to examine the feasibility and acceptability of delivering a mental health–informed physical activity program for first responders and their self-nominated support partners. This study also aims to assess the feasibility of applying a novel multiple time series design and to explore the impact of the intervention on mental health symptoms, sleep quality, quality of life, and physical activity levels. Methods: We co-designed a 10-week web-based physical activity program delivered via a private Facebook group. We provided education and motivation around different topics weekly (eg, goal setting, overcoming barriers to exercise, and reducing sedentary behavior) and provided participants with a Fitbit. A multiple time series design was applied to assess psychological distress levels, with participants acting as their own control before the intervention. Results: In total, 24 participants (12 first responders and 12 nominated support partners) were recruited, and 21 (88%) completed the postassessment questionnaires. High acceptability was observed in the qualitative interviews. Exploratory analyses revealed significant reductions in psychological distress during the intervention. Preintervention and postintervention analysis showed significant improvements in quality of life (P=.001; Cohen d=0.60); total depression, anxiety, and stress scores (P=.047; Cohen d=0.35); and minutes of walking (P=.04; Cohen d=0.55). Changes in perceived social support from family (P=.07; Cohen d=0.37), friends (P=.10; Cohen d=0.38), and sleep quality (P=.28; Cohen d=0.19) were not significant. Conclusions: The results provide preliminary support for the use of social media and a multiple time series design to deliver mental health–informed physical activity interventions for first responders and their support partners. Therefore, an adequately powered trial is required. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN): 12618001267246; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001267246. %M 33885376 %R 10.2196/23432 %U https://formative.jmir.org/2021/4/e23432 %U https://doi.org/10.2196/23432 %U http://www.ncbi.nlm.nih.gov/pubmed/33885376 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 4 %P e24522 %T Using Machine Learning Imputed Outcomes to Assess Drug-Dependent Risk of Self-Harm in Patients with Bipolar Disorder: A Comparative Effectiveness Study %A Nestsiarovich,Anastasiya %A Kumar,Praveen %A Lauve,Nicolas Raymond %A Hurwitz,Nathaniel G %A Mazurie,Aurélien J %A Cannon,Daniel C %A Zhu,Yiliang %A Nelson,Stuart James %A Crisanti,Annette S %A Kerner,Berit %A Tohen,Mauricio %A Perkins,Douglas J %A Lambert,Christophe Gerard %+ Center for Global Health, Department of Internal Medicine, University of New Mexico Health Sciences Center, 915 Camino de Salud NE, Albuquerque, NM, United States, 1 5052729709, cglambert@unm.edu %K bipolar %K mood %K mania %K depression %K pharmacotherapy %K self-harm %K suicide %K machine learning %K psychotherapy %D 2021 %7 21.4.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Incomplete suicidality coding in administrative claims data is a known obstacle for observational studies. With most of the negative outcomes missing from the data, it is challenging to assess the evidence on treatment strategies for the prevention of self-harm in bipolar disorder (BD), including pharmacotherapy and psychotherapy. There are conflicting data from studies on the drug-dependent risk of self-harm, and there is major uncertainty regarding the preventive effect of monotherapy and drug combinations. Objective: The aim of this study was to compare all commonly used BD pharmacotherapies, as well as psychotherapy for the risk of self-harm, in a large population of commercially insured individuals, using self-harm imputation to overcome the known limitations of this outcome being underrecorded within US electronic health care records. Methods: The IBM MarketScan administrative claims database was used to compare self-harm risk in patients with BD following 65 drug regimens and drug-free periods. Probable but uncoded self-harm events were imputed via machine learning, with different probability thresholds examined in a sensitivity analysis. Comparators included lithium, mood-stabilizing anticonvulsants (MSAs), second-generation antipsychotics (SGAs), first-generation antipsychotics (FGAs), and five classes of antidepressants. Cox regression models with time-varying covariates were built for individual treatment regimens and for any pharmacotherapy with or without psychosocial interventions (“psychotherapy”). Results: Among 529,359 patients, 1.66% (n=8813 events) had imputed and/or coded self-harm following the exposure of interest. A higher self-harm risk was observed during adolescence. After multiple testing adjustment (P≤.012), the following six regimens had higher risk of self-harm than lithium: tri/tetracyclic antidepressants + SGA, FGA + MSA, FGA, serotonin-norepinephrine reuptake inhibitor (SNRI) + SGA, lithium + MSA, and lithium + SGA (hazard ratios [HRs] 1.44-2.29), and the following nine had lower risk: lamotrigine, valproate, risperidone, aripiprazole, SNRI, selective serotonin reuptake inhibitor (SSRI), “no drug,” bupropion, and bupropion + SSRI (HRs 0.28-0.74). Psychotherapy alone (without medication) had a lower self-harm risk than no treatment (HR 0.56, 95% CI 0.52-0.60; P=8.76×10-58). The sensitivity analysis showed that the direction of drug-outcome associations did not change as a function of the self-harm probability threshold. Conclusions: Our data support evidence on the effectiveness of antidepressants, MSAs, and psychotherapy for self-harm prevention in BD. Trial Registration: ClinicalTrials.gov NCT02893371; https://clinicaltrials.gov/ct2/show/NCT02893371 %M 33688834 %R 10.2196/24522 %U https://mental.jmir.org/2021/4/e24522 %U https://doi.org/10.2196/24522 %U http://www.ncbi.nlm.nih.gov/pubmed/33688834 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 4 %P e21678 %T Chatbot-Based Assessment of Employees’ Mental Health: Design Process and Pilot Implementation %A Hungerbuehler,Ines %A Daley,Kate %A Cavanagh,Kate %A Garcia Claro,Heloísa %A Kapps,Michael %+ Vitalk, TNH Health, R. Pais Leme, 215 - Sala 2504, Pinheiros, São Paulo, 05424-150, Brazil, 55 11963883018, drkatedaley@gmail.com %K chatbot %K conversational agent %K online %K digital health %K mobile phone %K mental health %K workplace %K work stress %K survey %K response rate %D 2021 %7 21.4.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Stress, burnout, and mental health problems such as depression and anxiety are common, and can significantly impact workplaces through absenteeism and reduced productivity. To address this issue, organizations must first understand the extent of the difficulties by mapping the mental health of their workforce. Online surveys are a cost-effective and scalable approach to achieve this but typically have low response rates, in part due to a lack of interactivity. Chatbots offer one potential solution, enhancing engagement through simulated natural human conversation and use of interactive features. Objective: The aim of this study was to explore if a text-based chatbot is a feasible approach to engage and motivate employees to complete a workplace mental health assessment. This paper describes the design process and results of a pilot implementation. Methods: A fully automated chatbot (“Viki”) was developed to evaluate employee risks of suffering from depression, anxiety, stress, insomnia, burnout, and work-related stress. Viki uses a conversation style and gamification features to enhance engagement. A cross-sectional analysis was performed to gain first insights of a pilot implementation within a small to medium–sized enterprise (120 employees). Results: The response rate was 64.2% (77/120). In total, 98 employees started the assessment, 77 of whom (79%) completed it. The majority of participants scored in the mild range for anxiety (20/40, 50%) and depression (16/28, 57%), in the moderate range for stress (10/22, 46%), and at the subthreshold level for insomnia (14/20, 70%) as defined by their questionnaire scores. Conclusions: A chatbot-based workplace mental health assessment seems to be a highly engaging and effective way to collect anonymized mental health data among employees with response rates comparable to those of face-to-face interviews. %M 33881403 %R 10.2196/21678 %U https://formative.jmir.org/2021/4/e21678 %U https://doi.org/10.2196/21678 %U http://www.ncbi.nlm.nih.gov/pubmed/33881403 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 4 %P e25097 %T Learning the Mental Health Impact of COVID-19 in the United States With Explainable Artificial Intelligence: Observational Study %A Jha,Indra Prakash %A Awasthi,Raghav %A Kumar,Ajit %A Kumar,Vibhor %A Sethi,Tavpritesh %+ Indraprastha Institute of Information Technology, Room 309, R and D Building, IIIT Campus, Okhla Phase 3, New Delhi, India, 91 01126907533, tavpriteshsethi@iiitd.ac.in %K COVID-19 %K mental health %K Bayesian network %K machine learning %K artificial intelligence %K disorder %K susceptibility %K well-being %K explainable artificial intelligence %D 2021 %7 20.4.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic has affected the health, economic, and social fabric of many nations worldwide. Identification of individual-level susceptibility factors may help people in identifying and managing their emotional, psychological, and social well-being. Objective: This study is focused on learning a ranked list of factors that could indicate a predisposition to a mental disorder during the COVID-19 pandemic. Methods: In this study, we have used a survey of 17,764 adults in the United States from different age groups, genders, and socioeconomic statuses. Through initial statistical analysis and Bayesian network inference, we have identified key factors affecting mental health during the COVID-19 pandemic. Integrating Bayesian networks with classical machine learning approaches led to effective modeling of the level of mental health prevalence. Results: Overall, females were more stressed than males, and people in the age group 18-29 years were more vulnerable to anxiety than other age groups. Using the Bayesian network model, we found that people with a chronic mental illness were more prone to mental disorders during the COVID-19 pandemic. The new realities of working from home; homeschooling; and lack of communication with family, friends, and neighbors induces mental pressure. Financial assistance from social security helps in reducing mental stress during the COVID-19–generated economic crises. Finally, using supervised machine learning models, we predicted the most mentally vulnerable people with ~80% accuracy. Conclusions: Multiple factors such as social isolation, digital communication, and working and schooling from home were identified as factors of mental illness during the COVID-19 pandemic. Regular in-person communication with friends and family, a healthy social life, and social security were key factors, and taking care of people with a history of mental disease appears to be even more important during this time. %M 33877051 %R 10.2196/25097 %U https://mental.jmir.org/2021/4/e25097 %U https://doi.org/10.2196/25097 %U http://www.ncbi.nlm.nih.gov/pubmed/33877051 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 4 %P e26268 %T Digital Health Interventions in Prevention, Relapse, and Therapy of Mild and Moderate Depression: Scoping Review %A Tokgöz,Pinar %A Hrynyschyn,Robert %A Hafner,Jessica %A Schönfeld,Simone %A Dockweiler,Christoph %+ School of Public Health, Bielefeld University, Universitätsstraße 25, Bielefeld, 33615, Germany, 49 521 106 67136, pinar.tokgoez@uni-bielefeld.de %K digital health %K depression %K scoping review %K health care %D 2021 %7 16.4.2021 %9 Review %J JMIR Ment Health %G English %X Background: Depression is a major cause for disability worldwide, and digital health interventions are expected to be an augmentative and effective treatment. According to the fast-growing field of information and communication technologies and its dissemination, there is a need for mapping the technological landscape and its benefits for users. Objective: The purpose of this scoping review was to give an overview of the digital health interventions used for depression. The main goal of this review was to provide a comprehensive review of the system landscape and its technological state and functions, as well as its evidence and benefits for users. Methods: A scoping review was conducted to provide a comprehensive overview of the field of digital health interventions for the treatment of depression. PubMed, PSYNDEX, and the Cochrane Library were searched by two independent researchers in October 2020 to identify relevant publications of the last 10 years, which were examined using the inclusion and exclusion criteria. To conduct the review, we used Rayyan, a freely available web tool. Results: In total, 65 studies were included in the qualitative synthesis. After categorizing the studies into the areas of prevention, early detection, therapy, and relapse prevention, we found dominant numbers of studies in the area of therapy (n=52). There was only one study for prevention, 5 studies for early detection, and 7 studies for relapse prevention. The most dominant therapy approaches were cognitive behavioral therapy, acceptance and commitment therapy, and problem-solving therapy. Most of the studies revealed significant effects of digital health interventions when cognitive behavioral therapy was applied. Cognitive behavioral therapy as the most dominant form was often provided through web-based systems. Combined interventions consisting of web-based and smartphone-based approaches are increasingly found. Conclusions: Digital health interventions for treating depression are quite comprehensive. There are different interventions focusing on different fields of care. While most interventions can be beneficial to achieve a better depression treatment, it can be difficult to determine which approaches are suitable. Cognitive behavioral therapy through digital health interventions has shown good effects in the treatment of depression, but treatment for depression still stays very individualistic. %M 33861201 %R 10.2196/26268 %U https://mental.jmir.org/2021/4/e26268 %U https://doi.org/10.2196/26268 %U http://www.ncbi.nlm.nih.gov/pubmed/33861201 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 4 %P e24184 %T Gender Differences in Satisfaction With a Text Messaging Program (Text4Hope) and Anticipated Receptivity to Technology-Based Health Support During the COVID-19 Pandemic: Cross-sectional Survey Study %A Shalaby,Reham %A Vuong,Wesley %A Hrabok,Marianne %A Gusnowski,April %A Mrklas,Kelly %A Li,Daniel %A Snaterse,Mark %A Surood,Shireen %A Cao,Bo %A Li,Xin-Min %A Greiner,Russell %A Greenshaw,Andrew James %A Agyapong,Vincent Israel Opoku %+ Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 7807144315, agyapong@ualberta.ca %K COVID-19 %K Text4Hope %K satisfaction %K mobile phone %K text %K anxiety %K depression %K stress, pandemic %K e-mental health %K gender %D 2021 %7 15.4.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In March 2020, Text4Hope—a community health service—was provided to Alberta residents. This free service aims to promote psychological resilience and alleviate pandemic-associated stress, anxiety, and depression symptoms during the COVID-19 pandemic. Objective: This study aimed to evaluate the feedback, satisfaction, experience, and perceptions of Text4Hope subscribers and to examine any differences based on gender after subscribers received 6 weeks of daily supportive text messages. Additionally, this study examined subscribers’ anticipated receptivity to technology-based medical services that could be offered during major crises, emergencies, or pandemics. Methods: Individuals self-subscribed to Text4Hope to receive daily supportive text messages for 3 months. Subscribers were invited to complete a web-based survey at 6 weeks postintervention to provide service satisfaction–related information. Overall satisfaction was assessed on a scale of 0-10, and satisfaction scores were analyzed using a related-measures t test. Likert scale satisfaction responses were used to assess various aspects of the Text4Hope program. Gender differences were analyzed using one-way analysis of variance (ANOVA) and Chi-square analyses. Results: A total of 2032 subscribers completed the baseline and 6-week surveys; 1788 (88%) were female, 219 (10.8%) were male, and 25 (1.2%) were other gender. The mean age of study participants was 44.58 years (SD 13.45 years). The mean overall satisfaction score was 8.55 (SD 1.78), suggesting high overall satisfaction with Text4Hope. The ANOVA analysis, which was conducted using the Welch test (n=1716), demonstrated that females had significantly higher mean satisfaction scores than males (8.65 vs 8.11, respectively; mean difference=0.546; 95% CI 0.19 to 0.91; P<.001) and nonsignificantly lower satisfaction scores than other gender respondents (mean difference=−0.938; 95% CI −0.37 to 2.25; P=.15). More than 70% of subscribers agreed that Text4Hope helped them cope with stress (1334/1731, 77.1%) and anxiety (1309/1728, 75.8%), feel connected to a support system (1400/1729, 81%), manage COVID-19–related issues (1279/1728, 74%), and improve mental well-being (1308/1731, 75.6%). Similarly, subscribers agreed that messages were positive, affirmative, and succinct. Messages were always or often read by 97.9% (1681/1716) of respondents, and more than 20% (401/1716, 23.4%) always or often returned to messages. The majority of subscribers (1471/1666, 88.3%) read the messages and either reflected upon them or took a positive action. Subscribers welcomed almost all technology-based services as part of their health care during crisis or emergency situations. Text4Hope was perceived to be effective by many female subscribers, who reported higher satisfaction and improved coping after receiving text messages for 6 weeks. Conclusions: Respondents affirmed the high quality of the text messages with their positive feedback. Technology-based services can provide remotely accessible and population-level interventions that align with the recommended physical distancing practices for pandemics. Text4Hope subscriber feedback revealed high satisfaction and acceptance at 6 weeks postintervention. International Registered Report Identifier (IRRID): RR2-10.2196/19292 %M 33750738 %R 10.2196/24184 %U https://mhealth.jmir.org/2021/4/e24184 %U https://doi.org/10.2196/24184 %U http://www.ncbi.nlm.nih.gov/pubmed/33750738 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 8 %N 2 %P e26390 %T Impact of Individual, Organizational, and Technological Factors on the Implementation of an Online Portal to Support a Clinical Pathway Addressing Psycho-Oncology Care: Mixed Methods Study %A Masya,Lindy %A Shepherd,Heather L %A Butow,Phyllis %A Geerligs,Liesbeth %A Allison,Karen C %A Dolan,Colette %A Prest,Gabrielle %A , %A Shaw,Joanne %+ Psycho-Oncology Co-operative Research Group, School of Psychology, The University of Sydney, Griffith Taylor Building (A19), Sydney, NSW 2006, Australia, 61 2 86270828, heather.shepherd@sydney.edu.au %K decision support systems %K clinical decision making %K psycho-oncology %K health informatics %K clinical pathways %K health services research %D 2021 %7 14.4.2021 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Clinical pathways (CPs) can improve patient outcomes but can be complex to implement. Technologies, such as clinical decision support (CDS) tools, can facilitate their use, but require end-user testing in clinical settings. Objective: This study applied the Technology Acceptance Model to evaluate the individual, organizational, and technological contexts impacting application of a portal to facilitate a CP for anxiety and depression (the ADAPT Portal) in a metropolitan cancer service. The ADAPT Portal triggers patient screening on patient reported outcomes, alerts staff to high scores, recommends evidence-based management, and triggers review and rescreening at set intervals. Methods: Quantitative and qualitative data on portal activity, data accuracy, and health service staff perspectives were collected. Quantitative data were analyzed descriptively, and thematic analysis was applied to qualitative data. Results: Overall, 15 (100% of those invited) health service staff agreed to be interviewed. During the pilot, 73 users (36 health service staff members and 37 patients) were registered on the ADAPT Portal. Of the 37 patients registered, 16 (43%) completed screening at least once, with seven screening positive and triaged appropriately. In total, 34 support requests were lodged, resulting in 17 portal enhancements (technical issues). Health service staff considered the ADAPT Portal easy to use and useful; however, some deemed it unnecessary or burdensome (individual issues), particularly in a busy cancer service (organizational issues). Conclusions: User testing of a CDS to facilitate screening and assessment of anxiety and depression in cancer patients highlighted some technological issues in implementing the ADAPT CDS, resulting in 17 enhancements. Our results highlight the importance of obtaining health service staff feedback when piloting specialized CDS tools and addressing contextual factors when implementing them. %M 33851926 %R 10.2196/26390 %U https://humanfactors.jmir.org/2021/2/e26390 %U https://doi.org/10.2196/26390 %U http://www.ncbi.nlm.nih.gov/pubmed/33851926 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 4 %P e25438 %T Exploring the Association Between Physical Activity and Risk of Mental Health Disorders in Saudi Arabian Adults: Cross-sectional Study %A Althumiri,Nora A %A Basyouni,Mada H %A BinDhim,Nasser F %+ Sharik Association For Health Research, Anas Ibn Malik RD, Riyadh, Saudi Arabia, 966 505435544, nora@althumiri.net %K Saudi Arabia %K physical activity %K mental health %K depression %K anxiety %K risk %K symptoms %K cross-sectional %K survey %D 2021 %7 14.4.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The relationship between physical activity and mental health, especially the symptoms of major depressive disorder (MDD) and generalized anxiety disorder (GAD), has received increasing attention in recent years. Objective: The aim of this study was to explore the association between fulfilling the World Health Organization (WHO) global recommendations on physical activity and the risk and symptoms of MDD and GAD in the Saudi population. Methods: This study was a secondary analysis of data from a large nationwide cross-sectional survey conducted via phone interviews in June and July 2020. In this study, a proportional quota sampling technique was used to obtain an equal distribution of participants, stratified by age and gender, across the 13 regions of Saudi Arabia. The main mental health screening tool used for the risk of MDD was the Patient Health Questionnaire-9 (PHQ-9). Risk of GAD was measured using the Generalized Anxiety Disorder-7 (GAD-7) scale. Participants self-reported whether they fulfill the WHO global recommendations on (1) moderate-intensity aerobic physical activity (MIPA) and (2) vigorous-intensity aerobic physical activity (VIPA). The results were then analyzed based on the following two categories: fulfilling the WHO global recommendations or not. Results: The data analysis included 8333 participants recruited in the main study between June and July 2020. The response rate was 81.45% (8333/10,231). Of them, 50.3% (4192/8333) were female, and the mean age was 36.5 years, with a median age of 36 years and a range from 18 to 90 years. The average total PHQ-9 score was 5.61, and the average total GAD-7 score was 4.18. For men, the average total PHQ-9 and GAD-7 scores were associated with fulfilling recommendations for MIPA; however, there were no associations for VIPA in both sexes. Fulfilling the WHO’s recommendations for MIPA was associated with considerably fewer depressive symptoms in six of the nine items in the PHQ-9. Moreover, fulfilling recommendations for MIPA was associated with considerably fewer anxiety symptoms in six of the seven items in the GAD-7. However, fulfilling recommendations for VIPA was significantly associated with more depressive symptoms in one of the PHQ-9 items (“Thoughts that you would be better off dead or thoughts of hurting yourself in some way;” P<.001). Conclusions: This study has shown that fulfilling guidelines on MIPA is associated with less overall risk of MDD and GAD in males and fewer depressive and anxiety symptoms generally in a nonclinical population. In the general population, an increase in MIPA may improve well-being and general mental health. %M 33851932 %R 10.2196/25438 %U https://publichealth.jmir.org/2021/4/e25438 %U https://doi.org/10.2196/25438 %U http://www.ncbi.nlm.nih.gov/pubmed/33851932 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 9 %N 4 %P e22397 %T Using General-purpose Sentiment Lexicons for Suicide Risk Assessment in Electronic Health Records: Corpus-Based Analysis %A Bittar,André %A Velupillai,Sumithra %A Roberts,Angus %A Dutta,Rina %+ Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF, United Kingdom, 44 (0)20 3228 8553, andre.bittar@kcl.ac.uk %K psychiatry %K suicide %K suicide, attempted %K risk assessment %K electronic health records %K sentiment analysis %K natural language processing %K corpus linguistics %D 2021 %7 13.4.2021 %9 Original Paper %J JMIR Med Inform %G English %X Background: Suicide is a serious public health issue, accounting for 1.4% of all deaths worldwide. Current risk assessment tools are reported as performing little better than chance in predicting suicide. New methods for studying dynamic features in electronic health records (EHRs) are being increasingly explored. One avenue of research involves using sentiment analysis to examine clinicians’ subjective judgments when reporting on patients. Several recent studies have used general-purpose sentiment analysis tools to automatically identify negative and positive words within EHRs to test correlations between sentiment extracted from the texts and specific medical outcomes (eg, risk of suicide or in-hospital mortality). However, little attention has been paid to analyzing the specific words identified by general-purpose sentiment lexicons when applied to EHR corpora. Objective: This study aims to quantitatively and qualitatively evaluate the coverage of six general-purpose sentiment lexicons against a corpus of EHR texts to ascertain the extent to which such lexical resources are fit for use in suicide risk assessment. Methods: The data for this study were a corpus of 198,451 EHR texts made up of two subcorpora drawn from a 1:4 case-control study comparing clinical notes written over the period leading up to a suicide attempt (cases, n=2913) with those not preceding such an attempt (controls, n=14,727). We calculated word frequency distributions within each subcorpus to identify representative keywords for both the case and control subcorpora. We quantified the relative coverage of the 6 lexicons with respect to this list of representative keywords in terms of weighted precision, recall, and F score. Results: The six lexicons achieved reasonable precision (0.53-0.68) but very low recall (0.04-0.36). Many of the most representative keywords in the suicide-related (case) subcorpus were not identified by any of the lexicons. The sentiment-bearing status of these keywords for this use case is thus doubtful. Conclusions: Our findings indicate that these 6 sentiment lexicons are not optimal for use in suicide risk assessment. We propose a set of guidelines for the creation of more suitable lexical resources for distinguishing suicide-related from non–suicide-related EHR texts. %M 33847595 %R 10.2196/22397 %U https://medinform.jmir.org/2021/4/e22397 %U https://doi.org/10.2196/22397 %U http://www.ncbi.nlm.nih.gov/pubmed/33847595 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e19743 %T Perceptions of and Opinions on a Computerized Behavioral Activation Program for the Treatment of Depression in Young People: Thematic Analysis %A Tindall,Lucy %A Toner,Paul %A Mikocka-Walus,Antonina %A Wright,Barry %+ Department of Health Sciences, University of York, Heslington, York, YO105DD, United Kingdom, 44 7976774636, lucy.tindall@york.ac.uk %K depression %K qualitative %K thematic analysis %K young people %K health care professionals %K computerized therapies %D 2021 %7 13.4.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is one of the leading causes of illness and disability in young people, with approximately 20% having experienced a depressive episode by the age of 18 years. Behavioral activation (BA), a National Institute for Health and Care Excellence–recommended treatment for adults with depression, has shown preliminary support for its use with young people. BA may have the potential to be adapted and delivered in a computerized format to address the barriers often associated with young people accessing support. Despite the benefits of adopting computerized therapy delivery, the limited effectiveness of some programs has been attributed to a failure to tailor interventions to patients and practices. Therefore, while developing new treatments, it is important that target users be involved in the intervention design. Objective: This qualitative study aims to explore the views and preferences of young people and health care professionals regarding the development of a new computerized BA therapy for young people with low mood or depression, to ensure that the therapy was suitable for the target user. Methods: Semistructured focus groups and individual interviews were conducted with young people (those with experience in accessing support and those without) and health care professionals regarding the development of a new computerized BA therapy for young people with low mood or depression. The data were analyzed using thematic analysis. Results: A total of 27 individuals, comprising both health care professionals and young people, participated in this study. Vital information pertaining to the important components of a new therapy, including its presentation, delivery, and content, was collected. Conclusions: Variations in perspectives highlighted the need to adopt a systemic approach in therapy development by considering the opinions of young people with and without experience in accessing mental health support and health care professionals. %M 33847594 %R 10.2196/19743 %U https://www.jmir.org/2021/4/e19743 %U https://doi.org/10.2196/19743 %U http://www.ncbi.nlm.nih.gov/pubmed/33847594 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e24053 %T Association of Perceived Threat, Negative Emotions, and Self-Efficacy With Mental Health and Personal Protective Behavior Among Chinese Pregnant Women During the COVID-19 Pandemic: Cross-sectional Survey Study %A Mo,Phoenix Kit Han %A Fong,Vivian Wai In %A Song,Bo %A Di,Jiangli %A Wang,Qian %A Wang,Linhong %+ National Center for Women and Children's Health, Chinese Center for Disease Control and Prevention, No 12 Dahuisi Road, Haidian District, Beijing, 100081, China, 86 010 62170970, qianawang@chinawch.org.cn %K COVID-19 %K pregnant women %K depression %K anxiety %K self-efficacy %K mental health %K survey %K threat %K emotion %D 2021 %7 12.4.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: COVID-19 is an emerging infectious disease that has created health care challenges worldwide. Pregnant women are particularly affected by this disease. Objective: The aims of this study are to assess the levels of perceived threat (susceptibility, severity, impact), negative emotions (fear, worry), and self-efficacy of pregnant women in China related to COVID-19 and to examine their associations with mental health (depression and anxiety) and personal protective behavior (wearing a face mask). Methods: A total of 4087 pregnant women from China completed a cross-sectional web-based survey between March 3 and 10, 2020. Results: The prevalence of probable depression and anxiety was 48.7% (1989/4087) and 33.0% (1347/4087), respectively; 23.8% participants (974/4087) reported always wearing a face mask when going out. Of the 4087 participants, 32.1% (1313) and 36.4% (1490) perceived themselves or their family members to be susceptible to COVID-19 infection, respectively; 3216-3518 (78.7%-86.1%) agreed the disease would have various severe consequences. Additionally, 2275 of the 4087 participants (55.7%) showed self-efficacy in protecting themselves from contracting COVID-19, and 2232 (54.6%) showed efficacy in protecting their family members; 1303 (31.9%) reported a high level of fear of the disease, and 2780-3056 (68.0%-74.8%) expressed worry about various aspects of COVID-19. The results of the multivariate multinominal logistic regression analyses showed that perceived severity, perceived impact, fear, and worry were risk factors for probable depression and anxiety, while self-efficacy was a protective factor. The results of the multivariate logistic regression analysis showed that perceived susceptibility was associated with always wearing a face mask. Conclusions: Chinese pregnant women showed high levels of mental distress but low levels of personal protective behavior during the COVID-19 pandemic. Interventions are needed to promote the mental health and health behavior of pregnant women during the pandemic. %M 33729983 %R 10.2196/24053 %U https://www.jmir.org/2021/4/e24053 %U https://doi.org/10.2196/24053 %U http://www.ncbi.nlm.nih.gov/pubmed/33729983 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 4 %P e24604 %T Relationship Between Major Depression Symptom Severity and Sleep Collected Using a Wristband Wearable Device: Multicenter Longitudinal Observational Study %A Zhang,Yuezhou %A Folarin,Amos A %A Sun,Shaoxiong %A Cummins,Nicholas %A Bendayan,Rebecca %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Conde,Pauline %A Stewart,Callum %A Laiou,Petroula %A Matcham,Faith %A White,Katie M %A Lamers,Femke %A Siddi,Sara %A Simblett,Sara %A Myin-Germeys,Inez %A Rintala,Aki %A Wykes,Til %A Haro,Josep Maria %A Penninx,Brenda WJH %A Narayan,Vaibhav A %A Hotopf,Matthew %A Dobson,Richard JB %A , %+ Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, SGDP Centre, IoPPN, Box PO 80, De Crespigny Park, Denmark Hill, London, United Kingdom, 44 20 7848 0473, richard.j.dobson@kcl.ac.uk %K mobile health (mHealth) %K mental health %K depression %K sleep %K wearable device %K monitoring %D 2021 %7 12.4.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Sleep problems tend to vary according to the course of the disorder in individuals with mental health problems. Research in mental health has associated sleep pathologies with depression. However, the gold standard for sleep assessment, polysomnography (PSG), is not suitable for long-term, continuous monitoring of daily sleep, and methods such as sleep diaries rely on subjective recall, which is qualitative and inaccurate. Wearable devices, on the other hand, provide a low-cost and convenient means to monitor sleep in home settings. Objective: The main aim of this study was to devise and extract sleep features from data collected using a wearable device and analyze their associations with depressive symptom severity and sleep quality as measured by the self-assessed Patient Health Questionnaire 8-item (PHQ-8). Methods: Daily sleep data were collected passively by Fitbit wristband devices, and depressive symptom severity was self-reported every 2 weeks by the PHQ-8. The data used in this paper included 2812 PHQ-8 records from 368 participants recruited from 3 study sites in the Netherlands, Spain, and the United Kingdom. We extracted 18 sleep features from Fitbit data that describe participant sleep in the following 5 aspects: sleep architecture, sleep stability, sleep quality, insomnia, and hypersomnia. Linear mixed regression models were used to explore associations between sleep features and depressive symptom severity. The z score was used to evaluate the significance of the coefficient of each feature. Results: We tested our models on the entire dataset and separately on the data of 3 different study sites. We identified 14 sleep features that were significantly (P<.05) associated with the PHQ-8 score on the entire dataset, among them awake time percentage (z=5.45, P<.001), awakening times (z=5.53, P<.001), insomnia (z=4.55, P<.001), mean sleep offset time (z=6.19, P<.001), and hypersomnia (z=5.30, P<.001) were the top 5 features ranked by z score statistics. Associations between sleep features and PHQ-8 scores varied across different sites, possibly due to differences in the populations. We observed that many of our findings were consistent with previous studies, which used other measurements to assess sleep, such as PSG and sleep questionnaires. Conclusions: We demonstrated that several derived sleep features extracted from consumer wearable devices show potential for the remote measurement of sleep as biomarkers of depression in real-world settings. These findings may provide the basis for the development of clinical tools to passively monitor disease state and trajectory, with minimal burden on the participant. %M 33843591 %R 10.2196/24604 %U https://mhealth.jmir.org/2021/4/e24604 %U https://doi.org/10.2196/24604 %U http://www.ncbi.nlm.nih.gov/pubmed/33843591 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 4 %P e21127 %T Brief Interventions via Electronic Health Record Messaging for Population-Based Suicide Prevention: Mixed Methods Pilot Study %A Whiteside,Ursula %A Richards,Julie %A Simon,Gregory E %+ NowMattersNow.org, 1645 140th Ave NE, Suite A41053, Bellevue, WA, 98005, United States, 1 206 679 6349, ursulawhiteside@gmail.com %K suicide %K suicide prevention %K dialectical behavior therapy %K caring message %K web-based %K NowMattersNow.org %K prevention %D 2021 %7 12.4.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: New opportunities to create and evaluate population-based selective prevention programs for suicidal behavior are emerging in health care settings. Standard depression severity measures recorded in electronic medical records (EMRs) can be used to identify patients at risk for suicide and suicide attempt, and promising interventions for reducing the risk of suicide attempt in at-risk populations can be adapted for web-based delivery in health care. Objective: This study aims to evaluate a pilot of a psychoeducational program, focused on developing emotion regulation techniques via a web-based dialectical behavior therapy (DBT) skills site, including four DBT skills, and supported by secure message coaching, including elements of caring messages. Methods: Patients were eligible based on the EMR-documented responses to the Patient Health Questionnaire indicating suicidal thoughts. We measured feasibility via the proportion of invitees who opened program invitations, visited the web-based consent form page, and consented; acceptability via qualitative feedback from participants about the DBT program; and engagement via the proportion of invitees who began DBT skills as well as the number of website visits for DBT skills and the degree of site engagement. Results: A total of 60 patients were invited to participate. Overall, 93% (56/60) of the patients opened the invitation and 43% (26/60) consented to participate. DBT skills website users visited the home page on an average of 5.3 times (SD 6.0). Procedures resulted in no complaints and some participant feedback emphasizing the usefulness of DBT skills. Conclusions: This study supports the potential of using responses to patient health questionnaires in EMRs to identify a high-risk population and offer key elements of caring messages and DBT adapted for a low-intensity intervention. A randomized trial evaluating the effectiveness of this program is now underway (ClinicalTrials.gov: NCT02326883). %M 33843599 %R 10.2196/21127 %U https://formative.jmir.org/2021/4/e21127 %U https://doi.org/10.2196/21127 %U http://www.ncbi.nlm.nih.gov/pubmed/33843599 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 4 %P e20424 %T A Smartphone-Based Self-management Intervention for Bipolar Disorder (LiveWell): User-Centered Development Approach %A Jonathan,Geneva K %A Dopke,Cynthia A %A Michaels,Tania %A Bank,Andrew %A Martin,Clair R %A Adhikari,Krina %A Krakauer,Rachel L %A Ryan,Chloe %A McBride,Alyssa %A Babington,Pamela %A Frauenhofer,Ella %A Silver,Jamilah %A Capra,Courtney %A Simon,Melanie %A Begale,Mark %A Mohr,David C %A Goulding,Evan H %+ Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States, 1 3125031189, e-goulding@fsm.northwestern.edu %K behavioral intervention technology %K mHealth %K bipolar disorder %K depression %K illness management %K smartphone %K behavior change %K early warning signs %K self-management %K qualitative %D 2021 %7 12.4.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Bipolar disorder is a serious mental illness that results in significant morbidity and mortality. Pharmacotherapy is the primary treatment for bipolar disorder; however, adjunctive psychotherapy can help individuals use self-management strategies to improve outcomes. Yet access to this therapy is limited. Smartphones and other technologies have the potential to increase access to therapeutic strategies that enhance self-management while simultaneously providing real-time user feedback and provider alerts to augment care. Objective: This paper describes the user-centered development of LiveWell, a smartphone-based self-management intervention for bipolar disorder, to contribute to and support the ongoing improvement and dissemination of technology-based mental health interventions. Methods: Individuals with bipolar disorder first participated in a field trial of a simple smartphone app for self-monitoring of behavioral targets. To develop a complete technology-based intervention for bipolar disorder, this field trial was followed by design sessions, usability testing, and a pilot study of a smartphone-based self-management intervention for bipolar disorder. Throughout all phases of development, intervention revisions were made based on user feedback. Results: The core of the LiveWell intervention consists of a daily self-monitoring tool, the Daily Check-in. This self-monitoring tool underwent multiple revisions during the user-centered development process. Daily Check-in mood and thought rating scales were collapsed into a single wellness rating scale to accommodate user development of personalized scale anchors. These anchors are meant to assist users in identifying early warning signs and symptoms of impending episodes to take action based on personalized plans. When users identified personal anchors for the wellness scale, the anchors most commonly reflected behavioral signs and symptoms (40%), followed by cognitive (25%), mood (15%), physical (10%), and motivational (7%) signs and symptoms. Changes to the Daily Check-in were also made to help users distinguish between getting adequate sleep and keeping a regular routine. At the end of the pilot study, users reported that the Daily Check-in made them more aware of early warning signs and symptoms and how much they were sleeping. Users also reported that they liked personalizing their anchors and plans and felt this process was useful. Users experienced some difficulties with developing, tracking, and achieving target goals. Users also did not consistently follow up with app recommendations to contact providers when Daily Check-in data suggested they needed additional assistance. As a result, the human support roles for the technology were expanded beyond app use support to include support for self-management and clinical care communication. The development of these human support roles was aided by feedback on the technology's usability from the users and the coaches who provided the human support. Conclusions: User input guided the development of intervention content, technology, and coaching support for LiveWell. Users valued the provision of monitoring tools and the ability to personalize plans for staying well, supporting the role of monitoring and personalization as important features of digital mental health technologies. Users also valued human support of the technology in the form of a coach, and user difficulties with aspects of self-management and care-provider communication led to an expansion of the coach's support roles. Obtaining feedback from both users and coaches played an important role in the development of both the LiveWell technology and human support. Attention to all stakeholders involved in the use of mental health technologies is essential for optimizing intervention development. %M 33843607 %R 10.2196/20424 %U https://mental.jmir.org/2021/4/e20424 %U https://doi.org/10.2196/20424 %U http://www.ncbi.nlm.nih.gov/pubmed/33843607 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 4 %P e28089 %T Autonomic Nervous System Maturation and Emotional Coordination in Interactions of Preterm and Full-Term Infants With Their Parents: Protocol for a Multimethod Study %A Koumarela,Christina %A Kokkinaki,Theano %A Giannakakis,Giorgos %A Koutra,Katerina %A Hatzidaki,Eleftheria %+ Laboratory of Applied Psychology, Department of Psychology, University of Crete, Gallos, Rethymnon, 74 100, Greece, 30 2831077536, kokkinaki@uoc.gr %K preterm infants %K heart rate variability %K emotional coordination %K developmental outcomes %D 2021 %7 12.4.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is limited knowledge on the physiological and behavioral pathways that may affect the developmental outcomes of preterm infants and particularly on the link between autonomic nervous system maturation and early social human behavior. Thus, this study attempts to investigate the way heart rate variability (HRV) parameters are related to emotional coordination in interactions of preterm and full-term infants with their parents in the first year of life and the possible correlation with the developmental outcomes of infants at 18 months. Objective: The first objective is to investigate the relationship between emotional coordination and HRV in dyadic full-term infant–parent (group 1) and preterm infant–parent (group 2) interactions during the first postpartum year. The second objective is to examine the relationship of emotional coordination and HRV in groups 1 and 2 in the first postpartum year with the developmental outcomes of infants at 18 months. The third objective is to investigate the effect of maternal and paternal postnatal depression on the relation between emotional coordination and HRV in the two groups and on developmental outcomes at 18 months. The fourth objective is to examine the effect of family cohesion and coping on the relation between emotional coordination and HRV in the two groups and on developmental outcomes at 18 months. Methods: This is an observational, naturalistic, and longitudinal study applying a mixed method design that includes the following: (1) video recordings of mother-infant and father-infant interactions at the hospital, in the neonatal period, and at home at 2, 4, 6, 9, and 12 months of the infants’ life; (2) self-report questionnaires of parents on depressive symptoms, family cohesion, and dyadic coping of stress; (3) infants’ HRV parameters in the neonatal period and at each of the above age points during and after infant-parent video recordings; and (4) assessment of toddlers’ social and cognitive development at 18 months through an observational instrument. Results: The study protocol has been approved by the Research Ethics Committee of the University of Crete (number/date: 170/September 18, 2020). This work is supported by the Special Account for Research Funds of the University of Crete (grant number: 10792-668/08.02.2021). All mothers (with their partners) of full-term and preterm infants who give birth between March 2021 and January 2022 at the General University Hospital of Crete (northern Crete, Greece) will be invited to participate. The researcher will invite the parents of infants to participate in the study 1 to 2 days after birth. Data collection is expected to be completed by March 2023, and the first results will be published by the end of 2023. Conclusions: Investigating the regulatory role of HRV and social reciprocity in preterm infants may have implications for both medicine and psychology. International Registered Report Identifier (IRRID): PRR1-10.2196/28089 %M 33843606 %R 10.2196/28089 %U https://www.researchprotocols.org/2021/4/e28089 %U https://doi.org/10.2196/28089 %U http://www.ncbi.nlm.nih.gov/pubmed/33843606 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 4 %P e24617 %T Effects of Participating in a Research Project During the COVID-19 Pandemic on Medical Students’ Educational Routines and Mental Health: Protocol for a Web-Based Survey Study %A Calderaro,Débora Cerqueira %A Kahlow,Barbara Stadler %A Munhoz,Gabriela Araújo %A Dias,Samuel Elias Basualto %A Lopes,João Vitor Ziroldo %A Borges,Aline Rizzo %A Mariz,Henrique De Ataíde %A Gomes,Kirla Wagner Poti %A Valadares,Lilian David De Azevedo %A Araújo,Nafice Costa %A Ribeiro,Sandra Lucia Euzébio %A Kakehasi,Adriana Maria %A Reis,Ana Paula Monteiro Gomides %A Marques,Cláudia %A Reis-Neto,Edgard Torres %A Paiva,Eduardo Dos Santos %A Pileggi,Gecilmara Salviato %A Ferreira,Gilda Aparecida %A Provenza,José Roberto %A Mota,Licia Maria Henrique %A Xavier,Ricardo Machado %A Teodoro,Maycoln Leôni Martins %A Pinheiro,Marcelo De Medeiros %A , %+ Universidade Federal de Minas Gerais, 190 Professor Alfredo Balena Avenue, Belo Horizonte, 30130-100, Brazil, 55 3134099757, dccalderaro@gmail.com %K SARS-CoV-2 %K COVID-19 %K medical education %K observational %K cross-sectional %K case-control study %K voluntary %K mental health %K rheumatic disease %K medical student %K protocol %K survey %D 2021 %7 9.4.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The COVID-19 pandemic has resulted in social isolation, which has a potential negative impact on the educational routines (eg, the suspension of face-to-face appointments) and mental health of medical students. The Mario Pinotti II (MPII) study is a 24-week observational study that conducted scheduled telephone calls every 2 weeks to verify the occurrence of COVID-19 in patients with rheumatic diseases on chronic hydroxychloroquine therapy (from March 29, 2020, to September 30, 2020). The effects of voluntarily participating in a research project (ie, one that involves interactions via telephone contact with patients, professors, rheumatologists, and colleagues) on the daily lives and mental health of medical students requires evaluation. Objective: As medical students are professionals in training and have a high level of responsibility in terms of handling the emotional and physical aspects of several diseases, this study aims to evaluate the impacts of the COVID-19 pandemic and participation in the MPII study on the educational routines and mental health of medical students. Methods: A web-based survey was carried out to perform a cross-sectional comparative assessment of medical students who participated in the MPII study and their colleagues who were not involved in the MPII study. Participants from both groups were matched based on sex, age, and medical school. The web questionnaire was developed by a panel composed of graduate medical students, rheumatologists, medical school professors, and a psychology professor. The questionnaire included details on demographic and life habits data and evaluated participants' impressions of the MPII study and the impact of the COVID-19 pandemic on their educational routines and medical training. In addition, depression, anxiety, and stress were evaluated using the Brazilian version of the Depression, Anxiety, and Stress Scale (DASS)-21, and currently, the DASS-21 scores are grouped as those that indicate a low, moderate, or high risk of mental distress. This project was approved by the Federal University of São Paulo Ethics Committee (CAAE: 34034620.0.0000.5505). Results: Data were collected from both medical student groups from July 20 to August 31, 2020. Data extraction was completed in September 2020. The data analysis is ongoing. We expect the results to be published in the first semester of 2021. Conclusions: This study will provide insight into the effects of participating in a research project on depression, anxiety, and stress, which will be determined by applying the DASS-21 to a large sample of Brazilian undergraduate medical students. We will also evaluate the impact of the COVID-19 pandemic on medical students’ educational routines and medical training. International Registered Report Identifier (IRRID): DERR1-10.2196/24617 %M 33735094 %R 10.2196/24617 %U https://www.researchprotocols.org/2021/4/e24617 %U https://doi.org/10.2196/24617 %U http://www.ncbi.nlm.nih.gov/pubmed/33735094 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e24260 %T Moderated Online Social Therapy for Young People With Active Suicidal Ideation: Qualitative Study %A Bailey,Eleanor %A Robinson,Jo %A Alvarez-Jimenez,Mario %A Nedeljkovic,Maja %A Valentine,Lee %A Bendall,Sarah %A D'Alfonso,Simon %A Gilbertson,Tamsyn %A McKechnie,Ben %A Rice,Simon %+ Orygen, Locked Bag 10, 35 Poplar Road, Parkville, 3052, Australia, 61 412483600, eleanor.bailey@orygen.org.au %K suicide %K youth %K social media %K internet-based intervention %D 2021 %7 5.4.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based interventions are a promising approach to support youth at risk of suicide, and those incorporating peer-to-peer social networking may have the added potential to target interpersonal states of perceived burdensomeness and thwarted belongingness. Owing to feasibility and safety concerns, including fear of contagion, this had not been tested until recently. In 2018, we conducted a pilot evaluation to test the feasibility, safety, and acceptability of a Moderated Online Social Therapy intervention, called Affinity, with a sample of young people with active suicidal ideation. Objective: The aim of this study is to report qualitative data collected from study participants regarding their experience of the web-based social network and the consequent safety features. Methods: Affinity is a closed website incorporating 3 key components: therapeutic content delivered via comics, peer-to-peer social networking, and moderation by peers and clinicians. Semistructured interviews were conducted with 17 young people who participated in the pilot study after 8 weeks of exposure to the intervention. Interview data from 2 young people who did not use Affinity were excluded from the analysis. The interviews were analyzed using thematic analysis, with the frequency of responses characterized using the consensual qualitative research method. The results are reported in accordance with the Consolidated Criteria for Reporting Qualitative Research checklist. Results: A total of 4 overarching themes were identified: a safe and supportive environment, the importance of mutual experiences, difficulty engaging and connecting, and the pros and cons of banning discussions about suicide. Interestingly, although Affinity was perceived to be safe and free of judgment, concerns about negative evaluation and triggering others were significant barriers to posting on the social network. Participants generally supported the banning of conversations about suicide, although for some this was perceived to reinforce stigma or was associated with frustration and distress. Conclusions: The results not only support the safety and potential therapeutic benefit of the social networking aspect of Affinity but also highlight several implementation challenges. There is a need to carefully balance the need for stringent safety and design features while ensuring that the potential for therapeutic benefit is maximized. %M 33818392 %R 10.2196/24260 %U https://www.jmir.org/2021/4/e24260 %U https://doi.org/10.2196/24260 %U http://www.ncbi.nlm.nih.gov/pubmed/33818392 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 3 %P e24871 %T Optimizing Engagement in an Online Dietary Intervention for Depression (My Food & Mood Version 3.0): Cohort Study %A Young,Claire Louise %A Mohebbi,Mohammadreza %A Staudacher,Heidi M %A Kay-Lambkin,Frances %A Berk,Michael %A Jacka,Felice Nellie %A O'Neil,Adrienne %+ Food & Mood Centre, Institute for Mental and Physical Health and Clinical Translation, Deakin University, PO Box 281, Geelong, Victoria, 3220, Australia, 61 406754668, youngc@deakin.edu.au %K online intervention %K nutritional psychiatry %K depression %K low mood %K dietary intervention %K eHealth %K mHealth %K dietary intervention %K engagement %K nonusage attrition %D 2021 %7 31.3.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Online interventions can be a cost-effective and efficient way to deliver programs to large numbers of people regardless of geographic location. However, attrition in web-based interventions is often an issue. Developing ways to keep participants engaged is important for ensuring validity and limiting potential biases. We developed a web-based dietary intervention as part of The My Food & Mood study which aimed to optimize ways to engage participants with low mood or depressive symptoms to promote dietary behavior change. Different versions of the My Food & Mood program were tested during optimization. Iterations were developed based on user feedback and usage analysis. Objective: The purpose of this study was to compare engagement and nonusage attrition across 4 program iterations—which differed by platform format, delivery mode, and activity type—to create an optimized version. Methods: Each program version contained modular videos with key activities with respect to implementing behavior change techniques of equivalent levels of required participation and length: version 1.0, desktop program and smartphone app; version 2.1, desktop or smartphone program; version 2.2, desktop program; and version 3.0, smartphone app. Adults with PHQ-8 scores of 5 or greater were recruited online and assigned to 1 of the 4 versions. Participants were asked to use the program for 8 weeks and complete measures at weeks 4 and 8. Engagement data were collected from the web-based platform system logs and customized reports. Cox regression survival analysis examined nonusage attrition and Kruskal-Wallis tests compared engagement across each cohort. Results: A total of 614 adults participated. Kruskal-Wallis tests showed significant differences across the 4 cohorts in all engagement measures. The smartphone app (version 3.0) had the greatest engagement as measured by weeks engaged, total usage time, total time key activities, number of active sessions, percentage of activities completed against protocol, goals completed, and percentage of videos watched. Cox regression multivariate survival analysis showed referral from a health practitioner (hazard ratio [HR] 0.344, P=.001) and greater proficiency with computers (HR 0.796, P=.049) reduced the risk of nonusage attrition. Computer confidence was associated with an increased risk of nonusage attrition. Conclusions: My Food & Mood version 3.0, a dietary intervention delivered via smartphone app with self-monitoring tools for diet quality and mood monitoring, was the version with greatest engagement in a population with low mood or depression. The iterative design techniques employed and analysis of feedback from participants resulted in a program that achieved lower rates of nonusage attrition and higher rates of intensity of use. %M 33787501 %R 10.2196/24871 %U https://mental.jmir.org/2021/3/e24871 %U https://doi.org/10.2196/24871 %U http://www.ncbi.nlm.nih.gov/pubmed/33787501 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 3 %P e24727 %T Correlations Between Facial Expressivity and Apathy in Elderly People With Neurocognitive Disorders: Exploratory Study %A Zeghari,Radia %A König,Alexandra %A Guerchouche,Rachid %A Sharma,Garima %A Joshi,Jyoti %A Fabre,Roxane %A Robert,Philippe %A Manera,Valeria %+ Cognition Behaviour Technology Research Unit, Memory Center, Université Côte d’Azur, 10 Rue Molière, Nice, France, 33 4 92 03 47 66, radia.zeghari@univ-cotedazur.fr %K apathy %K action units %K assessment %K ICT %K facial video analysis %K neurocognitive disorders %K neurocognitive %K facial analysis %D 2021 %7 31.3.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Neurocognitive disorders are often accompanied by behavioral symptoms such as anxiety, depression, and/or apathy. These symptoms can occur very early in the disease progression and are often difficult to detect and quantify in nonspecialized clinical settings. Objective: We focus in this study on apathy, one of the most common and debilitating neuropsychiatric symptoms in neurocognitive disorders. Specifically, we investigated whether facial expressivity extracted through computer vision software correlates with the severity of apathy symptoms in elderly subjects with neurocognitive disorders. Methods: A total of 63 subjects (38 females and 25 males) with neurocognitive disorder participated in the study. Apathy was assessed using the Apathy Inventory (AI), a scale comprising 3 domains of apathy: loss of interest, loss of initiation, and emotional blunting. The higher the scale score, the more severe the apathy symptoms. Participants were asked to recall a positive and a negative event of their life, while their voice and face were recorded using a tablet device. Action units (AUs), which are basic facial movements, were extracted using OpenFace 2.0. A total of 17 AUs (intensity and presence) for each frame of the video were extracted in both positive and negative storytelling. Average intensity and frequency of AU activation were calculated for each participant in each video. Partial correlations (controlling for the level of depression and cognitive impairment) were performed between these indexes and AI subscales. Results: Results showed that AU intensity and frequency were negatively correlated with apathy scale scores, in particular with the emotional blunting component. The more severe the apathy symptoms, the less expressivity in specific emotional and nonemotional AUs was displayed from participants while recalling an emotional event. Different AUs showed significant correlations depending on the sex of the participant and the task’s valence (positive vs negative story), suggesting the importance of assessing male and female participants independently. Conclusions: Our study suggests the interest of employing computer vision-based facial analysis to quantify facial expressivity and assess the severity of apathy symptoms in subjects with neurocognitive disorders. This may represent a useful tool for a preliminary apathy assessment in nonspecialized settings and could be used to complement classical clinical scales. Future studies including larger samples should confirm the clinical relevance of this kind of instrument. %M 33787499 %R 10.2196/24727 %U https://formative.jmir.org/2021/3/e24727 %U https://doi.org/10.2196/24727 %U http://www.ncbi.nlm.nih.gov/pubmed/33787499 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e18517 %T Attitudes and Engagement of Pregnant and Postnatal Women With a Web-Based Emotional Health Tool (Mummatters): Cross-sectional Study %A Reilly,Nicole %A Austin,Marie-Paule %+ Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong, Building 234 (iC Enterprise 1), Innovation Campus, Wollongong, 2522, Australia, 61 0242218045, nreilly@uow.edu.au %K pregnancy %K postpartum %K self-assessment %K depression %K risk %D 2021 %7 26.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Mummatters is a web-based health tool that allows women to self-assess the symptoms of depression and the presence of psychosocial risk factors throughout pregnancy and the postnatal period. It aims to increase women’s awareness of their own symptoms or risk factors and their knowledge of the available support options, to encourage engagement with these support options (as appropriate), and to facilitate communication about emotional health issues between women and their health care providers. Objective: The aim of this study is to report the uptake of mummatters; the sociodemographic and psychosocial risk profiles of a subsample of users; and the acceptability, credibility, perceived effect, and motivational appeal of the tool. The help-seeking behaviors of the subsample of users and barriers to help seeking were also examined. Methods: Mummatters was launched in November 2016. Women who completed the mummatters baseline assessment were invited to complete a web-based follow-up survey 1 month later. Results: A total of 2817 women downloaded and used mummatters between November 13, 2016, and May 22, 2018, and 140 women participated in the follow-up study. Approximately half of these women (51%; 72/140) were Whooley positive (possible depression), and 43% (60/140) had an elevated psychosocial risk score on the Antenatal Risk Questionnaire. Mummatters was rated favorably by pregnant and postnatal women in terms of its acceptability (94%-99%), credibility (93%-97%), appeal (78%-91%), and potential to affect a range of health behaviors specific to supporting emotional wellness during the perinatal period (78%-93%). Whooley-positive women were more likely to speak with their families than with a health care provider about their emotional health. Normalizing symptoms and stigma were key barriers to seeking help. Conclusions: Although mummatters was rated positively by consumers, only 53% (19/36) to 61% (22/36) of women with possible depression reported speaking to their health care providers about their emotional health. There was a trend for more prominent barriers to seeking help among postnatal women than among pregnant women. Future studies that investigate whether social barriers to seeking help are greater once a woman has an infant are warranted. Such barriers potentially place these women at greater risk of remaining untreated, as the demands on them are greater. %M 33769302 %R 10.2196/18517 %U https://www.jmir.org/2021/3/e18517 %U https://doi.org/10.2196/18517 %U http://www.ncbi.nlm.nih.gov/pubmed/33769302 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 3 %P e27138 %T Effectiveness of a Postpartum Text Message Program (Essential Coaching for Every Mother) on Maternal Psychosocial Outcomes: Protocol for a Randomized Controlled Trial %A Dol,Justine %A Aston,Megan %A McMillan,Douglas %A Tomblin Murphy,Gail %A Campbell-Yeo,Marsha %+ Faculty of Health, Dalhousie University, 6299 South St, Halifax, NS, B3H 4R2, Canada, 1 902 470 2640, Justine.dol@dal.ca %K text message %K mobile health %K postpartum education %K self-efficacy %K social support %K postpartum anxiety %K postpartum depression %D 2021 %7 25.3.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Women experience changes both physically and psychologically during their transition to motherhood. The postnatal period is a critical time for women to develop maternal self-efficacy. Mobile health interventions may offer a way to reach women during this critical period to offer support and information. Essential Coaching for Every Mother is a text message program that seeks to educate and support women during the first 6 weeks postpartum. Objective: The primary effectiveness objective is to compare the effectiveness of the Essential Coaching for Every Mother program on maternal psychosocial outcomes (self-efficacy, social support, postpartum depression, and postpartum anxiety) immediately after the intervention and 6 months postpartum, collectively as well as stratified by parity. The primary implementation objective is to evaluate the implementation extent and quality of the Essential Coaching for Every Mother program. Methods: This will be a hybrid type 1 effectiveness-implementation randomized controlled trial. A total of 140 mothers-to-be or new mothers from Nova Scotia will be recruited and randomized to the intervention or control arm, stratified by parity. The intervention arm will receive the Essential Coaching for Every Mother program, which consists of 53 messages sent twice a day for the first 2 weeks and daily for weeks 3 through 6. The control group will receive usual care. Messages are personalized based on the infant’s age and the woman’s self-selected preference for breastfeeding or formula feeding and tailored with the infant’s name and gender. Women can enroll in the program if they are ≥37 weeks pregnant or within 10 days postpartum, with the first message designed to be sent on the second evening after birth. The actual number of messages received will vary based on the timing of enrollment and the infant’s date of birth. Participants will complete questionnaires assessing self-efficacy, social support, and postpartum depression and anxiety at baseline (enrollment after birth) and 6 weeks (postintervention) and 6 months postpartum. Implementation data will be collected throughout the trial, and evaluation feedback will be collected at 6 weeks from women who received the intervention. Results: Recruitment for this study started on January 5, 2021, and is currently ongoing, with an anticipated date of recruitment completion of January 2022. Conclusions: This study will assess the effectiveness of a postpartum text message program to improve maternal self-efficacy and social support while decreasing postpartum depression and anxiety. It will also shed light on the implementation effectiveness of the program. Trial Registration: ClinicalTrials.gov NCT04730570; https://clinicaltrials.gov/ct2/show/NCT04730570 International Registered Report Identifier (IRRID): DERR1-10.2196/27138 %M 33764309 %R 10.2196/27138 %U https://www.researchprotocols.org/2021/3/e27138 %U https://doi.org/10.2196/27138 %U http://www.ncbi.nlm.nih.gov/pubmed/33764309 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e24387 %T Barriers to and Facilitators of User Engagement With Digital Mental Health Interventions: Systematic Review %A Borghouts,Judith %A Eikey,Elizabeth %A Mark,Gloria %A De Leon,Cinthia %A Schueller,Stephen M %A Schneider,Margaret %A Stadnick,Nicole %A Zheng,Kai %A Mukamel,Dana %A Sorkin,Dara H %+ University of California Irvine, 6210 Donald Bren Hall, Irvine, CA, 92697-3425, United States, 1 9498240246, jborghou@uci.edu %K mHealth %K eHealth %K mental health %K depression %K anxiety %K behavior %K mobile phone %D 2021 %7 24.3.2021 %9 Review %J J Med Internet Res %G English %X Background: Digital mental health interventions (DMHIs), which deliver mental health support via technologies such as mobile apps, can increase access to mental health support, and many studies have demonstrated their effectiveness in improving symptoms. However, user engagement varies, with regard to a user’s uptake and sustained interactions with these interventions. Objective: This systematic review aims to identify common barriers and facilitators that influence user engagement with DMHIs. Methods: A systematic search was conducted in the SCOPUS, PubMed, PsycINFO, Web of Science, and Cochrane Library databases. Empirical studies that report qualitative and/or quantitative data were included. Results: A total of 208 articles met the inclusion criteria. The included articles used a variety of methodologies, including interviews, surveys, focus groups, workshops, field studies, and analysis of user reviews. Factors extracted for coding were related to the end user, the program or content offered by the intervention, and the technology and implementation environment. Common barriers included severe mental health issues that hampered engagement, technical issues, and a lack of personalization. Common facilitators were social connectedness facilitated by the intervention, increased insight into health, and a feeling of being in control of one’s own health. Conclusions: Although previous research suggests that DMHIs can be useful in supporting mental health, contextual factors are important determinants of whether users actually engage with these interventions. The factors identified in this review can provide guidance when evaluating DMHIs to help explain and understand user engagement and can inform the design and development of new digital interventions. %M 33759801 %R 10.2196/24387 %U https://www.jmir.org/2021/3/e24387 %U https://doi.org/10.2196/24387 %U http://www.ncbi.nlm.nih.gov/pubmed/33759801 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e24023 %T Development of a Smartphone App to Predict and Improve the Rates of Suicidal Ideation Among Transgender Persons (TransLife): Qualitative Study %A Dubov,Alex %A Fraenkel,Liana %A Goldstein,Zil %A Arroyo,Hansel %A McKellar,Derek %A Shoptaw,Steve %+ School of Behavioral Health, Loma Linda University, 11065 Campus Street, Loma Linda, CA, 92350, United States, 1 9095581900, adubov@llu.edu %K mobile health %K mHealth %K mobile app %K pilot study %K qualitative research %K user-centered design %K acceptability study %K health services for transgender persons %K suicide prevention %K mental health %K mobile phone %D 2021 %7 24.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Transgender people are at a high risk of suicidal ideation, suicide attempts, and deaths. Among transgender individuals, 77% and 41% engage in suicidal ideation and suicide attempt in their lifetime, respectively, which exceeds the general population rates (9.2% and 2.7%, respectively). Traditionally, suicide risk factors have been studied over a long period between measurements, making it difficult to understand the short-term variability in suicide risk. Mobile phone apps offer an opportunity to understand the immediate precursors of suicidality through the assessment of behaviors and moods in real time. This is the first study to use a mobile phone app (TransLife) to understand the short-term risk factors for suicide among transgender individuals. Objective: This study aims to beta test the usability of an evidence-informed mobile health (mHealth) suicide prevention phone app, TransLife. The primary aims are to obtain preliminary data on user engagement and satisfaction with the app, and to assess the feasibility of completing ecological momentary assessments (mood logs) within the app. Methods: We used qualitative methods and an exploratory research approach that combined naturalistic app use, focus groups, and semistructured phone interviews. The focus group was informed about the development of the prototype. We conducted a 3-week evaluation to determine engagement and obtain detailed user feedback about the app. After participation in the pilot, phone-based, semistructured, and audio-recorded exit interviews were conducted with the research participants. Results: In total, 16 transgender individuals participated in this study. On average, users logged in 4 (SD 2.7) times a week and spent approximately 5 (SD 3.5) minutes on the app per log-in. A total of 6 major themes emerged in this study. These themes focused on the app’s functionality, satisfaction with using the app, perceived ease of use, perceived safety of providing personal data within the app, trusting the app enough to share personal feelings, and features that make this app engaging. These themes suggest that TransLife is an engaging, useful, and acceptable mHealth intervention. Participants reported that the app was easy to use and understand, supported mental self-care, promoted self-awareness, and helped them identify triggers of negative moods. Conclusions: The results of this pilot study indicate that TransLife is an engaging, acceptable, and potentially effective mHealth intervention. Transgender participants reported many advantages of using TransLife, such as being able to track their mood, connecting to the community, and accessing local resources. This study provides initial support for the acceptability and usability of TransLife as an mHealth intervention designed for the transgender community. %M 33596181 %R 10.2196/24023 %U https://www.jmir.org/2021/3/e24023 %U https://doi.org/10.2196/24023 %U http://www.ncbi.nlm.nih.gov/pubmed/33596181 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e24850 %T A Therapeutic Relational Agent for Reducing Problematic Substance Use (Woebot): Development and Usability Study %A Prochaska,Judith J %A Vogel,Erin A %A Chieng,Amy %A Kendra,Matthew %A Baiocchi,Michael %A Pajarito,Sarah %A Robinson,Athena %+ Stanford Prevention Research Center, School of Medicine, Stanford University, Medical School Office Building, X316, 1265 Welch Road, Stanford, CA, 94305, United States, 1 650 724 3608, jpro@stanford.edu %K artificial intelligence %K conversational agent %K chatbot %K addiction %K substance misuse %K treatment %K acceptability %K feasibility %K craving %K psychoeducation %K psychotherapeutic %K mobile phone %D 2021 %7 23.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Misuse of substances is common, can be serious and costly to society, and often goes untreated due to barriers to accessing care. Woebot is a mental health digital solution informed by cognitive behavioral therapy and built upon an artificial intelligence–driven platform to deliver tailored content to users. In a previous 2-week randomized controlled trial, Woebot alleviated depressive symptoms. Objective: This study aims to adapt Woebot for the treatment of substance use disorders (W-SUDs) and examine its feasibility, acceptability, and preliminary efficacy. Methods: American adults (aged 18-65 years) who screened positive for substance misuse without major health contraindications were recruited from online sources and flyers and enrolled between March 27 and May 6, 2020. In a single-group pre/postdesign, all participants received W-SUDs for 8 weeks. W-SUDs provided mood, craving, and pain tracking and modules (psychoeducational lessons and psychotherapeutic tools) using elements of dialectical behavior therapy and motivational interviewing. Paired samples t tests and McNemar nonparametric tests were used to examine within-subject changes from pre- to posttreatment on measures of substance use, confidence, cravings, mood, and pain. Results: The sample (N=101) had a mean age of 36.8 years (SD 10.0), and 75.2% (76/101) of the participants were female, 78.2% (79/101) were non-Hispanic White, and 72.3% (73/101) were employed. Participants’ W-SUDs use averaged 15.7 (SD 14.2) days, 12.1 (SD 8.3) modules, and 600.7 (SD 556.5) sent messages. About 94% (562/598) of all completed psychoeducational lessons were rated positively. From treatment start to end, in-app craving ratings were reduced by half (87/101, 86.1% reporting cravings in the app; odds ratio 0.48, 95% CI 0.32-0.73). Posttreatment assessment completion was 50.5% (51/101), with better retention among those who initially screened higher on substance misuse. From pre- to posttreatment, confidence to resist urges to use substances significantly increased (mean score change +16.9, SD 21.4; P<.001), whereas past month substance use occasions (mean change −9.3, SD 14.1; P<.001) and scores on the Alcohol Use Disorders Identification Test-Concise (mean change −1.3, SD 2.6; P<.001), 10-item Drug Abuse Screening Test (mean change −1.2, SD 2.0; P<.001), Patient Health Questionnaire-8 item (mean change 2.1, SD 5.2; P=.005), Generalized Anxiety Disorder-7 (mean change −2.3, SD 4.7; P=.001), and cravings scale (68.6% vs 47.1% moderate to extreme; P=.01) significantly decreased. Most participants would recommend W-SUDs to a friend (39/51, 76%) and reported receiving the service they desired (41/51, 80%). Fewer felt W-SUDs met most or all of their needs (22/51, 43%). Conclusions: W-SUDs was feasible to deliver, engaging, and acceptable and was associated with significant improvements in substance use, confidence, cravings, depression, and anxiety. Study attrition was high. Future research will evaluate W-SUDs in a randomized controlled trial with a more diverse sample and with the use of greater study retention strategies. Trial Registration: ClinicalTrials.gov NCT04096001; http://clinicaltrials.gov/ct2/show/NCT04096001. %M 33755028 %R 10.2196/24850 %U https://www.jmir.org/2021/3/e24850 %U https://doi.org/10.2196/24850 %U http://www.ncbi.nlm.nih.gov/pubmed/33755028 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 3 %P e24465 %T Predicting Emotional States Using Behavioral Markers Derived From Passively Sensed Data: Data-Driven Machine Learning Approach %A Sükei,Emese %A Norbury,Agnes %A Perez-Rodriguez,M Mercedes %A Olmos,Pablo M %A Artés,Antonio %+ Signal Theory and Communications Department, Universidad Carlos III de Madrid, Torres Quevedo Bldg, Av de la Universidad, 30, Leganés, 28911, Spain, 34 916248839, esukei@tsc.uc3m.es %K mental health %K affect %K mobile health %K mobile phone %K digital phenotype %K machine learning %K Bayesian analysis %K probabilistic models %K personalized models %D 2021 %7 22.3.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental health disorders affect multiple aspects of patients’ lives, including mood, cognition, and behavior. eHealth and mobile health (mHealth) technologies enable rich sets of information to be collected noninvasively, representing a promising opportunity to construct behavioral markers of mental health. Combining such data with self-reported information about psychological symptoms may provide a more comprehensive and contextualized view of a patient’s mental state than questionnaire data alone. However, mobile sensed data are usually noisy and incomplete, with significant amounts of missing observations. Therefore, recognizing the clinical potential of mHealth tools depends critically on developing methods to cope with such data issues. Objective: This study aims to present a machine learning–based approach for emotional state prediction that uses passively collected data from mobile phones and wearable devices and self-reported emotions. The proposed methods must cope with high-dimensional and heterogeneous time-series data with a large percentage of missing observations. Methods: Passively sensed behavior and self-reported emotional state data from a cohort of 943 individuals (outpatients recruited from community clinics) were available for analysis. All patients had at least 30 days’ worth of naturally occurring behavior observations, including information about physical activity, geolocation, sleep, and smartphone app use. These regularly sampled but frequently missing and heterogeneous time series were analyzed with the following probabilistic latent variable models for data averaging and feature extraction: mixture model (MM) and hidden Markov model (HMM). The extracted features were then combined with a classifier to predict emotional state. A variety of classical machine learning methods and recurrent neural networks were compared. Finally, a personalized Bayesian model was proposed to improve performance by considering the individual differences in the data and applying a different classifier bias term for each patient. Results: Probabilistic generative models proved to be good preprocessing and feature extractor tools for data with large percentages of missing observations. Models that took into account the posterior probabilities of the MM and HMM latent states outperformed those that did not by more than 20%, suggesting that the underlying behavioral patterns identified were meaningful for individuals’ overall emotional state. The best performing generalized models achieved a 0.81 area under the curve of the receiver operating characteristic and 0.71 area under the precision-recall curve when predicting self-reported emotional valence from behavior in held-out test data. Moreover, the proposed personalized models demonstrated that accounting for individual differences through a simple hierarchical model can substantially improve emotional state prediction performance without relying on previous days’ data. Conclusions: These findings demonstrate the feasibility of designing machine learning models for predicting emotional states from mobile sensing data capable of dealing with heterogeneous data with large numbers of missing observations. Such models may represent valuable tools for clinicians to monitor patients’ mood states. %M 33749612 %R 10.2196/24465 %U https://mhealth.jmir.org/2021/3/e24465 %U https://doi.org/10.2196/24465 %U http://www.ncbi.nlm.nih.gov/pubmed/33749612 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e18048 %T Impact of Web-Based Sharing and Viewing of Self-Harm–Related Videos and Photographs on Young People: Systematic Review %A Marchant,Amanda %A Hawton,Keith %A Burns,Lauren %A Stewart,Anne %A John,Ann %+ Swansea University Medical School, Singleton Park, Swansea, SA2 8PP, United Kingdom, 44 1792602568, A.John@swansea.ac.uk %K self-harm %K suicide %K social media %K internet %K systematic review %D 2021 %7 19.3.2021 %9 Review %J J Med Internet Res %G English %X Background: Given recent moves to remove or blur self-harm imagery or content on the web, it is important to understand the impact of posting, viewing, and reposting self-harm images on young people. Objective: The aim of this study is to systematically review research related to the emotional and behavioral impact on children and young people who view or share web-based self-harm–related videos or images. Methods: We searched databases (including Embase, PsychINFO, and MEDLINE) from January 1991 to February 2019. Search terms were categorized into internet use, images nonspecific and specific to the internet, and self-harm and suicide. Stepwise screening against specified criteria and data extraction were completed by two independent reviewers. Eligible articles were quality assessed, and a narrative synthesis was conducted. Results: A total of 19 independent studies (20 articles) were included. Of these, 4 studies focused on images, 10 (11 articles) on videos, and 5 on both. There were 4 quantitative, 9 qualitative, and 7 mixed methods articles. In total, 11 articles were rated as high quality. There has been an increase in graphic self-harm imagery over time. Potentially harmful content congregated on platforms with little moderation, anonymity, and easy search functions for images. A range of reactions and intentions were reported in relation to posting or viewing images of self-harm: from empathy, a sense of solidarity, and the use of images to give or receive help to potentially harmful ones suggesting new methods, normalization, and exacerbation of self-harm. Viewing images as an alternative to self-harm or a creative outlet were regarded in 2 studies as positive impacts. Reactions of anger, hostility, and ambivalence have been reported. There was some evidence of the role of imitation and reinforcement, driven partly by the number of comments and wound severity, but this was not supported by time series analyses. Conclusions: Although the results of this review support concern related to safety and exacerbation of self-harm through viewing images of self-harm, there may be potential for positive impacts in some of those exposed. Future research should evaluate the effectiveness and potential harms of current posting restrictions, incorporate user perspectives, and develop recovery-oriented content. Clinicians assessing distressed young people should ask about internet use, including access to self-harm images, as part of their assessment. %M 33739289 %R 10.2196/18048 %U https://www.jmir.org/2021/3/e18048 %U https://doi.org/10.2196/18048 %U http://www.ncbi.nlm.nih.gov/pubmed/33739289 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 3 %P e26589 %T Understanding Side Effects of Antidepressants: Large-scale Longitudinal Study on Social Media Data %A Saha,Koustuv %A Torous,John %A Kiciman,Emre %A De Choudhury,Munmun %+ Georgia Institute of Technology, E1566R, CODA Tech Square, 765 W Peachtree Street NW, Atlanta, GA, 30308, United States, 1 4046929496, koustuv.saha@gatech.edu %K antidepressants %K symptoms %K side effects %K digital pharmacovigilance %K social media %K mental health %K linguistic markers %K digital health %D 2021 %7 19.3.2021 %9 Short Paper %J JMIR Ment Health %G English %X Background: Antidepressants are known to show heterogeneous effects across individuals and conditions, posing challenges to understanding their efficacy in mental health treatment. Social media platforms enable individuals to share their day-to-day concerns with others and thereby can function as unobtrusive, large-scale, and naturalistic data sources to study the longitudinal behavior of individuals taking antidepressants. Objective: We aim to understand the side effects of antidepressants from naturalistic expressions of individuals on social media. Methods: On a large-scale Twitter data set of individuals who self-reported using antidepressants, a quasi-experimental study using unsupervised language analysis was conducted to extract keywords that distinguish individuals who improved and who did not improve following the use of antidepressants. The net data set consists of over 8 million Twitter posts made by over 300,000 users in a 4-year period between January 1, 2014, and February 15, 2018. Results: Five major side effects of antidepressants were studied: sleep, weight, eating, pain, and sexual issues. Social media language revealed keywords related to these side effects. In particular, antidepressants were found to show a spectrum of effects from decrease to increase in each of these side effects. Conclusions: This work enhances the understanding of the side effects of antidepressants by identifying distinct linguistic markers in the longitudinal social media data of individuals showing the most and least improvement following the self-reported intake of antidepressants. One implication of this work concerns the potential of social media data as an effective means to support digital pharmacovigilance and digital therapeutics. These results can inform clinicians in tailoring their discussion and assessment of side effects and inform patients about what to potentially expect and what may or may not be within the realm of normal aftereffects of antidepressants. %M 33739296 %R 10.2196/26589 %U https://mental.jmir.org/2021/3/e26589 %U https://doi.org/10.2196/26589 %U http://www.ncbi.nlm.nih.gov/pubmed/33739296 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 3 %P e22805 %T The Neurostimulation of the Brain in Depression Trial: Protocol for a Randomized Controlled Trial of Transcranial Direct Current Stimulation in Treatment-Resistant Depression %A Suleman,Raheem %A Tucker,Benjamin V %A Dursun,Serdar M %A Demas,Michael L %+ Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Centre, University of Alberta, 8440-112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 7804076504, rsuleman@ualberta.ca %K neuromodulation %K neurostimulation %K transcranial direct current stimulation %K electrical stimulation therapy %K psychiatric somatic therapies %K depression %K depressive disorder %K major depressive disorder %K depressive disorder, treatment resistant %K randomized controlled trial %K therapeutics %K clinical trial protocol %D 2021 %7 17.3.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Major depressive disorder (MDD) is the second highest cause of disability worldwide. Standard treatments for MDD include medicine and talk therapy; however, approximately 1 in 5 Canadians fail to respond to these approaches and must consider alternatives. Transcranial direct current stimulation (tDCS) is a safe, noninvasive method that uses electrical stimulation to change the activation pattern of different brain regions. By targeting those regions known to be affected in MDD, tDCS may be useful in ameliorating treatment-resistant depression. Objective: The objective of the Neurostimulation of the Brain in Depression trial is to compare the effectiveness of active versus sham tDCS in treating patients with ultraresistant MDD. The primary outcome will be the improvement in depressive symptoms, as measured by the change on the Mongtomery-Asberg Depression Rating Scale. Secondary outcomes will include changes in the Quick Inventory of Depressive Symptomatology Scale (subjective assessment), the World Health Organization Disability Assessment Schedule 2.0 (functional assessment), and the Screen for Cognitive Impairment in Psychiatry (cognitive assessment). Adverse events will be captured using the Young Mania Rating Scale; tDCS Adverse Events Questionnaire; Frequency, Intensity, and Burden of Side Effects Rating Scale; and Patient-Rated Inventory of Side Effects Scale. A parallel component of the study will involve assaying for baseline language function and the effect of treatment on language using an exploratory acoustic and semantic corpus analysis on recorded interviews. Participant accuracy and response latency on an auditory lexical decision task will also be evaluated. Methods: We will recruit inpatients and outpatients in the city of Edmonton, Alberta, and will deliver the study interventions at the Grey Nuns and University of Alberta Hospitals. Written informed consent will be obtained from all participants before enrollment. Eligible participants will be randomly assigned, in a double-blinded fashion, to receive active or sham tDCS, and they will continue receiving their usual pharmacotherapy and psychotherapy throughout the trial. In both groups, participants will receive 30 weekday stimulation sessions, each session being 30 minutes in length, with the anode over the left dorsolateral prefrontal cortex and the cathode over the right. Participants in the active group will be stimulated at 2 mA throughout, whereas the sham group will receive only a brief period of stimulation to mimic skin sensations felt in the active group. Measurements will be conducted at regular points throughout the trial and 30 days after trial completion. Results: The trial has been approved by the University of Alberta Research Ethics Board and is scheduled to commence in June 2021. The target sample size is 60 participants. Conclusions: This is a protocol for a multicenter, double-blinded, randomized controlled superiority trial comparing active versus sham tDCS in patients with treatment-resistant MDD. Trial Registration: ClinicalTrials.gov NCT04159012; http://clinicaltrials.gov/ct2/show/NCT04159012. International Registered Report Identifier (IRRID): PRR1-10.2196/22805 %M 33729165 %R 10.2196/22805 %U https://www.researchprotocols.org/2021/3/e22805 %U https://doi.org/10.2196/22805 %U http://www.ncbi.nlm.nih.gov/pubmed/33729165 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 3 %P e22569 %T Mental Health Specialist Video Consultations Versus Treatment-as-Usual for Patients With Depression or Anxiety Disorders in Primary Care: Randomized Controlled Feasibility Trial %A Tönnies,Justus %A Hartmann,Mechthild %A Wensing,Michel %A Szecsenyi,Joachim %A Peters-Klimm,Frank %A Brinster,Regina %A Weber,Dorothea %A Vomhof,Markus %A Icks,Andrea %A Friederich,Hans-Christoph %A Haun,Markus W %+ Department of General Internal Medicine and Psychosomatics, Heidelberg University, Im Neuenheimer Feld 410, Heidelberg, D-69120, Germany, 49 622156 ext 8774, markus.haun@med.uni-heidelberg.de %K primary care %K integrated care %K telepsychiatry %K videoconferencing %K depression %K anxiety %K recovery %K randomized controlled trial %D 2021 %7 12.3.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Most people affected by depression or anxiety disorders are treated solely by their primary care physician. Access to specialized mental health care is impeded by patients’ comorbidity and immobility in aging societies and long waiting times at the providers’ end. Video-based integrated care models may leverage limited resources more efficiently and provide timely specialized care in primary care settings. Objective: The study aims to evaluate the feasibility of mental health specialist video consultations with primary care patients with depression or anxiety disorders. Methods: Participants were recruited by their primary care physicians during regular practice visits. Patients who had experienced at least moderate symptoms of depression and/or anxiety disorders were considered eligible for the study. Patients were randomized into 2 groups receiving either treatment-as-usual as provided by their general practitioner or up to 5 video consultations conducted by a mental health specialist. Video consultations focused on systematic diagnosis and proactive monitoring using validated clinical rating scales, the establishment of an effective working alliance, and a stepped-care algorithm within integrated care adjusting treatments based on clinical outcomes. Feasibility outcomes were recruitment, rate of loss to follow-up, acceptability of treatment, and attendance at sessions. Effectiveness outcomes included depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), burden of specific somatic complaints (Somatic Symptom Disorder-B Criteria Scale-12), recovery (Recovery Assessment Scale-German [RAS-G]), and perception of chronic illness care (Patient Assessment of Chronic Illness Care), which were measured at baseline and 16 weeks postallocation by assessors blinded to the group allocation. Results: A total of 50 patients with depression and/or anxiety disorders were randomized, 23 in the intervention group and 27 in the treatment-as-usual group. The recruitment yield (number randomized per number screened) and the consent rate (number randomized per number eligible) were 69% (50/73) and 86% (50/58), respectively. Regarding acceptability, 87% (20/23) of the participants in the intervention group completed the intervention. Of the 108 planned video consultations, 102 (94.4%) were delivered. Follow-up rates were 96% (22/23) and 85% (23/27) for the intervention and control groups, respectively. The change from baseline scores at postmeasurement for the No Domination by Symptoms domain of recovery (RAS-G) was somewhat higher in the intervention group than in the control group (Mann-Whitney U test: rank-biserial r=0.19; 95% CI −0.09 to 0.46; P=.18). We did not detect any notable differences between the intervention and control groups in terms of other effectiveness outcomes. We did not observe any serious adverse events related to the trial. Conclusions: The intervention and study procedures were found to be feasible for patients, primary care practice staff, and mental health specialists. A sufficiently powered pragmatic trial on mental health specialist video consultations should be conducted to investigate their effectiveness in routine care. Trial Registration: German Clinical Trials Register DRKS00015812; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015812. %M 33709931 %R 10.2196/22569 %U https://mental.jmir.org/2021/3/e22569 %U https://doi.org/10.2196/22569 %U http://www.ncbi.nlm.nih.gov/pubmed/33709931 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 4 %N 1 %P e26340 %T A New Tool for Detecting COVID-19 Psychological Burden Among Postacute and Long-term Care Residents (Mood-5 Scale): Observational Study %A Mansbach,William E %A Mace,Ryan A %A Tanner,Melissa A %+ Mansbach Health Tools, LLC, PO Box 307, Simpsonville, MD, 21150, United States, 1 4438967409, wmansbach@thebcat.com %K nursing homes %K long-term care %K COVID-19 %K depression %K stress %K coping %K burden %K mental health %K elderly %K older adults %K risk %K telehealth %K self-assessment %K scale %K mood %D 2021 %7 10.3.2021 %9 Original Paper %J JMIR Aging %G English %X Background: Older adults are at high risk for developing serious somatic and psychological symptoms associated with COVID-19. Currently available instruments may not be sensitive to the concerns about COVID-19 in postacute and long-term care and their applications in telehealth remain to be clarified. Objective: We investigated the psychometric properties of the Mood-5 Scale (M5) as a rapid self-assessment of the COVID-19 psychological burden among postacute and long-term care residents. Methods: Residents (N=131), aged 50 years and above, from 20 postacute and long-term care facilities in Maryland, USA, were evaluated in-person or via telehealth (43/131, 32.8%) across a 4-week period (May 11 to June 5, 2020) during the COVID-19 pandemic. The COVID-19 psychological burden experienced by the residents was rated by geriatric psychologists who independently reviewed their clinical documentation. Psychometric analyses were performed on the M5 in relation to psychological tests, COVID-19 psychological burden, and diagnostic data collected during the evaluation. Results: The M5 demonstrated acceptable internal consistency (Cronbach α=.77). M5 scores were not confounded by demographic variables or telehealth administration (P>.08). Convergent validity for the M5 was established via positive associations with anxiety (r=0.56, P<.001) and depressive (r=0.49, P<.001) symptoms. An M5 cutoff score of 3 demonstrated strong sensitivity (0.92) and adequate specificity (0.75) for identifying COVID-19 psychological distress among postacute and long-term care residents (area under the curve of 0.89, positive predictive value=0.79, negative predictive value=0.91). Conclusions: The M5 is a reliable and valid tool for self-assessment of mood that can help identify postacute and long-term care residents with significant psychological burden associated with COVID-19. It can be completed in less than 1 minute and is appropriate for use in both in-person and virtual visits. %M 33640866 %R 10.2196/26340 %U https://aging.jmir.org/2021/1/e26340 %U https://doi.org/10.2196/26340 %U http://www.ncbi.nlm.nih.gov/pubmed/33640866 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e24380 %T Online Mindfulness-Based Cognitive Behavioral Therapy Intervention for Youth With Major Depressive Disorders: Randomized Controlled Trial %A Ritvo,Paul %A Knyahnytska,Yuliya %A Pirbaglou,Meysam %A Wang,Wei %A Tomlinson,George %A Zhao,Haoyu %A Linklater,Renee %A Bai,Shari %A Kirk,Megan %A Katz,Joel %A Harber,Lillian %A Daskalakis,Zafiris %+ Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, United States, 1 (858) 534 2230, zdaskalakis@health.ucsd.edu %K intervention study %K telemedicine %K electronic CBT %K clinical trial %K depression %K cognitive behavioral therapy %K CBT %K online therapy %K online intervention %K youth %K young adult %D 2021 %7 10.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Approximately 70% of mental health disorders appear prior to 25 years of age and can become chronic when ineffectively treated. Individuals between 18 and 25 years old are significantly more likely to experience mental health disorders, substance dependencies, and suicidality. Treatment progress, capitalizing on the tendencies of youth to communicate online, can strategically address depressive disorders. Objective: We performed a randomized controlled trial (RCT) that compared online mindfulness-based cognitive behavioral therapy (CBT-M) combined with standard psychiatric care to standard psychiatric care alone in youth (18-30 years old) diagnosed with major depressive disorder. Methods: Forty-five participants were randomly assigned to CBT-M and standard care (n=22) or to standard psychiatric care alone (n=23). All participants were provided standard psychiatric care (ie, 1 session per month), while participants in the experimental group received an additional intervention consisting of the CBT-M online software program. Interaction with online workbooks was combined with navigation coaching delivered by phone and secure text messaging. Results: In a two-level linear mixed-effects model intention-to-treat analysis, significant between-group differences were found for the Beck Depression Inventory-II score (difference –8.54, P=.01), Quick Inventory of Depressive Symptoms score (difference –4.94, P=.001), Beck Anxiety Inventory score (difference –11.29, P<.001), and Brief Pain Inventory score (difference –1.99, P=.03), while marginal differences were found for the Five Facet Mindfulness Questionnaire–Nonjudging subscale (difference –2.68, P=.05). Conclusions: These results confirm that youth depression can be effectively treated with online CBT-M that can be delivered with less geographic restriction. Trial Registration: Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052 %M 33688840 %R 10.2196/24380 %U https://www.jmir.org/2021/3/e24380 %U https://doi.org/10.2196/24380 %U http://www.ncbi.nlm.nih.gov/pubmed/33688840 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 3 %P e24534 %T The Impact of a Web-Based Mindfulness, Nutrition, and Physical Activity Platform on the Health Status of First-Year University Students: Protocol for a Randomized Controlled Trial %A Trottier,Claire F %A Lieffers,Jessica R L %A Johnson,Steven T %A Mota,João F %A Gill,Roshni K %A Prado,Carla M %+ Human Nutrition Research Unit, Department of Agricultural, Food and Nutritional Science, University of Alberta, 2-004 Li Ka Shing Centre for Health and Innovation, 8602 - 112 Street, Edmonton, AB, T6G 2R3, Canada, 1 780 492 7934, cprado@ualberta.ca %K internet-based intervention %K wellness programs %K dietary intake %K physical activity %K mindfulness %K quality of life %K randomized controlled trial %D 2021 %7 10.3.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: First-year university students are at an increased risk for developing mental health issues and a poor nutritional status. Self-care plays an essential role in optimizing mental health and can prevent or manage stress, anxiety, and depression. Web-based self-monitoring of diet and physical activity can lead to similar or improved health outcomes compared with conventional methods. Such tools are also popular among university students. Objective: The primary aim of this 12-week randomized controlled trial is to assess the impact of a web-based wellness platform on perceived stress among first-year university students. The secondary aim is to assess the effects of the platform on diet quality. The exploratory objectives are to explore the effects of the platform on body composition, health-related quality of life, mindfulness, mental well-being, and physical activity. Methods: A total of 97 first-year undergraduate students were randomized to either the intervention (n=48) or control (n=49) group. The intervention consisted of access to a web-based platform called My Viva Plan (MVP), which aims to support healthy living by focusing on the topics of mindfulness, nutrition, and physical activity. The platform is fully automated and guided by the principles of cognitive behavioral theory. Participants in the intervention group were instructed to use the MVP as frequently as possible over 12 weeks. The control group did not receive access to MVP. Perceived stress was assessed using the Stress Indicators Questionnaire at baseline, week 6, and week 12. Three-day food records were used to analyze the dietary intake at baseline and week 12. Health-related quality of life, mindfulness, mental well-being, and physical activity questionnaires were completed at baseline, week 6, and week 12. Body composition was assessed at baseline and week 12. Study assessments were completed in person at baseline and week 12 and electronically at week 6. Results: Study recruitment started in August 2018, with batch enrollment for students registered in the fall (September 2018 to December 2018) and winter (January 2019 to April 2019) academic terms at the University of Alberta, Edmonton, Alberta. Conclusions: This study is the first to explore the impact of a web-based platform designed to promote health and wellness on perceived stress and diet quality among first-year university students. Trial Registration: ClinicalTrials.gov NCT03579264; https://clinicaltrials.gov/ct2/show/NCT03579264. International Registered Report Identifier (IRRID): DERR1-10.2196/24534 %M 33688844 %R 10.2196/24534 %U https://www.researchprotocols.org/2021/3/e24534 %U https://doi.org/10.2196/24534 %U http://www.ncbi.nlm.nih.gov/pubmed/33688844 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 3 %P e24365 %T Tracking and Monitoring Mood Stability of Patients With Major Depressive Disorder by Machine Learning Models Using Passive Digital Data: Prospective Naturalistic Multicenter Study %A Bai,Ran %A Xiao,Le %A Guo,Yu %A Zhu,Xuequan %A Li,Nanxi %A Wang,Yashen %A Chen,Qinqin %A Feng,Lei %A Wang,Yinghua %A Yu,Xiangyi %A Wang,Chunxue %A Hu,Yongdong %A Liu,Zhandong %A Xie,Haiyong %A Wang,Gang %+ The National Clinical Research Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, No 5 Ankang Lane, Xicheng District, Beijing, 100088, China, 86 13466604224, gangwangdoc@ccmu.edu.cn %K digital phenotype %K major depressive disorder %K machine learning %K mobile phone %D 2021 %7 8.3.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Major depressive disorder (MDD) is a common mental illness characterized by persistent sadness and a loss of interest in activities. Using smartphones and wearable devices to monitor the mental condition of patients with MDD has been examined in several studies. However, few studies have used passively collected data to monitor mood changes over time. Objective: The aim of this study is to examine the feasibility of monitoring mood status and stability of patients with MDD using machine learning models trained by passively collected data, including phone use data, sleep data, and step count data. Methods: We constructed 950 data samples representing time spans during three consecutive Patient Health Questionnaire-9 assessments. Each data sample was labeled as Steady or Mood Swing, with subgroups Steady-remission, Steady-depressed, Mood Swing-drastic, and Mood Swing-moderate based on patients’ Patient Health Questionnaire-9 scores from three visits. A total of 252 features were extracted, and 4 feature selection models were applied; 6 different combinations of types of data were experimented with using 6 different machine learning models. Results: A total of 334 participants with MDD were enrolled in this study. The highest average accuracy of classification between Steady and Mood Swing was 76.67% (SD 8.47%) and that of recall was 90.44% (SD 6.93%), with features from all types of data being used. Among the 6 combinations of types of data we experimented with, the overall best combination was using call logs, sleep data, step count data, and heart rate data. The accuracies of predicting between Steady-remission and Mood Swing-drastic, Steady-remission and Mood Swing-moderate, and Steady-depressed and Mood Swing-drastic were over 80%, and the accuracy of predicting between Steady-depressed and Mood Swing-moderate and the overall Steady to Mood Swing classification accuracy were over 75%. Comparing all 6 aforementioned combinations, we found that the overall prediction accuracies between Steady-remission and Mood Swing (drastic and moderate) are better than those between Steady-depressed and Mood Swing (drastic and moderate). Conclusions: Our proposed method could be used to monitor mood changes in patients with MDD with promising accuracy by using passively collected data, which can be used as a reference by doctors for adjusting treatment plans or for warning patients and their guardians of a relapse. Trial Registration: Chinese Clinical Trial Registry ChiCTR1900021461; http://www.chictr.org.cn/showprojen.aspx?proj=36173 %M 33683207 %R 10.2196/24365 %U https://mhealth.jmir.org/2021/3/e24365 %U https://doi.org/10.2196/24365 %U http://www.ncbi.nlm.nih.gov/pubmed/33683207 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 3 %P e20036 %T Transdiagnostic Internet Intervention for Indonesian University Students With Depression and Anxiety: Evaluation of Feasibility and Acceptability %A Rahmadiana,Metta %A Karyotaki,Eirini %A Schulte,Mieke %A Ebert,David Daniel %A Passchier,Jan %A Cuijpers,Pim %A Berger,Thomas %A van Ballegooijen,Wouter %A Wimbarti,Supra %A Riper,Heleen %+ Department of Clinical, Neuro and Developmental Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, Amsterdam, 1081 BT, Netherlands, 31 20 5988951, m.r.rahmadiana@vu.nl %K anxiety %K cultural adaptation %K depression %K guided %K internet-based intervention %K transdiagnostic %K university students %D 2021 %7 5.3.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: University students with depression and anxiety do not easily receive or seek treatment; therefore, internet-based interventions have been suggested to be a promising way to improve treatment accessibility and availability. However, it has not been examined whether a guided, culturally adapted, transdiagnostic, internet-based intervention is effective for treating symptoms of depression, anxiety, or both among university students in Indonesia. Objective: This study aims to investigate the feasibility (acceptability and satisfaction, usability, and uptake) of a guided, culturally adapted, transdiagnostic, internet-based intervention among university students with symptoms of depression, anxiety, or both in Indonesia. Methods: Students from Universitas Gadjah Mada, Yogyakarta, Indonesia, were screened for symptoms of depression, anxiety, or both, and filled online informed consent, demographic questionnaires, and a quality of life measure at pretreatment assessment (T0). Subsequently, the participants started the intervention. Seven weeks after T0, the primary outcomes of this feasibility study were analyzed at posttreatment assessment (T1) using the 8-item Client Satisfaction Questionnaire (CSQ-8) and the System Usability Scale (SUS). Mean and SDs for the CSQ-8 and SUS were calculated to examine feasibility. Within-group secondary outcomes (depression, anxiety, and quality of life) were inspected for outliers and normal distribution. Paired-sample t tests were used to investigate differences between time points of secondary outcomes. A mixed-method approach of quantitative and qualitative analyses was adopted. Both the primary and secondary outcomes were additionally explored with an individual semistructured interview and synthesized descriptively. Results: A total of 50 participants completed the intervention. We found a moderate to high level of satisfaction and acceptability, a slightly below-average level of desirable usability (≥70), and an adherence rate of 52% which was higher than expected given the novelty of the intervention. Results for the secondary outcomes indicated a decrease in depression and anxiety. For depression, the overall mean difference between the 2 time points for depression was 3.92 (95% CI 2.75-5.1; Hedges g 1.15; P<.001). For anxiety, the overall mean difference between the 2 time points was 3.34 (95% CI 2.06-4.61; Hedges g 1.02; P<.001). Further, a moderate effect in improving quality of life was found (g=0.50). Overall, participants were positive about the online intervention and ECoaches (online guidance), and they found the intervention to be culturally appropriate. Conclusions: A culturally adapted, transdiagnostic, internet-based intervention appears to be acceptable and feasible for reducing symptoms of depression, anxiety, or both, and increasing quality of life in university students in Indonesia. Future studies should include a randomized controlled trial to assess the effectiveness of such interventions as they may supplement existing counseling services in universities, reduce the treatment costs, and maximize treatment accessibility in low-resourced settings. International Registered Report Identifier (IRRID): RR2-10.1016/j.invent.2018.11.002 %M 33666553 %R 10.2196/20036 %U https://mental.jmir.org/2021/3/e20036 %U https://doi.org/10.2196/20036 %U http://www.ncbi.nlm.nih.gov/pubmed/33666553 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 3 %P e23892 %T Acceptability, Safety, and Resonance of the Pilot Digital Suicide Prevention Campaign “Better Off With You”: Qualitative Study %A Carrotte,Elise Rose %A Webb,Marianne %A Flego,Anna %A Vincent,Bonnie %A Heath,Jack %A Blanchard,Michelle %+ Anne Deveson Research Centre, SANE Australia, PO Box 226, South Melbourne, 3205, Australia, 61 3 9682 5933, elise.carrotte@sane.org %K suicide %K interpersonal theory of suicide %K social media %K co-design %K lived experience %D 2021 %7 3.3.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The Interpersonal Theory of Suicide posits that there are three key elements of suicidal behavior: perceived burdensomeness, thwarted belongingness, and the acquired capability for suicide. The digital campaign Better Off With You was developed to directly challenge the idea of perceived burdensomeness among people who are contemplating suicide in 2 communities within Australia. Objective: The aim of this study is to explore the needs and preferences of people with lived experience of suicidal thoughts and actions to inform the development of Better Off With You. Methods: This study involved a series of focus groups that aimed to discuss campaign messaging, scope, and approach. People with lived experience of suicidal thoughts and actions attended the focus groups. After the completion of initial focus groups, the results informed the creation of campaign collateral by creative agencies. Early versions of the campaign collateral were then presented in the user testing sessions. Transcriptions were analyzed via thematic analysis. Results: In total, 13 participants attended the focus groups and 14 attended the user testing sessions. The following three overarching themes were presented: acceptability, safety, and resonance. Participants believed that suicide is a serious and ongoing issue in their communities and welcomed a localized suicide prevention focus via peer-to-peer storytelling. The idea of perceived burdensomeness required clarification but was perceived as acceptable and relevant. Participants seemed drawn toward peer narratives that they perceived to be authentic, genuine, and believable as given by real people with lived experience. Campaign messaging needs to be clear and empathetic while directly talking about suicide. Participants did not anticipate any significant negative or harmful impact from any campaign videos and highlighted the importance of providing appropriate help-seeking information. Conclusions: This iterative study provided important insights and knowledge about peer-to-peer storytelling in suicide prevention campaigns. Future campaigns should involve simple messaging, be validating and empathetic, and consider including a lived experience perspective. %M 33656441 %R 10.2196/23892 %U https://formative.jmir.org/2021/3/e23892 %U https://doi.org/10.2196/23892 %U http://www.ncbi.nlm.nih.gov/pubmed/33656441 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 3 %P e23022 %T Using a Tablet-Based App to Deliver Evidence-Based Practices for Suicidal Patients in the Emergency Department: Pilot Randomized Controlled Trial %A Dimeff,Linda A %A Jobes,David A %A Koerner,Kelly %A Kako,Nadia %A Jerome,Topher %A Kelley-Brimer,Angela %A Boudreaux,Edwin D %A Beadnell,Blair %A Goering,Paul %A Witterholt,Suzanne %A Melin,Gabrielle %A Samike,Vicki %A Schak,Kathryn M %+ Evidence Based Practice Institute, Inc, 7241 36th Avenue SW, Seattle, WA, 98126, United States, 1 206 284 7371, linda.dimeff@jasprhealth.com %K suicide %K emergency department %K digital technology %K suicide prevention %D 2021 %7 1.3.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Emergency departments (EDs) have the potential to provide evidence-based practices for suicide prevention to patients who are acutely suicidal. However, few EDs have adequate time and personnel resources to deliver recommended evidence-based assessment and interventions. To raise the clinical standard of care for patients who are suicidal and seeking psychiatric crisis services in the ED, we developed Jaspr Health, a tablet-based app for direct use by such patients, which enables the delivery of 4 evidence-based practices. Objective: This study aims to evaluate the feasibility, acceptability, and effectiveness of Jaspr Health among suicidal adults in EDs. Methods: Patients who were acutely suicidal and seeking psychiatric crisis services participated in an unblinded pilot randomized controlled trial while in the ED. Participants were randomly assigned to Jaspr Health (n=14) or care as usual (control; n=17) groups. Participants were assessed at baseline, and a 2-hour posttest using self-report measures and a semistructured interview were conducted. Results: Conditions differed significantly at baseline with regard to age but not other demographic variables or baseline measures. On average, participants had been in the ED for 17 hours before enrolling in the study. Over their lifetime, 84% (26/31) of the sample had made a suicide attempt (mean 3.4, SD 6.4) and 61% (19/31) had engaged in nonsuicidal self-injurious behaviors, with an average rate of 8.8 times in the past 3 months. All established feasibility and acceptability criteria were met: no adverse events occurred, participants’ app use was high, Jaspr Health app user satisfaction ratings were high, and all participants using Jaspr Health recommended its use for other suicidal ED patients. Comparisons between study conditions provide preliminary support for the effectiveness of the app: participants using Jaspr Health reported a statistically significant increase in receiving 4 evidence-based suicide prevention interventions and overall satisfaction ratings with their ED experience. In addition, significant decreases in distress and agitation, along with significant increases in learning to cope more effectively with current and future suicidal thoughts, were observed among participants using Jaspr Health compared with those receiving care as usual. Conclusions: Even with limited statistical power, the results showed that Jaspr Health is feasible, acceptable, and clinically effective for use by ED patients who are acutely suicidal and seeking ED-based psychiatric crisis services. Trial Registration: ClinicalTrials.gov NCT03584386; https://clinicaltrials.gov/ct2/show/NCT03584386 %M 33646129 %R 10.2196/23022 %U https://mental.jmir.org/2021/3/e23022 %U https://doi.org/10.2196/23022 %U http://www.ncbi.nlm.nih.gov/pubmed/33646129 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 2 %P e25834 %T Improving Mood Through Community Connection and Resources Using an Interactive Digital Platform: Development and Usability Study %A Ortiz,Robin %A Southwick,Lauren %A Schneider,Rachelle %A Klinger,Elissa V %A Pelullo,Arthur %A Guntuku,Sharath Chandra %A Merchant,Raina M %A Agarwal,Anish K %+ Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Bvld, Philadelphia, PA, 19104, United States, 1 9145826995, robin.ortiz@pennmedicine.upenn.edu %K community %K COVID-19 %K digital health %K digital tool %K mental health %K mood %K prospective %K thematic analysis %K virtual support %K well-being %D 2021 %7 26.2.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: COVID-19 continues to disrupt global health and well-being. In April-May 2020, we generated a digital, remote interactive tool to provide health and well-being resources and foster connectivity among community members through a text messaging platform. Objective: This study aimed to prospectively investigate the ability of a health system–based digital, remote, interactive tool to provide health and well-being resources to local community participants and to foster connectivity among them during the early phases of COVID-19. Methods: We performed descriptive and nonparametric longitudinal statistical analyses to describe and compare the participants’ mood ratings over time and thematic analysis of their responses to text messages to further assess mood. Results: From among 393 individuals seeking care in an urban emergency department in an academic setting, engaged in a two-way text messaging platform, we recorded 287 mood ratings and 368 qualitative responses. We observed no difference in the initial mood rating by week of enrollment [Kruskal-Wallis chi-square H(5)=1.34; P=.93], and the average mood rating did not change for participants taken together [Friedman chi-square Q(3)=0.32; P=.96]. However, of participants providing mood ratings at baseline, mood improved significantly among participants who reported a low mood rating at baseline [n=25, 14.97%; Q(3)=20.68; P<.001] but remained stable among those who reported a high mood rating at baseline [n=142, 85.03%; Q(3)=2.84; P=.42]. Positive mood elaborations most frequently included words related to sentiments of thankfulness and gratitude, mostly for a sense of connection and communication; in contrast, negative mood elaborations most frequently included words related to anxiety. Conclusions: Our findings suggest the feasibility of engaging individuals in a digital community with an emergency department facilitation. Specifically, for those who opt to engage in a text messaging platform during COVID-19, it is feasible to assess and respond to mood-related queries with vetted health and well-being resources. %M 33635280 %R 10.2196/25834 %U https://mental.jmir.org/2021/2/e25834 %U https://doi.org/10.2196/25834 %U http://www.ncbi.nlm.nih.gov/pubmed/33635280 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e14179 %T Ecological Momentary Assessment Using Smartphones in Patients With Depression: Feasibility Study %A Maatoug,Redwan %A Peiffer-Smadja,Nathan %A Delval,Guillaume %A Brochu,Térence %A Pitrat,Benjamin %A Millet,Bruno %+ Sorbonne Université, AP-HP, Service de psychiatrie adulte de la Pitié-Salpêtrière, Institut du Cerveau, ICM, F-75013, 47-83 Boulevard de l'hôpital, Paris, 75013, France, 33 682476484, redwanmaatoug@gmail.com %K ecological momentary assessment %K depression %K smartphone %K feasibility study %K user experience %D 2021 %7 24.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Ecological momentary assessment (EMA) is a promising tool in the management of psychiatric disorders and particularly depression. It allows for a real-time evaluation of symptoms and an earlier detection of relapse or treatment efficacy. The generalization of the smartphone in the modern world offers a new, large-scale support for EMA. Objective: The main objective of this study was twofold: (1) to assess patients’ compliance with an EMA smartphone app defined by the number of EMAs completed, and (2) to estimate the external validity of the EMA using a correlation between self-esteem/guilt/mood variables and Hamilton Depression Rating Scale (HDRS) score. Methods: Eleven patients at the Pitié-Salpêtrière Hospital, Paris, France, were monitored for 28 days by means of a smartphone app. Every patient enrolled in the study had two types of assessment: (1) three outpatient consultations with a psychiatrist at three different time points (days 1, 15, and 28), and (2) real-time data collection using an EMA smartphone app with a single, fixed notification per day at 3 pm for 28 days. The results of the real-time data collected were reviewed during the three outpatient consultations by a psychiatrist using a dashboard that aggregated all of the patients’ data into a user-friendly format. Results: Of the 11 patients in the study, 6 patients attended the 3 outpatient consultations with the psychiatrist and completed the HDRS at each consultation. We found a positive correlation between the HDRS score and the variables of self-esteem, guilt, and mood (Spearman correlation coefficient 0.57). Seven patients completed the daily EMAs for 28 days or longer, with an average response rate to the EMAs of 62.5% (175/280). Furthermore, we observed a positive correlation between the number of responses to EMAs and the duration of follow-up (Spearman correlation coefficient 0.63). Conclusions: This preliminary study with a prolonged follow-up demonstrates significant patient compliance with the smartphone app. In addition, the self-assessments performed by patients seemed faithful to the standardized measurements performed by the psychiatrist. The results also suggest that for some patients it is more convenient to use the smartphone app than to attend outpatient consultations. %M 33625367 %R 10.2196/14179 %U https://formative.jmir.org/2021/2/e14179 %U https://doi.org/10.2196/14179 %U http://www.ncbi.nlm.nih.gov/pubmed/33625367 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 2 %P e22705 %T Factors Influencing Depression and Mental Distress Related to COVID-19 Among University Students in China: Online Cross-sectional Mediation Study %A Yu,Yanqiu %A She,Rui %A Luo,Sitong %A Xin,Meiqi %A Li,Lijuan %A Wang,Suhua %A Ma,Le %A Tao,Fangbiao %A Zhang,Jianxin %A Zhao,Junfeng %A Li,Liping %A Hu,Dongsheng %A Zhang,Guohua %A Gu,Jing %A Lin,Danhua %A Wang,Hongmei %A Cai,Yong %A Wang,Zhaofen %A You,Hua %A Hu,Guoqing %A Lau,Joseph Tak-Fai %+ Centre for Health Behaviours Research, Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Prince Whales Hospital, Sha Tin, Hong Kong, Hong Kong, 852 22528727, jlau@cuhk.edu.hk %K COVID-19 %K depression %K mental distress %K psychological responses %K mediation %K China %K online survey %D 2021 %7 22.2.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The COVID-19 epidemic may elevate mental distress and depressive symptoms in various populations in China. Objective: This study investigates the levels of depression and mental distress due to COVID-19, and the associations between cognitive, behavioral, and psychosocial factors, and depression and mental distress due to COVID-19 among university students in China. Methods: A large-scale online cross-sectional study (16 cities in 13 provinces) was conducted among university students from February 1 to 10, 2020, in China; 23,863 valid questionnaires were returned. The Patient Health Questionnaire-9 was used to assess depression. Structural equation modeling was performed to test mediation and suppression effects. Results: Of the 23,863 participants, 47.1% (n=11,235) reported high or very high levels of one or more types of mental distress due to COVID-19; 39.1% (n=9326) showed mild to severe depression. Mental distress due to COVID-19 was positively associated with depression. All but one factor (perceived infection risks, perceived chance of controlling the epidemic, staying at home, contacted people from Wuhan, and perceived discrimination) were significantly associated with mental distress due to COVID-19 and depression. Mental distress due to COVID-19 partially mediated and suppressed the associations between some of the studied factors and depression (effect size of 6.0%-79.5%). Conclusions: Both mental distress due to COVID-19 and depression were prevalent among university students in China; the former may have increased the prevalence of the latter. The studied cognitive, behavioral, and psychosocial factors related to COVID-19 may directly or indirectly (via mental distress due to COVID-19) affect depression. Interventions to modify such factors may reduce mental distress and depressive symptoms during the COVID-19 epidemic. %M 33616541 %R 10.2196/22705 %U https://mental.jmir.org/2021/2/e22705 %U https://doi.org/10.2196/22705 %U http://www.ncbi.nlm.nih.gov/pubmed/33616541 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 2 %P e23813 %T Impact of a Web-Based Psychiatric Assessment on the Mental Health and Well-Being of Individuals Presenting With Depressive Symptoms: Longitudinal Observational Study %A Mirea,Dan-Mircea %A Martin-Key,Nayra A %A Barton-Owen,Giles %A Olmert,Tony %A Cooper,Jason D %A Han,Sung Yeon Sarah %A Farrag,Lynn P %A Bell,Emily %A Friend,Lauren V %A Eljasz,Pawel %A Cowell,Daniel %A Tomasik,Jakub %A Bahn,Sabine %+ Department of Chemical Engineering and Biotechnology, University of Cambridge, Philippa Fawcett Dr, Cambridge CB3 0AS, Cambridge, United Kingdom, 44 1223 334151, sb209@cam.ac.uk %K online assessment %K mental health %K e-health %K digital diagnosis %K mood disorders %K bipolar disorder %K major depressive disorder %D 2021 %7 22.2.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Web-based assessments of mental health concerns hold great potential for earlier, more cost-effective, and more accurate diagnoses of psychiatric conditions than that achieved with traditional interview-based methods. Objective: The aim of this study was to assess the impact of a comprehensive web-based mental health assessment on the mental health and well-being of over 2000 individuals presenting with symptoms of depression. Methods: Individuals presenting with depressive symptoms completed a web-based assessment that screened for mood and other psychiatric conditions. After completing the assessment, the study participants received a report containing their assessment results along with personalized psychoeducation. After 6 and 12 months, participants were asked to rate the usefulness of the web-based assessment on different mental health–related outcomes and to self-report on their recent help-seeking behavior, diagnoses, medication, and lifestyle changes. In addition, general mental well-being was assessed at baseline and both follow-ups using the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Results: Data from all participants who completed either the 6-month or the 12-month follow-up (N=2064) were analyzed. The majority of study participants rated the study as useful for their subjective mental well-being. This included talking more openly (1314/1939, 67.77%) and understanding one’s mental health problems better (1083/1939, 55.85%). Although most participants (1477/1939, 76.17%) found their assessment results useful, only a small proportion (302/2064, 14.63%) subsequently discussed them with a mental health professional, leading to only a small number of study participants receiving a new diagnosis (110/2064, 5.33%). Among those who were reviewed, new mood disorder diagnoses were predicted by the digital algorithm with high sensitivity (above 70%), and nearly half of the participants with new diagnoses also had a corresponding change in medication. Furthermore, participants’ subjective well-being significantly improved over 12 months (baseline WEMWBS score: mean 35.24, SD 8.11; 12-month WEMWBS score: mean 41.19, SD 10.59). Significant positive predictors of follow-up subjective well-being included talking more openly, exercising more, and having been reviewed by a psychiatrist. Conclusions: Our results suggest that completing a web-based mental health assessment and receiving personalized psychoeducation are associated with subjective mental health improvements, facilitated by increased self-awareness and subsequent use of self-help interventions. Integrating web-based mental health assessments within primary and/or secondary care services could benefit patients further and expedite earlier diagnosis and effective treatment. International Registered Report Identifier (IRRID): RR2-10.2196/18453 %M 33616546 %R 10.2196/23813 %U https://mental.jmir.org/2021/2/e23813 %U https://doi.org/10.2196/23813 %U http://www.ncbi.nlm.nih.gov/pubmed/33616546 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e25175 %T A Web-Based eHealth Intervention to Improve the Quality of Life of Older Adults With Multiple Chronic Conditions: Protocol for a Randomized Controlled Trial %A Gustafson Sr,David H %A Mares,Marie-Louise %A Johnston,Darcie C %A Mahoney,Jane E %A Brown,Randall T %A Landucci,Gina %A Pe-Romashko,Klaren %A Cody,Olivia J %A Gustafson Jr,David H %A Shah,Dhavan V %+ Center for Health Enhancement Systems Studies, University of Wisconsin–Madison, Mechanical Engineering, 4th Fl, 1513 University Avenue, Madison, WI, 53706, United States, 1 608 890 2615, dcjohnston@wisc.edu %K eHealth %K telemedicine %K aged %K geriatrics %K multiple chronic conditions %K depression %K social support %K quality of life %K primary care %K health expenditures %K mobile phone %D 2021 %7 19.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Multiple chronic conditions (MCCs) are common among older adults and expensive to manage. Two-thirds of Medicare beneficiaries have multiple conditions (eg, diabetes and osteoarthritis) and account for more than 90% of Medicare spending. Patients with MCCs also experience lower quality of life and worse medical and psychiatric outcomes than patients without MCCs. In primary care settings, where MCCs are generally treated, care often focuses on laboratory results and medication management, and not quality of life, due in part to time constraints. eHealth systems, which have been shown to improve multiple outcomes, may be able to fill the gap, supplementing primary care and improving these patients’ lives. Objective: This study aims to assess the effects of ElderTree (ET), an eHealth intervention for older adults with MCCs, on quality of life and related measures. Methods: In this unblinded study, 346 adults aged 65 years and older with at least 3 of 5 targeted high-risk chronic conditions (hypertension, hyperlipidemia, diabetes, osteoarthritis, and BMI ≥30 kg/m2) were recruited from primary care clinics and randomized in a ratio of 1:1 to one of 2 conditions: usual care (UC) plus laptop computer, internet service, and ET or a control consisting of UC plus laptop and internet but no ET. Patients with ET have access for 12 months and will be followed up for an additional 6 months, for a total of 18 months. The primary outcomes of this study are the differences between the 2 groups with regard to measures of quality of life, psychological well-being, and loneliness. The secondary outcomes are between-group differences in laboratory scores, falls, symptom distress, medication adherence, and crisis and long-term health care use. We will also examine the mediators and moderators of the effects of ET. At baseline and months 6, 12, and 18, patients complete written surveys comprising validated scales selected for good psychometric properties with similar populations; laboratory data are collected from eHealth records; health care use and chronic conditions are collected from health records and patient surveys; and ET use data are collected continuously in system logs. We will use general linear models and linear mixed models to evaluate primary and secondary outcomes over time, with treatment condition as a between-subjects factor. Separate analyses will be conducted for outcomes that are noncontinuous or not correlated with other outcomes. Results: Recruitment was conducted from January 2018 to December 2019, and 346 participants were recruited. The intervention period will end in June 2021. Conclusions: With self-management and motivational strategies, health tracking, educational tools, and peer community and support, ET may help improve outcomes for patients coping with ongoing, complex MCCs. In addition, it may relieve some stress on the primary care system, with potential cost implications. Trial Registration: ClinicalTrials.gov NCT03387735; https://www.clinicaltrials.gov/ct2/show/NCT03387735. International Registered Report Identifier (IRRID): DERR1-10.2196/25175 %M 33605887 %R 10.2196/25175 %U http://www.researchprotocols.org/2021/2/e25175/ %U https://doi.org/10.2196/25175 %U http://www.ncbi.nlm.nih.gov/pubmed/33605887 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e25232 %T Impact of the COVID-19 Pandemic on the Psychological Distress of Medical Students in Japan: Cross-sectional Survey Study %A Nishimura,Yoshito %A Ochi,Kanako %A Tokumasu,Kazuki %A Obika,Mikako %A Hagiya,Hideharu %A Kataoka,Hitomi %A Otsuka,Fumio %+ Department of General Medicine, Okayama University Hospital, 2-5-1 Shikata-Cho, Kita-Ku, Okayama, Japan, 81 86 235 7342, nishimura-yoshito@okayama-u.ac.jp %K COVID-19 %K online education %K depression %K pandemic %K anxiety %K medical student %D 2021 %7 18.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has negatively affected medical education. However, little data are available about medical students’ distress during the pandemic. Objective: This study aimed to provide details on how medical students have been affected by the pandemic. Methods: A cross-sectional study was conducted. A total of 717 medical students participated in the web-based survey. The survey included questions about how the participants’ mental status had changed from before to after the Japanese nationwide state of emergency (SOE). Results: Out of 717 medical students, 473 (66.0%) participated in the study. In total, 29.8% (141/473) of the students reported concerns about the shift toward online education, mostly because they thought online education would be ineffective compared with in-person learning. The participants’ subjective mental health status significantly worsened after the SOE was lifted (P<.001). Those who had concerns about a shift toward online education had higher odds of having generalized anxiety and being depressed (odds ratio [OR] 1.97, 95% CI 1.19-3.28) as did those who said they would request food aid (OR 1.99, 95% CI 1.16-3.44) and mental health care resources (OR 3.56, 95% CI 2.07-6.15). Conclusions: Given our findings, the sudden shift to online education might have overwhelmed medical students. Thus, we recommend that educators inform learners that online learning is not inferior to in-person learning, which could attenuate potential depression and anxiety. %M 33556033 %R 10.2196/25232 %U http://www.jmir.org/2021/2/e25232/ %U https://doi.org/10.2196/25232 %U http://www.ncbi.nlm.nih.gov/pubmed/33556033 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e20700 %T Sociodemographic, Health and Lifestyle, Sampling, and Mental Health Determinants of 24-Hour Motor Activity Patterns: Observational Study %A Difrancesco,Sonia %A Riese,Harriëtte %A Merikangas,Kathleen R %A Shou,Haochang %A Zipunnikov,Vadim %A Antypa,Niki %A van Hemert,Albert M %A Schoevers,Robert A %A Penninx,Brenda W J H %A Lamers,Femke %+ Amsterdam Public Health Research Institute, Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Oldenaller 1, Amsterdam, 1078XL, Netherlands, 31 643193730, s.difrancesco@ggzingeest.nl %K actigraphy %K functional data analysis %K mental health %K well-being %K activity %D 2021 %7 17.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Analyzing actigraphy data using standard circadian parametric models and aggregated nonparametric indices may obscure temporal information that may be a hallmark of the circadian impairment in psychiatric disorders. Functional data analysis (FDA) may overcome such limitations by fully exploiting the richness of actigraphy data and revealing important relationships with mental health outcomes. To our knowledge, no studies have extensively used FDA to study the relationship between sociodemographic, health and lifestyle, sampling, and psychiatric clinical characteristics and daily motor activity patterns assessed with actigraphy in a sample of individuals with and without depression/anxiety. Objective: We aimed to study the association between daily motor activity patterns assessed via actigraphy and (1) sociodemographic, health and lifestyle, and sampling factors, and (2) psychiatric clinical characteristics (ie, presence and severity of depression/anxiety disorders). Methods: We obtained 14-day continuous actigraphy data from 359 participants from the Netherlands Study of Depression and Anxiety with current (n=93), remitted (n=176), or no (n=90) depression/anxiety diagnosis, based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Associations between patterns of daily motor activity, quantified via functional principal component analysis (fPCA), and sociodemographic, health and lifestyle, sampling, and psychiatric clinical characteristics were assessed using generalized estimating equation regressions. For exploratory purposes, function-on-scalar regression (FoSR) was applied to quantify the time-varying association of sociodemographic, health and lifestyle, sampling, and psychiatric clinical characteristics on daily motor activity. Results: Four components of daily activity patterns captured 77.4% of the variability in the data: overall daily activity level (fPCA1, 34.3% variability), early versus late morning activity (fPCA2, 16.5% variability), biphasic versus monophasic activity (fPCA3, 14.8% variability), and early versus late biphasic activity (fPCA4, 11.8% variability). A low overall daily activity level was associated with a number of sociodemographic, health and lifestyle, and psychopathology variables: older age (P<.001), higher education level (P=.005), higher BMI (P=.009), greater number of chronic diseases (P=.02), greater number of cigarettes smoked per day (P=.02), current depressive and/or anxiety disorders (P=.05), and greater severity of depressive symptoms (P<.001). A high overall daily activity level was associated with work/school days (P=.02) and summer (reference: winter; P=.03). Earlier morning activity was associated with older age (P=.02), having a partner (P=.009), work/school days (P<.001), and autumn and spring (reference: winter; P=.02 and P<.001, respectively). Monophasic activity was associated with older age (P=.005). Biphasic activity was associated with work/school days (P<.001) and summer (reference: winter; P<.001). Earlier biphasic activity was associated with older age (P=.005), work/school days (P<.001), and spring and summer (reference: winter; P<.001 and P=.005, respectively). In FoSR analyses, age, work/school days, and season were the main determinants having a time-varying association with daily motor activity (all P<.05). Conclusions: Features of daily motor activity extracted with fPCA reflect commonly studied factors such as the intensity of daily activity and preference for morningness/eveningness. The presence and severity of depression/anxiety disorders were found to be associated mainly with a lower overall activity pattern but not with the time of the activity. Age, work/school days, and season were the variables most strongly associated with patterns and time of activity, and thus future epidemiological studies on motor activity in depression/anxiety should take these variables into account. %M 33595445 %R 10.2196/20700 %U http://www.jmir.org/2021/2/e20700/ %U https://doi.org/10.2196/20700 %U http://www.ncbi.nlm.nih.gov/pubmed/33595445 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e23767 %T Evaluation of an Intergenerational and Technological Intervention for Loneliness: Protocol for a Feasibility Randomized Controlled Trial %A Hoang,Peter %A Whaley,Colin %A Thompson,Karen %A Ho,Venus %A Rehman,Uzma %A Boluk,Karla %A Grindrod,Kelly A %+ School of Pharmacy, University of Waterloo, 200 University Ave, Waterloo, ON, N2L 3G1, Canada, 1 5198884567 ext 21392, colin.whaley@uwaterloo.ca %K seniors %K communication technology %K social isolation %K computers %K intergenerational %K older adults %K mobile phone %D 2021 %7 17.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Social integration and mental health are vital aspects of healthy aging. However, close to half of Canadians older than 80 years report feeling socially isolated. Research has shown that social isolation leads to increased mortality and morbidity, and various interventions have been studied to alleviate loneliness among older adults. This proposal presents an evaluation of an intervention that provides one-on-one coaching, is intergenerational, provides both educational and socialization experiences, and increases technology literacy of older adults to overcome loneliness. Objective: This paper describes the protocol of a randomized, mixed-methods study that will take place in Ontario, Canada. The purpose of this study is to evaluate if an intergenerational technology literacy program can reduce social isolation and depression in older adults via quantitative and qualitative outcome measures. Methods: This study is a randomized, mixed-methods, feasibility trial with 2 conditions. Older adults in the intervention condition will receive 1 hour of weekly technological assistance to send an email to a family member, for 8 weeks, with the assistance of a volunteer. Participants in the control condition will not receive any intervention. The primary outcomes are loneliness, measured using the University of California, Los Angeles Loneliness Scale, and depression, measured using the Center for Epidemiologic Studies Depression scale, both of which are measured weekly. Secondary outcomes are quality of life, as assessed using the Older People’s Quality of Life-Brief version, and technological literacy, evaluated using the Computer Proficiency Questionnaire-12, both of which will be administered before and after the intervention. Semistructured interviews will be completed before and after the intervention to assess participants’ social connectedness, familiarity with technology, and their experience with the intervention. The study will be completed in a long-term care facility in Southwestern Ontario, Canada. Significance was set at P<.05. Results: This study was funded in April 2019 and ethical approval was obtained in August 2019. Recruitment for the study started in November 2019. The intervention began in February 2020 but was halted due to the COVID-19 pandemic. The trial will be restarted when safe. As of March 2020, 8 participants were recruited. Conclusions: Information and communication technology interventions have shown varying results in reducing loneliness and improving mental health among older adults. Few studies have examined the role of one-on-one coaching for older adults in addition to technology education in such interventions. Data from this study may have the potential to provide evidence for other groups to disseminate similar interventions in their respective communities. International Registered Report Identifier (IRRID): DERR1-10.2196/23767 %M 33595443 %R 10.2196/23767 %U http://www.researchprotocols.org/2021/2/e23767/ %U https://doi.org/10.2196/23767 %U http://www.ncbi.nlm.nih.gov/pubmed/33595443 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 2 %P e23960 %T Developmental Assets of Adolescents and Young Adults With Chronic Illness and Comorbid Depression: Qualitative Study Using YouTube %A Zheng,Katherine %A George,Maureen %A Roehlkepartain,Eugene %A Santelli,John %A Bruzzese,Jean-Marie %A Smaldone,Arlene %+ The Feinberg School of Medicine, Center for Education in Health Sciences, Northwestern University, 633 N Saint Clair St, 20th Floor, Chicago, IL, 60605, United States, 1 6032036736, katzheng1@gmail.com %K adolescent development %K chronic disease %K depression %K developmental assets %K positive youth development %K YouTube %D 2021 %7 16.2.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Developmental assets provide a framework for optimizing development among adolescents but have not been studied in adolescents with chronic illness and comorbid depression, which is a group at risk for poor health outcomes. YouTube postings provide valuable insights to understand this understudied population. Objective: This study aims to explore asset development from the perspectives of adolescents and young adults (AYAs) with chronic illness and comorbid depression. Methods: YouTube was searched using 12 chronic illnesses (eg, diabetes) coupled with “depression” as keywords. Videos were included if they were uploaded by AYAs aged between 11 and 29 years and discussed living with chronic illness and depression during adolescence. Video transcripts were coded deductively for 40 internal and external assets that constitute the Developmental Assets Framework. Categories not captured by deductive coding were identified using conventional content analysis. Categories and their respective assets were labeled as being discussed either negatively or positively. Results: In total, 31 videos from 16 AYAs met the inclusion criteria. A total of 7 asset categories, support, constructive use of time, boundaries and expectations (external assets), identity, commitment to learning, positive values, and social competence (internal assets), reflecting 25 (13 internal; 12 external) assets, were discussed. Internal assets, particularly relating to identity, were commonly discussed by AYAs either in a negative way or fluctuated between positive and negative perspectives. Conclusions: In this sample of AYAs with chronic illness and comorbid depression, internal assets were commonly discussed in a negative way. Future research is needed to better understand how assets develop and if the Developmental Assets Framework adequately represents the experiences of this population. %M 33591288 %R 10.2196/23960 %U http://mental.jmir.org/2021/2/e23960/ %U https://doi.org/10.2196/23960 %U http://www.ncbi.nlm.nih.gov/pubmed/33591288 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e23200 %T Evaluation of a Blended Relapse Prevention Program for Anxiety and Depression in General Practice: Qualitative Study %A Krijnen-de Bruin,Esther %A Geerlings,Jasmijn A %A Muntingh,Anna DT %A Scholten,Willemijn D %A Maarsingh,Otto R %A van Straten,Annemieke %A Batelaan,Neeltje M %A van Meijel,Berno %+ Amsterdam UMC, Vrije Universiteit, Psychiatry, Amsterdam Public Health research institute, De Boelelaan 1117, Amsterdam, Netherlands, 31 884662683, esther.krijnendebruin@inholland.nl %K relapse prevention %K anxiety disorder %K depressive disorder %K eHealth %K general practice %K qualitative research %D 2021 %7 16.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Existing studies have yet to investigate the perspectives of patients and professionals concerning relapse prevention programs for patients with remitted anxiety or depressive disorders in primary care. User opinions should be considered when optimizing the use and implementation of interventions. Objective: This study aimed to evaluate the GET READY relapse prevention programs for patients with remitted anxiety or depressive disorders in general practice. Methods: Semistructured interviews (N=26) and focus group interviews (N=2) with patients and mental health professionals (MHPs) in the Netherlands were performed. Patients with remitted anxiety or depressive disorders and their MHPs who participated in the GET READY study were interviewed individually. Findings from the interviews were tested in focus group interviews with patients and MHPs. Data were analyzed using thematic analysis. Results: Participants were positive about the program because it created awareness of relapse risks. Lack of motivation, lack of recognizability, lack of support from the MHP, and symptom severity (too low or too high) appeared to be limiting factors in the use of the program. MHPs play a crucial role in motivating and supporting patients in relapse prevention. The perspectives of patients and MHPs were largely in accordance, although they had different perspectives concerning responsibilities for taking initiative. Conclusions: The implementation of the GET READY program was challenging. Guidance from MHPs should be offered for relapse prevention programs based on eHealth. Both MHPs and patients should align their expectations concerning responsibilities in advance to ensure optimal usage. Usage of blended relapse prevention programs may be further enhanced by diagnosis-specific programs and easily accessible support from MHPs. International Registered Report Identifier (IRRID): RR2-10.1186/s12888-019-2034-6 %M 33591277 %R 10.2196/23200 %U http://formative.jmir.org/2021/2/e23200/ %U https://doi.org/10.2196/23200 %U http://www.ncbi.nlm.nih.gov/pubmed/33591277 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e25363 %T Exposure to COVID-19-Related Information and its Association With Mental Health Problems in Thailand: Nationwide, Cross-sectional Survey Study %A Mongkhon,Pajaree %A Ruengorn,Chidchanok %A Awiphan,Ratanaporn %A Thavorn,Kednapa %A Hutton,Brian %A Wongpakaran,Nahathai %A Wongpakaran,Tinakon %A Nochaiwong,Surapon %+ Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, 239, Suthep Road, Chiang Mai, 50200, Thailand, 66 899973365, surapon.nochaiwong@gmail.com %K coronavirus %K COVID-19 %K insomnia %K mental health %K social media %K depression %K anxiety %K stress %K psychosocial problem %D 2021 %7 12.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has had a negative impact on both the physical and mental health of individuals worldwide. Evidence regarding the association between mental health problems and information exposure among Thai citizens during the COVID-19 outbreak is limited. Objective: This study aimed to explore the relationship between information exposure and mental health problems during the COVID-19 pandemic in Thailand. Methods: Between April 21 and May 4, 2020, we conducted a cross-sectional, nationwide online survey of the general population in Thailand. We categorized the duration of exposure to COVID-19-related information as follows: <1 h/day (reference group), 1-2 h/day, and ≥3 h/day. Mental health outcomes were assessed using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7 scale, the Perceived Stress Scale-10, and the Insomnia Severity Index for symptoms of depression, anxiety, perceived stress, and insomnia, respectively. Multivariable logistic regression models were used to evaluate the relationship between information exposure and the risk of developing the aforementioned symptoms. An ancillary analysis using multivariable multinomial logistic regression models was also conducted to assess the possible dose-response relationship across the severity strata of mental health problems. Results: Of the 4322 eligible participants, 4004 (92.6%) completed the online survey. Of them, 1481 (37.0%), 1644 (41.1%), and 879 (22.0%) participants were exposed to COVID-19-related information for less than 1 hour per day, 1 to 2 hours per day, or 3 or more hours per day, respectively. The major source of information related to the COVID-19 pandemic was social media (95.3%), followed by traditional media (68.7%) and family members (34.9%). Those exposed to information for 3 or more hours per day had a higher risk of developing symptoms of depression (adjusted odds ratio [OR] 1.35, 95% CI 1.03-1.76; P=.03), anxiety (adjusted OR 1.88, 95% CI 1.43-2.46; P<.001), and insomnia (adjusted OR 1.52, 95% CI 1.17-1.97; P=.001) than people exposed to information for less than 1 hour per day. Meanwhile, people exposed to information for 1 to 2 hours per day were only at risk of developing symptoms of anxiety (adjusted OR 1.35, 95% CI 1.08-1.69; P=.008). However, no association was found between information exposure and the risk of perceived stress. In the ancillary analysis, a dose-response relationship was observed between information exposure of 3 or more hours per day and the severity of mental health problems. Conclusions: These findings suggest that social media is the main source of COVID-19-related information. Moreover, people who are exposed to information for 3 or more hours per day are more likely to develop psychological problems, including depression, anxiety, and insomnia. Longitudinal studies investigating the long-term effects of COVID-19-related information exposure on mental health are warranted. %M 33523828 %R 10.2196/25363 %U http://www.jmir.org/2021/2/e25363/ %U https://doi.org/10.2196/25363 %U http://www.ncbi.nlm.nih.gov/pubmed/33523828 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e24703 %T Effectiveness of Smartphone-Based Cognitive Behavioral Therapy Among Patients With Major Depression: Systematic Review of Health Implications %A Hrynyschyn,Robert %A Dockweiler,Christoph %+ Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Health and Nursing Science, Campus Virchow Klinikum, Berlin, 13353, Germany, 49 30 450 529 124, robert.hrynyschyn@charite.de %K mobile health %K depression %K cognitive behavioral therapy %K systematic review %K mobile phone %D 2021 %7 10.2.2021 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Depression is often associated with rapid changes in mood and quality of life that persist for a period of 2 weeks. Despite medical innovations, there are problems in the provision of care. Long waiting times for treatment and high recurrence rates of depression cause enormous costs for health care systems. At the same time, comprehensive limitations in physical, psychological, and social dimensions are observed for patients with depression, which significantly reduce their quality of life. In addition to patient-specific limitations, undersupply and inappropriate health care have been determined. For this reason, new forms of care are discussed. Smartphone-based therapy is considered to have great potential due to its reach and easy accessibility. Low socioeconomic groups, which are always difficult to reach for public health interventions, can now be accessed due to the high dispersion of smartphones. There is still little information about the impact and mechanisms of smartphone-based therapy on depression. In a systematic literature review, the health implications of smartphone-based therapy were presented in comparison with standard care. Objective: The objective of this review was to identify and summarize the existing evidence regarding smartphone-based cognitive behavioral therapy for patients with depression and to present the health implications of smartphone-based cognitive behavioral therapy of considered endpoints. Methods: A systematic literature review was conducted to identify relevant studies by means of inclusion and exclusion criteria. For this purpose, the PubMed and Psyndex databases were systematically searched using a search syntax. The endpoints of depressive symptoms, depression-related anxiety, self-efficacy or self-esteem, and quality of life were analyzed. Identified studies were evaluated for study quality and risk of bias. After applying the inclusion and exclusion criteria, 8 studies were identified. Results: The studies examined in this review reported contradictory results regarding the investigated endpoints. In addition, due to clinical and methodological heterogeneity, it was difficult to derive evident results. All included studies reported effects on depressive symptoms. The other investigated endpoints were only reported by isolated studies. Only 50% (4/8) of the studies reported effects on depression-related anxiety, self-efficacy or self-esteem, and quality of life. Conclusions: No clear implications of smartphone-based cognitive behavioral therapy could be established. Evidence for the treatment of depression using smartphone-based cognitive behavioral therapy is limited. Additional research projects are needed to demonstrate the effects of smartphone-based cognitive behavioral therapy in the context of evidence-based medicine and to enable its translation into standard care. Participatory technology development might help to address current problems in mobile health intervention studies. %M 33565989 %R 10.2196/24703 %U http://mhealth.jmir.org/2021/2/e24703/ %U https://doi.org/10.2196/24703 %U http://www.ncbi.nlm.nih.gov/pubmed/33565989 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 2 %P e21700 %T Evidence on Technology-Based Psychological Interventions in Diagnosed Depression: Systematic Review %A Köhnen,Moritz %A Dreier,Mareike %A Seeralan,Tharanya %A Kriston,Levente %A Härter,Martin %A Baumeister,Harald %A Liebherz,Sarah %+ Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr 52, Hamburg, 20246, Germany, 49 407410 ext 57705, m.koehnen@uke.de %K internet %K telephone %K psychotherapy %K depression %K depressive disorder %K systematic review %K mobile phone %D 2021 %7 10.2.2021 %9 Review %J JMIR Ment Health %G English %X Background: Evidence on technology-based psychological interventions (TBIs) for the treatment of depression is rapidly growing and covers a broad scope of research. Despite extensive research in this field, guideline recommendations are still limited to the general effectiveness of TBIs. Objective: This study aims to structure evidence on TBIs by considering different application areas (eg, TBIs for acute treatment and their implementation in health care, such as stand-alone interventions) and treatment characteristics (eg, therapeutic rationale of TBIs) to provide a comprehensive evidence base and to identify research gaps in TBIs for diagnosed depression. Moreover, the reporting of negative events in the included studies is investigated in this review to enable subsequent safety assessment of the TBIs. Methods: Randomized controlled trials on adults diagnosed with unipolar depression receiving any kind of psychotherapeutic treatment, which was at least partly delivered by a technical medium, were eligible for inclusion in our preregistered systematic review. We searched for trials in CENTRAL (Cochrane Central Register of Controlled Trials; until August 2020), MEDLINE, PsycINFO, PSYNDEX, CINAHL; until the end of January 2018), clinical trial registers, and sources of gray literature (until the end of January 2019). Study selection and data extraction were conducted by 2 review authors independently. Results: Database searches resulted in 15,546 records, of which 241 publications were included, representing 83 completed studies and 60 studies awaiting classification (ie, preregistered studies, study protocols). Almost all completed studies (78/83, 94%) addressed the acute treatment phase, being largely either implemented as stand-alone interventions (66/83, 80%) or blended treatment approaches (12/83, 14%). Studies on TBIs for aftercare (4/83, 5%) and for bridging waiting periods (1/83, 1%) were scarce. Most TBI study arms (n=107) were guided (59/107, 55.1%), delivered via the internet (80/107, 74.8%), and based on cognitive behavioral treatment approaches (88/107, 79.4%). Almost all studies (77/83, 93%) reported information on negative events, considering dropouts from treatment as a negative event. However, reports on negative events were heterogeneous and largely unsystematic. Conclusions: Research has given little attention to studies evaluating TBIs for aftercare and for bridging waiting periods in people with depression, even though TBIs are seen as highly promising in these application areas; thus, high quality studies are urgently needed. In addition, the variety of therapeutic rationales on TBIs has barely been represented by identified studies hindering the consideration of patient preferences when planning treatment. Finally, future studies should use specific guidelines to systematically assess and report negative events. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2018-028042 %M 33565981 %R 10.2196/21700 %U https://mental.jmir.org/2021/2/e21700 %U https://doi.org/10.2196/21700 %U http://www.ncbi.nlm.nih.gov/pubmed/33565981 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e21737 %T Development and Feasibility of a Digital Acceptance and Commitment Therapy–Based Intervention for Generalized Anxiety Disorder: Pilot Acceptability Study %A Hemmings,Nicola R %A Kawadler,Jamie M %A Whatmough,Rachel %A Ponzo,Sonia %A Rossi,Alessio %A Morelli,Davide %A Bird,Geoffrey %A Plans,David %+ Department of Organizational Psychology, Birkbeck University of London, Malet St, London, WC1E 7HX, United Kingdom, 44 7716362200, nhemmi01@mail.bbk.ac.uk %K anxiety %K depression %K acceptance and commitment therapy %K person-based approach %K mHealth %K mental health %K digital %K remote %K smartphone %K mobile phone %D 2021 %7 9.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Generalized anxiety disorder (GAD) is characterized by excessive worry that is difficult to control and has high comorbidity with mood disorders including depression. Individuals experience long wait times for diagnosis and often face accessibility barriers to treatment. There is a need for a digital solution that is accessible and acceptable to those with GAD. Objective: This paper aims to describe the development of a digital intervention prototype of acceptance and commitment therapy (ACT) for GAD that sits within an existing well-being app platform, BioBase. A pilot feasibility study evaluating acceptability and usability is conducted in a sample of adults with a diagnosis of GAD, self-referred to the study. Methods: Phase 1 applied the person-based approach (creation of guiding principles, intervention design objectives, and the key intervention features). In Phase 2 participants received the app-based therapeutic and paired wearable for 2 weeks. Self-report questionnaires were obtained at baseline and posttreatment. The primary outcome was psychological flexibility (Acceptance and Action Questionnaire-II [AAQ-II]) as this is the aim of ACT. Mental well-being (Warwick-Edinburgh Mental Well-being Scale [WEMWBS]) and symptoms of anxiety (7-item Generalized Anxiety Disorder Assessment [GAD-7]) and depression (9-item Patient Health Questionnaire [PHQ-9]) were also assessed. Posttreatment usability was assessed via self-report measures (System Usability Scale [SUS]) in addition to interviews that further explored feasibility of the digital intervention in this sample. Results: The app-based therapeutic was well received. Of 13 participants, 10 (77%) completed the treatment. Results show a high usability rating (83.5). Participants found the digital intervention to be relevant, useful, and helpful in managing their anxiety. Participants had lower anxiety (d=0.69) and depression (d=0.84) scores at exit, and these differences were significantly different from baseline (P=.03 and .008 for GAD-7 and PHQ-9, respectively). Participants had higher psychological flexibility and well-being scores at exit, although these were not significantly different from baseline (P=.11 and .55 for AAQ-II and WEMWBS, respectively). Conclusions: This ACT prototype within BioBase is an acceptable and feasible digital intervention in reducing symptoms of anxiety and depression. This study suggests that this intervention warrants a larger feasibility study in adults with GAD. %M 33560232 %R 10.2196/21737 %U https://formative.jmir.org/2021/2/e21737 %U https://doi.org/10.2196/21737 %U http://www.ncbi.nlm.nih.gov/pubmed/33560232 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e14378 %T A Brief Mobile-Augmented Suicide Prevention Intervention for People With Psychotic Disorders in Transition From Acute to Ongoing Care: Protocol for a Pilot Trial %A Depp,Colin %A Ehret,Blaire %A Villa,Jennifer %A Perivoliotis,Dimitri %A Granholm,Eric %+ Department of Psychiatry, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA, 92093-0603, United States, 1 858 822 4251, cdepp@ucsd.edu %K prevention %K mental health services %K psychosis %K technology %D 2021 %7 8.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: People with serious mental illnesses (SMIs) are at exceptionally high risk for lifetime suicidal ideation and behavior compared with the general population. The transition period between urgent evaluation and ongoing care could provide an important setting for brief suicide-specific interventions for SMIs. To address this concern, this trial, SafeTy and Recovery Therapy (START), involves a brief suicide-specific cognitive behavioral intervention for SMIs that is augmented with mobile phone interactions. Objective: The primary aim of this pilot trial is to evaluate the feasibility, acceptability, and preliminary effectiveness of the intervention. Methods: A 6-month pilot trial with 70 participants with a diagnosis of bipolar disorder, schizophrenia or schizoaffective disorder, and current active suicidal ideation were randomized to START or START with mobile augmentation. START consists of 4 weekly sessions addressing early warning signs and triggers, symptoms influencing suicidal thinking, and social relationships. Recovery planning is followed by biweekly telephone coaching. START with mobile augmentation includes personalized automated cognitive behavioral therapy scripts that build from in-person content. Participants were evaluated at baseline, 4 weeks (end of in-person sessions), 12 weeks (end of telephone coaching), and 24 weeks. In addition to providing point estimates of feasibility and acceptability, the primary outcome of the trial was the change in severity of suicidal ideation as measured with the Scale for Suicide Ideation (SSI) and secondary outcome included the rate of outpatient engagement. Results: The trial is ongoing. Feasibility and acceptability across conditions will be assessed using t tests or Mann-Whitney tests or chi-square tests. The reduction of SSI over time will be assessed using hierarchical linear models. Conclusions: The design considerations and results of this trial may be informative for adapted suicide prevention in psychotic disorders in applied community settings. Trial Registration: ClinicalTrials.gov NCT03198364; http://clinicaltrials.gov/ct2/show/NCT03198364 International Registered Report Identifier (IRRID): DERR1-10.2196/14378 %M 33555265 %R 10.2196/14378 %U https://www.researchprotocols.org/2021/2/e14378 %U https://doi.org/10.2196/14378 %U http://www.ncbi.nlm.nih.gov/pubmed/33555265 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e26192 %T Mobile Health–Supported HIV Self-Testing Strategy Among Urban Refugee and Displaced Youth in Kampala, Uganda: Protocol for a Cluster Randomized Trial (Tushirikiane, Supporting Each Other) %A Logie,Carmen %A Okumu,Moses %A Hakiza,Robert %A Kibuuka Musoke,Daniel %A Berry,Isha %A Mwima,Simon %A Kyambadde,Peter %A Kiera,Uwase Mimy %A Loutet,Miranda %A Neema,Stella %A Newby,Katie %A McNamee,Clara %A Baral,Stefan D %A Lester,Richard %A Musinguzi,Joshua %A Mbuagbaw,Lawrence %+ Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, , Canada, 1 (416) 978 6314, carmen.logie@utoronto.ca %K adolescents and youth %K implementation research %K HIV testing %K mobile health %K refugee %K Uganda %D 2021 %7 2.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: HIV is the leading cause of mortality among youth in sub-Saharan Africa. Uganda hosts over 1.43 million refugees, and more than 83,000 live in Kampala, largely in informal settlements. There is limited information about HIV testing uptake and preferences among urban refugee and displaced youth. HIV self-testing is a promising method for increasing testing uptake. Further, mobile health (mHealth) interventions have been effective in increasing HIV testing uptake and could be particularly useful among youth. Objective: This study aims to evaluate the feasibility and effectiveness of two HIV self-testing implementation strategies (HIV self-testing intervention alone and HIV self-testing combined with an mHealth intervention) in comparison with the HIV testing standard of care in terms of HIV testing outcomes among refugee/displaced youth aged 16 to 24 years in Kampala, Uganda. Methods: A three-arm cluster randomized controlled trial will be implemented across five informal settlements grouped into three sites, based on proximity, and randomization will be performed with a 1:1:1 method. Approximately 450 adolescents (150 per cluster) will be enrolled and followed for 12 months. Data will be collected at the following three time points: baseline enrollment, 8 months after enrollment, and 12 months after enrollment. Primary outcomes (HIV testing frequency, HIV status knowledge, linkage to confirmatory testing, and linkage to HIV care) and secondary outcomes (depression, condom use efficacy, consistent condom use, sexual relationship power, HIV stigma, and adolescent sexual and reproductive health stigma) will be evaluated. Results: The study has been conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. The study has received ethical approval from the University of Toronto (June 14, 2019), Mildmay Uganda (November 11, 2019), and the Uganda National Council for Science and Technology (August 3, 2020). The Tushirikiane trial launched in February 2020, recruiting a total of 452 participants. Data collection was paused for 8 months due to COVID-19. Data collection for wave 2 resumed in November 2020, and as of December 10, 2020, a total of 295 participants have been followed-up. The third, and final, wave of data collection will be conducted between February and March 2021. Conclusions: This study will contribute to the knowledge of differentiated HIV testing implementation strategies for urban refugee and displaced youth living in informal settlements. We will share the findings in peer-reviewed manuscripts and conference presentations. Trial Registration: ClinicalTrials.gov NCT04504097; https://clinicaltrials.gov/ct2/show/NCT04504097. International Registered Report Identifier (IRRID): DERR1-10.2196/26192 %M 33528378 %R 10.2196/26192 %U https://www.researchprotocols.org/2021/2/e26192 %U https://doi.org/10.2196/26192 %U http://www.ncbi.nlm.nih.gov/pubmed/33528378 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e21207 %T Optimizing the Context of Support to Improve Outcomes of Internet-Based Self-help in Individuals With Depressive Symptoms: Protocol for a Randomized Factorial Trial %A Bur,Oliver Thomas %A Krieger,Tobias %A Moritz,Steffen %A Klein,Jan Philipp %A Berger,Thomas %+ Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, Bern, 3012, Switzerland, 41 31 631 54 13, oliver.bur@psy.unibe.ch %K depression %K self-help %K adherence %K internet-based intervention %K factorial design %K problem-solving therapy %K online %K mental health %K multiphase optimization strategy %K digital health %D 2021 %7 2.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Internet-based self-help interventions for individuals with depressive symptoms, in which the main component is often a web-based self-help program, have been shown to be efficacious in many controlled trials. However, there are also trials on self-help programs showing no significant effect when delivered in routine care, and some studies report high dropout and low adherence rates. Research suggests that these findings do not emerge primarily due to the specific content of a self-help program. It seems more important how a program is embedded in the context of human and automated support before and during the use of a self-help program. Objective: This study aims to better understand the effects of 4 supportive contextual factors on outcomes of and adherence to a web-based self-help program for depressive symptoms. In a factorial experiment, 2 of 4 supportive factors, for which there is evidence for their role on outcomes and adherence, are realized during the intervention—personal guidance and automated email reminders. The other 2 factors are realized before the intervention—a diagnostic interview and a preintervention module aimed at increasing the motivation to use the program with motivational interviewing techniques. Methods: The study is a full factorial randomized trial. Adults with mild to moderate depressive symptoms (Patient Health Questionnaire–9 score: 5-14) are recruited from the community through the internet and conventional media. All participants receive access to a web-based self-help program based on problem-solving therapy. They are randomized across 4 experimental factors, each reflecting the presence versus absence of a supportive factor (guidance, automated reminders, diagnostic interview, preintervention module) resulting in a 16-condition balanced factorial design. The primary outcome is depressive symptoms at 10 weeks post assessment. Secondary outcomes include adherence to the program, anxiety, stress, health-related quality of life, possible negative effects, and treatment satisfaction. Potential moderators and mediators (eg, treatment expectancy, problem-solving skills, working alliance with the study team) will also be investigated. Results: Ethical approval was received on January 20, 2020. The study was initiated in February 2020, and 240 participants have been enrolled in the study as of November 1, 2020. Recruitment for a total of 255 participants is ongoing. Data collection is expected to be completed by May 2021. Conclusions: A better understanding of relevant supportive factors in the dissemination of web-based interventions is necessary to improve outcomes of and adherence to web-based self-help programs. This study may inform health care systems and guide decisions to optimize the implementation context of web-based self-help programs for depressive symptoms. Trial Registration: ClinicalTrials.gov NCT04318236; https://clinicaltrials.gov/ct2/show/NCT04318236 International Registered Report Identifier (IRRID): DERR1-10.2196/21207 %M 33528377 %R 10.2196/21207 %U http://www.researchprotocols.org/2021/2/e21207/ %U https://doi.org/10.2196/21207 %U http://www.ncbi.nlm.nih.gov/pubmed/33528377 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 1 %P e22723 %T Smartphone-Detected Ambient Speech and Self-Reported Measures of Anxiety and Depression: Exploratory Observational Study %A Di Matteo,Daniel %A Wang,Wendy %A Fotinos,Kathryn %A Lokuge,Sachinthya %A Yu,Julia %A Sternat,Tia %A Katzman,Martin A %A Rose,Jonathan %+ The Centre for Automation of Medicine, The Edward S Rogers Sr Department of Electrical and Computer Engineering, University of Toronto, DL Pratt Building, 6 King's College Road, Toronto, ON, M5S 3H5, Canada, 1 416 978 6992, dandm@ece.utoronto.ca %K mobile sensing %K passive sensing %K psychiatric assessment %K mood and anxiety disorders %K mobile apps %K linguistics %K speech recognition %K speech content %K lexical choice %D 2021 %7 29.1.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The ability to objectively measure the severity of depression and anxiety disorders in a passive manner could have a profound impact on the way in which these disorders are diagnosed, assessed, and treated. Existing studies have demonstrated links between both depression and anxiety and the linguistic properties of words that people use to communicate. Smartphones offer the ability to passively and continuously detect spoken words to monitor and analyze the linguistic properties of speech produced by the speaker and other sources of ambient speech in their environment. The linguistic properties of automatically detected and recognized speech may be used to build objective severity measures of depression and anxiety. Objective: The aim of this study was to determine if the linguistic properties of words passively detected from environmental audio recorded using a participant’s smartphone can be used to find correlates of symptom severity of social anxiety disorder, generalized anxiety disorder, depression, and general impairment. Methods: An Android app was designed to collect periodic audiorecordings of participants’ environments and to detect English words using automatic speech recognition. Participants were recruited into a 2-week observational study. The app was installed on the participants’ personal smartphones to record and analyze audio. The participants also completed self-report severity measures of social anxiety disorder, generalized anxiety disorder, depression, and functional impairment. Words detected from audiorecordings were categorized, and correlations were measured between words counts in each category and the 4 self-report measures to determine if any categories could serve as correlates of social anxiety disorder, generalized anxiety disorder, depression, or general impairment. Results: The participants were 112 adults who resided in Canada from a nonclinical population; 86 participants yielded sufficient data for analysis. Correlations between word counts in 67 word categories and each of the 4 self-report measures revealed a strong relationship between the usage rates of death-related words and depressive symptoms (r=0.41, P<.001). There were also interesting correlations between rates of word usage in the categories of reward-related words with depression (r=–0.22, P=.04) and generalized anxiety (r=–0.29, P=.007), and vision-related words with social anxiety (r=0.31, P=.003). Conclusions: In this study, words automatically recognized from environmental audio were shown to contain a number of potential associations with severity of depression and anxiety. This work suggests that sparsely sampled audio could provide relevant insight into individuals’ mental health. %M 33512325 %R 10.2196/22723 %U http://formative.jmir.org/2021/1/e22723/ %U https://doi.org/10.2196/22723 %U http://www.ncbi.nlm.nih.gov/pubmed/33512325 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e18328 %T Individualized Web-Based Attention Training With Evidence-Based Counseling to Address HIV Treatment Adherence and Psychological Distress: Exploratory Cohort Study %A Houston,Eric %A Fadardi,Javad Salehi %A Harawa,Nina T %A Argueta,Chris %A Mukherjee,Sukrit %+ Claremont Graduate University, 675 West Foothill Boulevard, Claremont, CA, 91711, United States, 1 909 621 8000, eric.houston@cgu.edu %K depression %K trauma %K HIV %K attention training %K implicit cognition %D 2021 %7 28.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The prevalence of mood, trauma, and stressor-related disorders is disproportionately higher among people living with HIV than among individuals without the virus. Poor adherence to HIV treatment and heightened psychological distress have been linked to symptoms associated with these disorders. Objective: The objective of this exploratory pilot study was to develop and implement an intervention that combined individualized web-based attention training with evidence-based counseling to promote HIV treatment adherence and reduce psychological distress among people living with HIV. The study targeted African American and Latino young men who have sex with men, two population groups in the US that continue to experience disparities in HIV treatment outcomes. Methods: Study participants with elevated symptoms of depression and suboptimal adherence to antiretroviral therapy were recruited primarily through referrals from Los Angeles health and social service providers as well as postings on social media. Participants enrolled in the 4-week intervention received weekly counseling for adherence and daily access to web-based attention training via their personal mobile devices or computers. Results: Of the 14 participants who began the intervention, 12 (86%) completed all sessions and study procedures. Using a pretest-posttest design, findings indicate significant improvements in adherence, depressive symptoms, and attention processing. Overall, the proportion of participants reporting low adherence to antiretroviral therapy declined from 42% at baseline to 25% at intervention completion (P=.02, phi=0.68). Mean depressive symptoms measured by the 9 item Patient Health Questionnaire (PHQ-9) showed a substantial reduction of 36% (P=.002, Cohen d=1.2). In addition, participants’ attentional processing speeds for all types of stimuli pairings presented during attention training improved significantly (P=.01 and P=.02) and were accompanied by large effect sizes ranging from 0.78 to 1.0. Conclusions: Our findings support the feasibility of web-based attention training combined with counseling to improve antiretroviral therapy adherence among patients with psychological distress. Future research should include a larger sample, a control group, and longer-term follow-up. %M 33507152 %R 10.2196/18328 %U http://mental.jmir.org/2021/1/e18328/ %U https://doi.org/10.2196/18328 %U http://www.ncbi.nlm.nih.gov/pubmed/33507152 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e21585 %T Evaluating the Effectiveness of an E-Mental Health Intervention for People Living in Lebanon: Protocol for Two Randomized Controlled Trials %A van 't Hof,Edith %A Heim,Eva %A Abi Ramia,Jinane %A Burchert,Sebastian %A Cornelisz,Ilja %A Cuijpers,Pim %A El Chammay,Rabih %A Harper Shehadeh,Melissa %A Noun,Philip %A Smit,Filip %A van Klaveren,Chris %A van Ommeren,Mark %A Zoghbi,Edwina %A Carswell,Kenneth %+ Department of Mental Health and Substance Use, World Health Organization, Avenue Appia 20, Geneva, 1211, Switzerland, 31 641692545, edithvanhof@gmail.com %K e-mental health %K psychological interventions %K guided-self-help %K global mental health %K adversity %K Lebanon %K Syrians %D 2021 %7 28.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The lack of availability of evidence-based services for people exposed to adversity globally has led to the development of psychological interventions with features that will likely make them more scalable. The evidence for the efficacy of e-mental health from high-income countries is compelling, and the use of these interventions could be a way to increase the coverage of evidence-based psychological interventions in low- and middle-income countries. Step-by-Step is a brief (5-session) intervention proposed by the World Health Organization as an innovative approach to reducing the suffering and disability associated with depression. Objective: This study aims to evaluate the effectiveness and cost-effectiveness of a locally adapted version of Step-by-Step with Syrian nationals (trial 1) and Lebanese nationals and other populations residing in Lebanon (trial 2). Methods: This Step-by-Step trial involves 2 parallel, two-armed, randomized controlled trials comparing the e-intervention Step-by-Step to enhanced care as usual in participants with depressive symptoms and impaired functioning. The randomized controlled trials are designed and powered to detect effectiveness in 2 populations: Syrians in Lebanon (n=568) and other people residing in Lebanon (n=568; Lebanese nationals and other populations resident in Lebanon). The primary outcomes are depressive symptomatology (measured with the Patient Health Questionnaire-9) and functioning (measured with the World Health Organization Disability Assessment Scale 2.0). Secondary outcomes include anxiety symptoms, posttraumatic stress disorder symptoms, personalized measures of psychosocial problems, subjective well-being, and economic effectiveness. Participants are mainly recruited through online advertising. Additional outreach methods will be used if required, for example through dissemination of information through partner agencies and organizations. They can access the intervention on a computer, tablet, and mobile phone through a hybrid app. Step-by-Step has 5 sessions, and users are guided by trained nonspecialist “e-helpers” providing phone-based or message-based support for around 15 minutes a week. Results: The trials were funded in 2018. The study protocol was last verified June 20, 2019 (WHO ERC.0002797) and registered with ClinicalTrials.gov (NCT03720769). The trials started recruitment as of December 9, 2019, and all data collection was completed in December 2020. Conclusions: The Step-by-Step trials will provide evidence about the effectiveness of an e-mental health intervention in Lebanon. If the intervention proves to be effective, this will inform future scale-up of this and similar interventions in Lebanon and in other settings across the world. Trial Registration: ClinicalTrials.gov NCT03720769; https://clinicaltrials.gov/ct2/show/NCT03720769 International Registered Report Identifier (IRRID): DERR1-10.2196/21585 %M 33507158 %R 10.2196/21585 %U http://www.researchprotocols.org/2021/1/e21585/ %U https://doi.org/10.2196/21585 %U http://www.ncbi.nlm.nih.gov/pubmed/33507158 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e23410 %T Effectiveness of Smartphone-Based Mindfulness Training on Maternal Perinatal Depression: Randomized Controlled Trial %A Sun,Yaoyao %A Li,Yanyan %A Wang,Juan %A Chen,Qingyi %A Bazzano,Alessandra N %A Cao,Fenglin %+ School of Nursing and Rehabilitation, Shandong University, 44 Wenhua Xi Road, Jinan, 250012, China, 86 053188382291, caofenglin2008@126.com %K mindfulness %K pregnancy %K perinatal care %K depression %K mHealth %K mobile health %K psychosocial intervention %D 2021 %7 27.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite potential for benefit, mindfulness remains an emergent area in perinatal mental health care, and evidence of smartphone-based mindfulness training for perinatal depression is especially limited. Objective: The objective of this study was to evaluate the effectiveness of a smartphone-based mindfulness training intervention during pregnancy on perinatal depression and other mental health problems with a randomized controlled design. Methods: Pregnant adult women who were potentially at risk of perinatal depression were recruited from an obstetrics clinic and randomized to a self-guided 8-week smartphone-based mindfulness training during pregnancy group or attention control group. Mental health indicators were surveyed over five time points through the postpartum period by online self-assessment. The assessor who collected the follow-up data was blind to the assignment. The primary outcome was depression as measured by symptoms, and secondary outcomes were anxiety, stress, affect, sleep, fatigue, memory, and fear. Results: A total of 168 participants were randomly allocated to the mindfulness training (n=84) or attention control (n=84) group. The overall dropout rate was 34.5%, and 52.4% of the participants completed the intervention. Mindfulness training participants reported significant improvement of depression (group × time interaction χ24=16.2, P=.003) and secondary outcomes (χ24=13.1, P=.01 for anxiety; χ24=8.4, P=.04 for positive affect) compared to attention control group participants. Medium between-group effect sizes were found on depression and positive affect at postintervention, and on anxiety in late pregnancy (Cohen d=0.47, –0.49, and 0.46, respectively). Mindfulness training participants reported a decreased risk of positive depressive symptom (Edinburgh Postnatal Depression Scale [EPDS] score>9) compared to attention control participants postintervention (odds ratio [OR] 0.391, 95% CI 0.164-0.930) and significantly higher depression symptom remission with different EPDS reduction scores from preintervention to postintervention (OR 3.471-27.986). Parity did not show a significant moderating effect; however, for nulliparous women, mindfulness training participants had significantly improved depression symptoms compared to nulliparous attention control group participants (group × time interaction χ24=18.1, P=.001). Conclusions: Smartphone-based mindfulness training is an effective intervention in improving maternal perinatal depression for those who are potentially at risk of perinatal depression in early pregnancy. Nulliparous women are a promising subgroup who may benefit more from mindfulness training. Trial Registration: Chinese Clinical Trial Registry ChiCTR1900028521; http://www.chictr.org.cn/showproj.aspx?proj=33474 %M 33502326 %R 10.2196/23410 %U http://www.jmir.org/2021/1/e23410/ %U https://doi.org/10.2196/23410 %U http://www.ncbi.nlm.nih.gov/pubmed/33502326 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e24495 %T Social, Cognitive, and eHealth Mechanisms of COVID-19–Related Lockdown and Mandatory Quarantine That Potentially Affect the Mental Health of Pregnant Women in China: Cross-Sectional Survey Study %A Yang,Xue %A Song,Bo %A Wu,Anise %A Mo,Phoenix K H %A Di,Jiangli %A Wang,Qian %A Lau,Joseph T F %A Wang,Linhong %+ National Center for Women and Children's Health, Chinese Center for Disease Control and Prevention, No 12 Dahuisi Road, Haidan District, Beijing, 100081, China, 86 01062170871, qianawang@chinawch.org.cn %K eHealth %K lockdown %K quarantine %K depression %K anxiety %K pregnant women %D 2021 %7 22.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Although lockdown and mandatory quarantine measures have played crucial roles in the sharp decrease of the number of newly confirmed/suspected COVID-19 cases, concerns have been raised over the threat that these measures pose to mental health, especially the mental health of vulnerable groups, including pregnant women. Few empirical studies have assessed whether and how these control measures may affect mental health, and no study has investigated the prevalence and impacts of the use of eHealth resources among pregnant women during the COVID-19 outbreak. Objective: This study investigated (1) the effects of lockdown and mandatory quarantine on mental health problems (ie, anxiety and depressive symptoms), (2) the potential mediation effects of perceived social support and maladaptive cognition, and (3) the moderation effects of eHealth-related factors (ie, using social media to obtain health information and using prenatal care services during the COVID-19 pandemic) on pregnant women in China. Methods: An online cross-sectional survey was conducted among 19,515 pregnant women from all 34 Chinese provincial-level administrative regions from February 25 to March 10, 2020. Results: Of the 19,515 participants, 12,209 (62.6%) were subjected to lockdown in their areas of residence, 737 (3.8%) were subjected to mandatory quarantine, 8712 (44.6%) had probable mild to severe depression, 5696 (29.2%) had probable mild to severe anxiety, and 1442 (7.4%) had suicidal ideations. Only 640 (3.3%) participants reported that they used online prenatal care services during the outbreak. Significant sociodemographic/maternal factors of anxiety/depressive symptoms included age, education, occupation, the area of residence, gestational duration, the number of children born, complication during pregnancy, the means of using prenatal care services, and social media use for obtaining health information. Multiple indicators multiple causes modeling (χ214=495.21; P<.05; comparative fit index=.99; nonnormed fit index=.98; root mean square error of approximation=.04, 90% CI 0.038-0.045) showed that quarantine was directly and indirectly strongly associated with poor mental health through decreased perceived social support and increased maladaptive cognition (B=.04; β=.02, 95% CI 0.01-0.02; P=.001), while lockdown was indirectly associated with mental health through increased social support and maladaptive cognition among pregnant women (B=.03; β=.03, 95% CI 0.02-0.03; P=.001). Multigroup analyses revealed that the use of social media for obtaining health information and the means of using prenatal care services were significant moderators of the model paths. Conclusions: Our findings provide epidemiological evidence for the importance of integrating mental health care and eHealth into the planning and implementation of control measure policies. The observed social and cognitive mechanisms and moderators in this study are modifiable, and they can inform the design of evidence-based mental health promotion among pregnant women. %M 33302251 %R 10.2196/24495 %U http://www.jmir.org/2021/1/e24495/ %U https://doi.org/10.2196/24495 %U http://www.ncbi.nlm.nih.gov/pubmed/33302251 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e22698 %T Efficacy of a Transdiagnostic Self-Help Internet Intervention for Reducing Depression, Anxiety, and Suicidal Ideation in Adults: Randomized Controlled Trial %A Batterham,Philip J %A Calear,Alison L %A Farrer,Louise %A Gulliver,Amelia %A Kurz,Ella %+ Centre for Mental Health Research, Research School of Population Health, Australian National University, 63 Eggleston Road, Canberra ACT, 2601, Australia, 61 261251031, philip.batterham@anu.edu.au %K depression %K anxiety %K randomized controlled trial %K internet %K implementation science %D 2021 %7 22.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Low-intensity self-guided mental health interventions that are delivered on the web may meet the needs and preferences of adults with mild to moderate symptoms. However, few clinical trials have examined the effectiveness of self-guided transdiagnostic interventions within a naturalistic setting. Objective: This randomized controlled trial (RCT) tests the effectiveness of the video-based transdiagnostic intervention FitMindKit in reducing depression symptoms (primary outcome), anxiety symptoms, disability, and suicidal ideation, relative to an attention-matched control condition called HealthWatch. Methods: The RCT was conducted with adults living in the Australian Capital Territory, Australia. Participants (n=1986) were recruited through the web using social media advertisements, screened for psychological distress, and then randomized to receive one of two 4-week programs: FitMindKit (12-module psychotherapy intervention) or HealthWatch (12-module program providing general health information). Participants were assessed at baseline and at 4 weeks postbaseline. To maintain the ecological validity of the trial, participants completed brief assessments and interventions without direct researcher contact or incentives. Results: Mixed model repeated-measures analyses of variance demonstrated that FitMindKit significantly improved depression symptoms (F1,701.7=3.97; P=.047), along with panic symptoms (F1,706.5=5.59; P=.02) and social anxiety symptoms (F1,680.0=12.37; P<.001), relative to the attention control condition. There were no significant effects on other outcomes. Conclusions: Self-guided transdiagnostic interventions can be beneficial when delivered directly to end users through the internet. Despite low adherence and small effect sizes, the availability of such interventions is likely to fill a critical gap in the accessibility of mental health services for the community. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618001688279; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376113. International Registered Report Identifier (IRRID): RR2-10.1016/j.conctc.2019.100341 %M 33480860 %R 10.2196/22698 %U https://www.jmir.org/2021/1/e22698 %U https://doi.org/10.2196/22698 %U http://www.ncbi.nlm.nih.gov/pubmed/33480860 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 7 %N 1 %P e17598 %T Twitter as a Mental Health Support System for Students and Professionals in the Medical Field %A Liu,Lisa %A Woo,Benjamin K P %+ Department of Molecular, Cell, and Developmental Biology, University of California, Los Angeles, 405 Hilgard Avenue, Los Angeles, CA, 90095, United States, 1 949 870 0827, lisa96liu@gmail.com %K Twitter %K social media %K mental health %K health professionals %K community %K social support %K depression %K physician suicide %D 2021 %7 19.1.2021 %9 Viewpoint %J JMIR Med Educ %G English %X Twitter is a rapidly growing social media site that has greatly integrated itself in the lives of students and professionals in the medical field. While Twitter has been found to be very helpful in facilitating education, there is also great potential for its usage as a social support system. Social support has become more essential as society grapples with declining mental health, particularly in the medical sector. In our previous paper, we saw that Twitter provides a promising tool to learn more about the online conversation about dementia and, in particular, the supportive network that can be created. Inspired by this, we decided to investigate the potential of using Twitter as a support system for students and professionals in the medical field. In this paper, we explore the current state of mental health in the medical field and suggest practical implementation methods for using Twitter. %M 33464210 %R 10.2196/17598 %U http://mededu.jmir.org/2021/1/e17598/ %U https://doi.org/10.2196/17598 %U http://www.ncbi.nlm.nih.gov/pubmed/33464210 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e24298 %T Mental Health and Burnout Syndrome Among Postgraduate Students in Medical and Multidisciplinary Residencies During the COVID-19 Pandemic in Brazil: Protocol for a Prospective Cohort Study %A Pinho,Rebeca Da Nóbrega Lucena %A Costa,Thais Ferreira %A Silva,Nayane Miranda %A Barros-Areal,Adriana F %A Salles,André De Mattos %A Oliveira,Andrea Pedrosa %A Rassi,Carlos %A Valero,Caroline Elizabeth Brero %A Gomes,Ciro Martins %A Mendonça-Silva,Dayde %A Oliveira,Fernando %A Jochims,Isadora %A Ranulfo,Ivan %A Neves,Juliana De Brito Seixas %A Oliveira,Lucas %A Dantas,Maria Nogueira %A Rosal,Marta %A Soares,Mayra %A Kurizky,Patrícia %A Peterle,Viviane Uliana %A Faro,Yasmin Furtado %A Gomides,Ana Paula %A da Mota,Licia %A Albuquerque,Cleandro %A Simaan,Cezar Kozak %A Amado,Veronica M %+ Programa de Pós-Graduação em Ciências Médicas FM-UnB, SGAN 605, Av. L2 Norte, Brasília, Brazil, 55 61 98343 6834, nlp.rebeca@gmail.com %K burnout syndrome %K medical residency %K multidisciplinary residency %K COVID-19 %K mental health %K burnout %K stress %K anxiety %K prospective %K cohort %K health care professional %K medical student %D 2021 %7 19.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The COVID-19 pandemic has led to high levels of physical, psychological, and social stress among health care professionals, including postgraduate students in medical and multidisciplinary residencies. This stress is associated with the intense fear of occupational exposure to SARS-CoV-2, the virus known to cause COVID-19. These professionals are at risk of developing physical and mental illnesses not only due to the infection but also due to prolonged exposure to multidimensional stress and continued work overload. Objective: This study aims to evaluate the prevalence of symptoms suggestive of mental disorders and burnout syndrome and determine the risk factors for burnout among postgraduate students in medical and multidisciplinary residencies in Brazil during the COVID-19 pandemic. Methods: For this prospective cohort study with parallel groups, participants were recruited between July and September 2020 to achieve a sample size of at least 1144 participants. Research instruments such as Depression, Anxiety, and Stress Scale; Patient Health Questionnaire; Brief Resilient Coping Scale; and Oldenburg Burnout Inventory will be used to collect data. Data will be collected in 2 waves: the first wave will include data related to sample characterization and psychosocial evaluation, and the second wave will be launched 12 weeks later and will include an evaluation of the incidence of burnout as well as correlations with the potential predictive factors collected in the first wave. Additionally, we will collect data regarding participants’ withdrawal from work. Results: The recruitment took place from July 29 to September 5, 2020. Data analyses for this phase is already in progress. The second phase of the study is also in progress. The final data collection began on December 1, 2020, and it will be completed by December 31, 2020. Conclusions: We believe the findings of this study will help evaluate the impact of the COVID-19 pandemic on the mental health conditions of health professionals in Brazil as well as contribute to the planning and implementation of appropriate measures that can alleviate these mental health challenges. International Registered Report Identifier (IRRID): DERR1-10.2196/24298 %M 33290246 %R 10.2196/24298 %U https://www.researchprotocols.org/2021/1/e24298 %U https://doi.org/10.2196/24298 %U http://www.ncbi.nlm.nih.gov/pubmed/33290246 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e24983 %T Mental Health Among Medical Professionals During the COVID-19 Pandemic in Eight European Countries: Cross-sectional Survey Study %A Hummel,Svenja %A Oetjen,Neele %A Du,Junfeng %A Posenato,Elisabetta %A Resende de Almeida,Rosa Maria %A Losada,Raquel %A Ribeiro,Oscar %A Frisardi,Vincenza %A Hopper,Louise %A Rashid,Asarnusch %A Nasser,Habib %A König,Alexandra %A Rudofsky,Gottfried %A Weidt,Steffi %A Zafar,Ali %A Gronewold,Nadine %A Mayer,Gwendolyn %A Schultz,Jobst-Hendrik %+ Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany, 49 62215632408, Neele.Oetjen@med.uni-heidelberg.de %K mental health %K COVID-19 %K Europe %K medical professionals %K stress %K depression %K anxiety %K coping %K stressors %D 2021 %7 18.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The death toll of COVID-19 topped 170,000 in Europe by the end of May 2020. COVID-19 has caused an immense psychological burden on the population, especially among doctors and nurses who are faced with high infection risks and increased workload. Objective: The aim of this study was to compare the mental health of medical professionals with nonmedical professionals in different European countries during the COVID-19 pandemic. We hypothesized that medical professionals, particularly those exposed to COVID-19 at work, would have higher levels of depression, anxiety, and stress. We also aimed to determine their main stressors and most frequently used coping strategies during the crisis. Methods: A cross-sectional online survey was conducted during peak COVID-19 months in 8 European countries. The questionnaire included demographic data and inquired whether the participants were exposed to COVID-19 at work or not. Mental health was assessed via the Depression Anxiety Stress Scales32 (23.53)–21 (DASS-21). A 12-item checklist on preferred coping strategies and another 23-item questionnaire on major stressors were completed by medical professionals. Results: The sample (N=609) consisted of 189 doctors, 165 nurses, and 255 nonmedical professionals. Participants from France and the United Kingdom reported experiencing severe/extremely severe depression, anxiety, and stress more often compared to those from the other countries. Nonmedical professionals had significantly higher scores for depression and anxiety. Among medical professionals, no significant link was reported between direct contact with patients with COVID-19 at work and anxiety, depression, or stress. “Uncertainty about when the epidemic will be under control” caused the most amount of stress for health care professionals while “taking protective measures” was the most frequently used coping strategy among all participants. Conclusions: COVID-19 poses a major challenge to the mental health of working professionals as a considerable proportion of our participants showed high values for depression, anxiety, and stress. Even though medical professionals exhibited less mental stress than nonmedical professionals, sufficient help should be offered to all occupational groups with an emphasis on effective coping strategies. %M 33411670 %R 10.2196/24983 %U http://www.jmir.org/2021/1/e24983/ %U https://doi.org/10.2196/24983 %U http://www.ncbi.nlm.nih.gov/pubmed/33411670 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e20819 %T A Mindfulness-Based Brain-Computer Interface to Augment Mandala Coloring for Depression: Protocol for a Single-Case Experimental Design %A Daudén Roquet,Claudia %A Sas,Corina %+ School of Computing and Communications, Lancaster University, InfoLab21, Lancaster University, Lancaster, LA1 4WA, United Kingdom, 44 01524510321, c.daudenroquet1@lancaster.ac.uk %K brain-computer interface %K mental well-being %K depression %K mindfulness %K mandala coloring %D 2021 %7 18.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The regular practice of mindfulness has been shown to provide benefits for mental well-being and prevent depression relapse. Technology-mediated interventions can facilitate the uptake and sustained practice of mindfulness, yet the evaluation of interactive systems, such as brain-computer interfaces, has been little explored. Objective: The objective of this paper is to present an interactive mindfulness-based technology to improve mental well-being in people who have experienced depression. The system, Anima, is a brain-computer interface that augments mandala coloring by providing a generative color palette based on the unfolding mindfulness states during the practice. In addition, this paper outlines a multiple-baseline, single-case experimental design methodology to evaluate training effectiveness. Methods: Adult participants who have experienced depression in the past, have finished treatment within the last year, and can provide informed consent will be able to be recruited. The Anima system, consisting of 2 tablets and a nonintrusive mental activity headband, will be delivered to participants to use during the study. Measures include state and trait mindfulness, depression symptoms, mental well-being, and user experience, and these measures will be taken throughout the baseline, intervention, and monitoring phases. The data collection will take place in the form of a questionnaire before and after each mandala-coloring session and a semistructured interview every 2 weeks. Trial results will be analyzed using structured visual analysis, supplemented with statistical analysis appropriate to single-case methodology. Results: Study results will offer new insights into the deployment and evaluation of novel interactive brain-computer interfaces for mindfulness training in the context of mental health. Moreover, findings will validate the effectiveness of this training protocol to improve the mental well-being of people who have had depression. Participants will be recruited locally through the National Health Service. Conclusions: Evidence will assist in the design and evaluation of brain-computer interfaces and mindfulness technologies for mental well-being and the necessary services to support people who have experienced depression. International Registered Report Identifier (IRRID): PRR1-10.2196/20819 %M 33459604 %R 10.2196/20819 %U http://www.researchprotocols.org/2021/1/e20819/ %U https://doi.org/10.2196/20819 %U http://www.ncbi.nlm.nih.gov/pubmed/33459604 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e17233 %T Virtual Reality Relaxation for Patients With a Psychiatric Disorder: Crossover Randomized Controlled Trial %A Veling,Wim %A Lestestuiver,Bart %A Jongma,Marieke %A Hoenders,H J Rogier %A van Driel,Catheleine %+ Department of Psychiatry, University Medical Center Groningen, University of Groningen, PO Box 30.001, Groningen, 9700 RB, Netherlands, 31 503612367, w.veling@umcg.nl %K virtual reality %K stress %K relaxation %K negative affect %K positive affect %K depression %K anxiety %K randomized controlled trial %D 2021 %7 15.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) relaxation is a promising mental health intervention that may be an effective tool for stress reduction but has hardly been tested in clinical trials with psychiatric patients. We developed an easy-to-use VR self-management relaxation tool (VRelax) with immersive 360° nature videos and interactive animated elements. Objective: To investigate the immediate effects of VR relaxation on negative and positive affective states and short-term effects on perceived stress and symptoms in patients with a psychiatric disorder, compared to standard relaxation exercises. Methods: A randomized crossover trial was conducted in 50 patients receiving ambulatory treatment for anxiety, psychotic, depressive, or bipolar disorder. Participants were randomly assigned to start with VRelax or standard relaxation and used both interventions for 10 days at home. They completed 8 visual analog scales of momentary negative and positive affective states before and after each session. Global perceived stress and psychiatric symptoms were measured before and after both intervention periods. Treatment effects were analyzed with multilevel mixed model regression analyses and 2-way analysis of variance. Results: Both VRelax and standard relaxation exercises led to a statistically significant immediate improvement of all negative and positive affective states. Compared to standard relaxation, VRelax resulted in a significantly greater reduction of total negative affective state (change 16.2% versus 21.2%; t1684=−2.02, 95% CI −18.70 to −0.28; P=.04). Specifically, VRelax had a stronger beneficial effect on momentary anxiety (t1684=−3.24, 95% CI −6.86 to −1.69), sadness (t1684=−2.32, 95% CI −6.51 to −0.55), and cheerfulness (t1684=2.35, 95% CI 0.51 to 5.75). There were no significant differences between short-term effects of the two treatments on global perceived stress and symptoms. Conclusions: If the results of this trial are replicated and extended, VRelax may provide a much-needed, effective, easy-to-use self-management relaxation intervention to enhance psychiatric treatments. Trial Registration: Netherlands Trial Register NTR7294; https://www.trialregister.nl/trial/7096 %M 33448933 %R 10.2196/17233 %U http://www.jmir.org/2021/1/e17233/ %U https://doi.org/10.2196/17233 %U http://www.ncbi.nlm.nih.gov/pubmed/33448933 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e23592 %T A Text Messaging Intervention for Coping With Social Distancing During COVID-19 (StayWell at Home): Protocol for a Randomized Controlled Trial %A Figueroa,Caroline Astrid %A Hernandez-Ramos,Rosa %A Boone,Claire Elizabeth %A Gómez-Pathak,Laura %A Yip,Vivian %A Luo,Tiffany %A Sierra,Valentín %A Xu,Jing %A Chakraborty,Bibhas %A Darrow,Sabrina %A Aguilera,Adrian %+ School of Social Welfare, University of California Berkeley, 105 Havilland Hall, Berkeley, CA, 94709, United States, 1 5106436669, c.a.figueroa@berkeley.edu %K COVID-19 %K mental health %K depression %K reinforcement learning %K microrandomized trial %D 2021 %7 14.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Social distancing is a crucial intervention to slow down person-to-person transmission of COVID-19. However, social distancing has negative consequences, including increases in depression and anxiety. Digital interventions, such as text messaging, can provide accessible support on a population-wide scale. We developed text messages in English and Spanish to help individuals manage their depressive mood and anxiety during the COVID-19 pandemic. Objective: In a two-arm randomized controlled trial, we aim to examine the effect of our 60-day text messaging intervention. Additionally, we aim to assess whether the use of machine learning to adapt the messaging frequency and content improves the effectiveness of the intervention. Finally, we will examine the differences in daily mood ratings between the message categories and time windows. Methods: The messages were designed within two different categories: behavioral activation and coping skills. Participants will be randomized into (1) a random messaging arm, where message category and timing will be chosen with equal probabilities, and (2) a reinforcement learning arm, with a learned decision mechanism for choosing the messages. Participants in both arms will receive one message per day within three different time windows and will be asked to provide their mood rating 3 hours later. We will compare self-reported daily mood ratings; self-reported depression, using the 8-item Patient Health Questionnaire; and self-reported anxiety, using the 7-item Generalized Anxiety Disorder scale at baseline and at intervention completion. Results: The Committee for the Protection of Human Subjects at the University of California Berkeley approved this study in April 2020 (No. 2020-04-13162). Data collection began in April 2020 and will run to April 2021. As of August 24, 2020, we have enrolled 229 participants. We plan to submit manuscripts describing the main results of the trial and results from the microrandomized trial for publication in peer-reviewed journals and for presentations at national and international scientific meetings. Conclusions: Results will contribute to our knowledge of effective psychological tools to alleviate the negative effects of social distancing and the benefit of using machine learning to personalize digital mental health interventions. Trial Registration: ClinicalTrials.gov NCT04473599; https://clinicaltrials.gov/ct2/show/NCT04473599 International Registered Report Identifier (IRRID): DERR1-10.2196/23592 %M 33370721 %R 10.2196/23592 %U http://www.researchprotocols.org/2021/1/e23592/ %U https://doi.org/10.2196/23592 %U http://www.ncbi.nlm.nih.gov/pubmed/33370721 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e22575 %T Participant Engagement in a Transmedia Storytelling Web-Based App Intervention for Mental Health of Latina Women: Qualitative Analysis %A Soderlund,Patricia D %A Martinez Hollingsworth,Adrienne S %A Heilemann,MarySue V %+ School of Nursing, University of California, Los Angeles, Factor Building, Box 6919, Los Angeles, CA, 90095-6919, United States, 1 310 206 4735, mheilema@sonnet.ucla.edu %K transmedia %K Latina %K mental health %K mobile applications %K internet %K depression %K anxiety %K storytelling %K mobile phone %D 2021 %7 13.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Stigma, fear, and lack of knowledge regarding treatment options or where to get help create delays for Latina women in accessing needed mental health help. Story-based media interventions hold appeal for Latina women. Thus, we drew upon the Social Cognitive Theory by Bandura to create an evidence-based, transmedia storytelling web-based app for mental health called Catalina: Confronting My Emotions to connect Latina women to a curated set of mental health resources. Understanding how Latina women perceive various aspects of the web-based app will help design future expansions. Objective: A previously published analysis led to the development of a category on how participants related to the lead character (Catalina) in the story line of the web-based app as a real person. However, the purpose of this analysis was to gain an understanding of participants’ experiences with the extension of the dramatic story line of the web-based app beyond Catalina to a Latina nurse-therapist character named Veronica, who was featured prominently in the app’s interactive content and bonus videos. Methods: Qualitative analyses were conducted with interview data from a community-based sample of 28 English-speaking Latina women aged between 21 and 50 years who scored above the threshold for anxiety (Generalized Anxiety Disorder-7) and/or depression (Patient Health Questionnaire-9) but were not suicidal at screening. Data were collected 72 hours after participants engaged with our transmedia storytelling web-based app for mental health. Grounded theory methodology guided the analysis and interpretation of data that had been collected telephonically, recorded, and transcribed with identifiers removed. Analyses included initial and focused coding using process codes (gerund form of verbs in codes focused on action), informed by symbolic interactionism, and the development of categories with properties through constant comparison, memo writing, and the use of charts and diagrams. Results: Our participants experienced a multiphase process that was most heavily related to Veronica, the Latina nurse-therapist character in our web-based app, who led them through a process to a place of action. We conceptualized this process as moving from passive viewer to active participant of a transmedia storytelling web-based app intervention. Overall, 3 new conceptual categories provided insight into women’s experiences, including encountering a trustworthy nurse-therapist character, taking in messages that dispel old beliefs, and preparing when and how to take action. Each category has nuanced properties that reflect participants’ experiences. Conclusions: Active engagement with our web-based app led our sample to successfully transition from the viewpoint of the observer to the viewpoint of the experiencer, moving from a passive position of watching to active engagement that involved imagining, thinking, reflecting, and acting. Careful development of dramatic material for health-related web-based apps using transmedia story extension and bonus videos needs to be based on input from the target group from the start of development through evaluation and testing. %M 33439137 %R 10.2196/22575 %U http://mental.jmir.org/2021/1/e22575/ %U https://doi.org/10.2196/22575 %U http://www.ncbi.nlm.nih.gov/pubmed/33439137 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e24333 %T Smartphone-Based Self-Reports of Depressive Symptoms Using the Remote Monitoring Application in Psychiatry (ReMAP): Interformat Validation Study %A Goltermann,Janik %A Emden,Daniel %A Leehr,Elisabeth Johanna %A Dohm,Katharina %A Redlich,Ronny %A Dannlowski,Udo %A Hahn,Tim %A Opel,Nils %+ Department of Psychiatry, University of Münster, Albert-Schweitzer-Campus 1, Münster, 48149, Germany, 49 251 8356610, n_opel01@uni-muenster.de %K mobile monitoring %K smartphone %K digital biomarkers %K digital phenotyping %K course of illness %K psychometric quality %K mood disorders %K depression %K affective disorders %K mobile phone %D 2021 %7 12.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Smartphone-based symptom monitoring has gained increased attention in psychiatric research as a cost-efficient tool for prospective and ecologically valid assessments based on participants’ self-reports. However, a meaningful interpretation of smartphone-based assessments requires knowledge about their psychometric properties, especially their validity. Objective: The goal of this study is to systematically investigate the validity of smartphone-administered assessments of self-reported affective symptoms using the Remote Monitoring Application in Psychiatry (ReMAP). Methods: The ReMAP app was distributed to 173 adult participants of ongoing, longitudinal psychiatric phenotyping studies, including healthy control participants, as well as patients with affective disorders and anxiety disorders; the mean age of the sample was 30.14 years (SD 11.92). The Beck Depression Inventory (BDI) and single-item mood and sleep information were assessed via the ReMAP app and validated with non–smartphone-based BDI scores and clinician-rated depression severity using the Hamilton Depression Rating Scale (HDRS). Results: We found overall high comparability between smartphone-based and non–smartphone-based BDI scores (intraclass correlation coefficient=0.921; P<.001). Smartphone-based BDI scores further correlated with non–smartphone-based HDRS ratings of depression severity in a subsample (r=0.783; P<.001; n=51). Higher agreement between smartphone-based and non–smartphone-based assessments was found among affective disorder patients as compared to healthy controls and anxiety disorder patients. Highly comparable agreement between delivery formats was found across age and gender groups. Similarly, smartphone-based single-item self-ratings of mood correlated with BDI sum scores (r=–0.538; P<.001; n=168), while smartphone-based single-item sleep duration correlated with the sleep item of the BDI (r=–0.310; P<.001; n=166). Conclusions: These findings demonstrate that smartphone-based monitoring of depressive symptoms via the ReMAP app provides valid assessments of depressive symptomatology and, therefore, represents a useful tool for prospective digital phenotyping in affective disorder patients in clinical and research applications. %M 33433392 %R 10.2196/24333 %U https://mental.jmir.org/2021/1/e24333 %U https://doi.org/10.2196/24333 %U http://www.ncbi.nlm.nih.gov/pubmed/33433392 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e23491 %T A Mindfulness-Based Intervention for Student Depression, Anxiety, and Stress: Randomized Controlled Trial %A Ritvo,Paul %A Ahmad,Farah %A El Morr,Christo %A Pirbaglou,Meysam %A Moineddin,Rahim %A , %+ School of Health Policy and Management, York University, 4700 Keele St,, Toronto, ON, M3J1P3, Canada, 1 4167362100, elmorr@yorku.ca %K online intervention %K randomized controlled trial %K university student %K depression %K anxiety %K stress %K mental health %K efficacy %K intervention %D 2021 %7 11.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: University students are experiencing higher levels of distress and mental health disorders than before. In addressing mental health needs, web-based interventions have shown increasing promise in overcoming geographic distances and high student-to-counselor ratios, leading to the potential for wider implementation. The Mindfulness Virtual Community (MVC) program, a web-based program, guided by mindfulness and cognitive behavioral therapy principles, is among efforts aimed at effectively and efficiently reducing symptoms of depression, anxiety, and perceived stress in students. Objective: This study’s aim was to evaluate the efficacy of an 8-week MVC program in reducing depression, anxiety, and perceived stress (primary outcomes), and improving mindfulness (secondary outcome) in undergraduate students at a large Canadian university. Guided by two prior randomized controlled trials (RCTs) that each demonstrated efficacy when conducted during regular university operations, this study coincided with a university-wide labor strike. Nonetheless, the students’ response to an online mental health program on a disrupted campus can provide useful information for anticipating the impact of other disruptions, including those related to the COVID-19 pandemic as well as future disruptions. Methods: In this parallel-arm RCT, 154 students were randomly allocated to an 8-week MVC intervention (n=76) or a wait-list control (WLC) condition (n=78). The MVC intervention included the following: (1) educational and mindfulness video modules, (2) anonymous peer-to-peer discussions, and (3) anonymous, group-based, professionally guided, 20-minute videoconferences. Study outcomes were evaluated at baseline and at 8-week follow-up using the following: Patient Health Questionnaire-9 (PHQ-9), the Beck Anxiety Inventory (BAI), the Perceived Stress Scale (PSS), and the Five Facets Mindfulness Questionnaire Short Form (FFMQ-SF). Generalized estimation equations with an AR (1) covariance structure were used to evaluate the impact of the intervention, with outcome evaluations performed on both an intention-to-treat (ITT) and per-protocol (PP) basis. Results: Participants (n=154) included 35 males and 117 females with a mean age of 23.1 years. There were no statistically significant differences at baseline between the MVC and WLC groups on demographics and psychological characteristics, indicating similar demographic and psychological characteristics across the two groups. Results under both ITT and PP approaches indicated that there were no statistically significant between-group differences in PHQ-9 (ITT: β=–0.44, P=.64; PP: β=–0.62, P=.053), BAI (ITT: β=–2.06, P=.31; PP: β=–2.32, P=.27), and FFMQ-SF (ITT: β=1.33, P=.43; PP: β=1.44, P=.41) compared to WLC. There was a significant difference for the PSS (ITT: β=–2.31, P=.03; PP: β=–2.38, P=.03). Conclusions: During a university labor strike, the MVC program led to statistically significant reductions in PSS compared to the WLC group, but there were no other significant between-group differences. Comparisons with previous cycles of intervention testing, undertaken during nondisrupted university operations, when efficacy was demonstrated, are discussed. Trial Registration: ISRCTN Registry ISRCTN92827275; https://www.isrctn.com/ISRCTN92827275 %M 33264098 %R 10.2196/23491 %U https://mental.jmir.org/2021/1/e23491 %U https://doi.org/10.2196/23491 %U http://www.ncbi.nlm.nih.gov/pubmed/33264098 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e21690 %T Content-Based Recommender Support System for Counselors in a Suicide Prevention Chat Helpline: Design and Evaluation Study %A Salmi,Salim %A Mérelle,Saskia %A Gilissen,Renske %A Brinkman,Willem-Paul %+ Department of Stochastics, Centrum Wiskunde & Informatica, Science Park 123, Amsterdam, 1098 XG, Netherlands, 31 640673474, s.salmi@cwi.nl %K suicide prevention %K content based recommender system %K chat corpus %K crisis line %K sentence embedding %K suicide %K mental health %D 2021 %7 7.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The working environment of a suicide prevention helpline requires high emotional and cognitive awareness from chat counselors. A shared opinion among counselors is that as a chat conversation becomes more difficult, it takes more effort and a longer amount of time to compose a response, which, in turn, can lead to writer’s block. Objective: This study evaluates and then designs supportive technology to determine if a support system that provides inspiration can help counselors resolve writer’s block when they encounter difficult situations in chats with help-seekers. Methods: A content-based recommender system with sentence embedding was used to search a chat corpus for similar chat situations. The system showed a counselor the most similar parts of former chat conversations so that the counselor would be able to use approaches previously taken by their colleagues as inspiration. In a within-subject experiment, counselors’ chat replies when confronted with a difficult situation were analyzed to determine if experts could see a noticeable difference in chat replies that were obtained in 3 conditions: (1) with the help of the support system, (2) with written advice from a senior counselor, or (3) when receiving no help. In addition, the system’s utility and usability were measured, and the validity of the algorithm was examined. Results: A total of 24 counselors used a prototype of the support system; the results showed that, by reading chat replies, experts were able to significantly predict if counselors had received help from the support system or from a senior counselor (P=.004). Counselors scored the information they received from a senior counselor (M=1.46, SD 1.91) as significantly more helpful than the information received from the support system or when no help was given at all (M=–0.21, SD 2.26). Finally, compared with randomly selected former chat conversations, counselors rated the ones identified by the content-based recommendation system as significantly more similar to their current chats (β=.30, P<.001). Conclusions: Support given to counselors influenced how they responded in difficult conversations. However, the higher utility scores given for the advice from senior counselors seem to indicate that specific actionable instructions are preferred. We expect that these findings will be beneficial for developing a system that can use similar chat situations to generate advice in a descriptive style, hence helping counselors through writer’s block. %M 33410755 %R 10.2196/21690 %U https://www.jmir.org/2021/1/e21690 %U https://doi.org/10.2196/21690 %U http://www.ncbi.nlm.nih.gov/pubmed/33410755 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 9 %N 1 %P e24618 %T Development of Social Support Networks by Patients With Depression Through Online Health Communities: Social Network Analysis %A Lu,Yingjie %A Luo,Shuwen %A Liu,Xuan %+ School of Business, East China University of Science and Technology, Meilong Road 130, Shanghai, 200237, China, 86 2164252489, xuanliu@ecust.edu.cn %K online depression community %K social support network %K exponential random graph model %K informational support %K emotional support %K mental health %K depression %K social network %D 2021 %7 7.1.2021 %9 Original Paper %J JMIR Med Inform %G English %X Background: In recent years, people with mental health problems are increasingly using online social networks to receive social support. For example, in online depression communities, patients can share their experiences, exchange valuable information, and receive emotional support to help them cope with their disease. Therefore, it is critical to understand how patients with depression develop online social support networks to exchange informational and emotional support. Objective: Our aim in this study was to investigate which user attributes have significant effects on the formation of informational and emotional support networks in online depression communities and to further examine whether there is an association between the two social networks. Methods: We used social network theory and constructed exponential random graph models to help understand the informational and emotional support networks in online depression communities. A total of 74,986 original posts were retrieved from 1077 members in an online depression community in China from April 2003 to September 2017 and the available data were extracted. An informational support network of 1077 participant nodes and 6557 arcs and an emotional support network of 1077 participant nodes and 6430 arcs were constructed to examine the endogenous (purely structural) effects and exogenous (actor-relation) effects on each support network separately, as well as the cross-network effects between the two networks. Results: We found significant effects of two important structural features, reciprocity and transitivity, on the formation of both the informational support network (r=3.6247, P<.001, and r=1.6232, P<.001, respectively) and the emotional support network (r=4.4111, P<.001, and r=0.0177, P<.001, respectively). The results also showed significant effects of some individual factors on the formation of the two networks. No significant effects of homophily were found for gender (r=0.0783, P=.20, and r=0.1122, P=.25, respectively) in the informational or emotional support networks. There was no tendency for users who had great influence (r=0.3253, P=.05) or wrote more posts (r=0.3896, P=.07) or newcomers (r=–0.0452, P=.66) to form informational support ties more easily. However, users who spent more time online (r=0.6680, P<.001) or provided more replies to other posts (r=0.5026, P<.001) were more likely to form informational support ties. Users who had a big influence (r=0.8325, P<.001), spent more time online (r=0.5839, P<.001), wrote more posts (r=2.4025, P<.001), or provided more replies to other posts (r=0.2259, P<.001) were more likely to form emotional support ties, and newcomers (r=–0.4224, P<.001) were less likely than old-timers to receive emotional support. In addition, we found that there was a significant entrainment effect (r=0.7834, P<.001) and a nonsignificant exchange effect (r=–0.2757, P=.32) between the two networks. Conclusions: This study makes several important theoretical contributions to the research on online depression communities and has important practical implications for the managers of online depression communities and the users involved in these communities. %M 33279878 %R 10.2196/24618 %U http://medinform.jmir.org/2021/1/e24618/ %U https://doi.org/10.2196/24618 %U http://www.ncbi.nlm.nih.gov/pubmed/33279878 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e19046 %T Examining the Correlation Between Depression and Social Behavior on Smartphones Through Usage Metadata: Empirical Study %A Wang,Yameng %A Ren,Xiaotong %A Liu,Xiaoqian %A Zhu,Tingshao %+ CAS Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, 16 Lincui Road, Chaoyang District, Beijing, 100101, China, 86 15010965509, tszhu@psych.ac.cn %K depression %K digital phenotyping %K social behavior %K smartphone usage %K mobile sensing %D 2021 %7 6.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: As smartphone has been widely used, understanding how depression correlates with social behavior on smartphones can be beneficial for early diagnosis of depression. An enormous amount of research relied on self-report questionnaires, which is not objective. Only recently the increased availability of rich data about human behavior in digital space has provided new perspectives for the investigation of individual differences. Objective: The objective of this study was to explore depressed Chinese individuals’ social behavior in digital space through metadata collected via smartphones. Methods: A total of 120 participants were recruited to carry a smartphone with a metadata collection app (MobileSens). At the end of metadata collection, they were instructed to complete the Center for Epidemiological Studies-Depression Scale (CES-D). We then separated participants into nondepressed and depressed groups based on their scores on CES-D. From the metadata of smartphone usage, we extracted 44 features, including traditional social behaviors such as making calls and sending SMS text messages, and the usage of social apps (eg, WeChat and Sina Weibo, 2 popular social apps in China). The 2-way ANOVA (nondepressed vs depressed × male vs female) and multiple logistic regression analysis were conducted to investigate differences in social behaviors on smartphones among users. Results: The results found depressed users received less calls from contacts (all day: F1,116=3.995, P=.048, η2=0.033; afternoon: F1,116=5.278, P=.02, η2=0.044), and used social apps more frequently (all day: F1,116=6.801, P=.01, η2=0.055; evening: F1,116=6.902, P=.01, η2=0.056) than nondepressed ones. In the depressed group, females used Weibo more frequently than males (all day: F1,116=11.744, P=.001, η2=0.092; morning: F1,116=9.105, P=.003, η2=0.073; afternoon: F1,116=14.224, P<.001, η2=0.109; evening: F1,116=9.052, P=.003, η2=0.072). Moreover, usage of social apps in the evening emerged as a predictor of depressive symptoms for all participants (odds ratio [OR] 1.007, 95% CI 1.001-1.013; P=.02) and male (OR 1.013, 95% CI 1.003-1.022; P=.01), and usage of Weibo in the morning emerged as a predictor for female (OR 1.183, 95% CI 1.015-1.378; P=.03). Conclusions: This paper finds that there exists a certain correlation between depression and social behavior on smartphones. The result may be useful to improve social interaction for depressed individuals in the daily lives and may be insightful for early diagnosis of depression. %M 33404512 %R 10.2196/19046 %U https://mhealth.jmir.org/2021/1/e19046 %U https://doi.org/10.2196/19046 %U http://www.ncbi.nlm.nih.gov/pubmed/33404512 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 6 %N 4 %P e24694 %T Time Trends of the Public’s Attention Toward Suicide During the COVID-19 Pandemic: Retrospective, Longitudinal Time-Series Study %A Burnett,Dayle %A Eapen,Valsamma %A Lin,Ping-I %+ School of Psychiatry, University of New South Wales, Level 1, Australian Graduate School of Management Building Gate, 11 Botany St, Kensington, 2052, Australia, 61 421315320, pingi.lin@gmail.com %K COVID-19 %K suicide %K infodemiology %K infoveillance %K Google Trends %K time trend %K school closure %K attention %K mental health %K crisis %K time series %D 2020 %7 30.12.2020 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The COVID-19 pandemic has overwhelmed health care systems around the world. Emerging evidence has suggested that substantially few patients seek help for suicidality at clinical settings during the COVID-19 pandemic, which has elicited concerns of an imminent mental health crisis as the course of the pandemic continues to unfold. Clarifying the relationship between the public’s attention to knowledge about suicide and the public’s attention to knowledge about the COVID-19 pandemic may provide insight into developing prevention strategies for a putative surge of suicide in relation to the impact of the COVID-19 pandemic. Objective: The goal of this retrospective, longitudinal time-series study is to understand the relationship between temporal trends of interest for the search term “suicide” and those of COVID-19–related terms, such as “social distancing,” “school closure,” and “lockdown.” Methods: We used the Google Trends platform to collect data on daily interest levels for search terms related to suicide, several other mental health-related issues, and COVID-19 over the period between February 14, 2020 and May 13, 2020. A correlational analysis was performed to determine the association between the search term ‘‘suicide’’ and COVID-19–related search terms in 16 countries. The Mann-Kendall test was used to examine significant differences between interest levels for the search term “suicide” before and after school closure. Results: We found that interest levels for the search term “suicide” statistically significantly inversely correlated with interest levels for the search terms “COVID-19” or “coronavirus” in nearly all countries between February 14, 2020 and May 13, 2020. Additionally, search interest for the term ‘‘suicide’’ significantly and negatively correlated with that of many COVID-19–related search terms, and search interest varied between countries. The Mann-Kendall test was used to examine significant differences between search interest levels for the term “suicide” before and after school closure. The Netherlands (P=.19), New Zealand (P=.003), the United Kingdom (P=.006), and the United States (P=.049) showed significant negative trends in interest levels for suicide in the 2-week period preceding school closures. In contrast, interest levels for suicide had a significant positive trend in Canada (P<.001) and the United States (P=.002) after school closures. Conclusions: The public’s attention to suicide might inversely correlate with the public’s attention to COVID-19–related issues. Additionally, several anticontagion policies, such as school closure, might have led to a turning point for mental health crises, because the attention to suicidality increased after restrictions were implemented. Our results suggest that an increased risk of suicidal ideation may ensue due to the ongoing anticontagion policies. Timely intervention strategies for suicides should therefore be an integral part of efforts to flatten the epidemic curve. %M 33326407 %R 10.2196/24694 %U http://publichealth.jmir.org/2020/4/e24694/ %U https://doi.org/10.2196/24694 %U http://www.ncbi.nlm.nih.gov/pubmed/33326407 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e24487 %T Anxiety and Suicidal Thoughts During the COVID-19 Pandemic: Cross-Country Comparative Study Among Indonesian, Taiwanese, and Thai University Students %A Pramukti,Iqbal %A Strong,Carol %A Sitthimongkol,Yajai %A Setiawan,Agus %A Pandin,Moses Glorino Rumambo %A Yen,Cheng-Fang %A Lin,Chung-Ying %A Griffiths,Mark D %A Ko,Nai-Ying %+ Institute of Allied Health Sciences, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan, 886 6 2353535 ext 5720, cylin36933@gmail.com %K anxiety %K COVID-19 %K cross-country %K suicidal thoughts %K university students %D 2020 %7 24.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has negatively affected the mental health of university students. Objective: This study examined the psychological responses toward COVID-19 among university students from 3 countries—Indonesia, Taiwan, and Thailand. Methods: We used a web-based, cross-sectional survey to recruit 1985 university students from 5 public universities (2 in Indonesia, 1 in Thailand, and 1 in Taiwan) via popular social media platforms such as Facebook, LINE, WhatsApp, and broadcast. All students (n=938 in Indonesia, n=734 in Thailand, and n=313 in Taiwan) answered questions concerning their anxiety, suicidal thoughts (or sadness), confidence in pandemic control, risk perception of susceptibility to infection, perceived support, resources for fighting infection, and sources of information in the context of the COVID-19 pandemic. Results: Among the 3 student groups, Thai students had the highest levels of anxiety but the lowest levels of confidence in pandemic control and available resources for fighting COVID-19. Factors associated with higher anxiety differed across countries. Less perceived satisfactory support was associated with more suicidal thoughts among Indonesian students. On the other hand, Taiwanese students were more negatively affected by information gathered from the internet and from medical staff than were Indonesian or Thai students. Conclusions: Our findings suggest that health care providers in Thailand may need to pay special attention to Thai university students given that high levels of anxiety were observed in this study population. In addition, health care providers should establish a good support system for university students, as the results of this study indicate a negative association between support and suicidal thoughts. %M 33296867 %R 10.2196/24487 %U http://www.jmir.org/2020/12/e24487/ %U https://doi.org/10.2196/24487 %U http://www.ncbi.nlm.nih.gov/pubmed/33296867 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e22740 %T Social Capital–Accrual, Escape-From-Self, and Time-Displacement Effects of Internet Use During the COVID-19 Stay-at-Home Period: Prospective, Quantitative Survey Study %A Cheng,Cecilia %A Lau,Yan-Ching %A Luk,Jeremy W %+ Social and Health Psychology Laboratory, Department of Psychology, The University of Hong Kong, Centennial Campus, Pokfulam Road, Hong Kong, Hong Kong, 852 39174224, ceci-cheng@hku.hk %K coping %K coronavirus %K COVID-19 %K cyberaggression %K cybervictimization %K epidemic %K gaming %K mental health %K psychological well-being %K social networking %K social support %D 2020 %7 24.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: COVID-19 has spread like wildfire across the globe, prompting many governments to impose unprecedented stay-at-home orders to limit its transmission. During an extended stay-at-home period, individuals may engage in more online leisure activities. Internet use is a double-edged sword that may have both desirable and undesirable effects on psychological well-being, and this study sought to disentangle adaptive from maladaptive internet use amidst this unusual health crisis. Objective: The objectives of this study were to assess the prevalence of probable depression during the COVID-19 stay-at-home period and to test three hypothesized risk reduction or risk elevation mechanisms, namely social capital–accrual, escape-from-self, and time-displacement effects. Methods: This study took place from March to May 2020 at the early stage of the pandemic. The study adopted a prospective design, with an online survey administered to 573 UK and 474 US adult residents at two assessment points 2 months apart. Results: The prevalence of moderate to severe depression was 36% (bootstrap bias-corrected and accelerated [BCa] 95% CI 33%-39%) at Time 1 (ie, initial time point) and 27% (bootstrap BCa 95% CI 25%-30%) at Time 2 (ie, follow-up time point). The results supported the social capital–accrual hypothesis by showing that the approach coping style was inversely associated with Time 2 depression through its positive associations with both social networking and perceived family support. The results also supported the escape-from-self hypothesis by revealing that the avoidant coping style was positively associated with Time 2 depression through its positive associations with both gaming and cyberbullying victimization, but the serial mediation model was no longer significant after Time 1 depression and some demographic risk factors had been controlled for. Finally, the results supported the time-displacement hypothesis by showing that gaming was positively associated with Time 2 depression through its inverse associations with social networking and perceived family support. Conclusions: During the extended stay-at-home period in the early stages of the COVID-19 pandemic, the prevalence of probable depression during the 2-month study period was high among the UK and US residents. Individuals with distinct coping styles may engage in different types of online leisure activities and perceive varying levels of social support, which are associated with risks of probable depression. %M 33320824 %R 10.2196/22740 %U http://www.jmir.org/2020/12/e22740/ %U https://doi.org/10.2196/22740 %U http://www.ncbi.nlm.nih.gov/pubmed/33320824 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 12 %P e22738 %T Digital Interventions for Depression and Anxiety in Older Adults: Protocol for a Systematic Review %A Riadi,Indira %A Kervin,Lucy %A Teo,Kelly %A Churchill,Ryan %A Cosco,Theodore D %+ Gerontology Research Centre, Simon Fraser University, #2800-515 West Hastings Street, Vancouver, BC, V6B 5K3, Canada, 1 778 782 5065, indira_riadi@sfu.ca %K systematic review %K digital intervention %K mental health %K depression %K anxiety %K older adults %D 2020 %7 23.12.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is a high prevalence of older adults experiencing depression and anxiety. In response to heightened demands for mental health interventions that are accessible and affordable, there has been a recent rise in the number of digital mental health interventions (DMHIs) that have been developed and incorporated into mental health treatments. Digital interventions are promising in their ability to provide researchers, medical practitioners, and patients with personalized tools for assessing behavior, consultation, treatment, and care that can be used remotely. Reviews and meta-analyses have shown the benefits of DMHIs for the treatment and prevention of depression, anxiety, and other mental illnesses, but there is still a lack of studies that focus on the benefits and use of DMHIs in the older population. Objective: The aim of this systematic review is to investigate the current evidence for the effect of technology-delivered interventions, such as smartphone/tablet applications, remote monitoring and tracking devices, and wearable technology, for the treatment and prevention of depression and anxiety in adults older than 50 years. Methods: The academic databases SCOPUS, PsycINFO, AgeLine (EBSCO), and Medline (PubMed) will be searched from January 1, 2010, to the date of search commencement to provide a review of existing randomized controlled trial studies. The search will include 3 key concepts: “older adults,” “digital intervention,” and “depression/anxiety.” A set of inclusion criteria will be followed during screening by two reviewers. Data will be extracted to address aims and objectives of the review. The risk of bias for each study will be determined using appropriate tools. If possible, a random-effects meta-analysis will be performed, and the heterogeneity of effect sizes will be calculated. Results: Preliminary searches were conducted in September 2020. The review is anticipated to be completed by April 2021. Conclusions: The data accumulated in this systematic review will demonstrate the potential benefits of technology-delivered interventions for the treatment of depression and anxiety disorders in older adults. This review will also identify any gaps in current studies of aging and mental health interventions, thereby navigating a way to move forward and paving the path to more accessible and user-friendly digital health interventions for the diverse population of older adults. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020192532; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020192532 International Registered Report Identifier (IRRID): PRR1-10.2196/22738 %M 33355095 %R 10.2196/22738 %U http://www.researchprotocols.org/2020/12/e22738/ %U https://doi.org/10.2196/22738 %U http://www.ncbi.nlm.nih.gov/pubmed/33355095 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e22423 %T Changes in Stress, Anxiety, and Depression Levels of Subscribers to a Daily Supportive Text Message Program (Text4Hope) During the COVID-19 Pandemic: Cross-Sectional Survey Study %A Agyapong,Vincent Israel Ouoku %A Hrabok,Marianne %A Vuong,Wesley %A Shalaby,Reham %A Noble,Jasmine Marie %A Gusnowski,April %A Mrklas,Kelly J %A Li,Daniel %A Urichuk,Liana %A Snaterse,Mark %A Surood,Shireen %A Cao,Bo %A Li,Xin-Min %A Greiner,Russell %A Greenshaw,Andrew James %+ Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Centre, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 780 215 7771, agyapong@ualberta.ca %K COVID-19 %K mobile technology %K text %K anxiety %K depression %K stress %K outbreak %K pandemic %K mental health %K outreach %D 2020 %7 18.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: In addition to the obvious physical medical impact of COVID-19, the disease poses evident threats to people’s mental health, psychological safety, and well-being. Provision of support for these challenges is complicated by the high number of people requiring support and the need to maintain physical distancing. Text4Hope, a daily supportive SMS text messaging program, was launched in Canada to mitigate the negative mental health impacts of the pandemic among Canadians. Objective: This paper describes the changes in the stress, anxiety, and depression levels of subscribers to the Text4Hope program after 6 weeks of exposure to daily supportive SMS text messages. Methods: We used self-administered, empirically supported web-based questionnaires to assess the demographic and clinical characteristics of Text4Hope subscribers. Perceived stress, anxiety, and depression were measured with the 10-Item Perceived Stress Scale (PSS-10), the Generalized Anxiety Disorder–7 (GAD-7) scale, and the Patient Health Questionnaire–9 (PHQ-9) scale at baseline and sixth week time points. Moderate or high perceived stress, likely generalized anxiety disorder, and likely major depressive disorder were assessed using cutoff scores of ≥14 for the PSS-10, ≥10 for the GAD-7, and ≥10 for the PHQ-9, respectively. At 6 weeks into the program, 766 participants had completed the questionnaires at both time points. Results: At the 6-week time point, there were statistically significant reductions in mean scores on the PSS-10 and GAD-7 scales but not on the PHQ-9 scale. Effect sizes were small overall. There were statistically significant reductions in the prevalence rates of moderate or high stress and likely generalized anxiety disorder but not likely major depressive disorder for the group that completed both the baseline and 6-week assessments. The largest reductions in mean scores and prevalence rates were for anxiety (18.7% and 13.5%, respectively). Conclusions: Text4Hope is a convenient, cost-effective, and accessible means of implementing a population-level psychological intervention. This service demonstrated significant reductions in anxiety and stress levels during the COVID-19 pandemic and could be used as a population-level mental health intervention during natural disasters and other emergencies. International Registered Report Identifier (IRRID): RR2-10.2196/19292 %M 33296330 %R 10.2196/22423 %U http://mental.jmir.org/2020/12/e22423/ %U https://doi.org/10.2196/22423 %U http://www.ncbi.nlm.nih.gov/pubmed/33296330 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e20920 %T Evaluating Behavioral and Linguistic Changes During Drug Treatment for Depression Using Tweets in Spanish: Pairwise Comparison Study %A Leis,Angela %A Ronzano,Francesco %A Mayer,Miguel Angel %A Furlong,Laura I %A Sanz,Ferran %+ Research Programme on Biomedical Informatics, Hospital del Mar Medical Research Institute, Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona Biomedical Research Park, Carrer Dr Aiguader 88, Barcelona, 08003, Spain, 34 933160540, ferran.sanz@upf.edu %K depression %K antidepressant drugs %K serotonin uptake inhibitors %K mental health %K social media %K infodemiology %K data mining %D 2020 %7 18.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Depressive disorders are the most common mental illnesses, and they constitute the leading cause of disability worldwide. Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed drugs for the treatment of depressive disorders. Some people share information about their experiences with antidepressants on social media platforms such as Twitter. Analysis of the messages posted by Twitter users under SSRI treatment can yield useful information on how these antidepressants affect users’ behavior. Objective: This study aims to compare the behavioral and linguistic characteristics of the tweets posted while users were likely to be under SSRI treatment, in comparison to the tweets posted by the same users when they were less likely to be taking this medication. Methods: In the first step, the timelines of Twitter users mentioning SSRI antidepressants in their tweets were selected using a list of 128 generic and brand names of SSRIs. In the second step, two datasets of tweets were created, the in-treatment dataset (made up of the tweets posted throughout the 30 days after mentioning an SSRI) and the unknown-treatment dataset (made up of tweets posted more than 90 days before or more than 90 days after any tweet mentioning an SSRI). For each user, the changes in behavioral and linguistic features between the tweets classified in these two datasets were analyzed. 186 users and their timelines with 668,842 tweets were finally included in the study. Results: The number of tweets generated per day by the users when they were in treatment was higher than it was when they were in the unknown-treatment period (P=.001). When the users were in treatment, the mean percentage of tweets posted during the daytime (from 8 AM to midnight) increased in comparison to the unknown-treatment period (P=.002). The number of characters and words per tweet was higher when the users were in treatment (P=.03 and P=.02, respectively). Regarding linguistic features, the percentage of pronouns that were first-person singular was higher when users were in treatment (P=.008). Conclusions: Behavioral and linguistic changes have been detected when users with depression are taking antidepressant medication. These features can provide interesting insights for monitoring the evolution of this disease, as well as offering additional information related to treatment adherence. This information may be especially useful in patients who are receiving long-term treatments such as people suffering from depression. %M 33337338 %R 10.2196/20920 %U http://www.jmir.org/2020/12/e20920/ %U https://doi.org/10.2196/20920 %U http://www.ncbi.nlm.nih.gov/pubmed/33337338 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 12 %P e24776 %T Psychological Impacts of COVID-19 During the First Nationwide Lockdown in Vietnam: Web-Based, Cross-Sectional Survey Study %A Ngoc Cong Duong,Khanh %A Nguyen Le Bao,Tien %A Thi Lan Nguyen,Phuong %A Vo Van,Thanh %A Phung Lam,Toi %A Pham Gia,Anh %A Anuratpanich,Luerat %A Vo Van,Bay %+ Department of Pharmacy, Thong Nhat Hospital, 1 Ly Thuong Kiet Street, Ward 7, Tan Binh District, Ho Chi Minh City, 70000, Vietnam, 84 988889315, vovanbay2005@yahoo.com.vn %K COVID-19 %K mental health %K psychological distress %K depression %K anxiety %K Vietnam %K psychology %K distress %K lockdown %K survey %D 2020 %7 15.12.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: The first nationwide lockdown due to the COVID-19 pandemic was implemented in Vietnam from April 1 to 15, 2020. Nevertheless, there has been limited information on the impact of COVID-19 on the psychological health of the public. Objective: This study aimed to estimate the prevalence of psychological issues and identify the factors associated with the psychological impact of COVID-19 during the first nationwide lockdown among the general population in Vietnam. Methods: We employed a cross-sectional study design with convenience sampling. A self-administered, online survey was used to collect data and assess psychological distress, depression, anxiety, and stress of participants from April 10 to 15, 2020. The Impact of Event Scale-Revised (IES-R) and the Depression, Anxiety, and Stress Scale-21 (DASS-21) were utilized to assess psychological distress, depression, anxiety, and stress of participants during social distancing due to COVID-19. Associations across factors were explored using regression analysis. Results: A total of 1385 respondents completed the survey. Of this, 35.9% (n=497) experienced psychological distress, as well as depression (n=325, 23.5%), anxiety (n=195, 14.1%), and stress (n=309, 22.3%). Respondents who evaluated their physical health as average had a higher IES-R score (beta coefficient [B]=9.16, 95% CI 6.43 to 11.89), as well as higher depression (B=5.85, 95% CI 4.49 to 7.21), anxiety (B=3.64, 95% CI 2.64 to 4.63), and stress (B=5.19, 95% CI 3.83 to 6.56) scores for DASS-21 than those who rated their health as good or very good. Those who self-reported their health as bad or very bad experienced more severe depression (B=9.57, 95% CI 4.54 to 14.59), anxiety (B=7.24, 95% CI 3.55 to 10.9), and stress (B=10.60, 95% CI 5.56 to 15.65). Unemployment was more likely to be associated with depression (B=3.34, 95% CI 1.68 to 5.01) and stress (B=2.34, 95% CI 0.84 to 3.85). Regarding worries about COVID-19, more than half (n=755, 54.5%) expressed concern for their children aged <18 years, which increased their IES-R score (B=7.81, 95% CI 4.98 to 10.64) and DASS-21 stress score (B=1.75, 95% CI 0.27 to 3.24). The majority of respondents (n=1335, 96.4%) were confident about their doctor’s expertise in terms of COVID-19 diagnosis and treatment, which was positively associated with less distress caused by the outbreak (B=–7.84, 95% CI –14.58 to –1.11). Conclusions: The findings highlight the effect of COVID-19 on mental health during the nationwide lockdown among the general population in Vietnam. The study provides useful evidence for policy decision makers to develop and implement interventions to mitigate these impacts. %M 33284778 %R 10.2196/24776 %U http://formative.jmir.org/2020/12/e24776/ %U https://doi.org/10.2196/24776 %U http://www.ncbi.nlm.nih.gov/pubmed/33284778 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e23520 %T Association Between LGB Sexual Orientation and Depression Mediated by Negative Social Media Experiences: National Survey Study of US Young Adults %A Escobar-Viera,César G %A Shensa,Ariel %A Sidani,Jaime %A Primack,Brian %A Marshal,Michael P %+ Center for Research on Behavioral Health, Media, and Technology, Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, United States, 1 412 246 5864, escobar-viera@pitt.edu %K social media %K depression %K mental health %K sexual minorities %K minority stress %K GSEM %K survey %K young adult %K adolescent %K LGBTQ %D 2020 %7 3.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Lesbian, gay, and bisexual (LGB) persons are disproportionately affected by depression and have high social media use rates. Negative social media experiences may modify depressive symptoms among LGB persons. We sought to assess the potential influence of negative social media experiences on the association between LGB orientation and depression. Objective: The aim of this study was to assess the potential influence of negative social media experiences on the association between LGB orientation and depression. Methods: We performed a web-based survey of a national sample of US young adults aged 18-30 years. We assessed the respondents’ LGB orientation, negative social media experiences, and depression using the 9-item Patient Health Questionnaire. We used generalized structural equation modeling to assess both the direct and indirect effects (via negative social media experiences) of LGB orientation on depression while controlling for relevant demographic and personal characteristics. Results: We found a conditional indirect effect (ab path) of LGB orientation on depressive symptoms via negative social media experience (a: observed coefficient 0.229; P<.001; bias-corrected bootstrapped 95% CI 0.162-0.319, and b: observed coefficient 2.158; P<.001; bias-corrected bootstrapped 95% CI 1.840-2.494). The results show that among LGB respondents, for those who reported negative social media experiences in the past year, a 1 unit increase in these experiences was associated with a 0.494 unit increase in depressive symptomatology. Conclusions: Our results suggest that higher rates of depression among LGB young adults are partially explained by negative social media experiences; these results could help inform future patient/provider conversations about mental health risk and protective factors related to social media use. Reducing these experiences and increasing positive social media experiences among LGB persons may mitigate depressive symptomatology in this population. %M 33270041 %R 10.2196/23520 %U https://mental.jmir.org/2020/12/e23520 %U https://doi.org/10.2196/23520 %U http://www.ncbi.nlm.nih.gov/pubmed/33270041 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e24240 %T Mental Health Burden in Different Professions During the Final Stage of the COVID-19 Lockdown in China: Cross-sectional Survey Study %A Du,Junfeng %A Mayer,Gwendolyn %A Hummel,Svenja %A Oetjen,Neele %A Gronewold,Nadine %A Zafar,Ali %A Schultz,Jobst-Hendrik %+ Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany, 49 62215635685, gwendolyn.mayer@med.uni-heidelberg.de %K mental health %K COVID-19 %K China %K depression %K anxiety %K lockdown %K coping strategies %K stressors %K stress %K doctors %K nurses %K students %K media consumption %K WeChat %D 2020 %7 2.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: COVID-19 resulted in considerable mental health burden in the Chinese general population and among health care workers at the beginning and peak of the pandemic. However, little is known about potentially vulnerable groups during the final stage of the lockdown. Objective: The aim of this survey study was to assess the mental health burden of different professions in China in order to find vulnerable groups, possible influencing factors, and successful ways of coping during the last 4 weeks of the lockdown in Hubei Province. Methods: A cross-sectional online survey asked participants about current residence, daily working hours, exposure to COVID-19 at work, and media preferences. We used a shortened version of the Depression, Anxiety and Stress Scale (DASS-21) to assess mental health. Further assessments included perceived stress (Simplified Chinese version of the 14-item Perceived Stress Scale), coping strategies for all participants, and specific stressors for health care workers. We followed the reporting guidelines of the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement for observational studies. Results: The sample (N=687) consisted of 158 doctors, 221 nurses, 24 other medical staff, 43 students, 60 teachers/government staff, 135 economy staff, 26 workers/farmers, and 20 professions designated under the “other” category. We found increased depression (n=123, 17.9%), anxiety (n=208, 30.3%), and stress (n=94, 13.7%) in our sample. Professions that were vulnerable to depression were other medical staff and students. Doctors, nurses, and students were vulnerable to anxiety; and other medical staff, students, and economy staff were vulnerable to stress. Coping strategies were reduced to three factors: active, mental, and emotional. Being female and emotional coping were independently associated with depression, anxiety, or stress. Applying active coping strategies showed lower odds for anxiety while mental coping strategies showed lower odds for depression, anxiety, and stress. Age, being inside a lockdown area, exposure to COVID-19 at work, and having a high workload (8-12 hours per day) were not associated with depression, anxiety, or stress. WeChat was the preferred way of staying informed across all groups. Conclusions: By the end of the lockdown, a considerable part of the Chinese population showed increased levels of depression and anxiety. Students and other medical staff were the most affected, while economy staff were highly stressed. Doctors and nurses need support regarding potential anxiety disorders. Future work should focus on longitudinal results of the pandemic and develop targeted preventive measures. %M 33197231 %R 10.2196/24240 %U https://www.jmir.org/2020/12/e24240 %U https://doi.org/10.2196/24240 %U http://www.ncbi.nlm.nih.gov/pubmed/33197231 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e24066 %T Repeated Digitized Assessment of Risk and Symptom Profiles During Inpatient Treatment of Affective Disorder: Observational Study %A Richter,Maike Frederike %A Storck,Michael %A Blitz,Rogério %A Goltermann,Janik %A Seipp,Juliana %A Dannlowski,Udo %A Baune,Bernhard T %A Dugas,Martin %A Opel,Nils %+ Department of Psychiatry, University of Münster, Albert-Schweitzer-Str. 11, Münster, 48149, Germany, 49 2518358160, n_opel01@uni-muenster.de %K affective disorders %K digital data collection %K psychiatry %K P4 medicine %D 2020 %7 1.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Predictive models have revealed promising results for the individual prognosis of treatment response and relapse risk as well as for differential diagnosis in affective disorders. Yet, in order to translate personalized predictive modeling from research contexts to psychiatric clinical routine, standardized collection of information of sufficient detail and temporal resolution in day-to-day clinical care is needed. Digital collection of self-report measures by patients is a time- and cost-efficient approach to gain such data throughout treatment. Objective: The objective of this study was to investigate whether patients with severe affective disorders were willing and able to participate in such efforts, whether the feasibility of such systems might vary depending on individual patient characteristics, and if digitally acquired assessments were of sufficient diagnostic validity. Methods: We implemented a system for longitudinal digital collection of risk and symptom profiles based on repeated self-reports via tablet computers throughout inpatient treatment of affective disorders at the Department of Psychiatry at the University of Münster. Tablet-handling competency and the speed of data entry were assessed. Depression severity was additionally assessed by a clinical interviewer at baseline and before discharge. Results: Of 364 affective disorder patients who were approached, 242 (66.5%) participated in the study; 88.8% of participants (215/242) were diagnosed with major depressive disorder, and 27 (11.2%) had bipolar disorder. During the duration of inpatient treatment, 79% of expected assessments were completed, with an average of 4 completed assessments per participant; 4 participants (4/242, 1.6%) dropped out of the study prematurely. During data entry, 89.3% of participants (216/242) did not require additional support. Needing support with tablet handling and slower data entry pace were predicted by older age, whereas depression severity at baseline did not influence these measures. Patient self-reporting of depression severity showed high agreement with standardized external assessments by a clinical interviewer. Conclusions: Our results indicate that digital collection of self-report measures is a feasible, accessible, and valid method for longitudinal data collection in psychiatric routine, which will eventually facilitate the identification of individual risk and resilience factors for affective disorders and pave the way toward personalized psychiatric care. %M 33258791 %R 10.2196/24066 %U https://mental.jmir.org/2020/12/e24066 %U https://doi.org/10.2196/24066 %U http://www.ncbi.nlm.nih.gov/pubmed/33258791 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e14296 %T Usage and Acceptability of the iBobbly App: Pilot Trial for Suicide Prevention in Aboriginal and Torres Strait Islander Youth %A Tighe,Joseph %A Shand,Fiona %A McKay,Kathy %A Mcalister,Taylor-Jai %A Mackinnon,Andrew %A Christensen,Helen %+ Black Dog Institute, Hospital Rd, Randwick, Sydney, Australia, 61 292824530, joetighe@hotmail.com %K mHealth %K suicide %K depression %K eHealth %K Indigenous %K Aboriginal %K First Nations %K mental health %K suicide ideation %K apps %D 2020 %7 1.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The proliferation of mental health apps purporting to target and improve psychological wellbeing is ever-growing and also concerning: Few apps have been rigorously evaluated, and, indeed, the safety of the vast majority of them has not been determined. Over 10,000 self-help apps exist but most are not used much after being downloaded. Gathering and analyzing usage data and the acceptability of apps are critical to inform consumers, researchers, and app developers. Objective: This paper presents pilot usage and acceptability data from the iBobbly suicide prevention app, an app distributed through a randomized controlled trial. Methods: Aboriginal and Torres Strait Islander participants from the Kimberley region of Western Australia completed a survey measuring their technology use in general (n=13), and data on their experiences with and views of the iBobbly app were also collected in semistructured interviews (n=13) and thematically analyzed. Finally, engagement with the app, such as the number of sessions completed and time spent on various acceptance-based therapeutic activities, was analyzed (n=18). Both groups were participants in the iBobbly app pilot randomized controlled trial (n=61) completed in 2015. Results: Regression analysis indicated that app use improved psychological outcomes, although only minimally, and effects were not significant. However, results of the thematic analysis indicated that the iBobbly app was deemed effective, acceptable, and culturally appropriate by those interviewed. Conclusions: There is a scarcity of randomized controlled trials and eHealth interventions in Indigenous communities, while extremely high rates of psychological distress and suicide persist. In this environment, studies that can add evidence from mixed-methods approaches are important. While the regression analysis in this study did not indicate a significant effect of app use on psychological wellbeing, this was predictable considering the small sample size (n=18) and typically brief app use. The results on engagement with the iBobbly app were however positive. This study showed that Indigenous youth are early and frequent users of technology in general, and they regarded the iBobbly app to be culturally safe and of therapeutic value. Qualitative analyses demonstrated that iBobbly app use was associated with self-reported improvements in psychological wellbeing, mental health literacy, and reductions in shame. Importantly, participants reported that they would recommend other similar apps if available to their peers. %M 33258782 %R 10.2196/14296 %U https://mental.jmir.org/2020/12/e14296 %U https://doi.org/10.2196/14296 %U http://www.ncbi.nlm.nih.gov/pubmed/33258782 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e22634 %T Screening for Depression in Daily Life: Development and External Validation of a Prediction Model Based on Actigraphy and Experience Sampling Method %A Minaeva,Olga %A Riese,Harriëtte %A Lamers,Femke %A Antypa,Niki %A Wichers,Marieke %A Booij,Sanne H %+ Interdisciplinary Center Psychopathology and Emotion regulation (ICPE), Department of Psychiatry, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen, 9713 GZ, Netherlands, 31 50 361 2065, o.minaeva@umcg.nl %K actigraphy %K activity tracker %K depression %K experience sampling method %K prediction model %K screening %D 2020 %7 1.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In many countries, depressed individuals often first visit primary care settings for consultation, but a considerable number of clinically depressed patients remain unidentified. Introducing additional screening tools may facilitate the diagnostic process. Objective: This study aimed to examine whether experience sampling method (ESM)-based measures of depressive affect and behaviors can discriminate depressed from nondepressed individuals. In addition, the added value of actigraphy-based measures was examined. Methods: We used data from 2 samples to develop and validate prediction models. The development data set included 14 days of ESM and continuous actigraphy of currently depressed (n=43) and nondepressed individuals (n=82). The validation data set included 30 days of ESM and continuous actigraphy of currently depressed (n=27) and nondepressed individuals (n=27). Backward stepwise logistic regression analysis was applied to build the prediction models. Performance of the models was assessed with goodness-of-fit indices, calibration curves, and discriminative ability (area under the receiver operating characteristic curve [AUC]). Results: In the development data set, the discriminative ability was good for the actigraphy model (AUC=0.790) and excellent for both the ESM (AUC=0.991) and the combined-domains model (AUC=0.993). In the validation data set, the discriminative ability was reasonable for the actigraphy model (AUC=0.648) and excellent for both the ESM (AUC=0.891) and the combined-domains model (AUC=0.892). Conclusions: ESM is a good diagnostic predictor and is easy to calculate, and it therefore holds promise for implementation in clinical practice. Actigraphy shows no added value to ESM as a diagnostic predictor but might still be useful when ESM use is restricted. %M 33258783 %R 10.2196/22634 %U https://www.jmir.org/2020/12/e22634 %U https://doi.org/10.2196/22634 %U http://www.ncbi.nlm.nih.gov/pubmed/33258783 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e15293 %T Detection of Suicidality Among Opioid Users on Reddit: Machine Learning–Based Approach %A Yao,Hannah %A Rashidian,Sina %A Dong,Xinyu %A Duanmu,Hongyi %A Rosenthal,Richard N %A Wang,Fusheng %+ Stony Brook University, 2313D Computer Science, Stony Brook, NY, 11794, United States, 1 631 632 2594, fusheng.wang@stonybrook.edu %K opioid epidemic %K opioid-related disorders %K suicide %K social media %K machine learning %K deep learning %K natural language processing %D 2020 %7 27.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In recent years, both suicide and overdose rates have been increasing. Many individuals who struggle with opioid use disorder are prone to suicidal ideation; this may often result in overdose. However, these fatal overdoses are difficult to classify as intentional or unintentional. Intentional overdose is difficult to detect, partially due to the lack of predictors and social stigmas that push individuals away from seeking help. These individuals may instead use web-based means to articulate their concerns. Objective: This study aimed to extract posts of suicidality among opioid users on Reddit using machine learning methods. The performance of the models is derivative of the data purity, and the results will help us to better understand the rationale of these users, providing new insights into individuals who are part of the opioid epidemic. Methods: Reddit posts between June 2017 and June 2018 were collected from r/suicidewatch, r/depression, a set of opioid-related subreddits, and a control subreddit set. We first classified suicidal versus nonsuicidal languages and then classified users with opioid usage versus those without opioid usage. Several traditional baselines and neural network (NN) text classifiers were trained using subreddit names as the labels and combinations of semantic inputs. We then attempted to extract out-of-sample data belonging to the intersection of suicide ideation and opioid abuse. Amazon Mechanical Turk was used to provide labels for the out-of-sample data. Results: Classification results were at least 90% across all models for at least one combination of input; the best classifier was convolutional neural network, which obtained an F1 score of 96.6%. When predicting out-of-sample data for posts containing both suicidal ideation and signs of opioid addiction, NN classifiers produced more false positives and traditional methods produced more false negatives, which is less desirable for predicting suicidal sentiments. Conclusions: Opioid abuse is linked to the risk of unintentional overdose and suicide risk. Social media platforms such as Reddit contain metadata that can aid machine learning and provide information at a personal level that cannot be obtained elsewhere. We demonstrate that it is possible to use NNs as a tool to predict an out-of-sample target with a model built from data sets labeled by characteristics we wish to distinguish in the out-of-sample target. %M 33245287 %R 10.2196/15293 %U http://www.jmir.org/2020/11/e15293/ %U https://doi.org/10.2196/15293 %U http://www.ncbi.nlm.nih.gov/pubmed/33245287 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 11 %P e20646 %T Leveraging the Power of Nondisruptive Technologies to Optimize Mental Health Treatment: Case Study %A Sadeh-Sharvit,Shiri %A Hollon,Steven D %+ Eleos Health, 1 Broadway, Cambridge, MD, 02141, United States, 1 5109848132, shiri@eleos.health %K anxiety %K behavioral health %K depression %K digital health %K Eleos Health %K mental health %K natural language processing %D 2020 %7 26.11.2020 %9 Industry Perspective %J JMIR Ment Health %G English %X Regular assessment of the effectiveness of behavioral interventions is a potent tool for improving their relevance to patients. However, poor provider and patient adherence characterize most measurement-based care tools. Therefore, a new approach for measuring intervention effects and communicating them to providers in a seamless manner is warranted. This paper provides a brief overview of the available research evidence on novel ways to measure the effects of behavioral treatments, integrating both objective and subjective data. We highlight the importance of analyzing therapeutic conversations through natural language processing. We then suggest a conceptual framework for capitalizing on data captured through directly collected and nondisruptive methodologies to describe the client’s characteristics and needs and inform clinical decision-making. We then apply this context in exploring a new tool to integrate the content of therapeutic conversations and patients’ self-reports. We present a case study of how both subjective and objective measures of treatment effects were implemented in cognitive-behavioral treatment for depression and anxiety and then utilized in treatment planning, delivery, and termination. In this tool, called Eleos, the patient completes standardized measures of depression and anxiety. The content of the treatment sessions was evaluated using nondisruptive, independent measures of conversation content, fidelity to the treatment model, and the back-and-forth of client-therapist dialogue. Innovative applications of advances in digital health are needed to disseminate empirically supported interventions and measure them in a noncumbersome way. Eleos appears to be a feasible, sustainable, and effective way to assess behavioral health care. %M 33242025 %R 10.2196/20646 %U http://mental.jmir.org/2020/11/e20646/ %U https://doi.org/10.2196/20646 %U http://www.ncbi.nlm.nih.gov/pubmed/33242025 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 11 %P e24882 %T The Role of Demoralization and Meaning in Life (DEMIL) in Influencing Suicidal Ideation Among Patients Affected by Chronic Pain: Protocol of a Single-Center, Observational, Case-Control Study %A Costanza,Alessandra %A Chytas,Vasileios %A Mazzola,Viridiana %A Piguet,Valérie %A Desmeules,Jules %A Bondolfi,Guido %A Cedraschi,Christine %+ Department of Psychiatry, Faculty of Medicine, University of Geneva, rue Michel Servet 1, Geneva, 1211, Switzerland, 41 +41767273740, alessandra.costanza@unige.ch %K suicide %K suicide behavior %K suicide attempt %K suicidal ideation %K chronic pain %K demoralization %K meaning in life %K study protocol %D 2020 %7 26.11.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Chronic pain is a significant risk factor for suicidal ideation (SI) and suicidal behavior (SB), including a 20%-40% prevalence rate of SI, a prevalence between 5% and 14% of suicide attempts, and a doubled risk of death by suicide in patients with chronic pain compared to controls. In most studies, associations between chronic pain and suicidality are robust, even after adjusting for the effect of sociodemographics and psychiatric comorbidity, and particularly for depressive conditions. A number of specific conditions that can modulate suicidality risk in patients with chronic pain have been investigated, but there is a need for their more specific characterization. Numerous recent studies have shown that demoralization and meaning in life (MiL) constructs affect suicidality as risk and protective factors, respectively. These constructs have been mainly investigated in patients with somatic illness and in community-dwelling individuals who may present with SI or SB independently of a psychiatric diagnosis of depression. However, a paucity of studies investigated them in suicidal patients affected by chronic pain. Objective: The primary objective of this project is to investigate the relationship between demoralization and MiL on SI risk in patients with chronic pain. The secondary objectives are (1) to test whether demoralization can occur independently of depression in patients with chronic pain and SI, (2) to examine whether the expected association between demoralization and SI may be explained by a sole dimension of demoralization: hopelessness, (3) to examine whether the presence of MiL, but not the search for MiL, is associated with less SI, and (4) to explore whether previously described MiL profiles (ie, high presence-high search, high presence-low search, moderate presence-moderate search, low presence-low search, and low presence-high search) emerge in our cohort. Methods: This project is a single-center, observational, case-control study—the Demoralization and Meaning in Life (DEMiL) study—conducted by the Division of Clinical Pharmacology and Toxicology, the Multidisciplinary Pain Centre, and the Service of Liaison Psychiatry and Crisis Intervention at the Geneva University Hospitals. Self- and hetero-administered questionnaires were conducted among patients and controls, matched by age and gender. The Ethics Committee of the Canton of Geneva approved the scientific utilization of collected data (project No. 2017-02138; decision dated January 25, 2018). Data have been analyzed with SPSS, version 23.0, software (IBM Corp). Results: From March 1, 2018, to November 30, 2019, 70 patients and 70 controls were enrolled. Statistical analyses are still in progress and are expected to be finalized in November 2020. To date, we did not observe any unfavorable event for which a causal relationship with the collection of health-related personal data could be ruled out. Results of this study are expected to form the basis for possible prevention and psychotherapeutic interventions oriented toward demoralization and MiL constructs for suicidal patients with chronic pain. Conclusions: The interest in exploring demoralization and MiL in chronic pain patients with SI arises from the common clinical observation that experiencing chronic pain often requires a revision of one’s life goals and expectations. Hence, the impact of chronic pain is not limited to patients’ biopsychosocial functioning, but it affects the existential domain as well. The major clinical implications in suicidal patients with chronic pain consist in trying to (1) delineate a more precise and individualized suicide risk profile, (2) improve detection and prevention strategies by investigating SI also in individuals who do not present with a clinically diagnosed depression, and (3) enhance the panel of interventions by broadening supportive or psychotherapeutic actions, taking into consideration the existential condition of a person who suffers and strives to deal with his or her suffering. International Registered Report Identifier (IRRID): DERR1-10.2196/24882 %M 33144275 %R 10.2196/24882 %U https://www.researchprotocols.org/2020/11/e24882 %U https://doi.org/10.2196/24882 %U http://www.ncbi.nlm.nih.gov/pubmed/33144275 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 11 %P e23748 %T A Mental Health Surveillance System for the General Population During the COVID-19 Pandemic: Protocol for a Multiwave Cross-sectional Survey Study %A BinDhim,Nasser F %A Althumiri,Nora A %A Basyouni,Mada H %A Alageel,Asem A %A Alghnam,Suliman %A Al-Qunaibet,Ada M %A Almubark,Rasha A %A Aldhukair,Shahla %A Ad-Dab'bagh,Yasser %+ Sharik Association for Health Research, 4 Ans Ibn Malik St, Riyadh, , Saudi Arabia, 966 580033299, nd@nasserdhim.com %K mental health %K depression %K anxiety %K screening %K surveillance %K COVID-19 %D 2020 %7 26.11.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: The COVID-19 outbreak can potentially be categorized as a traumatic event. Public health surveillance is one of the cornerstones of public health practice, and it empowers decision makers to lead and manage public health crises and programs more effectively by providing timely and useful evidence. Objective: This paper presents the protocol for a study that aims to identify, track, and monitor trends in the population in Saudi Arabia at risk of major depressive disorders and anxiety during the COVID-19 pandemic. Methods: This study utilizes continuous, cross-sectional, national-level mental health screening via computer-assisted phone interviews, conducted in four waves on a monthly basis (between May and August 2020). Arabic-speaking adults, aged ≥18 years, and living in Saudi Arabia were recruited via a random phone list. This surveillance system used the proportional quota sampling technique to achieve an equal distribution of participants, stratified by age and gender, and region, within and across the 13 administrative regions of Saudi Arabia. A sample size of 4056 participants per wave was calculated to achieve enough power to detect changes in mental health status. The questionnaire includes the Arabic version of the Patient Health Questionnaire-9 (PHQ-9) to measure depressive symptoms and the General Anxiety Disorder-7 (GAD-7) to measure anxiety. In addition, it will collect data on sociodemographic variables and potential risk factors. Results: Study recruitment began in May 2020. The data analysis was completed in October 2020, and the final report is expected to be published by the end of December 2020. Conclusions: Monitoring the population’s mental health status during the COVID-19 pandemic will inform decision makers of any potential deterioration in mental health on a national level and among subgroups, including across regions, age groups, and gender groups. It will allow decision makers to recognize issues and intervene sooner. It will also provide valuable scientific data to help understand the effects of epidemics and pandemics on mental health. As far as we know, this is the only study that attempts to monitor the mental health status of the general population on a monthly basis. International Registered Report Identifier (IRRID): DERR1-10.2196/23748 %M 33156802 %R 10.2196/23748 %U http://www.researchprotocols.org/2020/11/e23748/ %U https://doi.org/10.2196/23748 %U http://www.ncbi.nlm.nih.gov/pubmed/33156802 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e22600 %T Psychosocial Effects of the COVID-19 Pandemic: Large-scale Quasi-Experimental Study on Social Media %A Saha,Koustuv %A Torous,John %A Caine,Eric D %A De Choudhury,Munmun %+ School of Interactive Computing, Georgia Institute of Technology, North Ave NW, Atlanta, GA, 30332, United States, 1 4046929496, koustuv.saha@gatech.edu %K social media %K Twitter %K language %K psychosocial effects %K mental health %K transfer learning %K depression %K anxiety %K stress %K social support %K emotions %K COVID-19 %K coronavirus %K crisis %D 2020 %7 24.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has caused several disruptions in personal and collective lives worldwide. The uncertainties surrounding the pandemic have also led to multifaceted mental health concerns, which can be exacerbated with precautionary measures such as social distancing and self-quarantining, as well as societal impacts such as economic downturn and job loss. Despite noting this as a “mental health tsunami”, the psychological effects of the COVID-19 crisis remain unexplored at scale. Consequently, public health stakeholders are currently limited in identifying ways to provide timely and tailored support during these circumstances. Objective: Our study aims to provide insights regarding people’s psychosocial concerns during the COVID-19 pandemic by leveraging social media data. We aim to study the temporal and linguistic changes in symptomatic mental health and support expressions in the pandemic context. Methods: We obtained about 60 million Twitter streaming posts originating from the United States from March 24 to May 24, 2020, and compared these with about 40 million posts from a comparable period in 2019 to attribute the effect of COVID-19 on people’s social media self-disclosure. Using these data sets, we studied people’s self-disclosure on social media in terms of symptomatic mental health concerns and expressions of support. We employed transfer learning classifiers that identified the social media language indicative of mental health outcomes (anxiety, depression, stress, and suicidal ideation) and support (emotional and informational support). We then examined the changes in psychosocial expressions over time and language, comparing the 2020 and 2019 data sets. Results: We found that all of the examined psychosocial expressions have significantly increased during the COVID-19 crisis—mental health symptomatic expressions have increased by about 14%, and support expressions have increased by about 5%, both thematically related to COVID-19. We also observed a steady decline and eventual plateauing in these expressions during the COVID-19 pandemic, which may have been due to habituation or due to supportive policy measures enacted during this period. Our language analyses highlighted that people express concerns that are specific to and contextually related to the COVID-19 crisis. Conclusions: We studied the psychosocial effects of the COVID-19 crisis by using social media data from 2020, finding that people’s mental health symptomatic and support expressions significantly increased during the COVID-19 period as compared to similar data from 2019. However, this effect gradually lessened over time, suggesting that people adapted to the circumstances and their “new normal.” Our linguistic analyses revealed that people expressed mental health concerns regarding personal and professional challenges, health care and precautionary measures, and pandemic-related awareness. This study shows the potential to provide insights to mental health care and stakeholders and policy makers in planning and implementing measures to mitigate mental health risks amid the health crisis. %M 33156805 %R 10.2196/22600 %U http://www.jmir.org/2020/11/e22600/ %U https://doi.org/10.2196/22600 %U http://www.ncbi.nlm.nih.gov/pubmed/33156805 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 11 %P e19112 %T Family Members’ Perspectives on Family and Social Support Available to Suicidal Patients, and Health Systems’ Interactions and Responses to Suicide Cases in Alberta: Protocol for a Quantitative Research Study %A Abou El-Magd,Rabab M %A Urichuk,Liana %A Surood,Shireen %A Li,Daniel %A Greenshaw,Andrew %A Grunau,Mara %A MacNeil,Laureen %A Challborn,Ione %A Grauwiler,David %A Olson,Robert %A Agyapong,Vincent Israel Opoku %+ Department of Psychiatry, Faculty of Medicine, University of Alberta, 8440 112 St NW, Edmonton, AB, T6R 3P5, Canada, 1 780 714 4315, agyapong@ualberta.ca %K suicide in Alberta %K suicide %K family members’ perspectives %K social support %K health systems interactions %D 2020 %7 24.11.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is a major cause of preventable death globally and a leading cause of death by injury in Canada. To support people who experience suicidal thoughts and behaviors and to ultimately prevent people from dying by suicide, it is important to understand individual and familial experiences with the health care system. Objective: We present the protocol for a study, the objective of which is to explore how people who died by suicide, and their family members, interacted with the health care system. Methods: This is a quantitative research study. Data will be collected through a self-administered paper-based or online survey of the family member of patients who died by suicide. The sample size was calculated to be 385 (margin of error ±3%). Results: Data collection will start in October 2020 and results will be available by March 2021. We expect the results to shed light on the experiences of individuals who died by suicide and their family members with the health care system. The study has received ethical clearance from the Health Ethics Research Board of the University of Alberta (Pro00096342). Conclusions: Our study may inform practice, policy, and future research. The findings may shape how members of the health care system respond to people who are at risk of suicide and their families. International Registered Report Identifier (IRRID): PRR1-10.2196/19112 %M 33231553 %R 10.2196/19112 %U https://www.researchprotocols.org/2020/11/e19112 %U https://doi.org/10.2196/19112 %U http://www.ncbi.nlm.nih.gov/pubmed/33231553 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 11 %P e17065 %T Artificial Intelligence Chatbot for Depression: Descriptive Study of Usage %A Dosovitsky,Gilly %A Pineda,Blanca S %A Jacobson,Nicholas C %A Chang,Cyrus %A Escoredo,Milagros %A Bunge,Eduardo L %+ Palo Alto University, 1791 Arastradero Road, Palo Alto, CA, 94304, United States, 1 650 417 2015, ebunge@paloaltou.edu %K chatbot %K artificial intelligence %K depression %K mobile health %K telehealth %D 2020 %7 13.11.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Chatbots could be a scalable solution that provides an interactive means of engaging users in behavioral health interventions driven by artificial intelligence. Although some chatbots have shown promising early efficacy results, there is limited information about how people use these chatbots. Understanding the usage patterns of chatbots for depression represents a crucial step toward improving chatbot design and providing information about the strengths and limitations of the chatbots. Objective: This study aims to understand how users engage and are redirected through a chatbot for depression (Tess) to provide design recommendations. Methods: Interactions of 354 users with the Tess depression modules were analyzed to understand chatbot usage across and within modules. Descriptive statistics were used to analyze participant flow through each depression module, including characters per message, completion rate, and time spent per module. Slide plots were also used to analyze the flow across and within modules. Results: Users sent a total of 6220 messages, with a total of 86,298 characters, and, on average, they engaged with Tess depression modules for 46 days. There was large heterogeneity in user engagement across different modules, which appeared to be affected by the length, complexity, content, and style of questions within the modules and the routing between modules. Conclusions: Overall, participants engaged with Tess; however, there was a heterogeneous usage pattern because of varying module designs. Major implications for future chatbot design and evaluation are discussed in the paper. %M 33185563 %R 10.2196/17065 %U http://formative.jmir.org/2020/11/e17065/ %U https://doi.org/10.2196/17065 %U http://www.ncbi.nlm.nih.gov/pubmed/33185563 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 11 %P e14988 %T Evaluation of Treatment Descriptions and Alignment With Clinical Guidance of Apps for Depression on App Stores: Systematic Search and Content Analysis %A Bowie-DaBreo,Dionne %A Sünram-Lea,Sandra I %A Sas,Corina %A Iles-Smith,Heather %+ Research and Innovation Centre, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, United Kingdom, 44 113 206 0469, dionne.bowie@nhs.net %K mobile mental health %K mHealth %K mobile apps %K depression %K clinical guidance %K NICE guidelines %K NHS %K safety %K ethics %K content analysis %D 2020 %7 13.11.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: The use of apps for the treatment of depression shows great promise. However, there is uncertainty regarding the alignment of publicly available apps for depression with clinical guidance, their treatment fidelity and evidence base, and their overall safety. Objective: Built on previous analyses and reviews, this study aims to explore the treatment and safety issues of publicly available apps for depression. Methods: We conducted a content analysis of apps for depression in the 2 main UK app stores (Google Play and Apple App Store). App store listings were analyzed for intervention content, treatment fidelity, and fit with the National Institute for Health and Care Excellence (NICE) guidelines for the treatment of depression in adults. Results: A total of 353 apps for depression were included in the review. App descriptions reported the use of 20 treatment approaches and 37 treatment strategies. Many apps used transdiagnostic (155/353, 43.9%) and multitheoretical interventions to treat multiple disorders including depression. Although many interventions appeared to be evidence-informed, there were issues with treatment fidelity, research evidence, and fit with clinical guidelines. None of the apps fully aligned with the NICE guidelines for depression. Conclusions: App developers have adopted many evidence-informed treatments in their interventions; however, more work is needed to improve clinical validity, treatment fidelity, and the safety of apps. We urge developers to consult relevant guidelines and standards, and to engage in reflective questioning on treatment and safety to address these issues and to improve treatment content and intervention design. %M 33185566 %R 10.2196/14988 %U http://formative.jmir.org/2020/11/e14988/ %U https://doi.org/10.2196/14988 %U http://www.ncbi.nlm.nih.gov/pubmed/33185566 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 11 %P e17405 %T A Mobile Health Mindfulness Intervention for Women With Moderate to Moderately Severe Postpartum Depressive Symptoms: Feasibility Study %A Avalos,Lyndsay A %A Aghaee,Sara %A Kurtovich,Elaine %A Quesenberry Jr,Charles %A Nkemere,Linda %A McGinnis,MegAnn K %A Kubo,Ai %+ Kaiser Permanente Northern California, Division of Research, 2000 Broadway, Oakland, CA, 94612, United States, 1 510 891 3426, Lyndsay.A.Avalos@kp.org %K depression %K postpartum %K health services, mental %K eHealth %K mental health %K internet-based intervention %K mindfulness %K behavioral intervention %K mobile phone %D 2020 %7 12.11.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Approximately 20% of women suffer from postpartum depression (PPD). Due to barriers such as limited access to care, half of the women with PPD do not receive treatment. Therefore, it is critical to identify effective and scalable interventions. Traditional mindfulness programs have been effective in reducing depressive symptoms, however access remains a barrier. A self-paced mobile health (mHealth) mindfulness program may fit the lifestyle of busy mothers who are unable to attend in-person classes. However, little is known regarding the feasibility or efficacy of mHealth mindfulness interventions in postpartum women with depressive symptoms. Objective: This study aims to assess the feasibility, acceptability, and preliminary efficacy of an mHealth mindfulness intervention for postpartum women with moderate to moderately severe depressive symptoms. Methods: We conducted a single-arm feasibility trial of an mHealth mindfulness intervention within Kaiser Permanente Northern California (KPNC), a large integrated health care system. Participants were identified through clinician referral and electronic health records via KPNC's universal perinatal depression screening program and recruited by the study team. Inclusion criteria included the following: English-speaking, up to 6 months postpartum with a Patient Health Questionnaire (PHQ-8) score of 10 to 19, and no regular mindfulness/meditation practice. Participants were asked to use a mindfulness app, Headspace, 10 to 20 min/day for 6 weeks. Baseline and postintervention surveys captured data on patient-reported outcomes (depression and stress symptoms, sleep quality, and mindfulness). Semistructured interviews captured acceptability. Retention and adherence were used to assess feasibility. Results: Of the 115 women who were contacted and met the eligibility criteria or declined participation before eligibility assessment, 27 (23%) were enrolled. In addition, 70% (19/27) completed the study. The mean age of participants was 31 years (SD 5.2), 30% (8/27) were non-Hispanic White, and, on average, participants were 12.3 weeks postpartum (SD 5.7). Of the women who completed the study, 100% (19/19) used the Headspace app at least once, and nearly half (9/19, 47%) used the app on ≥50% of the days during the 6-week intervention period. Of the 16 participants who completed the postintervention interview, 69% (11/16) reported that they were very or extremely satisfied with the app. Interviews indicated that women appreciated the variety of meditations and felt that the program led to reduced anxiety and improved sleep. Significant improvements in pre- and postintervention scores were observed for depressive symptoms (PHQ-8: −3.8, P=.004), perceived stress (10-item Perceived Stress Scale: −6.0, P=.005), and sleep quality (Pittsburgh Sleep Quality Index: −2.1, P=.02, indicating less sleep disturbance). Improvements in mindfulness were also significant (Five Facet Mindfulness Questionnaire-Short Form: 10.9, P=.01). Conclusions: An mHealth mindfulness intervention for postpartum women with moderate to moderately severe depressive symptoms is feasible and acceptable. An efficacy trial is warranted. %M 33180028 %R 10.2196/17405 %U https://mental.jmir.org/2020/11/e17405 %U https://doi.org/10.2196/17405 %U http://www.ncbi.nlm.nih.gov/pubmed/33180028 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 11 %P e22984 %T Behavior of Callers to a Crisis Helpline Before and During the COVID-19 Pandemic: Quantitative Data Analysis %A Turkington,Robin %A Mulvenna,Maurice %A Bond,Raymond %A Ennis,Edel %A Potts,Courtney %A Moore,Ciaran %A Hamra,Louise %A Morrissey,Jacqui %A Isaksen,Mette %A Scowcroft,Elizabeth %A O'Neill,Siobhan %+ School of Computing, Ulster University, Shore Road, Newtownabbey, United Kingdom, 44 28 9036 6129, Turkington-R@ulster.ac.uk %K COVID-19 %K coronavirus %K pandemic %K mental health %K crisis helplines %K machine learning %K clustering %K caller behavior %D 2020 %7 6.11.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The World Health Organization declared the outbreak of COVID-19 to be an international pandemic in March 2020. While numbers of new confirmed cases of the disease and death tolls are rising at an alarming rate on a daily basis, there is concern that the pandemic and the measures taken to counteract it could cause an increase in distress among the public. Hence, there could be an increase in need for emotional support within the population, which is complicated further by the reduction of existing face-to-face mental health services as a result of measures taken to limit the spread of the virus. Objective: The objective of this study was to determine whether the COVID-19 pandemic has had any influence on the calls made to Samaritans Ireland, a national crisis helpline within the Republic of Ireland. Methods: This study presents an analysis of calls made to Samaritans Ireland in a four-week period before the first confirmed case of COVID-19 (calls=41,648, callers=3752) and calls made to the service within a four-week period after a restrictive lockdown was imposed by the government of the Republic of Ireland (calls=46,043, callers=3147). Statistical analysis was conducted to explore any differences between the duration of calls in the two periods at a global level and at an hourly level. We performed k-means clustering to determine the types of callers who used the helpline based on their helpline call usage behavior and to assess the impact of the pandemic on the caller type usage patterns. Results: The analysis revealed that calls were of a longer duration in the postlockdown period in comparison with the pre–COVID-19 period. There were changes in the behavior of individuals in the cluster types defined by caller behavior, where some caller types tended to make longer calls to the service in the postlockdown period. There were also changes in caller behavior patterns with regard to the time of day of the call; variations were observed in the duration of calls at particular times of day, where average call durations increased in the early hours of the morning. Conclusions: The results of this study highlight the impact of COVID-19 on a national crisis helpline service. Statistical differences were observed in caller behavior between the prelockdown and active lockdown periods. The findings suggest that service users relied on crisis helpline services more during the lockdown period due to an increased sense of isolation, worsening of underlying mental illness due to the pandemic, and reduction or overall removal of access to other support resources. Practical implications and limitations are discussed. %M 33112759 %R 10.2196/22984 %U http://mental.jmir.org/2020/11/e22984/ %U https://doi.org/10.2196/22984 %U http://www.ncbi.nlm.nih.gov/pubmed/33112759 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e19548 %T Classification of Depression Through Resting-State Electroencephalogram as a Novel Practice in Psychiatry: Review %A Čukić,Milena %A López,Victoria %A Pavón,Juan %+ HealthInc 3EGA, Amsterdam Health and Technology Institute, Koningin Wilhelminaplein 644, Amsterdam, 1062 KS, Netherlands, 31 615178926, micu@3ega.nl %K computational psychiatry %K physiological complexity %K machine learning %K theory-driven approach %K resting-state EEG %K personalized medicine %K computational neuroscience %K unwarranted optimism %D 2020 %7 3.11.2020 %9 Review %J J Med Internet Res %G English %X Background: Machine learning applications in health care have increased considerably in the recent past, and this review focuses on an important application in psychiatry related to the detection of depression. Since the advent of computational psychiatry, research based on functional magnetic resonance imaging has yielded remarkable results, but these tools tend to be too expensive for everyday clinical use. Objective: This review focuses on an affordable data-driven approach based on electroencephalographic recordings. Web-based applications via public or private cloud-based platforms would be a logical next step. We aim to compare several different approaches to the detection of depression from electroencephalographic recordings using various features and machine learning models. Methods: To detect depression, we reviewed published detection studies based on resting-state electroencephalogram with final machine learning, and to predict therapy outcomes, we reviewed a set of interventional studies using some form of stimulation in their methodology. Results: We reviewed 14 detection studies and 12 interventional studies published between 2008 and 2019. As direct comparison was not possible due to the large diversity of theoretical approaches and methods used, we compared them based on the steps in analysis and accuracies yielded. In addition, we compared possible drawbacks in terms of sample size, feature extraction, feature selection, classification, internal and external validation, and possible unwarranted optimism and reproducibility. In addition, we suggested desirable practices to avoid misinterpretation of results and optimism. Conclusions: This review shows the need for larger data sets and more systematic procedures to improve the use of the solution for clinical diagnostics. Therefore, regulation of the pipeline and standard requirements for methodology used should become mandatory to increase the reliability and accuracy of the complete methodology for it to be translated to modern psychiatry. %M 33141088 %R 10.2196/19548 %U https://www.jmir.org/2020/11/e19548 %U https://doi.org/10.2196/19548 %U http://www.ncbi.nlm.nih.gov/pubmed/33141088 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 11 %P e24331 %T Virtual Reality Behavioral Activation as an Intervention for Major Depressive Disorder: Case Report %A Paul,Margot %A Bullock,Kim %A Bailenson,Jeremy %+ PGSP-Stanford PsyD Consortium, 1791 Arastradero Rd, Palo Alto, CA, 94304, United States, 1 781 572 4136, mdpaul@stanford.edu %K virtual reality %K case report %K major depressive disorder %K behavioral activation %K VR %K depression %K COVID-19 %K behavior %K intervention %K feasibility %K acceptability %K telehealth %K pilot study %D 2020 %7 3.11.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Major depressive disorder (MDD) is a global problem with an increasing incidence and prevalence. There has additionally been an increase in depression due to the COVID-19 pandemic. Behavioral activation is considered an evidence-based treatment for MDD. However, there are many barriers that could hinder one’s ability to engage in behavioral activation, with COVID-19 “shelter-in-place” and social distancing orders being current and large impediments. Virtual reality (VR) has been successfully used to help treat a variety of mental health conditions, but it has not yet been used as a method of administering behavioral activation to a clinical population. Using VR to engage in behavioral activation could eliminate barriers that pandemic precautions place and help decrease symptoms of depression that are especially exacerbated in these times. Objective: The following case report examines the feasibility, acceptability, and tolerability of VR behavioral activation for an adult with MDD during a global pandemic. This participant was part of a larger pilot study, and the case serves as a description of the VR intervention. Methods: The participant engaged in a weekly 50-minute psychotherapy Zoom session for 4 weeks, in which a modified behavioral activation protocol was administered using a VR headset to simulate activities. Data on mood ratings, homework compliance, and headset use were obtained from the headset. Acceptability, tolerability, and depression symptoms were obtained using self-report rating scales. Results: The intervention was feasible, acceptable, and tolerable, as reported by this participant. The participant’s depressive symptoms decreased by five-points on the Patient Health Questionnaire-9 over a month, with a beginning score of 10 (moderate depression) and a final score of 5 (mild depression). Conclusions: The implications of these findings for future research are discussed. Trial Registration: ClinicalTrials.gov NCT04268316; http://clinicaltrials.gov/ct2/show/NCT04268316 %M 33031046 %R 10.2196/24331 %U https://mental.jmir.org/2020/11/e24331 %U https://doi.org/10.2196/24331 %U http://www.ncbi.nlm.nih.gov/pubmed/33031046 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e22835 %T Depression, Anxiety, and Lifestyle Among Essential Workers: A Web Survey From Brazil and Spain During the COVID-19 Pandemic %A De Boni,Raquel Brandini %A Balanzá-Martínez,Vicent %A Mota,Jurema Correa %A Cardoso,Taiane De Azevedo %A Ballester,Pedro %A Atienza-Carbonell,Beatriz %A Bastos,Francisco I %A Kapczinski,Flavio %+ Institute of Scientific and Technological Communication and Information in Health, Oswaldo Cruz Foundation, Av Brasil 4365 Pavilhao Haity Moussatche, Room 229, Rio de Janeiro, 21040-360, Brazil, 55 21 3865 3231, raqueldeboni@gmail.com %K COVID-19 %K depression %K anxiety %K lifestyle %K Brazil %K Spain %D 2020 %7 30.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Essential workers have been shown to present a higher prevalence of positive screenings for anxiety and depression during the COVID-19 pandemic. Individuals from countries with socioeconomic inequalities may be at increased risk for mental health disorders. Objective: We aimed to assess the prevalence and predictors of depression, anxiety, and their comorbidity among essential workers in Brazil and Spain during the COVID-19 pandemic. Methods: A web survey was conducted between April and May 2020 in both countries. The main outcome was a positive screening for depression only, anxiety only, or both. Lifestyle was measured using a lifestyle multidimensional scale adapted for the COVID-19 pandemic (Short Multidimensional Inventory Lifestyle Evaluation–Confinement). A multinomial logistic regression model was performed to evaluate the factors associated with depression, anxiety, and the presence of both conditions. Results: From the 22,786 individuals included in the web survey, 3745 self-reported to be essential workers. Overall, 8.3% (n=311), 11.6% (n=434), and 27.4% (n=1027) presented positive screenings for depression, anxiety, and both, respectively. After adjusting for confounding factors, the multinomial model showed that an unhealthy lifestyle increased the likelihood of depression (adjusted odds ratio [AOR] 4.00, 95% CI 2.72-5.87), anxiety (AOR 2.39, 95% CI 1.80-3.20), and both anxiety and depression (AOR 8.30, 95% CI 5.90-11.7). Living in Brazil was associated with increased odds of depression (AOR 2.89, 95% CI 2.07-4.06), anxiety (AOR 2.81, 95%CI 2.11-3.74), and both conditions (AOR 5.99, 95% CI 4.53-7.91). Conclusions: Interventions addressing lifestyle may be useful in dealing with symptoms of common mental disorders during the strain imposed among essential workers by the COVID-19 pandemic. Essential workers who live in middle-income countries with higher rates of inequality may face additional challenges. Ensuring equitable treatment and support may be an important challenge ahead, considering the possible syndemic effect of the social determinants of health. %M 33038075 %R 10.2196/22835 %U http://www.jmir.org/2020/10/e22835/ %U https://doi.org/10.2196/22835 %U http://www.ncbi.nlm.nih.gov/pubmed/33038075 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e22076 %T Responses to Concerning Posts on Social Media and Their Implications for Suicide Prevention Training for Military Veterans: Qualitative Study %A Teo,Alan R %A Strange,Wynn %A Bui,Ricky %A Dobscha,Steven K %A Ono,Sarah S %+ Health Services Research and Development Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Road, , Portland, OR, 97239, United States, 1 5032208262 ext 52461, teoa@ohsu.edu %K concerning post %K social media %K suicide prevention %K gatekeeper training %K military veterans %D 2020 %7 30.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: A “concerning post” is a display of a user’s emotional crisis on a social media platform. A better understanding of concerning posts is relevant to suicide prevention, but little is known about social media users’ attitudes and responses to concerning posts. Military veterans in the United States are disproportionately affected by suicide, often use social media, and may have exposure to individuals with elevated suicide risk via concerning posts. Objective: The objective of the study was (1) to obtain insight into whether and how US military veterans respond to members of their social network on social media (ie, “friends”) who are experiencing substantial emotional distress, and (2) to identify potential interventions that could assist in users’ response to concerning posts. Methods: We recruited veterans through Facebook and conducted semistructured interviews with 30 participants between June and December 2017. We used a summary template for rapid analysis of each interview, followed by double-coding using a codebook based on topic domains from the interview guide. Members of the research team met regularly to discuss emerging patterns in the data, generate themes, and select representative quotes for inclusion in the manuscript. Results: Veterans were reluctant to disclose emotional and health issues on Facebook, but they were open to reaching out to others’ concerning posts. There was a complex calculus underlying whether and how veterans responded to a concerning post, which involved considering (1) physical proximity to the person posting, (2) relationship closeness, (3) existing responses to the post, and (4) ability to maintain contact with the person. Veterans desired additional training, backed by community-based veteran organizations, in how to respond to concerning posts from peers. Conclusions: There is a need to incorporate features that will help veterans effectively respond to concerning posts from peers into suicide prevention training and to expand access for veterans to such training. %M 33124990 %R 10.2196/22076 %U https://www.jmir.org/2020/10/e22076 %U https://doi.org/10.2196/22076 %U http://www.ncbi.nlm.nih.gov/pubmed/33124990 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 10 %P e22528 %T Consumer-Guided Development of an Engagement-Facilitation Intervention for Increasing Uptake and Adherence for Self-Guided Web-Based Mental Health Programs: Focus Groups and Online Evaluation Survey %A Gulliver,Amelia %A Calear,Alison L %A Sunderland,Matthew %A Kay-Lambkin,Frances %A Farrer,Louise M %A Banfield,Michelle %A Batterham,Philip J %+ Centre for Mental Health Research, Research School of Population Health, The Australian National University, Acton, Canberra, 2601, Australia, 61 26125 ext 9472, amelia.gulliver@anu.edu.au %K mental health %K internet %K anxiety %K depression %K technology %K treatment adherence and compliance %D 2020 %7 29.10.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Self-guided web-based mental health programs are effective in treating and preventing mental health problems. However, current engagement with these programs in the community is suboptimal, and there is limited evidence indicating how to increase the use of existing evidence-based programs. Objective: This study aims to investigate the views of people with lived experience of depression and anxiety on factors influencing their engagement with self-guided web-based mental health (e–mental health) programs and to use these perspectives to develop an engagement-facilitation intervention (EFI) to increase engagement (defined as both uptake and adherence) with these programs. Methods: A total of 24 community members (female=21; male=3) with lived experience of depression and anxiety or depression or anxiety alone participated in 1 of 4 focus groups discussing the factors influencing their engagement with self-guided e–mental health programs and the appearance, delivery mode, and functionality of content for the proposed EFI. A subsequent evaluation survey of the focus group participants (n=14) was conducted to evaluate the resultant draft EFI. Data were thematically analyzed using both inductive and deductive qualitative methods. Results: Participants suggested that the critical component of an EFI was information that would challenge personal barriers to engagement, including receiving personalized symptom feedback, information regarding the program’s content or effectiveness and data security, and normalization of using e–mental health programs (eg, testimonials). Reminders, rewards, feedback about progress, and coaching were all mentioned as facilitating adherence. Conclusions: EFIs have the potential to improve community uptake of e–mental health programs. They should focus on providing information on the content and effectiveness of e–mental health programs and normalizing their use. Given that the sample comprised predominantly young females, this study may not be generalizable to other population groups. There is a strong value in involving people with a lived experience in the design and development of EFIs to maximize their effectiveness. %M 33118939 %R 10.2196/22528 %U http://formative.jmir.org/2020/10/e22528/ %U https://doi.org/10.2196/22528 %U http://www.ncbi.nlm.nih.gov/pubmed/33118939 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e20847 %T Relationship Between Patient Engagement and Depressive Symptoms Among People Living With HIV in a Mobile Health Intervention: Secondary Analysis of a Randomized Controlled Trial %A Zeng,Yu %A Guo,Yan %A Li,Linghua %A Hong,Y Alicia %A Li,Yiran %A Zhu,Mengting %A Zeng,Chengbo %A Zhang,Hanxi %A Cai,Weiping %A Liu,Cong %A Wu,Shaomin %A Chi,Peilian %A Monroe-Wise,Aliza %A Hao,Yuantao %A Ho,Rainbow Tin Hung %+ Department of Medical Statistics, School of Public Health, Sun Yat-sen University, No.74, 2nd Zhongshan Road, Guangzhou, 510000, China, 86 13501502582, guoy8@mail.sysu.edu.cn %K mHealth %K patient engagement %K latent growth curve model %K depressive symptoms %K HIV %D 2020 %7 29.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Associations between higher levels of patient engagement and better health outcomes have been found in face-to-face interventions; studies on such associations with mobile health (mHealth) interventions have been limited and the results are inconclusive. Objective: The objective of this study is to investigate the relationship between patient engagement in an mHealth intervention and depressive symptoms using repeated measures of both patient engagement and patient outcomes at 4 time points. Methods: Data were drawn from a randomized controlled trial (RCT) of an mHealth intervention aimed at reducing depressive symptoms among people living with HIV and elevated depressive symptoms. We examined the association between patient engagement and depressive symptoms in the intervention group (n=150) where participants received an adapted cognitive-behavioral stress management (CBSM) course and physical activity promotion on their WeChat social media app. Depressive symptoms were repeatedly measured using the Patient Health Questionnaire (PHQ-9) at baseline and 1 month, 2 months, and 3 months. Patient engagement was correspondingly measured by the completion rate, frequency of items completed, and time spent on the program at 1 month, 2 months, and 3 months. Latent growth curve models (LGCMs) were used to explore the relationship between patient engagement and depressive symptoms at multiple time points in the intervention. Results: The mean PHQ-9 scores were 10.2 (SD 4.5), 7.7 (SD 4.8), 6.5 (SD 4.7), and 6.7 (SD 4.1) at baseline, 1 month, 2 months, and 3 months, respectively. The mean completion rates were 50.6% (SD 31.8%), 51.5% (SD 32.2%), and 50.8% (SD 33.7%) at 1, 2, and 3 months, respectively; the average frequencies of items completed were 18.0 (SD 14.6), 32.6 (SD 24.8), and 47.5 (SD 37.2) at 1, 2, and 3 months, respectively, and the mean times spent on the program were 32.7 (SD 66.7), 65.4 (SD 120.8), and 96.4 (SD 180.4) minutes at 1, 2, and 3 months, respectively. LGCMs showed good model fit and indicated that a higher completion rate (β at 3 months=–2.184, P=.048) and a greater frequency of items completed (β at 3 months=–0.018, P=.04) were associated with fewer depressive symptoms at 3 months. Although not significant, similar trends were found in the abovementioned relationships at 1 and 2 months. There was no significant relationship between time spent on the program and depressive symptoms. Conclusions: This study revealed a positive association between patient engagement and health outcomes at 3 months of an mHealth intervention using LGCMs and repeated measures data. The results underscore the importance of improving patient engagement in mHealth interventions to improve patient-centered health outcomes. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://tinyurl.com/yxb64mef International Registered Report Identifier (IRRID): RR2-10.1186/s12889-018-5693-1 %M 33118956 %R 10.2196/20847 %U http://mhealth.jmir.org/2020/10/e20847/ %U https://doi.org/10.2196/20847 %U http://www.ncbi.nlm.nih.gov/pubmed/33118956 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 10 %P e18366 %T A Systematic Framework for Analyzing Observation Data in Patient-Centered Registries: Case Study for Patients With Depression %A Zolnoori,Maryam %A Williams,Mark D %A Leasure,William B %A Angstman,Kurt B %A Ngufor,Che %+ Mayo Clinic, 200 1st St SW, Rochester, MN 55902, Rochester, MN, , United States, 1 3175151950, Zolnoori.Maryam@mayo.edu %K patient-centered registry %K collaborative care model %K care coordination management %K integrated behavior health %K systematic framework %D 2020 %7 29.10.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Patient-centered registries are essential in population-based clinical care for patient identification and monitoring of outcomes. Although registry data may be used in real time for patient care, the same data may further be used for secondary analysis to assess disease burden, evaluation of disease management and health care services, and research. The design of a registry has major implications for the ability to effectively use these clinical data in research. Objective: This study aims to develop a systematic framework to address the data and methodological issues involved in analyzing data in clinically designed patient-centered registries. Methods: The systematic framework was composed of 3 major components: visualizing the multifaceted and heterogeneous patient-centered registries using a data flow diagram, assessing and managing data quality issues, and identifying patient cohorts for addressing specific research questions. Results: Using a clinical registry designed as a part of a collaborative care program for adults with depression at Mayo Clinic, we were able to demonstrate the impact of the proposed framework on data integrity. By following the data cleaning and refining procedures of the framework, we were able to generate high-quality data that were available for research questions about the coordination and management of depression in a primary care setting. We describe the steps involved in converting clinically collected data into a viable research data set using registry cohorts of depressed adults to assess the impact on high-cost service use. Conclusions: The systematic framework discussed in this study sheds light on the existing inconsistency and data quality issues in patient-centered registries. This study provided a step-by-step procedure for addressing these challenges and for generating high-quality data for both quality improvement and research that may enhance care and outcomes for patients. International Registered Report Identifier (IRRID): DERR1-10.2196/18366 %M 33118958 %R 10.2196/18366 %U http://www.researchprotocols.org/2020/10/e18366/ %U https://doi.org/10.2196/18366 %U http://www.ncbi.nlm.nih.gov/pubmed/33118958 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e17049 %T Acceptability and Effectiveness of NHS-Recommended e-Therapies for Depression, Anxiety, and Stress: Meta-Analysis %A Simmonds-Buckley,Melanie %A Bennion,Matthew Russell %A Kellett,Stephen %A Millings,Abigail %A Hardy,Gillian E %A Moore,Roger K %+ Department of Psychology, University of Sheffield, Cathedral Court, 1 Vicar Lane, S1 2LT, Sheffield, S1 2LT, United Kingdom, 44 01142226630, m.simmonds-buckley@sheffield.ac.uk %K e-therapy %K anxiety %K depression %K treatment effectiveness %K National Health Service %K meta-analysis %K mobile phone %D 2020 %7 28.10.2020 %9 Review %J J Med Internet Res %G English %X Background: There is a disconnect between the ability to swiftly develop e-therapies for the treatment of depression, anxiety, and stress, and the scrupulous evaluation of their clinical utility. This creates a risk that the e-therapies routinely provided within publicly funded psychological health care have evaded appropriate rigorous evaluation in their development. Objective: This study aims to conduct a meta-analytic review of the gold standard evidence of the acceptability and clinical effectiveness of e-therapies recommended for use in the National Health Service (NHS) in the United Kingdom. Methods: Systematic searches identified appropriate randomized controlled trials (RCTs). Depression, anxiety, and stress outcomes at the end of treatment and follow-up were synthesized using a random-effects meta-analysis. The grading of recommendations assessment, development, and evaluation approach was used to assess the quality of each meta-analytic comparison. Moderators of treatment effect were examined using subgroup and meta-regression analysis. Dropout rates for e-therapies (as a proxy for acceptability) were compared against controls. Results: A total of 24 studies evaluating 7 of 48 NHS-recommended e-therapies were qualitatively and quantitatively synthesized. Depression, anxiety, and stress outcomes for e-therapies were superior to controls (depression: standardized mean difference [SMD] 0.38, 95% CI 0.24 to 0.52, N=7075; anxiety and stress: SMD 0.43, 95% CI 0.24 to 0.63, n=4863), and these small effects were maintained at follow-up. Average dropout rates for e-therapies (31%, SD 17.35) were significantly higher than those of controls (17%, SD 13.31). Limited moderators of the treatment effect were found. Conclusions: Many NHS-recommended e-therapies have not been through an RCT-style evaluation. The e-therapies that have been appropriately evaluated generate small but significant, durable, beneficial treatment effects. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) registration CRD42019130184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130184 %M 33112238 %R 10.2196/17049 %U http://www.jmir.org/2020/10/e17049/ %U https://doi.org/10.2196/17049 %U http://www.ncbi.nlm.nih.gov/pubmed/33112238 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e16802 %T 24-Month Outcomes of Primary Care Web-Based Depression Prevention Intervention in Adolescents: Randomized Clinical Trial %A Van Voorhees,Benjamin %A Gladstone,Tracy R G %A Sobowale,Kunmi %A Brown,C Hendricks %A Aaby,David A %A Terrizzi,Daniela A %A Canel,Jason %A Ching,Eumene %A Berry,Anita D %A Cantorna,James %A Eder,Milton %A Beardslee,William %A Fitzgibbon,Marian %A Marko-Holguin,Monika %A Schiffer,Linda %A Lee,Miae %A de Forest,Sarah A %A Sykes,Emily E %A Suor,Jennifer H %A Crawford,Theodore J %A Burkhouse,Katie L %A Goodwin,Brady C %A Bell,Carl %+ Department of General Pediatrics, University of Illinois at Chicago, College of Medicine, 840 South Wood Street (MC 856), Chicago, IL, United States, 1 312 996 8352, bvanvoor@uic.edu %K adolescent %K depression %K prevention %K scalable %K eHealth %D 2020 %7 28.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Adolescent depression carries a high burden of disease worldwide, but access to care for this population is limited. Prevention is one solution to curtail the negative consequences of adolescent depression. Internet interventions to prevent adolescent depression can overcome barriers to access, but few studies examine long-term outcomes. Objective: This study compares CATCH-IT (Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training), an internet-based intervention, to a general health education active control for depression onset at 12 and 24 months in adolescents presenting to primary care settings. Methods: A 2-site randomized trial, blinded to the principal investigators and assessors, was conducted comparing Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training to health education to prevent depressive episodes in 369 adolescents (193 youths were randomly assigned to Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training and 176 to health education) with subthreshold depressive symptoms or prior depressive episodes. Participants were recruited from primary care settings in the United States. The primary outcome was the occurrence of a depressive episode, determined by the Depression Symptom Rating. The secondary outcome was functioning, measured by the Global Assessment Scale. Results: In intention-to-treat analyses, the adjusted hazard ratio favoring Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training for first depressive episode was not statistically significant at 12 months (hazard ratio 0.77, 95% CI 0.42-1.40, P=.39) and 24 months (hazard ratio 0.87, 95% CI 0.52-1.47, P=.61). Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training provided preventive benefit for first depressive episode for those with mild hopelessness or at least moderate paternal monitoring at baseline. Global Assessment Scale scores improved comparably in both groups (intention-to-treat). Conclusions: A technology-based intervention for adolescent depression prevention implemented in primary care did not have additional benefit at 12 or 24 months. Further research is necessary to determine whether internet interventions have long-term benefit. Trial Registration: ClinicalTrials.gov NCT01893749; http://clinicaltrials.gov/ct2/show/NCT01893749. %M 33112254 %R 10.2196/16802 %U https://www.jmir.org/2020/10/e16802 %U https://doi.org/10.2196/16802 %U http://www.ncbi.nlm.nih.gov/pubmed/33112254 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 3 %N 2 %P e20976 %T Repeated Psychosocial Screening of High School Students Using YouthCHAT: Cohort Study %A Thabrew,Hiran %A Kumar,Harshali %A Goldfinch,Mary %A Cavadino,Alana %A Goodyear-Smith,Felicity %+ Department of Psychological Medicine, The University of Auckland, Building 507, 22-30 Park Avenue, Grafton, Auckland, 1023, New Zealand, 64 21402055, h.thabrew@auckland.ac.nz %K mass screening %K mental health %K school health services %K eHealth %D 2020 %7 26.10.2020 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Psychosocial problems are common during adolescence and can have long-lasting effects on health and on academic and social functioning. YouthCHAT, an electronic HEEADSSS (home, education, eating, activities, drugs and alcohol, suicide and depression, sexuality and safety)-aligned instrument, has recently been demonstrated to be an acceptable and effective school-based psychosocial screener for 13-year-old (Year 9) high school students. Objective: This study aims to compare acceptability and detection rates with repeated YouthCHAT screenings of high school students when they are 13 years old (Year 9) and 14 years old (Year 10). Methods: We invited all Year-10 students to complete a YouthCHAT screening in 2018. Rates of positively identified issues were compared between the subset of students screened in both 2017 and 2018. Student acceptability toward YouthCHAT was investigated through focus group sessions. Onward clinical referral rates in 2018 were also investigated to explore the potential referral burden following screening. Data analysis for rates of positively identified issues were conducted with the McNemar test. Chi-square, Fisher exact test, and Kruskal-Wallis test were used to analyze the focus group data. Results: Of 141 eligible Year-10 students, 114 (81%) completed a YouthCHAT screening during 2018, and 97 (85%) of them completed it for a second time. Apart from depression, which increased (P=.002), and perceived life stress, which decreased (P=.04), rates of identified issues were broadly similar between 13 and 14 years of age. Repeated screenings via YouthCHAT was acceptable to students and time-efficient (mean, 6 minutes and 32 seconds) but did not reduce the overall number of individuals with identified issues. Onward clinical referrals from positive screens were mostly managed by school-based health services without the need for external referrals. Conclusions: Although further evaluation is needed, our results support the value of YouthCHAT as an acceptable and effective instrument with which to achieve routine identification of psychosocial issues and early intervention within a high school environment. %M 33104007 %R 10.2196/20976 %U http://pediatrics.jmir.org/2020/2/e20976/ %U https://doi.org/10.2196/20976 %U http://www.ncbi.nlm.nih.gov/pubmed/33104007 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 10 %P e22043 %T Mental Health During the COVID-19 Pandemic in the United States: Online Survey %A Jewell,Jennifer S %A Farewell,Charlotte V %A Welton-Mitchell,Courtney %A Lee-Winn,Angela %A Walls,Jessica %A Leiferman,Jenn A %+ Colorado School of Public Health, Building 500, 13001 E 17th Place, Aurora, CO , United States, 1 303 519 6620, jennifer.jewell@cuanschutz.edu %K COVID-19 %K mental health %K pandemic %K depression %K anxiety %K well-being %K stress %D 2020 %7 23.10.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: The COVID-19 pandemic has had numerous worldwide effects. In the United States, there have been 8.3 million cases and nearly 222,000 deaths as of October 21, 2020. Based on previous studies of mental health during outbreaks, the mental health of the population will be negatively affected in the aftermath of this pandemic. The long-term nature of this pandemic may lead to unforeseen mental health outcomes and/or unexpected relationships between demographic factors and mental health outcomes. Objective: This research focused on assessing the mental health status of adults in the United States during the early weeks of an unfolding pandemic. Methods: Data was collected from English-speaking adults from early April to early June 2020 using an online survey. The final convenience sample included 1083 US residents. The 71-item survey consisted of demographic questions, mental health and well-being measures, a coping mechanisms checklist, and questions about COVID-19–specific concerns. Hierarchical multivariable logistic regression was used to explore associations among demographic variables and mental health outcomes. Hierarchical linear regression was conducted to examine associations among demographic variables, COVID-19–specific concerns, and mental health and well-being outcomes. Results: Approximately 50% (536/1076) of the US sample was aged ≥45 years. Most of the sample was White (1013/1054, 96%), non-Hispanic (985/1058, 93%), and female (884/1073, 82%). Participants reported high rates of depression (295/1034, 29%), anxiety (342/1007, 34%), and stress (773/1058, 73%). Older individuals were less likely to report depressive symptomology (OR 0.78, P<.001) and anxiety symptomology (OR 0.72, P<.001); in addition, they had lower stress scores (–0.15 points, SE 0.01, P<.001) and increased well-being scores (1.86 points, SE 0.22, P<.001). Individuals who were no longer working due to COVID-19 were 2.25 times more likely to report symptoms of depression (P=.02), had a 0.51-point increase in stress (SE 0.17, P=.02), and a 3.9-point decrease in well-being scores (SE 1.49, P=.009) compared to individuals who were working remotely before and after COVID-19. Individuals who had partial or no insurance coverage were 2-3 times more likely to report depressive symptomology compared to individuals with full coverage (P=.02 and P=.01, respectively). Individuals who were on Medicare/Medicaid and individuals with no coverage were 1.97 and 4.48 times more likely to report moderate or severe anxiety, respectively (P=.03 and P=.01, respectively). Financial and food access concerns were significantly and positively related to depression, anxiety, and stress (all P<.05), and significantly negatively related to well-being (both P<.001). Economy, illness, and death concerns were significantly positively related to overall stress scores (all P<.05). Conclusions: Our findings suggest that many US residents are experiencing high stress, depressive, and anxiety symptomatology, especially those who are underinsured, uninsured, or unemployed. Longitudinal investigation of these variables is recommended. Health practitioners may provide opportunities to allay concerns or offer coping techniques to individuals in need of mental health care. These messages should be shared in person and through practice websites and social media. %M 33006939 %R 10.2196/22043 %U http://formative.jmir.org/2020/10/e22043/ %U https://doi.org/10.2196/22043 %U http://www.ncbi.nlm.nih.gov/pubmed/33006939 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 10 %P e18762 %T Performance, Cost-Effectiveness, and Representativeness of Facebook Recruitment to Suicide Prevention Research: Online Survey Study %A Lee,Sylvia %A Torok,Michelle %A Shand,Fiona %A Chen,Nicola %A McGillivray,Lauren %A Burnett,Alexander %A Larsen,Mark Erik %A Mok,Katherine %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney, 2031, Australia, 61 0415677477, m.torok@unsw.edu.au %K research subject recruitment %K social media %K suicide %D 2020 %7 22.10.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Researchers are increasingly using social media advertisements to recruit participants because of their many advantages over traditional methods. Although there is growing evidence for the effectiveness and cost-effectiveness of social media recruitment in the health sciences, no studies have yet examined this in the context of suicide prevention, which remains to be a highly stigmatized and sensitive topic. Objective: This study aims to recruit a general community sample to complete a survey on suicide literacy, stigma, and risk via Facebook advertisements. Specifically, we aim to establish the performance of the advertisements, cost-effectiveness, sample representativeness, and the impact of gender-specific advertising on recruiting men into the study. Methods: From June 2017 to March 2019, we released Facebook advertisements targeted at adults 18 years or older, residing in the New South Wales (NSW) trial or control regions, and involved in the LifeSpan suicide prevention trial. Cost-effectiveness was examined descriptively using metrics provided by Facebook. Chi-square analyses were conducted to determine demographic differences between our sample and the general NSW population as well as the impact of gender-specific advertisements on gender engagement. Results: The 14 Facebook advertisement campaigns reached a total of 675,199 people, yielding 25,993 link clicks and resulting in 9603 individuals initiating the survey (7487 completions) at an overall cost of Aus $2.81 (US $2.01) per participant. There was an overrepresentation of younger (P=.003), female (P=.003), highly educated (P<.001) participants and mental health conditions (P<.001) compared with the total NSW population. The use of male-specific advertisements resulted in a significantly higher proportion of men completing the survey relative to gender-neutral advertisements (38.2% vs 24.6%; P<.001). Conclusions: This study demonstrates the potential of Facebook to be an effective, low-cost strategy for recruiting a large sample of general community participants for suicide prevention research. Strategies to improve sample representativeness warrant further investigation in future research. %M 33090115 %R 10.2196/18762 %U http://mental.jmir.org/2020/10/e18762/ %U https://doi.org/10.2196/18762 %U http://www.ncbi.nlm.nih.gov/pubmed/33090115 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 10 %P e19876 %T Investigating the Impact of COVID-19 Lockdown on the Psychological Health of University Students and Their Attitudes Toward Mobile Mental Health Solutions: Two-Part Questionnaire Study %A Drissi,Nidal %A Alhmoudi,Ayat %A Al Nuaimi,Hana %A Alkhyeli,Mahra %A Alsalami,Shaikha %A Ouhbi,Sofia %+ United Arab Emirates University, , Al Ain, United Arab Emirates, 971 37135568, sofia.ouhbi@uaeu.ac.ae %K COVID-19 %K GHQ-12 %K mobile %K apps %K m-health %K m-mental health %K UAE %K attitudes %K university students %K questionnaire %D 2020 %7 20.10.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: The COVID-19 outbreak was first reported to the World Health Organization on December 31, 2019, and it was officially declared a public health emergency of international concern on January 30, 2020. The COVID-19 outbreak and the safety measures taken to control it caused many psychological issues in populations worldwide, such as depression, anxiety, and stress. Objective: The objectives of this study were to assess the psychological effects of the lockdown due to the COVID-19 outbreak on university students in the United Arab Emirates (UAE) and to investigate the students’ awareness of mobile mental health care apps as well as their attitudes toward the use of these apps. Methods: A two-part self-administered web-based questionnaire was delivered to students at United Arab Emirates University. The first part of the questionnaire assessed the mental state of the participants using the 12-item General Health Questionnaire (GHQ-12), while the second part contained questions investigating the participants’ awareness of and attitudes toward mental health care apps. Students were invited to fill out the web-based questionnaire via social media and mailing lists. Results: A total of 154 students participated in the survey, and the majority were female. The results of the GHQ-12 analysis showed that the students were experiencing psychological issues related to depression and anxiety as well as social dysfunction. The results also revealed a lack of awareness of mental health care apps and uncertainty regarding the use of such apps. Approximately one-third of the participants (44/154, 28.6%) suggested preferred functionalities and characteristics of mobile mental health care apps, such as affordable price, simple design, ease of use, web-based therapy, communication with others experiencing the same issues, and tracking of mental status. Conclusions: Like many groups of people worldwide, university students in the UAE were psychologically affected by the lockdown due to the COVID-19 outbreak. Although apps can be useful tools for mental health care delivery, especially in circumstances such as those produced by the outbreak, the students in this study showed a lack of awareness of these apps and mixed attitudes toward them. Improving the digital health literacy of university students in the UAE by increasing their awareness of mental health care apps and the treatment methods and benefits of the apps, as well as involving students in the app creation process, may encourage students to use these tools for mental health care. %M 32969340 %R 10.2196/19876 %U http://formative.jmir.org/2020/10/e19876/ %U https://doi.org/10.2196/19876 %U http://www.ncbi.nlm.nih.gov/pubmed/32969340 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 10 %P e21280 %T Evaluation of ReachOut.com, an Unstructured Digital Youth Mental Health Intervention: Prospective Cohort Study %A Kahl,Bianca Lorraine %A Miller,Hilary May %A Cairns,Kathryn %A Giniunas,Hayley %A Nicholas,Mariesa %+ ReachOut Australia, Suite 2.04, Building B, 35 Saunders Street, Pyrmont, 2009, Australia, 61 02 8029 7734, bianca.kahl@reachout.com %K digital mental health %K digital intervention %K youth %K internet-based intervention %K depression %K anxiety %K stress %K suicide %D 2020 %7 15.10.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Young people experience a disproportionate burden associated with mental illness that Australia’s mental health care system is ill-equipped to handle. Despite improvements in the provision of mental health services, the rates of service utilization among young people remain suboptimal, and there are still considerable barriers to seeking help. Digital mental health services can overcome a number of barriers and connect young people requiring support; however, the evidence base of digital interventions is limited. Objective: The aim of this study is to examine the effectiveness of a brief, self-directed, unstructured digital intervention, ReachOut.com (hereafter ReachOut), in reducing depression, anxiety, stress, and risk of suicide. Methods: A cohort of 1982 ReachOut users participated in a 12-week longitudinal study, with a retention rate of 81.18% (1609/1982) across the duration of the study. Participants completed web-based surveys, with outcome measures of mental health status and suicide risk assessed at 3 time points across the study period. Results: The results demonstrated that over the 12-week study period, young people using ReachOut experienced modest yet significant reductions in symptoms of depression, anxiety, and stress. Significant, albeit modest, reductions in the proportion of participants at high risk of suicide were also observed. Conclusions: The findings of this research provide preliminary evidence of the promise of an unstructured digital mental health intervention, ReachOut, in alleviating symptoms of mental ill-health and promoting well-being in young people. These findings are particularly important given that digital services are not only acceptable and accessible but also have the potential to cater to the diverse mental health needs of young people at scale, in a way that other services cannot. %M 33055066 %R 10.2196/21280 %U http://mental.jmir.org/2020/10/e21280/ %U https://doi.org/10.2196/21280 %U http://www.ncbi.nlm.nih.gov/pubmed/33055066 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 10 %P e15037 %T Understanding Problems With Sleep, Sexual Functioning, Energy, and Appetite Among Patients Who Access Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Anxiety and Depression: Qualitative Exploratory Study %A Edmonds,Michael R %A Hadjistavropoulos,Heather D %A Gullickson,Kirsten M %A Asmundson,Aleiia JN %A Dear,Blake F %A Titov,Nickolai %+ Online Therapy Unit, Department of Psychology, University of Regina, 3737 Wascana Pkwy, Regina, SK, Canada, 1 306 585 5133, hadjista@uregina.ca %K cognitive behavioral therapy %K anxiety %K depression %K internet-based intervention %K sleep %K sexual health %K motivation %K appetite %D 2020 %7 13.10.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Transdiagnostic internet-delivered cognitive behavioral therapy (T-ICBT) is an effective treatment for anxiety and depression, and nowadays, there is interest in exploring ways to optimize T-ICBT in routine care. T-ICBT programs are designed to address the primary cognitive-affective and behavioral symptoms of anxiety and depression (eg, low mood, worry, anhedonia, and avoidance). Treatment also has the potential to resolve other symptom concerns (eg, sleep disruption, sexual dysfunction, lack of energy, and appetite or weight changes). Having additional information regarding the extent of these concerns and how concerns change over time could prove beneficial for further development of T-ICBT in routine care. Objective: This exploratory formative study aims to better understand sleep, sexual functioning, energy, and appetite concerns among T-ICBT clients seeking treatment for depression and anxiety. A qualitative analytic approach was used to identify themes in the symptom concerns reported by patients in the areas of sleep, sexual functioning, energy, and appetite at the time of enrollment. Patient responses to related items from screening measures for anxiety and depression were also examined pre- and posttreatment. Methods: Patients in routine care who applied for a T-ICBT program for depression and anxiety over a 1-year period were included in this study. As part of the application and screening process, participants completed depression and anxiety symptom measures (ie, 9-item Patient Health Questionnaire and 7-item Generalized Anxiety Disorder scale). These same measures were administered posttreatment. Subsequently, they were asked if they were experiencing any problems with sleep, sexual activity, energy, or appetite (yes or no). If their response was yes, they were presented with an open-ended comment box that asked them to describe the problems they had experienced in those areas. Results: A total of 462 patients were admitted to T-ICBT during the study period, of which 438 endorsed having some problems with sleep, sexual activity, energy, or appetite. The analysis of open-ended responses indicated that 73.4% (339/462) of patients reported sleep problems (eg, difficulty initiating or maintaining sleep), 69.3% (320/462) of patients reported problems with energy or motivation (eg, tiredness and low motivation), 57.4% (265/462) of patients reported appetite or body weight concerns (eg, changes in appetite and weight loss or gain), and 30.1% (139/462) of patients described concerns with sexual functioning (eg, loss of interest in sex and difficulty with arousal). Item analysis of symptom measures demonstrated that T-ICBT produced improvements in sleep, energy, and appetite in 8 weeks. Sexual dysfunction and weight changes were not represented in the screening measures, so it remains unclear what effect T-ICBT has on these symptoms. Conclusions: Sleep disruption, lack of energy, appetite or weight changes, and sexual dysfunction are common concerns reported by clients enrolled in T-ICBT in routine practice and may deserve greater attention in T-ICBT program development and administration. %M 33048054 %R 10.2196/15037 %U http://formative.jmir.org/2020/10/e15037/ %U https://doi.org/10.2196/15037 %U http://www.ncbi.nlm.nih.gov/pubmed/33048054 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e22635 %T Natural Language Processing Reveals Vulnerable Mental Health Support Groups and Heightened Health Anxiety on Reddit During COVID-19: Observational Study %A Low,Daniel M %A Rumker,Laurie %A Talkar,Tanya %A Torous,John %A Cecchi,Guillermo %A Ghosh,Satrajit S %+ Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, 43 Vassar St, Cambridge, MA, 02139, United States, 1 6176317230, dlow@mit.edu %K COVID-19 %K mental health %K psychiatry %K infodemiology %K infoveillance %K infodemic %K social media %K Reddit %K natural language processing %K ADHD %K eating disorders %K anxiety %K suicidality %D 2020 %7 12.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic is impacting mental health, but it is not clear how people with different types of mental health problems were differentially impacted as the initial wave of cases hit. Objective: The aim of this study is to leverage natural language processing (NLP) with the goal of characterizing changes in 15 of the world’s largest mental health support groups (eg, r/schizophrenia, r/SuicideWatch, r/Depression) found on the website Reddit, along with 11 non–mental health groups (eg, r/PersonalFinance, r/conspiracy) during the initial stage of the pandemic. Methods: We created and released the Reddit Mental Health Dataset including posts from 826,961 unique users from 2018 to 2020. Using regression, we analyzed trends from 90 text-derived features such as sentiment analysis, personal pronouns, and semantic categories. Using supervised machine learning, we classified posts into their respective support groups and interpreted important features to understand how different problems manifest in language. We applied unsupervised methods such as topic modeling and unsupervised clustering to uncover concerns throughout Reddit before and during the pandemic. Results: We found that the r/HealthAnxiety forum showed spikes in posts about COVID-19 early on in January, approximately 2 months before other support groups started posting about the pandemic. There were many features that significantly increased during COVID-19 for specific groups including the categories “economic stress,” “isolation,” and “home,” while others such as “motion” significantly decreased. We found that support groups related to attention-deficit/hyperactivity disorder, eating disorders, and anxiety showed the most negative semantic change during the pandemic out of all mental health groups. Health anxiety emerged as a general theme across Reddit through independent supervised and unsupervised machine learning analyses. For instance, we provide evidence that the concerns of a diverse set of individuals are converging in this unique moment of history; we discovered that the more users posted about COVID-19, the more linguistically similar (less distant) the mental health support groups became to r/HealthAnxiety (ρ=–0.96, P<.001). Using unsupervised clustering, we found the suicidality and loneliness clusters more than doubled in the number of posts during the pandemic. Specifically, the support groups for borderline personality disorder and posttraumatic stress disorder became significantly associated with the suicidality cluster. Furthermore, clusters surrounding self-harm and entertainment emerged. Conclusions: By using a broad set of NLP techniques and analyzing a baseline of prepandemic posts, we uncovered patterns of how specific mental health problems manifest in language, identified at-risk users, and revealed the distribution of concerns across Reddit, which could help provide better resources to its millions of users. We then demonstrated that textual analysis is sensitive to uncover mental health complaints as they appear in real time, identifying vulnerable groups and alarming themes during COVID-19, and thus may have utility during the ongoing pandemic and other world-changing events such as elections and protests. %M 32936777 %R 10.2196/22635 %U http://www.jmir.org/2020/10/e22635/ %U https://doi.org/10.2196/22635 %U http://www.ncbi.nlm.nih.gov/pubmed/32936777 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 10 %P e21075 %T Examining an App-Based Mental Health Self-Care Program, IntelliCare for College Students: Single-Arm Pilot Study %A Lattie,Emily %A Cohen,Katherine A %A Winquist,Nathan %A Mohr,David C %+ Department of Medical Social Sciences, Northwestern University, 750 N Lake Shore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 3125033741, emily.lattie@northwestern.edu %K mHealth %K college students %K depression %K anxiety %K mobile phone %D 2020 %7 10.10.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: In recent years, there has been an increase in symptoms of depression, anxiety, and other mental illnesses in college student populations alongside a steady rise in the demand for counseling services. Digital mental health programs, such as those delivered through mobile apps, can add to the array of available services but must be tested for usability and acceptability before implementation. Objective: This study aims to examine how students used IntelliCare for College Students over an 8-week period to examine the preliminary associations between app use and psychosocial targets and to gather user feedback about usability issues that need to be remedied before a larger implementation study. Methods: IntelliCare for College Students is an app-based platform that provides symptom assessments with personalized feedback, information about campus resources, lessons on mental health and wellness topics, and access to the suite of interactive skill–focused IntelliCare apps. A total of 20 students were recruited to participate in an 8-week study. To test for a broad range of potential users, we recruited a mixed sample of students with elevated symptoms of depression or anxiety and students without elevated symptoms. Participants completed psychosocial questionnaires at baseline, week 4, and week 8. Participants also completed user feedback interviews at weeks 4 and 8 in which they provided feedback on their experience using the app and suggestions for changes they would like to be made to the app. Results: Of the 20 students who downloaded the app, 19 completed the study, indicating a high rate of retention. Over the study period, participants completed an average of 5.85 (SD 2.1; range 1-8) symptom assessments. Significant improvements were observed in the Anxiety Literacy Questionnaire scores (Z=−2.006; P=.045) and in the frequency with which participants used both cognitive (Z=−2.091; P=.04) and behavioral (Z=−2.249; P=.03) coping skills. In the feedback interviews, we identified a high degree of usability with minor bugs in the app software, which were quickly fixed. Furthermore, in feedback interviews, we identified that users found the app to be convenient and appreciated the ability to use the program in short bursts of time. Conclusions: The findings indicate that the IntelliCare for College Students program was perceived as largely usable and engaging. Although the program demonstrated usability and preliminary benefits to students, further testing is needed to determine its clinical utility among college students. Trial Registration: ClinicalTrials.gov NCT04035577; https://clinicaltrials.gov/ct2/show/NCT04035577 %M 33037874 %R 10.2196/21075 %U http://mental.jmir.org/2020/10/e21075/ %U https://doi.org/10.2196/21075 %U http://www.ncbi.nlm.nih.gov/pubmed/33037874 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e18140 %T User Perspectives of Mood-Monitoring Apps Available to Young People: Qualitative Content Analysis %A Widnall,Emily %A Grant,Claire Ellen %A Wang,Tao %A Cross,Lauren %A Velupillai,Sumithra %A Roberts,Angus %A Stewart,Robert %A Simonoff,Emily %A Downs,Johnny %+ Institute of Psychiatry, Psychology and Neuroscience, Kings College London, 16 De Crespigny Park, London, United Kingdom, 44 7730683269, emily.widnall@kcl.ac.uk %K mood monitoring %K engagement %K mobile applications %K mHealth %K mental health %K smartphone %K qualitative research %K mobile phone %D 2020 %7 10.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health apps are increasingly available and used in a clinical context to monitor young people’s mood and mental health. Despite the benefits of accessibility and cost-effectiveness, consumer engagement remains a hurdle for uptake and continued use. Hundreds of mood-monitoring apps are publicly available to young people on app stores; however, few studies have examined consumer perspectives. App store reviews held on Google and Apple platforms provide a large, rich source of naturally generated, publicly available user reviews. Although commercial developers use these data to modify and improve their apps, to date, there has been very little in-depth evaluation of app store user reviews within scientific research, and our current understanding of what makes apps engaging and valuable to young people is limited. Objective: This study aims to gain a better understanding of what app users consider useful to encourage frequent and prolonged use of mood-monitoring apps appropriate for young people. Methods: A systematic approach was applied to the selection of apps and reviews. We identified mood-monitoring apps (n=53) by a combination of automated application programming interface (API) methods. We only included apps appropriate for young people based on app store age categories (apps available to those younger than 18 years). We subsequently downloaded all available user reviews via API data scraping methods and selected a representative subsample of reviews (n=1803) for manual qualitative content analysis. Results: The qualitative content analysis revealed 8 main themes: accessibility (34%), flexibility (21%), recording and representation of mood (18%), user requests (17%), reflecting on mood (16%), technical features (16%), design (13%), and health promotion (11%). A total of 6 minor themes were also identified: notification and reminders; recommendation; privacy, security, and transparency; developer; adverts; and social/community. Conclusions: Users value mood-monitoring apps that can be personalized to their needs, have a simple and intuitive design, and allow accurate representation and review of complex and fluctuating moods. App store reviews are a valuable repository of user engagement feedback and provide a wealth of information about what users value in an app and what user needs are not being met. Users perceive mood-monitoring apps positively, but over 20% of reviews identified the need for improvement. %M 33037875 %R 10.2196/18140 %U http://mhealth.jmir.org/2020/10/e18140/ %U https://doi.org/10.2196/18140 %U http://www.ncbi.nlm.nih.gov/pubmed/33037875 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e18672 %T The Role of Technology and the Continuum of Care for Youth Suicidality: Systematic Review %A Szlyk,Hannah %A Tan,Jia %+ School of Social Work, Rutgers, The State University of New Jersey, 390 George Street, New Brunswick, NJ, 08901, United States, 1 9178364225, hannah.szlyk@rutgers.edu %K youth %K suicide prevention %K technology %K continuum of care %D 2020 %7 9.10.2020 %9 Review %J J Med Internet Res %G English %X Background: Youth suicide is a global public health issue, and using technology is one strategy to increase participation in preventive interventions. However, there is minimal knowledge on how technology-enhanced interventions for youth correspond to the stages of care, from illness or risk recognition to treatment follow-up. Objective: This systematic review aims to examine the efficacy of technology-enhanced youth suicide prevention and interventions across the continuum of care. Methods: Four electronic databases were searched up to spring 2019 for youth suicide preventive interventions that used technology. The review was not restricted by study design and eligible studies could report outcomes on suicidality or related behaviors, such as formal treatment initiation. An adapted version of the Methodological Quality Ratings Scale was used to assess study quality. Results: A total of 26 studies were identified. The findings support the emerging efficacy of technology-enhanced interventions, including a decline in suicidality and an increase in proactive behaviors. However, evidence suggests that there are gaps in the continuum of care and recent study samples do not represent the diverse identities of vulnerable youth. Conclusions: The majority of identified studies were conducted in school settings and were universal interventions that aligned with the illness and risk recognition and help-seeking stages of the continuum of care. This field could be strengthened by having future studies target the stages of assessment and treatment initiation, include diverse youth demographics, and examine the varying roles of providers and technological components in emerging interventions. %M 33034568 %R 10.2196/18672 %U http://www.jmir.org/2020/10/e18672/ %U https://doi.org/10.2196/18672 %U http://www.ncbi.nlm.nih.gov/pubmed/33034568 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e15741 %T A Digital Companion, the Emma App, for Ecological Momentary Assessment and Prevention of Suicide: Quantitative Case Series Study %A Morgiève,Margot %A Genty,Catherine %A Azé,Jérôme %A Dubois,Jonathan %A Leboyer,Marion %A Vaiva,Guillaume %A Berrouiguet,Sofian %A Courtet,Philippe %+ Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital, CHU Montpellier, INSERM, Univ Montpellier, Neuropsychiatry: Epidemiological and Clinical Research, 371 Av. du Doyen Gaston Giraud, Montpellier, 34090, France, 33 609596532, margotmorgieve@yahoo.fr %K suicide %K ecological momentary assessment %K prediction %K prevention %K mobile health %K mHealth %K case reports %K ecological momentary intervention %D 2020 %7 9.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Many suicide risk factors have been identified, but traditional clinical methods do not allow for the accurate prediction of suicide behaviors. To face this challenge, emma, an app for ecological momentary assessment (EMA), ecological momentary intervention (EMI), and prediction of suicide risk in high-risk patients, was developed. Objective: The aim of this case report study was to describe how subjects at high risk of suicide use the emma app in real-world conditions. Methods: The Ecological Mental Momentary Assessment (EMMA) study is an ongoing, longitudinal, interventional, multicenter trial in which patients at high risk for suicide are recruited to test emma, an app designed to be used as a self-help tool for suicidal crisis management. Participants undergo clinical assessment at months 0, 1, 3, and 6 after inclusion, mainly to assess and characterize the presence of mental disorders and suicidal thoughts and behaviors. Patient recruitment is still ongoing. Some data from the first 14 participants who already completed the 6-month follow-up were selected for this case report study, which evaluated the following: (1) data collected by emma (ie, responses to EMAs), (2) metadata on emma use, (3) clinical data, and (4) qualitative assessment of the participants' experiences. Results: EMA completion rates were extremely heterogeneous with a sharp decrease over time. The completion rates of the weekly EMAs (25%-87%) were higher than those of the daily EMAs (0%-53%). Most patients (10/14, 71%) answered the EMA questionnaires spontaneously. Similarly, the use of the Safety Plan Modules was very heterogeneous (2-75 times). Specifically, 11 patients out of 14 (79%) used the Call Module (1-29 times), which was designed by our team to help them get in touch with health care professionals and/or relatives during a crisis. The diversity of patient profiles and use of the EMA and EMI modules proposed by emma were highlighted by three case reports. Conclusions: These preliminary results indicate that patients have different clinical and digital profiles and needs that require a highly scalable, interactive, and customizable app. They also suggest that it is possible and acceptable to collect longitudinal, fine-grained, contextualized data (ie, EMA) and to offer personalized intervention (ie, EMI) in real time to people at high risk of suicide. To become a complementary tool for suicide prevention, emma should be integrated into existing emergency procedures. Trial Registration: ClinicalTrials.gov NCT03410381; https://clinicaltrials.gov/ct2/show/NCT03410381 %M 33034567 %R 10.2196/15741 %U https://mhealth.jmir.org/2020/10/e15741 %U https://doi.org/10.2196/15741 %U http://www.ncbi.nlm.nih.gov/pubmed/33034567 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e21336 %T Twelve-Month Follow-Up to a Fully Automated Internet-Based Cognitive Behavior Therapy Intervention for Rural Adults With Depression Symptoms: Single-Arm Longitudinal Study %A Schure,Mark %A McCrory,Bernadette %A Tuchscherer Franklin,Kathryn %A Greist,John %A Weissman,Ruth Striegel %+ Department of Health & Human Development, Montana State University, 305 Herrick Hall, Bozeman, MT, 59717, United States, 1 406 994 3248, mark.schure@montana.edu %K internet-based cognitive behavior therapy %K depression %K anxiety %K long-term outcomes %K iCBT %K CBT %K therapy %K mental health %K outcome %D 2020 %7 2.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet-based cognitive behavior therapy (iCBT) interventions have the potential to help individuals with depression, regardless of time and location. Yet, limited information exists on the longer-term (>6 months) effects of iCBT and adherence to these interventions. Objective: The primary aim of this study was to evaluate the longitudinal (12 months) effectiveness of a fully automated, self-guided iCBT intervention called Thrive, designed to enhance engagement with a rural population of adults with depression symptoms. The secondary aim was to determine whether the program adherence enhanced the effectiveness of the Thrive intervention. Methods: We analyzed data from 181 adults who used the Thrive intervention. Using self-reports, participants were evaluated at baseline, 8 weeks, 6 months, and 12 months for the primary outcome of depression symptom severity using the Patient Health Questionnaire-9 (PHQ-9) scale and secondary outcome measures, namely, the Generalized Anxiety Disorder Scale-7 (GAD-7) scores, Work and Social Adjustment Scale (WSAS) scores, Conner-Davidson Resilience Scale-10 (CD-RISC-10) scores, and suicidal ideation (ninth item of the PHQ-9 scale) scores. The Thrive program adherence was measured using the numbers of program logins, page views, and lessons completed. Results: The assessment response rates for 8-week, 6-month, and 12-month outcomes were 58.6% (106/181), 50.3% (91/181), and 51.4% (93/181), respectively. By 8 weeks, significant improvements were observed for all outcome measures. These improvements were maintained at 12 months with mean reductions in severities of depression (mean –6.5; P<.001) and anxiety symptoms (mean –4.3; P<.001). Improvements were also observed in work and social functioning (mean –6.9; P<.001) and resilience (mean 4.3; P<.001). Marked decreases were observed in suicidal ideation (PHQ-9 ninth item score >1) at 6 months (16.5%) and 12 months (17.2%) compared to baseline (39.8%) (P<.001). In regard to the program adherence, cumulative counts of page views and lessons completed were significantly related to lower PHQ-9, GAD-7, and WSAS scores and higher CD-RISC-10 scores (all P values <.001 with an exception of page views with WSAS for which P value was .02). Conclusions: The Thrive intervention was effective at reducing depression and anxiety symptom severity and improving functioning and resilience among a population of adults from mostly rural communities in the United States. These gains were maintained at 1 year. Program adherence, measured by the number of logins and lessons completed, indicates that users who engage more with the program benefit more from the intervention. Trial Registration: ClinicalTrials.gov NCT03244878; https://clinicaltrials.gov/ct2/show/NCT03244878 %M 33006561 %R 10.2196/21336 %U https://www.jmir.org/2020/10/e21336 %U https://doi.org/10.2196/21336 %U http://www.ncbi.nlm.nih.gov/pubmed/33006561 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 9 %P e18086 %T Evaluating the Relationship Between Fitbit Sleep Data and Self-Reported Mood, Sleep, and Environmental Contextual Factors in Healthy Adults: Pilot Observational Cohort Study %A Thota,Darshan %+ Madigan Army Medical Center, 9040A Jackson Ave, Joint Base Lewis-McChord, WA, 98431, United States, 1 253 968 5958, thota1@gmail.com %K Fitbit %K sleep %K healthy %K mood %K context %K waking %D 2020 %7 29.9.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Mental health disorders can disrupt a person’s sleep, resulting in lower quality of life. Early identification and referral to mental health services are critical for active duty service members returning from forward-deployed missions. Although technologies like wearable computing devices have the potential to help address this problem, research on the role of technologies like Fitbit in mental health services is in its infancy. Objective: If Fitbit proves to be an appropriate clinical tool in a military setting, it could provide potential cost savings, improve clinician access to patient data, and create real-time treatment options for the greater active duty service member population. The purpose of this study was to determine if the Fitbit device can be used to identify indicators of mental health disorders by measuring the relationship between Fitbit sleep data, self-reported mood, and environmental contextual factors that may disrupt sleep. Methods: This observational cohort study was conducted at the Madigan Army Medical Center. The study included 17 healthy adults who wore a Fitbit Flex for 2 weeks and completed a daily self-reported mood and sleep log. Daily Fitbit data were obtained for each participant. Contextual factors were collected with interim and postintervention surveys. This study had 3 specific aims: (1) Determine the correlation between daily Fitbit sleep data and daily self-reported sleep, (2) Determine the correlation between number of waking events and self-reported mood, and (3) Explore the qualitative relationships between Fitbit waking events and self-reported contextual factors for sleep. Results: There was no significant difference in the scores for the pre-intevention Pittsburg Sleep Quality Index (PSQI; mean 5.88 points, SD 3.71 points) and postintervention PSQI (mean 5.33 points, SD 2.83 points). The Wilcoxon signed-ranks test showed that the difference between the pre-intervention PSQI and postintervention PSQI survey data was not statistically significant (Z=0.751, P=.05). The Spearman correlation between Fitbit sleep time and self-reported sleep time was moderate (r=0.643, P=.005). The Spearman correlation between number of waking events and self-reported mood was weak (r=0.354, P=.163). Top contextual factors disrupting sleep were “pain,” “noises,” and “worries.” A subanalysis of participants reporting “worries” found evidence of potential stress resilience and outliers in waking events. Conclusions: Findings contribute valuable evidence on the strength of the Fitbit Flex device as a proxy that is consistent with self-reported sleep data. Mood data alone do not predict number of waking events. Mood and Fitbit data combined with further screening tools may be able to identify markers of underlying mental health disease. %M 32990631 %R 10.2196/18086 %U http://formative.jmir.org/2020/9/e18086/ %U https://doi.org/10.2196/18086 %U http://www.ncbi.nlm.nih.gov/pubmed/32990631 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e18407 %T Exploring Suicidal Ideation Using an Innovative Mobile App-Strength Within Me: The Usability and Acceptability of Setting up a Trial Involving Mobile Technology and Mental Health Service Users %A Bruen,Ashley Jane %A Wall,Abbie %A Haines-Delmont,Alina %A Perkins,Elizabeth %+ Department of Primary Care and Mental Health, University of Liverpool, Waterhouse Building, 2nd Floor, Block H, Liverpool, L693GF, United Kingdom, 44 0151 795 5343, ashley.bruen@liverpool.ac.uk %K mobile applications %K smartphone %K mobile phone %K mHealth %K mental health %K suicide %K social media %D 2020 %7 28.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide is a growing global public health problem that has resulted in an increase in the demand for psychological services to address mental health issues. It is expected that 1 in 6 people on a waiting list for mental health services will attempt suicide. Although suicidal ideation has been shown to be linked to a higher risk of death by suicide, not everybody openly discloses their suicidal thoughts or plans to friends and family or seeks professional help before suicide. Therefore, new methods are needed to track suicide risk in real time together with a better understanding of the ways in which people communicate or express their suicidality. Considering the dynamic nature and challenges in understanding suicide ideation and suicide risk, mobile apps could be better suited to prevent suicide as they have the ability to collect real-time data. Objective: This study aims to report the practicalities and acceptability of setting up and trialing digital technologies within an inpatient mental health setting in the United Kingdom and highlight their implications for future studies. Methods: Service users were recruited from 6 inpatient wards in the north west of England. Service users who were eligible to participate and provided consent were given an iPhone and Fitbit for 7 days and were asked to interact with a novel phone app, Strength Within Me (SWiM). Interaction with the app involved journaling (recording daily activities, how this made them feel, and rating their mood) and the option to create safety plans for emotions causing difficulties (identifying strategies that helped with these emotions). Participants also had the option to allow the study to access their personal Facebook account to monitor their social media use and activity. In addition, clinical data (ie, assessments conducted by trained researchers targeting suicidality, depression, and sleep) were also collected. Results: Overall, 43.0% (80/186 response rate) of eligible participants were recruited for the study. Of the total sample, 67 participants engaged in journaling, with the average number of entries per user being 8.2 (SD 8.7). Overall, only 24 participants created safety plans and the most common difficult emotion to be selected was feeling sad (n=21). This study reports on the engagement with the SWiM app, the technical difficulties the research team faced, the importance of building key relationships, and the implications of using Facebook as a source to detect suicidality. Conclusions: To develop interventions that can be delivered in a timely manner, prediction of suicidality must be given priority. This paper has raised important issues and highlighted lessons learned from implementing a novel mobile app to detect the risk of suicidality for service users in an inpatient setting. %M 32985995 %R 10.2196/18407 %U http://mental.jmir.org/2020/9/e18407/ %U https://doi.org/10.2196/18407 %U http://www.ncbi.nlm.nih.gov/pubmed/32985995 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22142 %T The Relation Between Official WhatsApp-Distributed COVID-19 News Exposure and Psychological Symptoms: Cross-Sectional Survey Study %A Liu,Jean C J %A Tong,Eddie M W %+ Yale-NUS College, 02-221, 16 College Avenue West, Singapore, 138527, Singapore, 65 66013694, jeanliu@yale-nus.edu.sg %K mental health %K social media %K pandemic %K depression %K anxiety %K stress %K COVID-19 %K app %K risk factor %K psychology %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In a global pandemic, digital technology offers innovative methods to disseminate public health messages. As an example, the messenger app WhatsApp was adopted by both the World Health Organization and government agencies to provide updates on the coronavirus disease (COVID-19). During a time when rumors and excessive news threaten psychological well-being, these services allow for rapid transmission of information and may boost resilience. Objective: In this study, we sought to accomplish the following: (1) assess well-being during the pandemic; (2) replicate prior findings linking exposure to COVID-19 news with psychological distress; and (3) examine whether subscription to an official WhatsApp channel can mitigate this risk. Methods: Across 8 weeks of the COVID-19 outbreak (March 7 to April 21, 2020), we conducted a survey of 1145 adults in Singapore. As the primary outcome measure, participants completed the Depression, Anxiety, and Stress Scale (DASS-21). As predictor variables, participants also answered questions pertaining to the following: (1) their exposure to COVID-19 news; (2) their use of the Singapore government’s WhatsApp channel; and (3) their demographics. Results: Within the sample, 7.9% of participants had severe or extremely severe symptoms on at least one DASS-21 subscale. Depression scores were associated with increased time spent receiving COVID-19 updates, whereas use of the official WhatsApp channel emerged as a protective factor (b=–0.07, t[863]=–2.04, P=.04). Similarly, increased anxiety scores were associated with increased exposure to both updates and rumors, but this risk was mitigated by trust in the government’s WhatsApp messages (b=–0.05, t[863]=–2.13, P=.03). Finally, although stress symptoms increased with the amount of time spent receiving updates, these symptoms were not significantly related to WhatsApp use. Conclusions: Our findings suggest that messenger apps may be an effective medium for disseminating pandemic-related information, allowing official agencies to reach a broad sector of the population rapidly. In turn, this use may promote public well-being amid an “infodemic.” Trial Registration: ClinicalTrials.gov NCT04305574; https://clinicaltrials.gov/ct2/show/NCT04305574 %M 32877349 %R 10.2196/22142 %U http://www.jmir.org/2020/9/e22142/ %U https://doi.org/10.2196/22142 %U http://www.ncbi.nlm.nih.gov/pubmed/32877349 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17831 %T Internet and Computer-Based Cognitive Behavioral Therapy for Anxiety and Depression in Adolescents and Young Adults: Systematic Review and Meta-Analysis %A Christ,Carolien %A Schouten,Maria JE %A Blankers,Matthijs %A van Schaik,Digna JF %A Beekman,Aartjan TF %A Wisman,Marike A %A Stikkelbroek,Yvonne AJ %A Dekker,Jack JM %+ Department of Psychiatry, GGZ inGeest, Amsterdam UMC, Vrije Universiteit Amsterdam, Oldenaller 1, Amsterdam, 1081 HJ, Netherlands, 31 20 590 1339, c.christ@ggzingeest.nl %K cognitive behavior therapy %K internet %K anxiety %K depression %K youth %K meta-analysis %D 2020 %7 25.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Anxiety and depressive disorders are prevalent in adolescents and young adults. However, most young people with mental health problems do not receive treatment. Computerized cognitive behavior therapy (cCBT) may provide an accessible alternative to face-to-face treatment, but the evidence base in young people is limited. Objective: The objective was to perform an up-to-date comprehensive systematic review and meta-analysis of the effectiveness of cCBT in treating anxiety and depression in adolescents and young adults compared with active treatment and passive controls. We aimed to examine posttreatment and follow-up effects and explore the moderators of treatment effects. Methods: We conducted systematic searches in the following six electronic databases: PubMed, EMBASE, PsycINFO, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing cCBT with any control group in adolescents or young adults (age 12-25 years) with anxiety or depressive symptoms. The quality of included studies was assessed using the Cochrane risk-of-bias tool for randomized trials, version 2.0. Overall quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Posttreatment means and SDs were compared between intervention and control groups, and pooled effect sizes (Hedges g) were calculated. Random-effects meta-analyses were conducted using Comprehensive Meta-Analysis software. Subgroup analyses and meta-regression analyses were conducted to explore whether age, guidance level, and adherence rate were associated with treatment outcome. Results: The search identified 7670 papers, of which 24 studies met the inclusion criteria. Most included studies (22/24) had a high risk of bias owing to self-report measures and/or inappropriate handling of missing data. Compared with passive controls, cCBT yielded small to medium posttreatment pooled effect sizes regarding depressive symptoms (g=0.51, 95% CI 0.30-0.72, number needed to treat [NNT]=3.55) and anxiety symptoms (g=0.44, 95% CI 0.23-0.65, NNT=4.10). cCBT yielded effects similar to those of active treatment controls regarding anxiety symptoms (g=0.04, 95% CI −0.23 to 0.31). For depressive symptoms, the nonsignificant pooled effect size favored active treatment controls (g=−0.70, 95% CI −1.51 to 0.11, P=.09), but heterogeneity was very high (I2=90.63%). No moderators of treatment effects were identified. At long-term follow-up, cCBT yielded a small pooled effect size regarding depressive symptoms compared with passive controls (g=0.27, 95% CI 0.09-0.45, NNT=6.58). No other follow-up effects were found; however, power was limited owing to the small number of studies. Conclusions: cCBT is beneficial for reducing posttreatment anxiety and depressive symptoms in adolescents and young adults compared with passive controls. Compared with active treatment controls, cCBT yielded similar effects regarding anxiety symptoms. Regarding depressive symptoms, however, the results remain unclear. More high-quality research involving active controls and long-term follow-up assessments is needed in this population. Trial Registration: PROSPERO CRD42019119725; https://tinyurl.com/y5acfgd9. %M 32673212 %R 10.2196/17831 %U https://www.jmir.org/2020/9/e17831 %U https://doi.org/10.2196/17831 %U http://www.ncbi.nlm.nih.gov/pubmed/32673212 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e22408 %T Prevalence of Perceived Stress, Anxiety, Depression, and Obsessive-Compulsive Symptoms in Health Care Workers and Other Workers in Alberta During the COVID-19 Pandemic: Cross-Sectional Survey %A Mrklas,Kelly %A Shalaby,Reham %A Hrabok,Marianne %A Gusnowski,April %A Vuong,Wesley %A Surood,Shireen %A Urichuk,Liana %A Li,Daniel %A Li,Xin-Min %A Greenshaw,Andrew James %A Agyapong,Vincent Israel Opoku %+ Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, 2047 Hilliard Place NW, Edmonton, AB, T6R 3P5, Canada, 1 7807144315, agyapong@ualberta.ca %K health care worker %K COVID-19 %K pandemic %K mental health %K depression %K anxiety %K stress %K obsessive compulsive %D 2020 %7 25.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: During pandemics, effective containment and mitigation measures may also negatively influence psychological stability. As knowledge about COVID-19 rapidly evolves, global implementation of containment and mitigation measures has varied greatly, with impacts to mental wellness. Assessing the impact of COVID-19 on the mental health needs of health care workers and other workers may help mitigate mental health impacts and secure sustained delivery of health care and other essential goods and services. Objective: This study assessed the self-reported prevalence of stress, anxiety, depression, and obsessive-compulsive symptoms in health care workers and other workers seeking support through Text4Hope, an evidence-based SMS text messaging service supporting the mental health of residents of Alberta, Canada, during the COVID-19 pandemic. Methods: An online cross-sectional survey gathered demographic (age, gender, ethnicity, education, relationship, housing and employment status, employment type, and isolation status) and clinical characteristics using validated tools (self-reported stress, anxiety, depression, and contamination/hand hygiene obsessive-compulsive symptoms). Descriptive statistics and chi-square analysis were used to compare the clinical characteristics of health care workers and other workers. Post hoc analysis was conducted on variables with >3 response categories using adjusted residuals. Logistic regression determined associations between worker type and likelihood of self-reported symptoms of moderate or high stress, generalized anxiety disorder, and major depressive disorder, while controlling for other variables. Results: Overall, 8267 surveys were submitted by 44,992 Text4Hope subscribers (19.39%). Of these, 5990 respondents were employed (72.5%), 958 (11.6%) were unemployed, 454 (5.5%) were students, 559 (6.8%) were retired, 234 (2.8%) selected “other,” and 72 (0.9%) did not indicate their employment status. Most employed survey respondents were female (n=4621, 86.2%). In the general sample, the 6-week prevalence rates for moderate or high stress, anxiety, and depression symptoms were 85.6%, 47.0%, and 44.0%, respectively. Self-reported symptoms of moderate or high stress, anxiety, and depression were all statistically significantly higher in other workers than in health care workers (P<.001). Other workers reported higher obsessive-compulsive symptoms (worry about contamination and compulsive handwashing behavior) after the onset of the pandemic (P<.001), while health care worker symptoms were statistically significantly higher before and during the COVID-19 pandemic (P<.001). This finding should be interpreted with caution, as it is unclear the extent to which the adaptive behavior of health care workers or the other workers might be misclassified by validated tools during a pandemic. Conclusions: Assessing symptoms of prevalent stress, anxiety, depression, and obsessive-compulsive behavior in health care workers and other workers may enhance our understanding of COVID-19 mental health needs. Research is needed to understand more fully the relationship between worker type, outbreak phase, and mental health changes over time, as well as the utility of validated tools in health care workers and other workers during pandemics. Our findings underscore the importance of anticipating and mitigating the mental health effects of pandemics using integrated implementation strategies. Finally, we demonstrate the ease of safely and rapidly assessing mental health needs using an SMS text messaging platform during a pandemic. International Registered Report Identifier (IRRID): RR2-10.2196/19292 %M 32915764 %R 10.2196/22408 %U http://mental.jmir.org/2020/9/e22408/ %U https://doi.org/10.2196/22408 %U http://www.ncbi.nlm.nih.gov/pubmed/32915764 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 9 %P e18902 %T Reward Responsiveness, Optimism, and Social and Mental Functioning in Children Aged 6-7: Protocol of a Cross-Sectional Pilot Study %A Vrijen,Charlotte %A Ackermans,Mégane Alice %A Bosma,Anna %A Kretschmer,Tina %+ Faculty of Behavioural and Social Sciences, University of Groningen, Grote Rozenstraat 38, Groningen, 9712 TJ, Netherlands, 31 503635640, c.vrijen@rug.nl %K optimism %K reward responsiveness %K risk-taking %K children %K mental health %K social relations %D 2020 %7 24.9.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is evidence that reward responsiveness and optimism are associated with mental and social functioning in adolescence and adulthood, but it is unknown if this is also the case for young children. Part of the reason for this gap in the literature is that the instruments that are used to assess reward responsiveness and optimism in adolescents and adults are usually not suitable for young children. Objective: Two behavioral tasks to assess reward learning, a questionnaire on reward responsiveness, and a questionnaire on optimism/pessimism will be tested on their feasibility and reliability in children aged 6-7. Depending on their feasibility and reliability, these instruments will also be used to investigate if reward responsiveness and optimism are associated with mental and social functioning in young children. Methods: For this cross-sectional pilot study, we adapted a number of tasks and questionnaires to the needs of 6-7-year-old children, by simplification of items, oral rather than written assessment, and reducing the number of conditions and items. We will approach teachers and, with their help, aim to include 70 children aged 6-7 to assess the feasibility and reliability of the tasks and questionnaires. Feasibility measures that will be reported are the proportion of children completing the task/questionnaire, the proportion of children that were able to explain the instructions in their own words to the researcher, and the proportion of children that correctly answered the control questions. The reliability of the scales will be assessed by computing Cronbach α and item-total score correlations and the reliability of the tasks by correlations between different consecutive blocks of trials. Ethics approval was obtained from the Ethics Committee of the Department of Pedagogy and Educational Sciences. Results: Data collection was originally planned in March and April 2020, but has been postponed due to Corona virus regulations. We expect to collect the data in the first half of 2021. The findings will be disseminated in preprints and peer-reviewed publications. Conclusions: The development of feasible and reliable instruments for assessing reward responsiveness and optimism in young children is expected to benefit future research on underlying mechanisms of mental and social functioning in young children. If the instruments assessed in this study are usable with young children, it would be particularly interesting to include them in cohort studies because this would enable investigating not only concurrent associations, but also prospective associations between reward responsiveness and optimism early in life and mental and social functioning later in life. If, as we hypothesize, reward responsiveness and optimism are not only associated with (prospective) mental and social functioning in adults and adolescents but also in young children, this could provide a way of identifying vulnerable children already at an early stage. International Registered Report Identifier (IRRID): PRR1-10.2196/18902 %M 32969825 %R 10.2196/18902 %U http://www.researchprotocols.org/2020/9/e18902/ %U https://doi.org/10.2196/18902 %U http://www.ncbi.nlm.nih.gov/pubmed/32969825 %0 Journal Article %@ 2561-3278 %I JMIR Publications %V 5 %N 1 %P e20730 %T Ease of Use of the Electroconvulsive Therapy App by Its Users: Cross-Sectional Questionnaire Study %A Khan,Kinza %A Basavarajappa,Chethan %A Kunigiri,Girish %+ Bradgate Mental Health Unit, Leicester, Leicester, LE3 9EJ, United Kingdom, 44 1530 453827, Girish.Kunigiri@leicspart.nhs.uk %K mHealth %K depression %K apps %K electroconvulsive therapy %K smartphone %K mobile phone %K surveys %K psychiatry %D 2020 %7 22.9.2020 %9 Original Paper %J JMIR Biomed Eng %G English %X Background: Electroconvulsive therapy (ECT) is one of the oldest, most effective, and potentially life-saving noninvasive brain stimulation treatments for psychiatric illnesses such as severe depression, mania, and catatonia. The decision-making process to use ECT involves well-informed discussion between the clinician and the client. A platform, like an app, which provides this information in an easy-to-understand format may be of benefit to various stakeholders in making an informed decision. Apps developed by clinicians/hospitals taking into consideration user perspectives will filter and provide trustworthy information to the users. In this regard, the ECT app, an app which is freely available for download at the Apple Store, was developed by the Leicestershire Partnership National Health Service (NHS) Trust and Leicestershire Health Informatics Service (LHIS). Objective: The objective of this study is to evaluate and demonstrate the accessibility of the ECT app to the chosen audiences it was created for, via a paper and electronic questionnaire. Methods: A survey was conducted between January 2017 and March 2019. A survey questionnaire designed for the study was sent to mental health professionals, medical students, patients, carers, and members of the public via post, email, and SurveyMonkey or informed via posts shared in Psychiatry online groups and face-to-face contact. All participants who were willing to participate in the study were included. Results: Results were collected via paper forms, email responses, and SurveyMonkey and all were inputted into SurveyMonkey to facilitate analysis. A total of 20 responses were received during the study period (January 2017 to March 2019). The participants of the survey, which included a mixed group of professionals (12/20, 60%), patients (3/20, 15%), and carers (1/20, 5%), opined that the app was easy to download (14/20, 70%) and use (9/20, 45%); contained adequate information (19/20, 95%); they felt more informed after having used the app (9/20, 45%); and they would recommend it to others (19/20, 95%). The participants of the survey also provided suggestions on the app (10/20, 50%). Conclusions: The ECT app can be beneficial in sharing appropriate information to professionals and the public alike and help in gathering unbiased and nonjudgmental information on the current use of ECT as a treatment option. %R 10.2196/20730 %U http://biomedeng.jmir.org/2020/1/e20730/ %U https://doi.org/10.2196/20730 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e19476 %T A Smartphone App to Monitor Mood Symptoms in Bipolar Disorder: Development and Usability Study %A Ryan,Kelly Ann %A Babu,Pallavi %A Easter,Rebecca %A Saunders,Erika %A Lee,Andy Jinseok %A Klasnja,Predrag %A Verchinina,Lilia %A Micol,Valerie %A Doil,Brent %A McInnis,Melvin G %A Kilbourne,Amy M %+ Department of Psychiatry, University of Michigan, 2101 Commonwealth Blvd, Suite C, Ann Arbor, MI, 49105, United States, 1 734 936 5524, karyan@umich.edu %K bipolar disorder %K momentary assessment %K mood %K mobile phone %K mobile app %D 2020 %7 22.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is considerable scientific interest in finding new and innovative ways to capture rapid fluctuations in functioning within individuals with bipolar disorder (BD), a severe, recurrent mental disorder associated with frequent shifts in symptoms and functioning. The use of smartphones can provide valid and real-world tools for use in measurement-based care and could be used to inform more personalized treatment options for this group, which can improve standard of care. Objective: We examined the feasibility and usability of a smartphone to capture daily fluctuations in mood within BD and to relate daily self-rated mood to smartphone use behaviors indicative of psychomotor activity or symptoms of the illness. Methods: Participants were 26 individuals with BD and 12 healthy control individuals who were recruited from the Prechter Longitudinal Study of BD. All were given a smartphone with a custom-built app and prompted twice a day to complete questions of mood for 28 days. The app automatically and unobtrusively collected phone usage data. A poststudy satisfaction survey was also completed. Results: Our sample showed a very high adherence rate to the daily momentary assessments (91% of the 58 prompts completed). Multivariate mixed effect models showed that an increase in rapid thoughts over time was associated with a decrease in outgoing text messages (β=–.02; P=.04), and an increase in impulsivity self-ratings was related to a decrease in total call duration (β=–.29; P=.02). Participants generally reported positive experiences using the smartphone and completing daily prompts. Conclusions: Use of mobile technology shows promise as a way to collect important clinical information that can be used to inform treatment decision making and monitor outcomes in a manner that is not overly burdensome to the patient or providers, highlighting its potential use in measurement-based care. %M 32960185 %R 10.2196/19476 %U http://mental.jmir.org/2020/9/e19476/ %U https://doi.org/10.2196/19476 %U http://www.ncbi.nlm.nih.gov/pubmed/32960185 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e19168 %T Mental Health Professional Consultations and the Prevalence of Mood and Anxiety Disorders Among Immigrants: Multilevel Analysis of the Canadian Community Health Survey %A Nwoke,Chinenye Nmanma %A Okpalauwaekwe,Udoka %A Bwala,Hauwa %+ Faculty of Health Sciences, University of Lethbridge, 4401 University Drive, Lethbridge, AB, T1K 3M4, Canada, 1 403 561 7125, chinenye.nwoke@uleth.ca %K immigrants %K immigrant mental health %K mental health consultations %K mood disorders %K anxiety disorders %K mental health visits %K Canadian Community Health Survey %D 2020 %7 16.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is a significant body of evidence on the link between migration and mental health stressors. However, there has been very little research on the use of mental health services by immigrants in Canada. The prevalence of mental health professional consultations among immigrants, as well as its correlations, are not well understood and remain largely unknown. Objective: This study aims to examine how specialist mental health visits (to a psychiatrist) differ from general mental health visits (to a family doctor or general practitioner) from immigrants, when compared to visits from those born in Canada, in a nationally representative sample of Canadian adults. This study also examines which group—immigrant or Canadian-born—suffers more from depression or anxiety, 2 of the more common mental health conditions. Methods: We used data from the Canadian Community Health Survey (CCHS) between the years 2015 and 2016. The outcome variables included consultation with any mental health professional, consultation with a specialist (psychiatrist), and the prevalence of mood and anxiety disorders. The independent variable was immigrant status. Other variables of interest were adjusted for in the analyses. Multilevel regression models were developed, and all analyses were performed with Stata IC statistical software (version 13.0, StataCorp). Results: The prevalence of mood and anxiety disorders was significantly lower among immigrants compared with individuals born in Canada; the prevalence of mood disorders was 5.24% (389,164/7,422,773) for immigrants vs. 9.15% (2,001,829/21,885,625) for individuals born in Canada, and the prevalence of anxiety disorders was 4.47% (330,937/7,410,437) for immigrants vs. 9.51% (2,083,155/21,898,839) for individuals born in Canada. It is expected that individuals with a lower prevalence of mood or anxiety disorders would use mental health services less frequently. However, results show that immigrants, while less likely to consult with any mental health professional (OR=0.80, 95% CI 0.72-0.88, P<.001), were more likely to consult with a psychiatrist (OR=1.24, 95% CI 1.04-1.48, P=.02) for their mental health visits when compared to individuals born in Canada. Conclusions: The results of this study reveal an unusual discord between the likelihood of mental health professional consultations with any mental health professional and mental health visits with psychiatrists among immigrants compared to nonimmigrants in Canada. Mental health initiatives need to be cognizant of the differences in the associated characteristics of consultations for immigrants to better tailor mental health services to be responsive to the unique needs of immigrant populations in Canada. %M 32801115 %R 10.2196/19168 %U http://mental.jmir.org/2020/9/e19168/ %U https://doi.org/10.2196/19168 %U http://www.ncbi.nlm.nih.gov/pubmed/32801115 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e18383 %T Suicidal Thoughts and Behaviors and Their Associations With Transitional Life Events in Men and Women: Findings From an International Web-Based Sample %A Milton,Alyssa Clare %A Davenport,Tracey A %A Iorfino,Frank %A Flego,Anna %A Burns,Jane M %A Hickie,Ian B %+ Brain and Mind Centre, University of Sydney, 88 Mallet St, Camperdown, 2050, Australia, 61 2 86276947, alyssa.milton@sydney.edu.au %K suicidal ideation %K suicide %K suicide, attempted %K men %K women %K sex differences %K life change events %K adaptation, psychological %K health surveys %D 2020 %7 11.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Although numerous studies have demonstrated sex differences in the prevalence of suicidal thoughts and behaviors (STB), there is a clear lack of research examining the similarities and differences between men and women in terms of the relationship between STB, transitional life events, and the coping strategies employed after experiencing such events when they are perceived as stressful. Objective: This study aims to examine the differences between men’s and women’s experiences of STB, sociodemographic predictors of STB, and how coping responses after experiencing a stressful transitional life event predict STB. Methods: A web-based self-report survey was used to assess the health and well-being of a voluntary community-based sample of men and women aged 16 years and older, living in Australia, Canada, New Zealand, the United Kingdom, and the United States, who were recruited using web-based social media promotion and snowballing. Results: In total, 10,765 eligible web-based respondents participated. Compared with men, a significantly greater proportion of women reported STB (P<.001) and endorsed experiencing a transitional life event as stressful (P<.001). However, there were no gender differences in reporting that the transitional life event or events was stressful for those who also reported STB. Significant sociodemographic adjusted risk factors of STB included younger age; identifying as a sexual minority; lower subjective social connectedness; lower subjective intimate bonds; experiencing a stressful transitional life event in the past 12 months; living alone (women only); not being in employment, education, or training (women only); suddenly or unexpectedly losing a job (men only); and experiencing a relationship breakdown (men only). Protective factors included starting a new job, retiring, having a language background other than English, and becoming a parent for the first time (men only). The results relating to coping after experiencing a self-reported stressful transitional life event in the past 12 months found that regardless of sex, respondents who reported STB compared with those who did not were less likely to engage in activities that promote social connections, such as talking about their feelings (P<.001). Coping strategies significantly explained 19.0% of the STB variance for men (F16,1027=14.64; P<.001) and 22.0% for women (F16,1977=36.45; P<.001). Conclusions: This research highlights multiple risk factors for STB, one of which includes experiencing at least one stressful transitional life event in the past 12 months. When individuals are experiencing such events, support from services and the community alike should consider using sex-specific or targeted strategies, as this research indicates that compared with women, more men do nothing when experiencing stress after a transitional life event and may be waiting until they experience STB to engage with their social networks for support. %M 32915160 %R 10.2196/18383 %U http://mental.jmir.org/2020/9/e18383/ %U https://doi.org/10.2196/18383 %U http://www.ncbi.nlm.nih.gov/pubmed/32915160 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22227 %T Depression and Psychological-Behavioral Responses Among the General Public in China During the Early Stages of the COVID-19 Pandemic: Survey Study %A Zhang,Weiyu %A Yang,Xiaoting %A Zhao,Jinfeng %A Yang,Fengzhi %A Jia,Yajing %A Cui,Can %A Yang,Xiaoshi %+ Department of Social Medicine, School of Public Health, China Medical University, No 77 Puhe Road, Shenyang North New Area, Shenyang, 110122, China, 86 18900910796, xsyang@cmu.edu.cn %K depression %K COVID-19 %K social support %K the general public %D 2020 %7 4.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has recently spread dramatically worldwide, raising considerable concerns and resulting in detrimental effects on the psychological health of people who are vulnerable to the disease. Therefore, assessment of depression in members of the general public and their psychological and behavioral responses is essential for the maintenance of health. Objective: This study aimed to assess the prevalence of depression and the associated factors among the general public during the early stages of the COVID-19 pandemic in China. Methods: A cross-sectional survey with convenience sampling was conducted from February 11 to 16, 2020, in the early stages of the COVID-19 outbreak in China. A self-administrated smartphone questionnaire based on the Patient Health Questionnaire-9 (PHQ-9) and psychological and behavioral responses was distributed to the general public. Hierarchical multiple regression analysis and multivariate logistic regression analysis were conducted to explore the associated factors of depression.aA cross-sectional survey with convenience sampling was conducted from February 11 to 16, 2020, in the early stages of the COVID-19 outbreak in China. A self-administrated smartphone questionnaire based on the Patient Health Questionnaire-9 (PHQ-9) and psychological and behavioral responses was distributed to the general public. Hierarchical multiple regression analysis and multivariate logistic regression analysis were conducted to explore the associated factors of depression. Results: The prevalence of depression (PHQ-9 score ≥10) among the general public during the COVID-19 pandemic was 182/1342 (13.6%). Regression analysis indicated that feeling stressed, feeling helpless, persistently being worried even with support, never feeling clean after disinfecting, scrubbing hands and items repeatedly, hoarding food, medicine, or daily supplies, and being distracted from work or study were positively associated with depression, while social support and being calm were negatively associated with depression. Conclusions: The general public suffered from high levels of depression during the early stages of the COVID-19 pandemic. Thus, COVID-19–related mood management and social support should be provided to attenuate depression in the general public. %M 32886066 %R 10.2196/22227 %U https://www.jmir.org/2020/9/e22227 %U https://doi.org/10.2196/22227 %U http://www.ncbi.nlm.nih.gov/pubmed/32886066 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e15972 %T Design Considerations for the Integrated Delivery of Cognitive Behavioral Therapy for Depression: User-Centered Design Study %A Stawarz,Katarzyna %A Preist,Chris %A Tallon,Debbie %A Wiles,Nicola %A Kessler,David %A Turner,Katrina %A Shafran,Roz %A Coyle,David %+ School of Computer Science and Informatics, Cardiff University, Queen's Buildings, 5 The Parade, Cardiff, 3AA, United Kingdom, 44 29 2251 0037, stawarzk@cardiff.ac.uk %K cognitive behavioral therapy %K depression %K mental health %K blended therapy %K integrated therapy %K user-centered design %K qualitative research %D 2020 %7 3.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Adherence to computerized cognitive behavioral therapy (cCBT) programs in real-world settings can be poor, and in the absence of therapist support, effects are modest and short term. Moreover, because cCBT systems tend toward limited support and thus low-intensity treatment, they are typically most appropriate for people experiencing mild to moderate mental health difficulties. Blended therapy, that is, combining direct therapist contact with cCBT or psychoeducational materials, has been identified as one possible approach to address these limitations and widen access to individual CBT for depression. Building on the initial success of blended therapy, we explore an integrated approach that seeks to seamlessly combine face-to-face contact, electronic contact, and between-session activities. Integration also considers how the technology can support therapists’ workflow and integrate with broader health care systems. The ultimate aim is to provide a structure within which therapists can deliver high-intensity treatments, while also greatly reducing face-to-face contact. Objective: The research aimed to explore patients’ and therapists’ views on using a system for the delivery of individual treatment for depression that integrates face-to-face therapist contact with access to online resources and with synchronous online therapy sessions that allow collaborative exercises, and to establish design requirements and thus key design considerations for integrated systems that more seamlessly combine different modes of communication. Methods: We conducted a series of four user-centered design studies. This included four design workshops and seven prototype testing sessions with 18 people who had received CBT for depression in the past, and 11 qualitative interviews and three role-play sessions with 12 CBT therapists experienced in the treatment of depression. Studies took place between July and December 2017 in Bristol, United Kingdom. Results: Workshops and prototyping sessions with people who had received CBT identified three important requirements for integrated platforms delivering CBT therapy for depression as follows: (1) features that help to overcome depression-related barriers, (2) features that support engagement, and (3) features that reinforce learning and support the development of new skills. Research with therapists highlighted the importance of the therapist and client working together, the impact of technology on therapists’ workflow and workload, challenges and opportunities related to the use of online resources, and the potential of technology to support patient engagement. We use these findings to inform 12 design considerations for developing integrated therapy systems. Conclusions: To meet clients’ and therapists’ needs, integrated systems need to help retain the personal connection, support both therapist- and patient-led activities, and provide access to materials and the ability to monitor progress. However, developers of such systems should be mindful of their capacity to disrupt current work practices and increase therapists’ workload. Future research should evaluate the impact of integrated systems on patients and therapists in a real-world context. %M 32880580 %R 10.2196/15972 %U https://mental.jmir.org/2020/9/e15972 %U https://doi.org/10.2196/15972 %U http://www.ncbi.nlm.nih.gov/pubmed/32880580 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20581 %T Digital Interventions for Screening and Treating Common Mental Disorders or Symptoms of Common Mental Illness in Adults: Systematic Review and Meta-analysis %A Sin,Jacqueline %A Galeazzi,Gian %A McGregor,Elicia %A Collom,Jennifer %A Taylor,Anna %A Barrett,Barbara %A Lawrence,Vanessa %A Henderson,Claire %+ School of Psychology and Clinical Language Sciences, University of Reading, Earley Gate, Whiteknights, Reading, RG6 6AL, United Kingdom, 44 7817027035, jacqueline.sin@reading.ac.uk %K eHealth %K mHealth %K psychiatric illness %K mental disorders %K common mental illness %K depression %K anxiety %K self-care %D 2020 %7 2.9.2020 %9 Review %J J Med Internet Res %G English %X 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. %M 32876577 %R 10.2196/20581 %U https://www.jmir.org/2020/9/e20581 %U https://doi.org/10.2196/20581 %U http://www.ncbi.nlm.nih.gov/pubmed/32876577 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18458 %T Compensatory Social Networking Site Use, Family Support, and Depression Among College Freshman: Three-Wave Panel Study %A Zhou,Mingjie %A Li,Fugui %A Wang,Yanhong %A Chen,Shuang %A Wang,Kexin %+ College of Media and International Culture, Zhejiang University, Main Teaching Building, 4th Fl., Hangzhou, 310007, China, 86 18611897400, wangkexin0809@zju.edu.cn %K freshmen %K introversion %K compensatory use of SNS %K depression %K family support %K social media %D 2020 %7 2.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Freshmen were found to use social networking sites (SNS) as a useful medium to effectively adjust to college life, which hints at a tendency to resort to SNS for social compensation. However, the compensatory use of SNS is usually problematic. Objective: This study explores why a subgroup of freshmen developed depressive symptoms while socially adjusting to college by investigating the antecedent role of introversion, the explanatory role of compensatory use of SNS, and the protective role of perceived family support. The study is among the first to point out the relevance of the compensatory use of SNS in explaining the indirect association between introversion and depression with a longitudinal design. Methods: A 3-wave panel sample of freshmen (N=1137) is used to examine the moderated mediation model. Results: We found that introversion at Wave 1 positively predicted compensatory use of SNS at Wave 2 and subsequently increased depression at Wave 3 (unstandardized B=0.07, SE 0.02, P<.001, 95% CI 0.04-0.10; unstandardized B=0.09, SE 0.01, P<.001, 95% CI 0.06-0.12). The moderated mediation model further examined the buffering role of perceived family support within the link between introversion and compensatory SNS use (index=0.0031, SE 0.0015, 95% CI 0.0003-0.0062). Unexpectedly, we found that family support in Wave 1 decreased compensatory SNS use for less introverted freshmen in Wave 2 and further decreased depression in Wave 3. Conclusions: Unexpectedly, our findings uncover an enhancing effect, rather than a buffering effect, of family support by embedding its effect within the relationship between introversion and compensatory SNS use. Appreciating the differences in the casual pathways for freshmen with different levels of introversion clarifies how SNS affect young adults' lives. %M 32795999 %R 10.2196/18458 %U https://www.jmir.org/2020/9/e18458 %U https://doi.org/10.2196/18458 %U http://www.ncbi.nlm.nih.gov/pubmed/32795999 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e18100 %T Effects of Internet-Based Cognitive Behavioral Therapy in Routine Care for Adults in Treatment for Depression and Anxiety: Systematic Review and Meta-Analysis %A Etzelmueller,Anne %A Vis,Christiaan %A Karyotaki,Eirini %A Baumeister,Harald %A Titov,Nickolai %A Berking,Matthias %A Cuijpers,Pim %A Riper,Heleen %A Ebert,David Daniel %+ Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Nägelsbachstr 25a, Erlangen, 91052, Germany, 49 9131 85 67575, anne.etzelmueller@fau.de %K internet-based interventions %K depression %K anxiety %K effectiveness %K acceptability %K routine care %D 2020 %7 31.8.2020 %9 Review %J J Med Internet Res %G English %X Background: Although there is evidence for the efficacy of internet-based cognitive behavioral therapy (iCBT), the generalizability of results to routine care is limited. Objective: This study systematically reviews effectiveness studies of guided iCBT interventions for the treatment of depression or anxiety. Methods: The acceptability (uptake, participants’ characteristics, adherence, and satisfaction), effectiveness, and negative effects (deterioration) of nonrandomized pre-post designs conducted under routine care conditions were synthesized using systematic review and meta-analytic approaches. Results: A total of 19 studies including 30 groups were included in the analysis. Despite high heterogeneity, individual effect sizes of investigated studies indicate clinically relevant changes, with effect sizes ranging from Hedges’ g=0.42-1.88, with a pooled effect of 1.78 for depression and 0.94 for anxiety studies. Uptake, participants’ characteristics, adherence, and satisfaction indicate a moderate to high acceptability of the interventions. The average deterioration across studies was 2.9%. Conclusions: This study provides evidence supporting the acceptability and effectiveness of guided iCBT for the treatment of depression and anxiety in routine care. Given the high heterogeneity between interventions and contexts, health care providers should select interventions that have been proven in randomized controlled clinical trials. The successful application of iCBT may be an effective way of increasing health care in multiple contexts. %M 32865497 %R 10.2196/18100 %U http://www.jmir.org/2020/8/e18100/ %U https://doi.org/10.2196/18100 %U http://www.ncbi.nlm.nih.gov/pubmed/32865497 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e21304 %T Digital Cognitive Behavior Therapy Intervention for Depression and Anxiety: Retrospective Study %A Venkatesan,Aarathi %A Rahimi,Lily %A Kaur,Manpreet %A Mosunic,Christopher %+ Vida Health, 100 Montgomery St, Ste 750, San Francisco, CA, 94104, United States, 1 (415) 989 1017, aarathi.venkatesan@vida.com %K depression %K anxiety %K CBT %K digital mental health intervention %K digital therapeutics %K cognitive behavioral therapy %K therapy %K digital health %K intervention %K mental health %D 2020 %7 26.8.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Digital mental health interventions offer a scalable solution that reduces barriers to seeking care for clinical depression and anxiety. Objective: We aimed to examine the effectiveness of a 12-week therapist supported, app-based cognitive behavioral therapy program in improving symptoms of depression and anxiety within 9 months. Methods: A total of 323 participants with mild to moderately severe depression or anxiety were enrolled in a 12-week digital cognitive behavior therapy program. The analysis was restricted to participants who provided at least one follow-up assessment after baseline. As a result, 146 participants (45.2%) were included in the analysis—74 (50.7%) participants completed assessments at 3 months, 31 participants (21.2%) completed assessments at 6 months, and 21 participants (14.4%) completed assessments at 9 months. The program included structured lessons and tools (ie, exercises and practices) as well as one-on-one weekly video counseling sessions with a licensed therapist for 12 weeks and monthly check-in sessions for 1 year. The clinically validated Patient Health Questionnaire (PHQ-8) and Generalized Anxiety Disorder Scale (GAD-7) were used to assess depression and anxiety, respectively. Linear mixed-effects modeling was employed to examine changes in depression and anxiety over time. Results: We observed a significant positive effect of program time on improvement in depression (β=–0.12, P<.001) and anxiety scores (β=–0.10, P<.001). At the end of the 12-week intervention, we observed an average reduction of 3.76 points (95% CI –4.76 to –2.76) in PHQ-8 scores. Further reductions in depression were seen at program month 6 (4.75-point reduction, 95% CI –6.61 to –2.88) and program month 9 (6.42-point reduction, 95% CI –8.66 to –6.55, P<.001). A similar pattern of improvement emerged for anxiety, with a 3.17-point reduction at the end of the 12-week intervention (95% CI –4.21 to –2.13). These improvements were maintained at program month 6 (4.87-point reduction, 95% CI –6.85 to –2.87) and program month 9 (5.19-point, 95% –6.85 to 4.81). In addition, greater program engagement during the first 12 weeks predicted a greater reduction in depression (β=–0.29, P<.001) Conclusions: The results suggest that digital interventions can support sustained and clinically meaningful improvements in depression and anxiety. Furthermore, it appears that strong initial digital mental health intervention engagement may facilitate this effect. However, the study was limited by postintervention participant attrition as well as the retrospective observational study design. %M 32845246 %R 10.2196/21304 %U http://mental.jmir.org/2020/8/e21304/ %U https://doi.org/10.2196/21304 %U http://www.ncbi.nlm.nih.gov/pubmed/32845246 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e16388 %T Relationship Between Depression and the Use of Mobile Technologies and Social Media Among Adolescents: Umbrella Review %A Arias-de la Torre,Jorge %A Puigdomenech,Elisa %A García,Xavier %A Valderas,Jose M %A Eiroa-Orosa,Francisco Jose %A Fernández-Villa,Tania %A Molina,Antonio J %A Martín,Vicente %A Serrano-Blanco,Antoni %A Alonso,Jordi %A Espallargues,Mireia %+ Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, Denmark Hill campus, London, SE5 8AF, United Kingdom, 44 634722677, jorgeariasdelatorre@gmail.com %K mobile technologies and social media %K depression %K adolescents %K review %D 2020 %7 26.8.2020 %9 Review %J J Med Internet Res %G English %X Background: Despite the relevance of mobile technologies and social media (MTSM) for adolescents, their association with depressive disorders in this population remains unclear. While there are previous reviews that have identified the use of MTSM as a risk factor for developing depression, other reviews have indicated their possible preventive effect. Objective: The aim of this review was to synthesize the current evidence on the association between MTSM use and the development or prevention of depressive disorders in adolescents. Methods: An umbrella review was conducted using information published up to June 2019 from PubMed/MEDLINE, PsycINFO, Web of Science, and The Cochrane Library. Systematic reviews focusing on the adolescent population (up to 20 years old) and depression and its potential relationship with MTSM use were included. Screening of titles, abstracts, and full texts was performed. After selecting the reviews and given the heterogeneity of the outcome variables and exposures, a narrative synthesis of the results was carried out. Results: The search retrieved 338 documents, from which 7 systematic reviews (3 meta-analyses) were selected for data extraction. There were 11-70 studies and 5582-46,015 participants included in the 7 reviews. All reviews included quantitative research, and 2 reviews also included qualitative studies. A statistically significant association between social media and developing depressive symptoms was reported in 2 reviews, while 5 reviews reported mixed results. Conclusions: Excessive social comparison and personal involvement when using MTSM could be associated with the development of depressive symptomatology. Nevertheless, MTSM might promote social support and even become a point of assistance for people with depression. Due to the mixed results, prospective research could be valuable for providing stronger evidence. %M 32663157 %R 10.2196/16388 %U http://www.jmir.org/2020/8/e16388/ %U https://doi.org/10.2196/16388 %U http://www.ncbi.nlm.nih.gov/pubmed/32663157 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e19706 %T Digital Tools to Ameliorate Psychological Symptoms Associated With COVID-19: Scoping Review %A Zhang,Melvyn %A Smith,Helen Elizabeth %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Level 11, Family Medicine and Primary Care, 308322, Singapore, 65 98556631, melvynzhangweibin@gmail.com %K COVID-19 %K digital tool %K psychiatry %K mental health %K digital health %K psychology %K distress %K stress %K anxiety %K depression %D 2020 %7 21.8.2020 %9 Review %J J Med Internet Res %G English %X Background: In the four months after the discovery of the index case of coronavirus disease (COVID-19), several studies highlighted the psychological impact of COVID-19 on frontline health care workers and on members of the general public. It is evident from these studies that individuals experienced elevated levels of anxiety and depression in the acute phase, when they first became aware of the pandemic, and that the psychological distress persisted into subsequent weeks. It is becoming apparent that technological tools such as SMS text messages, web-based interventions, mobile interventions, and conversational agents can help ameliorate psychological distress in the workplace and in society. To our knowledge, there are few publications describing how digital tools have been used to ameliorate psychological symptoms among individuals. Objective: The aim of this review was to identify existing SMS text message, web-based, mobile, and conversational agents that the general public can access to ameliorate the psychological symptoms they are experiencing during the COVID-19 pandemic. Methods: To identify digital tools that were published specifically for COVID-19, a search was performed in the PubMed and MEDLINE databases from the inception of the databases through June 17, 2020. The following search strings were used: “NCOV OR 2019-nCoV OR SARS-CoV-2 OR Coronavirus OR COVID19 OR COVID” and “mHealth OR eHealth OR text”. Another search was conducted in PubMed and MEDLINE to identify existing digital tools for depression and anxiety disorders. A web-based search engine (Google) was used to identify if the cited web-based interventions could be accessed. A mobile app search engine, App Annie, was used to determine if the identified mobile apps were commercially available. Results: A total of 6 studies were identified. Of the 6 identified web-based interventions, 5 websites (83%) could be accessed. Of the 32 identified mobile interventions, 7 apps (22%) could be accessed. Of the 7 identified conversational agents, only 2 (29%) could be accessed. Results: A total of 6 studies were identified. Of the 6 identified web-based interventions, 5 websites (83%) could be accessed. Of the 32 identified mobile interventions, 7 apps (22%) could be accessed. Of the 7 identified conversational agents, only 2 (29%) could be accessed. Conclusions: The COVID-19 pandemic has caused significant psychological distress. Digital tools that are commercially available may be useful for at-risk individuals or individuals with pre-existing psychiatric symptoms. %M 32721922 %R 10.2196/19706 %U http://www.jmir.org/2020/8/e19706/ %U https://doi.org/10.2196/19706 %U http://www.ncbi.nlm.nih.gov/pubmed/32721922 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e18642 %T Barriers and Facilitators for Referrals of Primary Care Patients to Blended Internet-Based Psychotherapy for Depression: Mixed Methods Study of General Practitioners’ Views %A Titzler,Ingrid %A Berking,Matthias %A Schlicker,Sandra %A Riper,Heleen %A Ebert,David Daniel %+ Department of Clinical Psychology and Psychotherapy, University of Erlangen-Nürnberg, Nägelsbachstraße 25a, Erlangen, 91052, Germany, 49 91318567567, ingrid.titzler@fau.de %K barriers and facilitators %K general practitioners %K depression %K referral %K blended therapy %K internet-based intervention %K mobile phone %K psychotherapy %K qualitative research %D 2020 %7 18.8.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Major depressive disorder (MDD) is highly prevalent and often managed by general practitioners (GPs). GPs mostly prescribe medication and show low referral rates to psychotherapy. Many patients remain untreated. Blended psychotherapy (bPT) combines internet-based interventions with face-to-face psychotherapy and could increase treatment access and availability. Effectively implementing bPT in routine care requires an understanding of professional users’ perspectives and behavior. Objective: This study aims to identify barriers and facilitators perceived by GPs in referring patients to bPT. Explanations for variations in referral rates were examined. Methods: Semistructured interviews were conducted with 12 of 110 GPs participating in a German randomized controlled trial (RCT) to investigate barriers to and facilitators for referrals to bPT for MDD (10 web-based modules, app-based assessments, and 6 face-to-face sessions). The interview guide was based on the theoretical domains framework. The interviews were audio recorded and transcribed verbatim, and the qualitative content was analyzed by 2 independent coders (intercoder agreement, k=0.71). A follow-up survey with 12 interviewed GPs enabled the validation of emergent themes. The differences in the barriers and facilitators identified between groups with different characteristics (eg, GPs with high or low referral rates) were described. Correlations between referrals and characteristics, self-rated competences, and experiences managing depression of the RCT-GPs (n=76) were conducted. Results: GPs referred few patients to bPT, although varied in their referral rates, and interviewees referred more than twice as many patients as RCT-GPs (interview-GPs: mean 6.34, SD 9.42; RCT-GPs: mean 2.65, SD 3.92). A negative correlation was found between GPs’ referrals and their self-rated pharmacotherapeutic competence, r(73)=−0.31, P<.001. The qualitative findings revealed a total of 19 barriers (B) and 29 facilitators (F), at the levels of GP (B=4 and F=11), patient (B=11 and F=9), GP practice (B=1 and F=3), and sociopolitical circumstances (B=3 and F=6). Key barriers stated by all interviewed GPs included “little knowledge about internet-based interventions” and “patients’ lack of familiarity with technology/internet/media” (number of statements, each k=22). Key facilitators were “perceived patient suitability, e.g. well-educated, young” (k=22) and “no conflict with GP’s role” (k=16). The follow-up survey showed a very high agreement rate of at least 75% for 71% (34/48) of the identified themes. Descriptive findings indicated differences between GPs with low and high referral rates in terms of which and how many barriers (low: mean 9.75, SD 1.83; high: mean 10.50, SD 2.38) and facilitators (low: mean 18.25, SD 4.13; high: mean 21.00; SD 3.92) they mentioned. Conclusions: This study provides insights into factors influencing GPs’ referrals to bPT as gatekeepers to depression care. Barriers and facilitators should be considered when designing implementation strategies to enhance referral rates. The findings should be interpreted with care because of the small and self-selected sample and low response rates. %M 32673213 %R 10.2196/18642 %U http://mental.jmir.org/2020/8/e18642/ %U https://doi.org/10.2196/18642 %U http://www.ncbi.nlm.nih.gov/pubmed/32673213 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 8 %P e18751 %T The Relationship Between Smartphone-Recorded Environmental Audio and Symptomatology of Anxiety and Depression: Exploratory Study %A Di Matteo,Daniel %A Fotinos,Kathryn %A Lokuge,Sachinthya %A Yu,Julia %A Sternat,Tia %A Katzman,Martin A %A Rose,Jonathan %+ The Centre for Automation of Medicine, The Edward S Rogers Sr Department of Electrical and Computer Engineering, University of Toronto, DL Pratt Building, 6 King's College Road, Toronto, ON, M5S 3H5, Canada, 1 416 978 6992, dandm@ece.utoronto.ca %K depression %K anxiety %K mobile phone %K ecological momentary assessment %K mobile apps %K mobile health %K digital signal processing %K acoustics %K speech recognition software %D 2020 %7 13.8.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Objective and continuous severity measures of anxiety and depression are highly valuable and would have many applications in psychiatry and psychology. A collective source of data for objective measures are the sensors in a person’s smartphone, and a particularly rich source is the microphone that can be used to sample the audio environment. This may give broad insight into activity, sleep, and social interaction, which may be associated with quality of life and severity of anxiety and depression. Objective: This study aimed to explore the properties of passively recorded environmental audio from a subject’s smartphone to find potential correlates of symptom severity of social anxiety disorder, generalized anxiety disorder, depression, and general impairment. Methods: An Android app was designed, together with a centralized server system, to collect periodic measurements of the volume of sounds in the environment and to detect the presence or absence of English-speaking voices. Subjects were recruited into a 2-week observational study during which the app was run on their personal smartphone to collect audio data. Subjects also completed self-report severity measures of social anxiety disorder, generalized anxiety disorder, depression, and functional impairment. Participants were 112 Canadian adults from a nonclinical population. High-level features were extracted from the environmental audio of 84 participants with sufficient data, and correlations were measured between the 4 audio features and the 4 self-report measures. Results: The regularity in daily patterns of activity and inactivity inferred from the environmental audio volume was correlated with the severity of depression (r=−0.37; P<.001). A measure of sleep disturbance inferred from the environmental audio volume was also correlated with the severity of depression (r=0.23; P=.03). A proxy measure of social interaction based on the detection of speaking voices in the environmental audio was correlated with depression (r=−0.37; P<.001) and functional impairment (r=−0.29; P=.01). None of the 4 environmental audio-based features tested showed significant correlations with the measures of generalized anxiety or social anxiety. Conclusions: In this study group, the environmental audio was shown to contain signals that were associated with the severity of depression and functional impairment. Associations with the severity of social anxiety disorder and generalized anxiety disorder were much weaker in comparison and not statistically significant at the 5% significance level. This work also confirmed previous work showing that the presence of voices is associated with depression. Furthermore, this study suggests that sparsely sampled audio volume could provide potentially relevant insight into subjects’ mental health. %M 32788153 %R 10.2196/18751 %U https://formative.jmir.org/2020/8/e18751 %U https://doi.org/10.2196/18751 %U http://www.ncbi.nlm.nih.gov/pubmed/32788153 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e18033 %T Views of Implementers and Nonimplementers of Internet-Administered Cognitive Behavioral Therapy for Depression and Anxiety: Survey of Primary Care Decision Makers in Sweden %A Brantnell,Anders %A Woodford,Joanne %A Baraldi,Enrico %A van Achterberg,Theo %A von Essen,Louise %+ Clinical Psychology in Healthcare, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds Väg 14B, Uppsala, Sweden, 46 18 471 70 55, anders.brantnell@angstrom.uu.se %K mental health %K internet-administered CBT %K self-management %K implementation %K barriers and facilitators %K decision-making %K eHealth %K primary care %D 2020 %7 12.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet-administered cognitive behavioral therapy (ICBT) has been demonstrated to be an effective intervention for adults with depression and/or anxiety and is recommended in national guidelines for provision within Swedish primary care. However, the number and type of organizations that have implemented ICBT within primary care in Sweden is currently unclear. Further, there is a lack of knowledge concerning barriers and facilitators to ICBT implementation. Objective: The two primary objectives were to identify and describe primary care organizations providing ICBT in Sweden and compare decision makers’ (ie, directors of primary care organizations) views on barriers and facilitators to implementation of ICBT among ICBT implementers (ie, organizations that offered ICBT) and nonimplementers (ie, organizations that did not offer ICBT). Methods: An online survey based on a checklist for identifying barriers and facilitators to implementation was developed and made accessible to decision makers from all primary care organizations in Sweden. The survey consisted of background questions (eg, provision of ICBT and number of persons working with ICBT) and barriers and facilitators relating to the following categories: users, therapists, ICBT programs, organizations, and wider society. Results: The participation rate was 35.75% (404/1130). The majority (250/404, 61.8%) of participants were health care center directors and had backgrounds in nursing. Altogether, 89.8% (363/404) of the participating organizations provided CBT. A minority (83/404, 20.5%) of organizations offered ICBT. Most professionals delivering ICBT were psychologists (67/83, 80%) and social workers (31/83, 37%). The majority (61/83, 73%) of organizations had 1 to 2 persons delivering ICBT interventions. The number of patients treated with ICBT during the last 12 months was 1 to 10 in 65% (54/83) of the organizations, ranging between 1 and 400 treated patients across the whole sample. There were 9 significant (P<.05) differences out of 37 possible between implementers and nonimplementers. For example, more implementers (48/51, 94%) than nonimplementers (107/139, 76.9%) perceived few technical problems (P<.001), and more implementers (53/77, 68%) than nonimplementers (103/215, 47.9%) considered that their organization has resources to offer ICBT programs (P<.001). Conclusions: Despite research demonstrating the effectiveness of ICBT for depression and anxiety and national guidelines recommending its use, ICBT is implemented in few primary care organizations in Sweden. Several interesting differences between implementers and nonimplementers were identified, which may help inform interventions focusing on facilitating the implementation of ICBT. %M 32784186 %R 10.2196/18033 %U https://www.jmir.org/2020/8/e18033 %U https://doi.org/10.2196/18033 %U http://www.ncbi.nlm.nih.gov/pubmed/32784186 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e16969 %T Designing a Clinician-Facing Tool for Using Insights From Patients’ Social Media Activity: Iterative Co-Design Approach %A Yoo,Dong Whi %A Birnbaum,Michael L %A Van Meter,Anna R %A Ali,Asra F %A Arenare,Elizabeth %A Abowd,Gregory D %A De Choudhury,Munmun %+ School of Interactive Computing, Georgia Institute of Technology, 756 W Peachtree St NW, Atlanta, GA, 30308, United States, 1 4043858603, yoo@gatech.edu %K social media %K psychotic disorders %K information technology %D 2020 %7 12.8.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Recent research has emphasized the need for accessing information about patients to augment mental health patients’ verbal reports in clinical settings. Although it has not been introduced in clinical settings, computational linguistic analysis on social media has proved it can infer mental health attributes, implying a potential use as collateral information at the point of care. To realize this potential and make social media insights actionable to clinical decision making, the gaps between computational linguistic analysis on social media and the current work practices of mental health clinicians must be bridged. Objective: This study aimed to identify information derived from patients’ social media data that can benefit clinicians and to develop a set of design implications, via a series of low-fidelity (lo-fi) prototypes, on how to deliver the information at the point of care. Methods: A team of clinical researchers and human-computer interaction (HCI) researchers conducted a long-term co-design activity for over 6 months. The needs-affordances analysis framework was used to refine the clinicians’ potential needs, which can be supported by patients’ social media data. On the basis of those identified needs, the HCI researchers iteratively created 3 different lo-fi prototypes. The prototypes were shared with both groups of researchers via a videoconferencing software for discussion and feedback. During the remote meetings, potential clinical utility, potential use of the different prototypes in a treatment setting, and areas of improvement were discussed. Results: Our first prototype was a card-type interface that supported treatment goal tracking. Each card included attribute levels: depression, anxiety, social activities, alcohol, and drug use. This version confirmed what types of information are helpful but revealed the need for a glanceable dashboard that highlights the trends of these information. As a result, we then developed the second prototype, an interface that shows the clinical state and trend. We found that focusing more on the changes since the last visit without visual representation can be more compatible with clinicians’ work practices. In addition, the second phase of needs-affordances analysis identified 3 categories of information relevant to patients with schizophrenia: symptoms related to psychosis, symptoms related to mood and anxiety, and social functioning. Finally, we developed the third prototype, a clinical summary dashboard that showed changes from the last visit in plain texts and contrasting colors. Conclusions: This exploratory co-design research confirmed that mental health attributes inferred from patients’ social media data can be useful for clinicians, although it also revealed a gap between computational social media analyses and clinicians’ expectations and conceptualizations of patients’ mental health states. In summary, the iterative co-design process crystallized design directions for the future interface, including how we can organize and provide symptom-related information in a way that minimizes the clinicians’ workloads. %M 32784180 %R 10.2196/16969 %U http://mental.jmir.org/2020/8/e16969/ %U https://doi.org/10.2196/16969 %U http://www.ncbi.nlm.nih.gov/pubmed/32784180 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e17593 %T Effects of a Brief Electronic Mindfulness-Based Intervention on Relieving Prenatal Depression and Anxiety in Hospitalized High-Risk Pregnant Women: Exploratory Pilot Study %A Goetz,Maren %A Schiele,Claudia %A Müller,Mitho %A Matthies,Lina M %A Deutsch,Thomas M %A Spano,Claudio %A Graf,Johanna %A Zipfel,Stephan %A Bauer,Armin %A Brucker,Sara Y %A Wallwiener,Markus %A Wallwiener,Stephanie %+ Department of Obstetrics and Gynecology, University of Heidelberg, Im Neuenheimer Feld 440, Heidelberg, 69120, Germany, 49 6221 5636956, stephanie.wallwiener@googlemail.com %K pregnancy %K high-risk pregnancy %K hospitalization %K preterm labor %K anxiety %K depression %K psychological stress %K mindfulness %K stress reduction %K mobile app %D 2020 %7 11.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Peripartum depression and anxiety disorders are highly prevalent and are correlated with adverse maternal and neonatal outcomes. Antenatal care in Germany does not yet include structured screening and effective low-threshold treatment options for women facing peripartum depression and anxiety disorders. Mindfulness-based interventions (MBIs) are increasingly becoming a focus of interest for the management of such patients. Studies have shown a decrease in pregnancy-related stress and anxiety in expectant mothers following mindfulness programs. Objective: The aim of this study was to explore the clinical effectiveness of a 1-week electronic course of mindfulness on prenatal depression and anxiety in hospitalized, high-risk pregnant women. We hypothesized that participating in a 1-week electronic MBI (eMBI) could alleviate symptoms of depression and anxiety during the hospital stay. Methods: A prospective pilot study with an explorative study design was conducted from January to May 2019 in a sample of 68 women hospitalized due to high-risk pregnancies. After enrolling into the study, the participants were given access to an eMBI app on how to deal with stress, anxiety, and symptoms of depression. Psychometric parameters were assessed via electronic questionnaires comprising the Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI-S), and abridged version of the Pregnancy-Related Anxiety Questionnaire (PRAQ-R). Results: We observed a high prevalence of peripartum depression and anxiety among hospitalized high-risk pregnant women: 39% (26/67) of the study participants in the first assessment and 41% (16/39) of the participants in the second assessment achieved EPDS scores above the cutoff value for minor/major depression. The number of participants with anxiety levels above the cutoff value (66% [45/68] of the participants in the first assessment and 67% [26/39] of the participants in the second assessment) was significantly more than that of the participants with anxiety levels below the cutoff value, as measured with the STAI-S. After completing the 1-week electronic course on mindfulness, the participants showed a significant reduction in the mean state anxiety levels (P<.03). Regarding pregnancy-related anxiety, participants who completed more than 50% of the 1-week course showed lower scores in PRAQ-R in the second assessment (P<.05). No significant changes in the EPDS scores were found after completing the intervention. Conclusions: Peripartum anxiety and depression represent a relevant health issue in hospitalized pregnant patients. Short-term eMBIs could have the potential to reduce anxiety levels and pregnancy-related anxiety. However, we observed that compliance to eMBI seems to be related to lower symptoms of pregnancy-related stress among high-risk patients. eMBIs represent accessible mental health resources at reduced costs and can be adapted for hospitalized patients during pregnancy. %M 32780023 %R 10.2196/17593 %U https://www.jmir.org/2020/8/e17593 %U https://doi.org/10.2196/17593 %U http://www.ncbi.nlm.nih.gov/pubmed/32780023 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e15506 %T Mobile App for Mental Health Monitoring and Clinical Outreach in Veterans: Mixed Methods Feasibility and Acceptability Study %A Betthauser,Lisa M %A Stearns-Yoder,Kelly A %A McGarity,Suzanne %A Smith,Victoria %A Place,Skyler %A Brenner,Lisa A %+ Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center, 1700 N Wheeling St, Aurora, CO, 80045, United States, 1 720 723 4867, lisa.betthauser@va.gov %K veterans %K mobile app %K smartphone %K mental health %K acceptability %K feasibility %D 2020 %7 11.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Advances in mobile health (mHealth) technology have made it possible for patients and health care providers to monitor and track behavioral health symptoms in real time. Ideally, mHealth apps include both passive and interactive monitoring and demonstrate high levels of patient engagement. Digital phenotyping, the measurement of individual technology usage, provides insight into individual behaviors associated with mental health. Objective: Researchers at a Veterans Affairs Medical Center and Cogito Corporation sought to explore the feasibility and acceptability of an mHealth app, the Cogito Companion. Methods: A mixed methodological approach was used to investigate the feasibility and acceptability of the app. Veterans completed clinical interviews and self-report measures, at baseline and at a 3-month follow-up. During the data collection period, participants were provided access to the Cogito Companion smartphone app. The mobile app gathered passive and active behavioral health indicators. Data collected (eg, vocal features and digital phenotyping of everyday social signals) are analyzed in real time. Passive data collected include location via global positioning system (GPS), phone calls, and SMS text message metadata. Four primary model scores were identified as being predictive of the presence or absence of depression or posttraumatic stress disorder (PTSD). Veterans Affairs clinicians monitored a provider dashboard and conducted clinical outreach when indicated. Results: Findings suggest that use of the Cogito Companion app was feasible and acceptable. Veterans (n=83) were interested in and used the app; however, active use declined over time. Nonetheless, data were passively collected, and outreach occurred throughout the study period. On the Client Satisfaction Questionnaire–8, 79% (53/67) of the sample reported scores demonstrating acceptability of the app (mean 26.2, SD 4.3). Many veterans reported liking specific app features (day-to-day monitoring) and the sense of connection they felt with the study clinicians who conducted outreach. Only a small percentage (4/67, 6%) reported concerns regarding personal privacy. Conclusions: Feasibility and acceptability of the Cogito Corporation platform to monitor mental health symptoms, behaviors, and facilitate follow-up in a sample of veterans were supported. Clinically, platforms such as the Cogito Companion system may serve as useful methods to promote monitoring, thereby facilitating early identification of risk and mitigating negative psychiatric outcomes, such as suicide. %M 32779572 %R 10.2196/15506 %U https://www.jmir.org/2020/8/e15506 %U https://doi.org/10.2196/15506 %U http://www.ncbi.nlm.nih.gov/pubmed/32779572 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 8 %P e18453 %T A Combined Digital and Biomarker Diagnostic Aid for Mood Disorders (the Delta Trial): Protocol for an Observational Study %A Olmert,Tony %A Cooper,Jason D %A Han,Sung Yeon Sarah %A Barton-Owen,Giles %A Farrag,Lynn %A Bell,Emily %A Friend,Lauren V %A Ozcan,Sureyya %A Rustogi,Nitin %A Preece,Rhian L %A Eljasz,Pawel %A Tomasik,Jakub %A Cowell,Daniel %A Bahn,Sabine %+ Department of Chemical Engineering and Biotechnology, University of Cambridge, Philippa Fawcett Dr, Cambridge, CB3 0AS, United Kingdom, 44 1223 334151, sb209@cam.ac.uk %K proteomics %K early diagnosis %K mood disorders %K bipolar disorder %K major depressive disorders %D 2020 %7 10.8.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mood disorders affect hundreds of millions of people worldwide, imposing a substantial medical and economic burden. Existing diagnostic methods for mood disorders often result in a delay until accurate diagnosis, exacerbating the challenges of these disorders. Advances in digital tools for psychiatry and understanding the biological basis of mood disorders offer the potential for novel diagnostic methods that facilitate early and accurate diagnosis of patients. Objective: The Delta Trial was launched to develop an algorithm-based diagnostic aid combining symptom data and proteomic biomarkers to reduce the misdiagnosis of bipolar disorder (BD) as a major depressive disorder (MDD) and achieve more accurate and earlier MDD diagnosis. Methods: Participants for this ethically approved trial were recruited through the internet, mainly through Facebook advertising. Participants were then screened for eligibility, consented to participate, and completed an adaptive digital questionnaire that was designed and created for the trial on a purpose-built digital platform. A subset of these participants was selected to provide dried blood spot (DBS) samples and undertake a World Health Organization World Mental Health Composite International Diagnostic Interview (CIDI). Inclusion and exclusion criteria were chosen to maximize the safety of a trial population that was both relevant to the trial objectives and generalizable. To provide statistical power and validation sets for the primary and secondary objectives, 840 participants were required to complete the digital questionnaire, submit DBS samples, and undertake a CIDI. Results: The Delta Trial is now complete. More than 3200 participants completed the digital questionnaire, 924 of whom also submitted DBS samples and a CIDI, whereas a total of 1780 participants completed a 6-month follow-up questionnaire and 1542 completed a 12-month follow-up questionnaire. The analysis of the trial data is now underway. Conclusions: If a diagnostic aid is able to improve the diagnosis of BD and MDD, it may enable earlier treatment for patients with mood disorders. International Registered Report Identifier (IRRID): DERR1-10.2196/18453 %M 32773373 %R 10.2196/18453 %U https://www.researchprotocols.org/2020/8/e18453 %U https://doi.org/10.2196/18453 %U http://www.ncbi.nlm.nih.gov/pubmed/32773373 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e21283 %T Effectiveness of a Smartphone App With a Wearable Activity Tracker in Preventing the Recurrence of Mood Disorders: Prospective Case-Control Study %A Cho,Chul-Hyun %A Lee,Taek %A Lee,Jung-Been %A Seo,Ju Yeon %A Jee,Hee-Jung %A Son,Serhim %A An,Hyonggin %A Kim,Leen %A Lee,Heon-Jeong %+ Department of Psychiatry, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, Republic of Korea, 82 29206721, leehjeong@korea.ac.kr %K circadian rhythm %K digital therapeutics %K mood disorder %K recurrence prevention %K smartphone app %K wearable activity tracker %D 2020 %7 5.8.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Smartphones and wearable devices can be used to obtain diverse daily log data related to circadian rhythms. For patients with mood disorders, giving feedback via a smartphone app with appropriate behavioral correction guides could play an important therapeutic role in the real world. Objective: We aimed to evaluate the effectiveness of a smartphone app named Circadian Rhythm for Mood (CRM), which was developed to prevent mood episodes based on a machine learning algorithm that uses passive digital phenotype data of circadian rhythm behaviors obtained with a wearable activity tracker. The feedback intervention for the CRM app consisted of a trend report of mood prediction, H-score feedback with behavioral guidance, and an alert system triggered when trending toward a high-risk state. Methods: In total, 73 patients with a major mood disorder were recruited and allocated in a nonrandomized fashion into 2 groups: the CRM group (14 patients) and the non-CRM group (59 patients). After the data qualification process, 10 subjects in the CRM group and 33 subjects in the non-CRM group were evaluated over 12 months. Both groups were treated in a similar manner. Patients took their usual medications, wore a wrist-worn activity tracker, and checked their eMoodChart daily. Patients in the CRM group were provided with daily feedback on their mood prediction and health scores based on the algorithm. For the CRM group, warning alerts were given when irregular life patterns were observed. However, these alerts were not given to patients in the non-CRM group. Every 3 months, mood episodes that had occurred in the previous 3 months were assessed based on the completed daily eMoodChart for both groups. The clinical course and prognosis, including mood episodes, were evaluated via face-to-face interviews based on the completed daily eMoodChart. For a 1-year prospective period, the number and duration of mood episodes were compared between the CRM and non-CRM groups using a generalized linear model. Results: The CRM group had 96.7% fewer total depressive episodes (n/year; exp β=0.033, P=.03), 99.5% shorter depressive episodes (total; exp β=0.005, P<.001), 96.1% shorter manic or hypomanic episodes (exp β=0.039, P<.001), 97.4% fewer total mood episodes (exp β=0.026, P=.008), and 98.9% shorter mood episodes (total; exp β=0.011, P<.001) than the non-CRM group. Positive changes in health behaviors due to the alerts and in wearable device adherence rates were observed in the CRM group. Conclusions: The CRM app with a wearable activity tracker was found to be effective in preventing and reducing the recurrence of mood disorders, improving prognosis, and promoting better health behaviors. Patients appeared to develop a regular habit of using the CRM app. Trial Registration: ClinicalTrials.gov NCT03088657; https://clinicaltrials.gov/ct2/show/NCT03088657 %M 32755884 %R 10.2196/21283 %U http://mental.jmir.org/2020/8/e21283/ %U https://doi.org/10.2196/21283 %U http://www.ncbi.nlm.nih.gov/pubmed/32755884 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e18392 %T The Association Between App-Administered Depression Assessments and Suicidal Ideation in User Comments: Retrospective Observational Study %A DeForte,Shelly %A Huang,Yungui %A Bourgeois,Tran %A Hussain,Syed-Amad %A Lin,Simon %+ Abigail Wexner Research Institute, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43215, United States, 1 202 318 1627, simon.lin@nationwidechildrens.org %K mobile health %K mHealth %K depression %K qualitative research %K mental health %D 2020 %7 4.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Many people use apps to help understand and manage their depression symptoms. App-administered questionnaires for the symptoms of depression, such as the Patient Health Questionnaire-9, are easy to score and implement in an app, but may not be accompanied by essential resources and access needed to provide proper support and avoid potential harm. Objective: Our primary goal was to evaluate the differences in risks and helpfulness associated with using an app to self-diagnose depression, comparing assessment-only apps with multifeatured apps. We also investigated whether, what, and how additional app features may mitigate potential risks. Methods: In this retrospective observational study, we identified apps in the Google Play store that provided a depression assessment as a feature and had at least five user comments. We separated apps into two categories based on those having only a depression assessment versus those that offered additional supportive features. We conducted theoretical thematic analyses over the user reviews, with thematic coding indicating the helpfulness of the app, the presence of suicidal ideation, and how and why the apps were used. We compared the results across the two categories of apps and analyzed the differences using chi-square statistical tests. Results: We evaluated 6 apps; 3 provided only a depression assessment (assessment only), and 3 provided features in addition to self-assessment (multifeatured). User comments for assessment-only apps indicated significantly more suicidal ideation or self-harm (n=31, 9.4%) compared to comments for multifeatured apps (n=48, 2.3%; X21=43.88, P<.001). Users of multifeatured apps were over three times more likely than assessment-only app users to comment in favor of the app’s helpfulness, likely due to features like mood tracking, journaling, and informational resources (n=56, 17% vs n=1223, 59% respectively; X21=200.36, P<.001). The number of users under the age of 18 years was significantly higher among assessment-only app users (n=40, 12%) than multifeatured app users (n=9, 0.04%; X21=189.09, P<.001). Conclusions: Apps that diagnose depression by self-assessment without context or other supportive features are more likely to be used by those under 18 years of age and more likely to be associated with increased user distress and potential harm. Depression self-assessments in apps should be implemented with caution and accompanied by evidence-based capabilities that establish proper context, increase self-empowerment, and encourage users to seek clinical diagnostics and outside help. %M 32663158 %R 10.2196/18392 %U https://mhealth.jmir.org/2020/8/e18392 %U https://doi.org/10.2196/18392 %U http://www.ncbi.nlm.nih.gov/pubmed/32663158 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e16180 %T Characteristics of Neuropsychiatric Mobile Health Trials: Cross-Sectional Analysis of Studies Registered on ClinicalTrials.gov %A Minen,Mia Tova %A Reichel,Julia Frederica %A Pemmireddy,Pallavi %A Loder,Elizabeth %A Torous,John %+ NYU Langone Health, 222 E 41st Street,, New York, NY, 10017, United States, 1 2122637744, minenmd@gmail.com %K smartphones %K mobile phones %K apps %K mental health %K regulation %K stroke %K migraine %K major depressive disorder %K Alzheimer disease %K anxiety disorders %K alcohol use disorders %K opioid use disorders %K epilepsy %K schizophrenia %D 2020 %7 4.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The development of mobile health (mHealth) technologies is progressing at a faster pace than that of the science to evaluate their validity and efficacy. Under the International Committee of Journal Medical Editors (ICMJE) guidelines, clinical trials that prospectively assign people to interventions should be registered with a database before the initiation of the study. Objective: The aim of this study was to better understand the smartphone mHealth trials for high-burden neuropsychiatric conditions registered on ClinicalTrials.gov through November 2018, including the number, types, and characteristics of the studies being conducted; the frequency and timing of any outcome changes; and the reporting of results. Methods: We conducted a systematic search of ClinicalTrials.gov for the top 10 most disabling neuropsychiatric conditions and prespecified terms related to mHealth. According to the 2016 World Health Organization Global Burden of Disease Study, the top 10 most disabling neuropsychiatric conditions are (1) stroke, (2) migraine, (3) major depressive disorder, (4) Alzheimer disease and other dementias, (5) anxiety disorders, (6) alcohol use disorders, (7) opioid use disorders, (8) epilepsy, (9) schizophrenia, and (10) other mental and substance use disorders. There were no date, location, or status restrictions. Results: Our search identified 135 studies. A total of 28.9% (39/135) of studies evaluated interventions for major depressive disorder, 14.1% (19/135) of studies evaluated interventions for alcohol use disorders, 12.6% (17/135) of studies evaluated interventions for stroke, 11.1% (15/135) of studies evaluated interventions for schizophrenia, 8.1% (11/135) of studies evaluated interventions for anxiety disorders, 8.1% (11/135) of studies evaluated interventions for other mental and substance use disorders, 7.4% (10/135) of studies evaluated interventions for opioid use disorders, 3.7% (5/135) of studies evaluated interventions for Alzheimer disease or other dementias, 3.0% (4/135) of studies evaluated interventions for epilepsy, and 3.0% (4/135) of studies evaluated interventions for migraine. The studies were first registered in 2008; more than half of the studies were registered from 2016 to 2018. A total of 18.5% (25/135) of trials had results reported in some publicly accessible location. Across all the studies, the mean estimated enrollment (reported by the study) was 1078, although the median was only 100. In addition, across all the studies, the actual reported enrollment was lower, with a mean of 249 and a median of 80. Only about a quarter of the studies (35/135, 25.9%) were funded by the National Institutes of Health. Conclusions: Despite the increasing use of health-based technologies, this analysis of ClinicalTrials.gov suggests that only a few apps for high-burden neuropsychiatric conditions are being clinically evaluated in trials. %M 32749230 %R 10.2196/16180 %U https://mhealth.jmir.org/2020/8/e16180 %U https://doi.org/10.2196/16180 %U http://www.ncbi.nlm.nih.gov/pubmed/32749230 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 8 %P e18578 %T Immediate and Long-Term Effects of an 8-Week Digital Mental Health Intervention on Adults With Poorly Managed Type 2 Diabetes: Protocol for a Randomized Controlled Trial %A Boucher,Eliane %A Moskowitz,Judith T %A Kackloudis,Gina M %A Stafford,Julia L %A Kwok,Ian %A Parks,Acacia C %+ Happify Health, 51 East 12th Street, 5th Floor, New York, NY, 10003, United States, 1 4322585233, eliane@happify.com %K online intervention %K diabetes mellitus %K type 2 %K mental health %K randomized clinical trial %K positive psychology %K HbA1c %D 2020 %7 4.8.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Diabetes is a leading cause of years of life lost and accounts for approximately one-fourth of health care dollars spent in the United States. Many of these costs are related to poor medication adherence and lack of self-care behaviors and are thus preventable. Depression, which is more prevalent among people with diabetes than in the general population, predicts poorer management of one’s diabetes, whereas positive affect predicts engaging in more positive health behaviors. Consequently, interventions that improve depression and positive affect may also improve diabetes-related outcomes among people with diabetes. Although preliminary research on the impact of such interventions among people with diabetes is promising, these studies focused primarily on in-person interventions, have had small samples, and lack long-term follow-up. Objective: This study aims to examine the short- and long-term effects of a digital therapeutic platform focused on mental health among adults with poorly managed type 2 diabetes and elevated levels of depression. Methods: This is a randomized controlled trial in which adults with a type 2 diabetes diagnosis, elevated hemoglobin A1c (HbA1c) levels (≧7), and moderate to severe depressive symptoms will be randomly assigned to a positive emotion regulation skills intervention group or a sham digital intervention with only psychoeducational content. The study will take place over 14 months, including the 8-week intervention (or control) delivered via a digital therapeutic platform (Happify Health) and follow-up assessments at 3, 6, and 12 months postintervention. Throughout the intervention and for 1 week at each postintervention follow-up, participants will complete daily assessments of diabetes-related distress, diabetes regimen adherence, and mood. Our primary outcome, HbA1c, will be self-reported every 3 months throughout the study. Secondary and exploratory outcomes will be assessed at baseline; at 8 weeks; and at 3, 6, and 12 months postintervention. Results: Recruitment is expected to begin in June 2020. Participants will begin the study as they are recruited and will finish in waves. The final wave of data collection from the 8-week intervention is expected for winter 2020, with the completion of the 12-month follow-up in winter 2021. Conclusions: Although previous research suggests that in-person psychological interventions have promising effects on both psychological and physical outcomes among adults with diabetes, digital interventions can be advantageous because they are easily scalable and reduce many barriers that prevent people from seeking treatment. This trial will provide important information about the effects of a digital mental health intervention among adults with type 2 diabetes, assessing both short- and long-term effects of this intervention on HbA1c, depressive symptoms, and other diabetes-specific outcomes. If successful, this may introduce a scalable intervention that would help reduce some of the preventable costs associated with diabetes. Trial Registration: ClinicalTrials.gov NCT04068805; https://clinicaltrials.gov/ct2/show/NCT04068805. International Registered Report Identifier (IRRID): PRR1-10.2196/18578 %M 32749998 %R 10.2196/18578 %U https://www.researchprotocols.org/2020/8/e18578 %U https://doi.org/10.2196/18578 %U http://www.ncbi.nlm.nih.gov/pubmed/32749998 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e15418 %T Effectiveness of a Mobile App Intervention for Anxiety and Depression Symptoms in University Students: Randomized Controlled Trial %A McCloud,Tayla %A Jones,Rebecca %A Lewis,Gemma %A Bell,Vaughan %A Tsakanikos,Elias %+ Division of Psychiatry, University College London, 149 Tottenham Court Road, London, W1T 7NF, United Kingdom, 44 2031087765, t.mccloud@ucl.ac.uk %K anxiety %K depression %K cognitive behavioral therapy %K eHealth %K online intervention %K mobile apps %K randomized controlled trial %K mobile phone %D 2020 %7 31.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depression and anxiety symptoms are common among university students, but many do not receive treatment. This is often because of lack of availability, reluctance to seek help, and not meeting the diagnostic criteria required to access services. Internet-based interventions, including smartphone apps, can overcome these issues. However, a large number of apps are available, each with little evidence of their effectiveness. Objective: This study aims to evaluate for the first time the effectiveness of a self-guided mobile app, Feel Stress Free, for the treatment of depression and anxiety symptoms in students. Methods: A web-based randomized controlled trial compared a cognitive behavioral therapy (CBT)–based mobile app Feel Stress Free with a wait-list control. University students self-identified as experiencing symptoms of anxiety or depression and were randomized to 6 weeks of intervention (n=84) or control (n=84), unblinded. The app is self-guided and incorporates behavioral relaxation activities, mood tracking and thought challenging, and minigames. Participants completed the Hospital Anxiety and Depression Scale online at baseline and every fortnight. Results: At week 6, the primary end point, there was evidence that the Feel Stress Free app reduced depression symptoms (mean difference −1.56; 95% CI −2.67 to −0.44; P=.006) but only very weak evidence that it reduced anxiety symptoms (mean difference −1.36; 95% CI −2.93 to 0.21; P=.09). At week 4, there was evidence to support the effectiveness of the intervention for anxiety symptoms (mean difference −1.94; 95% CI −3.11 to −0.77; P=.001) and, though weaker, depression symptoms (mean difference −1.08; 95% CI −2.12 to −0.04; P=.04). At week 6, 83% (34/41) of participants indicated that they were using the app weekly or more frequently. Conclusions: The Feel Stress Free app is a promising mobile intervention for treating symptoms of anxiety and depression in students and overcomes many of the barriers to traditional CBT. Further research is needed to establish its effectiveness at and beyond 6 weeks. Trial Registration: ClinicalTrials.gov NCT03032952; https://clinicaltrials.gov/ct2/show/NCT03032952 %M 32735221 %R 10.2196/15418 %U http://mhealth.jmir.org/2020/7/e15418/ %U https://doi.org/10.2196/15418 %U http://www.ncbi.nlm.nih.gov/pubmed/32735221 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16961 %T Perceived Effectiveness and Motivations for the Use of Web-Based Mental Health Programs: Qualitative Study %A Eccles,Heidi %A Nannarone,Molly %A Lashewicz,Bonnie %A Attridge,Mark %A Marchand,Alain %A Aiken,Alice %A Ho,Kendall %A Wang,Jianli %+ Work & Mental Health Research Unit, The Institute of Mental Health Research, University of Ottawa, Room 5404, 1145 Carling Ave, Ottawa, ON, K1Z7K4, Canada, 1 6137226521, jianli.wang@theroyal.ca %K prevention %K mental health %K depression %K cognitive behavioral therapy %K motivators %K perceived effectiveness %K internet-based intervention %K interview %D 2020 %7 31.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The prevalence of depression is high and has been stable despite increased treatment, research, and dissemination. People encounter barriers to seeking traditional mental health services, which could be mitigated by using web-based prevention methods. Objective: This study aims to understand what people at high risk for depression perceive as effective aspects of web-based mental health programs and what motivates people at high risk for depression to use web-based mental health programs. Methods: We conducted an inductive content analysis using telephone interview data from 77 participants at high risk for depression who were recruited from 2 randomized controlled trials (RCTs). Participants from the first RCT were working men who had been randomly assigned to 1 of the following 3 groups: control group, who had access to general depression information from a website called BroMatters; intervention group 1, who had access to the BroMatters website along with the associated BroHealth web-based mental health program; and intervention group 2, who had access to the BroMatters website, the BroHealth web-based mental health program, and telephone sessions with a life coach. Participants from the second RCT were men and women who had been assigned to the intervention group, who received access to the HardHat web-based mental health program, or the control group, who only received access to the HardHat web-based mental health program following completion of the RCT. Participants for this inductive content analysis study were recruited from the intervention groups in both RCTs. Two groups of participants (n=41 and n=20) were recruited from the BroHealth RCT, and a third group comprised 16 participants that were recruited from the HardHat RCT. Results: We generated four categories regarding the perceived effectiveness of web-based programs and five categories related to what motivates the use of web-based programs. Participants identified awareness, program medium and functionality, program content, and coaches as categories related to the effectiveness of the programs. Categories of motivators to use web-based programs included providing reminders or incentives, promotion of the programs, providing appropriate medium and functionality, appropriate content, and perceived need. The final category related to motivators reflects perceptions of participants who were either unsure about what motivates them or believed that there is no way to motivate use. Conclusions: Conflicting evidence was obtained regarding the perceived effectiveness of aspects of the content and functionality of web-based programs. In general, web-based mental health programs were perceived to help increase mental health awareness, especially when it includes live access to a coach. However, the results also revealed that it is difficult to motivate people to begin using web-based mental health programs. Strategies that may motivate the use of such programs include perceived personal need, effective promotion, providing incentives and reminders, and improving functionality. %M 32735216 %R 10.2196/16961 %U http://www.jmir.org/2020/7/e16961/ %U https://doi.org/10.2196/16961 %U http://www.ncbi.nlm.nih.gov/pubmed/32735216 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17481 %T A Mobile Health Approach for Improving Outcomes in Suicide Prevention (SafePlan) %A O'Grady,Conor %A Melia,Ruth %A Bogue,John %A O'Sullivan,Mary %A Young,Karen %A Duggan,Jim %+ School of Computer Science, National University of Ireland Galway, University Road, Galway, H91 TK33, Ireland, 353 91493336, james.duggan@nuigalway.ie %K mobile apps %K suicide %K mHealth %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is a prominent cause of death worldwide, particularly among young people. It was the second leading cause of death among those aged 15-29 years globally in 2016. Treatment for patients with suicidal thoughts or behaviors often includes face-to-face psychological therapy with a mental health professional. These forms of interventions may involve maintaining and updating paper-based reports or worksheets in between sessions. Mobile technology can offer a way to support the implementation of evidence-based psychological techniques and the acquisition of protective coping skills. Objective: This study aims to develop a mobile app to facilitate service users’ access to mental health support and safety planning. This process involved eliciting expert input from clinicians who are actively engaged in the provision of mental health care. Methods: A survey was distributed to targeted health care professionals to determine what features should be prioritized in a new mobile app relating to suicide prevention. On the basis of the survey results, a clinical design group, comprising 6 members with experience in fields such as mobile health (mHealth), clinical psychology, and suicide prevention, was established. This group was supplemented with further input from additional clinicians who provided feedback over three focus group sessions. The sessions were centered on refining existing app components and evaluating new feature requests. This process was iterated through regular feedback until agreement was reached on the overall app design and functionality. Results: A fully functional mobile app, known as the SafePlan app, was developed and tested with the input of clinicians through an iterative design process. The app’s core function is to provide an interactive safety plan to support users with suicidal thoughts or behaviors as an adjunct to face-to-face therapy. A diary component that facilitates the generalization of skills learned through dialectical behavior therapy was also implemented. Usability testing was carried out on the final prototype by students from a local secondary school, who are representative of the target user population in both age and technology experience. The students were asked to complete a system usability survey (SUS) at the end of this session. The mean overall SUS rating was 71.85 (SD 1.38). Conclusions: The participatory process involving key stakeholders (clinicians, psychologists, and information technology specialists) has resulted in the creation of an mHealth intervention technology that has the potential to increase accessibility to this type of mental health service for the target population. The app has gone through the initial testing phase, and the relevant recommendations have been implemented, and it is now ready for trialing with both clinicians and their patients. %M 32729845 %R 10.2196/17481 %U http://www.jmir.org/2020/7/e17481/ %U https://doi.org/10.2196/17481 %U http://www.ncbi.nlm.nih.gov/pubmed/32729845 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 7 %P e17784 %T Identifying and Predicting Intentional Self-Harm in Electronic Health Record Clinical Notes: Deep Learning Approach %A Obeid,Jihad S %A Dahne,Jennifer %A Christensen,Sean %A Howard,Samuel %A Crawford,Tami %A Frey,Lewis J %A Stecker,Tracy %A Bunnell,Brian E %+ Medical University of South Carolina, 135 Cannon St. Suite 405 MSC200, Charleston, SC, 29425, United States, 1 8437920272, jobeid@musc.edu %K machine learning %K deep learning %K suicide %K suicide, attempted %K electronic health records %K natural language processing %D 2020 %7 30.7.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Suicide is an important public health concern in the United States and around the world. There has been significant work examining machine learning approaches to identify and predict intentional self-harm and suicide using existing data sets. With recent advances in computing, deep learning applications in health care are gaining momentum. Objective: This study aimed to leverage the information in clinical notes using deep neural networks (DNNs) to (1) improve the identification of patients treated for intentional self-harm and (2) predict future self-harm events. Methods: We extracted clinical text notes from electronic health records (EHRs) of 835 patients with International Classification of Diseases (ICD) codes for intentional self-harm and 1670 matched controls who never had any intentional self-harm ICD codes. The data were divided into training and holdout test sets. We tested a number of algorithms on clinical notes associated with the intentional self-harm codes using the training set, including several traditional bag-of-words–based models and 2 DNN models: a convolutional neural network (CNN) and a long short-term memory model. We also evaluated the predictive performance of the DNNs on a subset of patients who had clinical notes 1 to 6 months before the first intentional self-harm event. Finally, we evaluated the impact of a pretrained model using Word2vec (W2V) on performance. Results: The area under the receiver operating characteristic curve (AUC) for the CNN on the phenotyping task, that is, the detection of intentional self-harm in clinical notes concurrent with the events was 0.999, with an F1 score of 0.985. In the predictive task, the CNN achieved the highest performance with an AUC of 0.882 and an F1 score of 0.769. Although pretraining with W2V shortened the DNN training time, it did not improve performance. Conclusions: The strong performance on the first task, namely, phenotyping based on clinical notes, suggests that such models could be used effectively for surveillance of intentional self-harm in clinical text in an EHR. The modest performance on the predictive task notwithstanding, the results using DNN models on clinical text alone are competitive with other reports in the literature using risk factors from structured EHR data. %M 32729840 %R 10.2196/17784 %U https://medinform.jmir.org/2020/7/e17784 %U https://doi.org/10.2196/17784 %U http://www.ncbi.nlm.nih.gov/pubmed/32729840 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 7 %P e17958 %T Depression Risk Prediction for Chinese Microblogs via Deep-Learning Methods: Content Analysis %A Wang,Xiaofeng %A Chen,Shuai %A Li,Tao %A Li,Wanting %A Zhou,Yejie %A Zheng,Jie %A Chen,Qingcai %A Yan,Jun %A Tang,Buzhou %+ Department of Computer Science, Harbin Institute of Technology Shenzhen Graduate School, L1407, Shenzhen, China, 86 13725525983, tangbuzhou@gmail.com %K depression risk prediction %K deep learning %K pretrained language model %K Chinese microblogs %D 2020 %7 29.7.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Depression is a serious personal and public mental health problem. Self-reporting is the main method used to diagnose depression and to determine the severity of depression. However, it is not easy to discover patients with depression owing to feelings of shame in disclosing or discussing their mental health conditions with others. Moreover, self-reporting is time-consuming, and usually leads to missing a certain number of cases. Therefore, automatic discovery of patients with depression from other sources such as social media has been attracting increasing attention. Social media, as one of the most important daily communication systems, connects large quantities of people, including individuals with depression, and provides a channel to discover patients with depression. In this study, we investigated deep-learning methods for depression risk prediction using data from Chinese microblogs, which have potential to discover more patients with depression and to trace their mental health conditions. Objective: The aim of this study was to explore the potential of state-of-the-art deep-learning methods on depression risk prediction from Chinese microblogs. Methods: Deep-learning methods with pretrained language representation models, including bidirectional encoder representations from transformers (BERT), robustly optimized BERT pretraining approach (RoBERTa), and generalized autoregressive pretraining for language understanding (XLNET), were investigated for depression risk prediction, and were compared with previous methods on a manually annotated benchmark dataset. Depression risk was assessed at four levels from 0 to 3, where 0, 1, 2, and 3 denote no inclination, and mild, moderate, and severe depression risk, respectively. The dataset was collected from the Chinese microblog Weibo. We also compared different deep-learning methods with pretrained language representation models in two settings: (1) publicly released pretrained language representation models, and (2) language representation models further pretrained on a large-scale unlabeled dataset collected from Weibo. Precision, recall, and F1 scores were used as performance evaluation measures. Results: Among the three deep-learning methods, BERT achieved the best performance with a microaveraged F1 score of 0.856. RoBERTa achieved the best performance with a macroaveraged F1 score of 0.424 on depression risk at levels 1, 2, and 3, which represents a new benchmark result on the dataset. The further pretrained language representation models demonstrated improvement over publicly released prediction models. Conclusions: We applied deep-learning methods with pretrained language representation models to automatically predict depression risk using data from Chinese microblogs. The experimental results showed that the deep-learning methods performed better than previous methods, and have greater potential to discover patients with depression and to trace their mental health conditions. %M 32723719 %R 10.2196/17958 %U http://medinform.jmir.org/2020/7/e17958/ %U https://doi.org/10.2196/17958 %U http://www.ncbi.nlm.nih.gov/pubmed/32723719 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e19008 %T Assessing Digital Risk in Psychiatric Patients: Mixed Methods Study of Psychiatry Trainees’ Experiences, Views, and Understanding %A Aref-Adib,Golnar %A Landy,Gabriella %A Eskinazi,Michelle %A Sommerlad,Andrew %A Morant,Nicola %A Johnson,Sonia %A Graham,Richard %A Osborn,David %A Pitman,Alexandra %+ Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, United Kingdom, 44 7968035509, a.pitman@ucl.ac.uk %K risk assessment %K internet %K suicide %K self-injurious behavior %K mental health %K psychiatrists %K mixed methods %K mobile phone %D 2020 %7 29.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The use of digital technology can help people access information and provide support for their mental health problems, but it can also expose them to risk, such as bullying or prosuicide websites. It may be important to consider internet-related risk behavior (digital risk) within a generic psychiatric risk assessment, but no studies have explored the practice or acceptability of this among psychiatrists. Objective: This study aimed to explore psychiatry trainees’ experiences, views, and understanding of digital risk in psychiatry. We predicted that clinician awareness would be highest among trainees who work in child and adolescent mental health services. Methods: We conducted a cross-sectional survey of psychiatry trainees attending a UK regional trainees’ conference to investigate how they routinely assess patients’ internet use and related risk of harm and their experience and confidence in assessing these risks. We conducted focus groups to further explore trainees’ understandings and experiences of digital risk assessment. Descriptive statistics and chi-squared tests were used to present the quantitative data. A thematic analysis was used to identify the key themes in the qualitative data set. Results: The cross-sectional survey was completed by 113 out of 312 psychiatry trainees (response rate 36.2%), from a range of subspecialties and experience levels. Half of the trainees (57/113, 50.4%) reported treating patients exposed to digital risk, particularly trainees subspecializing in child and adolescent psychiatry (17/22, 77% vs 40/91, 44%;P=.02). However, 67.3% (76/113) reported not feeling competent to assess digital risk. Child and adolescent psychiatrists were more likely than others to ask patients routinely about specific digital risk domains, including reckless web-based behavior (18/20, 90% vs 54/82, 66%; P=.03), prosuicide websites (20/21, 95% vs 57/81, 70%; P=.01), and online sexual behavior (17/21, 81% vs 44/81, 54%; P=.02). Although 84.1% (95/113) of the participants reported using a proforma to record general risk assessment, only 5% (5/95) of these participants prompted an assessment of internet use. Only 9.7% (11/113) of the trainees had received digital risk training, and 73.5% (83/113) reported that they would value this. Our thematic analysis of transcripts from 3 focus groups (comprising 11 trainees) identified 2 main themes: barriers to assessment and management of digital risk, and the double-edged sword of web use. Barriers reported included the novelty and complexity of the internet, a lack of confidence and guidance in addressing internet use directly, and ongoing tension between assessment and privacy. Conclusions: Although it is common for psychiatrists to encounter patients subject to digital risk, trainee psychiatrists lack competence and confidence in their assessment. Training in digital risk and the inclusion of prompts in standardized risk proformas would promote good clinical practice and prevent a potential blind spot in general risk assessment. %M 32726288 %R 10.2196/19008 %U http://mental.jmir.org/2020/7/e19008/ %U https://doi.org/10.2196/19008 %U http://www.ncbi.nlm.nih.gov/pubmed/32726288 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15683 %T Exploring the Relationship Between Internet Use and Mental Health Among Older Adults in England: Longitudinal Observational Study %A Lam,Sabrina Sze Man %A Jivraj,Stephen %A Scholes,Shaun %+ University College London, Gower Street, London, WC1E 6BT, United Kingdom, 44 20 7679 1721, stephen.jivraj@gmail.com %K internet %K socioeconomic factors %K mental health %K life satisfaction %K depression %K effect modifier %D 2020 %7 28.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: There is uncertainty about the impact of internet use on mental health in older adults. Moreover, there is very little known specifically about the impact of particular purposes of internet use. Objective: This study aims to investigate the longitudinal relationship between two distinct concepts of mental health with the frequency of internet use among older adults: the moderating role of socioeconomic position (SEP) and the association between specific purposes of internet use. Methods: Longitudinal fixed and random effects (27,507 person-years) models were fitted using waves 6-8 of the English Longitudinal Study of Ageing to examine the relationship between different aspects of internet use (frequency and purpose) and two mental health outcomes (depression and life satisfaction). The potential moderating effect of SEP on these associations was tested using interaction terms. Results: Infrequent internet use (monthly or less vs daily) was predictive of deteriorating life satisfaction (β=−0.512; P=.02) but not depression. Education and occupational class had a moderating effect on the association between frequency of internet use and mental health. The associations were stronger in the highest educational group in both depression (P=.09) and life satisfaction (P=.02), and in the highest occupational group in life satisfaction (P=.05) only. Using the internet for communication was associated with lower depression (β=−0.24; P=.002) and better life satisfaction (β=.97; P<.001), whereas those using the internet for information access had worse life satisfaction (β=−0.86; P<.001) compared with those who did not. Conclusions: Policies to improve mental health in older adults should encourage internet use, especially as a tool to aid communication. %M 32718913 %R 10.2196/15683 %U https://www.jmir.org/2020/7/e15683 %U https://doi.org/10.2196/15683 %U http://www.ncbi.nlm.nih.gov/pubmed/32718913 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15732 %T Scheduled Telephone Support for Internet Cognitive Behavioral Therapy for Depression in Patients at Risk for Dropout: Pragmatic Randomized Controlled Trial %A Pihlaja,Satu %A Lahti,Jari %A Lipsanen,Jari Olavi %A Ritola,Ville %A Gummerus,Eero-Matti %A Stenberg,Jan-Henry %A Joffe,Grigori %+ Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Hospital District of Helsinki and Uusimaa, PO Box 590, Helsinki, 00029 HUS, Finland, 358 40 513 6500, Grigori.joffe@hus.fi %K internet CBT %K depression %K scheduled telephone support %K adherence %K routine clinical practice %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficient in the treatment of depression. However, the optimal mode and intensity of therapist support remain to be identified. Scheduled telephone support (STS) may improve adherence and outcomes but, as it is time- and resource-consuming, should be reserved for patients for whom the usual support may be insufficient. Objective: This paper aims to reveal whether add-on STS for patients at risk of dropping out improves treatment adherence and symptoms in iCBT for depression. Methods: Among patients participating in an ongoing large observational routine clinical practice study of iCBT for depression delivered nationwide by Helsinki University Hospital (HUS-iCBT), those demonstrating a ≥14-day delay in initiation of treatment received invitations to this subsidiary STS study. A total of 100 consenting patients were randomly allocated to either HUS-iCBT as usual (control group, n=50) or HUS-iCBT plus add-on STS (intervention group, n=50). Proportions of those reaching midtreatment and treatment end point served as the primary outcome; secondary outcomes were change in Beck Depression Inventory (BDI)–measured depressive symptoms and time spent in treatment. Results: Add-on STS raised the proportion of patients reaching midtreatment compared with HUS-iCBT as usual (29/50, 58% vs 18/50, 36%; P=.045) and treatment end point (12/50, 24% vs 3/50, 6%; P=.02). Change in BDI score also favored add-on STS (3.63 points vs 1.1 points; P=.049), whereas duration of treatment did not differ. Conclusions: Add-on STS enhances adherence and symptom improvement of patients at risk of dropping out of iCBT for depression in routine clinical practice. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 55123131; http://www.isrctn.com/ISRCTN55123131. %M 32706658 %R 10.2196/15732 %U http://www.jmir.org/2020/7/e15732/ %U https://doi.org/10.2196/15732 %U http://www.ncbi.nlm.nih.gov/pubmed/32706658 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e17075 %T Design, Recruitment, and Baseline Characteristics of a Virtual 1-Year Mental Health Study on Behavioral Data and Health Outcomes: Observational Study %A Kumar,Shefali %A Tran,Jennifer L A %A Ramirez,Ernesto %A Lee,Wei-Nchih %A Foschini,Luca %A Juusola,Jessie L %+ Evidation Health, 167 2nd Ave, San Mateo, CA, 94401, United States, 1 650 279 8855, jjuusola@evidation.com %K mental health %K anxiety %K depression %K behavioral data %D 2020 %7 23.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression and anxiety greatly impact daily behaviors, such as sleep and activity levels. With the increasing use of activity tracking wearables among the general population, there has been a growing interest in how data collected from these devices can be used to further understand the severity and progression of mental health conditions. Objective: This virtual 1-year observational study was designed with the objective of creating a longitudinal data set combining self-reported health outcomes, health care utilization, and quality of life data with activity tracker and app-based behavioral data for individuals with depression and anxiety. We provide an overview of the study design, report on baseline health and behavioral characteristics of the study population, and provide initial insights into how behavioral characteristics differ between groups of individuals with varying levels of disease severity. Methods: Individuals who were existing members of an online health community (Achievement, Evidation Health Inc) and were 18 years or older who had self-reported a diagnosis of depression or anxiety were eligible to enroll in this virtual 1-year study. Participants agreed to connect wearable activity trackers that captured data related to physical activity and sleep behavior. Mental health outcomes such as the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder Questionnaire (GAD-7), mental health hospitalizations, and medication use were captured with surveys completed at baseline and months 3, 6, 9, and 12. In this analysis, we report on baseline characteristics of the sample, including mental health disease severity and health care utilization. Additionally, we explore the relationship between passively collected behavioral data and baseline mental health status and health care utilization. Results: Of the 1304 participants enrolled in the study, 1277 individuals completed the baseline survey and 1068 individuals had sufficient activity tracker data. Mean age was 33 (SD 9) years, and the majority of the study population was female (77.2%, 994/1288) and identified as Caucasian (88.3%, 1137/1288). At baseline, 94.8% (1211/1277) of study participants reported experiencing depression or anxiety symptoms in the last year. This baseline analysis found that some passively tracked behavioral traits are associated with more severe forms of anxiety or depression. Individuals with depressive symptoms were less active than those with minimal depressive symptoms. Severe forms of depression were also significantly associated with inconsistent sleep patterns and more disordered sleep. Conclusions: These initial findings suggest that longitudinal behavioral and health outcomes data may be useful for developing digital measures of health for mental health symptom severity and progression. %M 32706712 %R 10.2196/17075 %U http://mental.jmir.org/2020/7/e17075/ %U https://doi.org/10.2196/17075 %U http://www.ncbi.nlm.nih.gov/pubmed/32706712 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e17712 %T Internet-Based Cognitive-Behavioral Therapy for College Students With Anxiety, Depression, Social Anxiety, or Insomnia: Four Single-Group Longitudinal Studies of Archival Commercial Data and Replication of Employee User Study %A Attridge,Mark D %A Morfitt,Russell C %A Roseborough,David J %A Jones,Edward R %+ Attridge Consulting, Inc, 1129 Cedar Lake Rd S, Minneapolis, MN, United States, 1 612 889 2398, mark@attridgeconsulting.com %K anxiety %K cognitive behavioral %K college %K depression %K insomnia %K mental health %K social phobia %K stress %D 2020 %7 23.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: The growing behavioral health needs of college students have resulted in counseling centers reporting difficulties in meeting student demand. Objective: This study aims to test the real-world voluntary use by college students of 4 digital, self-directed mental health modules based on a cognitive behavioral therapy clinical model. The findings were also compared with those of employee users. Methods: Archival operational data from Learn to Live were extracted for student users at 4 colleges and universities in the Midwest region of the United States (N=951). The inclusion criteria were having clinical symptoms at established levels of moderate or higher severity and the use of 2 or more of the 8 lessons of a program within a 6-month period. Unique users in each program included 347 for depression; 325 for stress, anxiety, and worry; 203 for social anxiety; and 76 for insomnia. Paired t tests (two-tailed) compared the average level of change over time on a standardized measure of clinical symptoms appropriate to each program. Cohen d statistical effect sizes were calculated for each program. Potential moderator factors (age, gender, preliminary comprehensive assessment, number of lessons, duration, live coach support, and live teammate support) were tested together in repeated measures analysis of variance models with covariates in the full sample. Follow-up survey data (n=136) were also collected to explore user satisfaction and outcomes. Select data from another study of the same 4 programs by employee users meeting the same criteria (N=707) were examined for comparison. Results: The percentage of users who improved to a clinical status of no longer being at risk after program use was as follows: stress, anxiety, and worry program (149/325, 45.8%); insomnia program (33/76, 43.4%), depression program (124/347, 35.7%); and social anxiety program (45/203, 22.2%). Significant improvements (all P<.001) over time were found in the mean scores for the clinical measures for each program: stress, anxiety, and worry (t324=16.21; d=1.25); insomnia (t75=6.85; d=1.10); depression (t346=12.71; d=0.91); and social anxiety (t202=8.33; d=0.80). Tests of the moderating factors across programs indicated that greater improvement was strongly associated with the use of more lessons and it also differed by program, by gender (males demonstrated more improvement than females), and by the use of live support (particularly coaching). Analyses of survey data found high satisfaction, improved academic outcomes, and successful integration into the university counseling ecosystem. The operational profile and outcomes of the college students were also similar to those of employee users of the same programs from our other study of employee users. Thus, this study provides a replication. Conclusions: Self-directed internet-based cognitive behavioral therapy mental health modules are promising as a supplement to traditional in-person counseling services provided by college counseling centers. %M 32706662 %R 10.2196/17712 %U http://formative.jmir.org/2020/7/e17712/ %U https://doi.org/10.2196/17712 %U http://www.ncbi.nlm.nih.gov/pubmed/32706662 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17926 %T Psychometric Properties of the Korean Version of the PsyMate Scale Using a Smartphone App: Ecological Momentary Assessment Study %A Yang,Yong Sook %A Ryu,Gi Wook %A Delespaul,Philippe A E G %A Choi,Mona %+ Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2 2228 3341, monachoi@yuhs.ac %K psychometrics %K reliability %K validity %K PsyMate scale %K ecological momentary assessment %D 2020 %7 21.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Ecological momentary assessment (EMA) is a method for capturing the changes in the variables in daily life with increased accuracy and decreased recall bias. The PsyMate scale assesses momentary moods in daily life and can be used in various settings. Objective: The aim of this study was to develop a Korean version of the PsyMate (K-PsyMate) scale and evaluate its psychometric properties by using the EMA method in patients with moyamoya disease (MMD) in South Korea. Methods: Patients with MMD aged over 18 years were recruited from July 2018 to January 2019 at the inpatient and outpatient departments of a university hospital in South Korea. The K-PsyMate scale comprising 13 items was developed following a translation/back translation approach of the English version and loaded onto a mobile app. Participants were instructed to enter their moods 4 times a day for 7 consecutive days. Content validity index, factor analysis, and Pearson’s correlation were performed for validity analysis. For reliability, intraclass correlation coefficients between the first and last measurements were estimated by mean rating, absolute agreement, and a 2-way mixed-effects model. Usability was analyzed through a descriptive analysis, 2-tailed t test, and analysis of variance, and the results were confirmed by Mann-Whitney U test and the Kruskal-Wallis test, as the dependent variable was not normally distributed. Results: In total, 1929 assessments from 93 patients were analyzed. The mean age of the participants was 40.59 (SD 10.06) years, and 66 (71%) of the 93 participants were women. Content validity was excellent as content validity index was 0.99, and 2 factors, negative affect and positive affect, were derived by an exploratory factor analysis. The correlations between the subdomains of the K-PsyMate scale and Hospital Anxiety and Depression Scale were significant (P<.001). The agreement between the first and last measurements was poor to moderate according to the obtained intraclass correlation coefficient values. Usability was evaluated by 67 (72%) out of the 93 participants. The participants rated the accuracy of assessing their momentary moods on the app at 4.13 (SD 0.97), easiness in understanding questions, operating, and inputting answers at 4.12 (SD 0.88), and interruption by the survey alarms at 2.48 (SD 1.02) out of 5. Conclusions: The K-PsyMate scale has good validity but poor to moderate agreement, which reflects the characteristics of the EMA data collected in real and natural living environments without control. The findings of our study show that the K-PsyMate scale uploaded in a mobile app can be a valid and reliable tool for evaluating the momentary mood of patients with MMD because using a mobile app is convenient and patients are familiar with their own smartphones, which they use in their daily lives. %M 32706707 %R 10.2196/17926 %U http://mhealth.jmir.org/2020/7/e17926/ %U https://doi.org/10.2196/17926 %U http://www.ncbi.nlm.nih.gov/pubmed/32706707 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e16455 %T Effectiveness of a Voice-Based Mental Health Evaluation System for Mobile Devices: Prospective Study %A Higuchi,Masakazu %A Nakamura,Mitsuteru %A Shinohara,Shuji %A Omiya,Yasuhiro %A Takano,Takeshi %A Mitsuyoshi,Shunji %A Tokuno,Shinichi %+ Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, , Japan, 81 3 5841 3432, higuchi@bioeng.t.u-tokyo.ac.jp %K mental health %K monitoring system %K stress evaluation %K voice analysis %D 2020 %7 20.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: We developed a system for monitoring mental health using voice data from daily phone calls, termed Mind Monitoring System (MIMOSYS), by implementing a method for estimating mental health status from voice data. Objective: The objective of this study was to evaluate the potential of this system for detecting depressive states and monitoring stress-induced mental changes. Methods: We opened our system to the public in the form of a prospective study in which data were collected over 2 years from a large, unspecified sample of users. We used these data to analyze the relationships between the rate of continued use, the men-to-women ratio, and existing psychological tests for this system over the study duration. Moreover, we analyzed changes in mental data over time under stress from particular life events. Results: The system had a high rate of continued use. Voice indicators showed that women have more depressive tendencies than men, matching the rate of depression in Japan. The system’s voice indicators and the scores on classical psychological tests were correlated. We confirmed deteriorating mental health for users in areas affected by major earthquakes in Japan around the time of the earthquakes. Conclusions: The results suggest that although this system is insufficient for detecting depression, it may be effective for monitoring changes in mental health due to stress. The greatest feature of our system is mental health monitoring, which is most effectively accomplished by performing long-term time-series analysis of the acquired data considering the user’s life events. Such a system can improve the implementation of patient interventions by evaluating objective data along with life events. %M 32554367 %R 10.2196/16455 %U http://formative.jmir.org/2020/7/e16455/ %U https://doi.org/10.2196/16455 %U http://www.ncbi.nlm.nih.gov/pubmed/32554367 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e16338 %T Implementation Determinants and Outcomes of a Technology-Enabled Service Targeting Suicide Risk in High Schools: Mixed Methods Study %A Adrian,Molly %A Coifman,Jessica %A Pullmann,Michael D %A Blossom,Jennifer B %A Chandler,Casey %A Coppersmith,Glen %A Thompson,Paul %A Lyon,Aaron R %+ Department of Psychiatry and Behavioral Sciences, University of Washington, 6200 NE 74th St, Suite 110, Seattle, WA, 98115, United States, 1 206 221 1689, adriam@uw.edu %K technology-enabled services %K suicide prevention %K school-based mental health %K user-centered design %K mobile phone %D 2020 %7 20.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Technology-enabled services (TESs), which integrate human service and digital components, are popular strategies to increase the reach and impact of mental health interventions, but large-scale implementation of TESs has lagged behind their potential. Objective: This study applied a mixed qualitative and quantitative approach to gather input from multiple key user groups (students and educators) and to understand the factors that support successful implementation (implementation determinants) and implementation outcomes of a TES for universal screening, ongoing monitoring, and support for suicide risk management in the school setting. Methods: A total of 111 students in the 9th to 12th grade completed measures regarding implementation outcomes (acceptability, feasibility, and appropriateness) via an open-ended survey. A total of 9 school personnel (school-based mental health clinicians, nurses, and administrators) completed laboratory-based usability testing of a dashboard tracking the suicide risk of students, quantitative measures, and qualitative interviews to understand key implementation outcomes and determinants. School personnel were presented with a series of scenarios and common tasks focused on the basic features and functions of the dashboard. Directed content analysis based on the Consolidated Framework for Implementation Research was used to extract multilevel determinants (ie, the barriers or facilitators at the levels of the outer setting, inner setting, individuals, intervention, and implementation process) related to positive implementation outcomes of the TES. Results: Overarching themes related to implementation determinants and outcomes suggest that both student and school personnel users view TESs for suicide prevention as moderately feasible and acceptable based on the Acceptability of Intervention Measure and Feasibility of Intervention Measure and as needing improvements in usability based on the System Usability Scale. Qualitative results suggest that students and school personnel view passive data collection based on social media data as a relative advantage to the current system; however, the findings indicate that the TES and the school setting need to address issues of privacy, integration into existing workflows and communication patterns, and options for individualization for student-centered care. Conclusions: Innovative suicide prevention strategies that rely on passive data collection in the school context are a promising and appealing idea. Usability testing identified key issues for revision to facilitate widespread implementation. %M 32706691 %R 10.2196/16338 %U https://mental.jmir.org/2020/7/e16338 %U https://doi.org/10.2196/16338 %U http://www.ncbi.nlm.nih.gov/pubmed/32706691 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e14536 %T A Digital Intervention for Adolescent Depression (MoodHwb): Mixed Methods Feasibility Evaluation %A Bevan Jones,Rhys %A Thapar,Anita %A Rice,Frances %A Mars,Becky %A Agha,Sharifah Shameem %A Smith,Daniel %A Merry,Sally %A Stallard,Paul %A Thapar,Ajay K %A Jones,Ian %A Simpson,Sharon A %+ Division of Psychological Medicine and Clinical Neurosciences, Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Hadyn Ellis Building, Maindy Road, Cardiff, Wales, CF24 4HQ, United Kingdom, 44 02920688451, bevanjonesr1@cardiff.ac.uk %K adolescent %K depression %K internet %K education %K early medical intervention %K feasibility study %D 2020 %7 17.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Treatment and prevention guidelines highlight the key role of health information and evidence-based psychosocial interventions for adolescent depression. Digital health technologies and psychoeducational interventions have been recommended to help engage young people and to provide accurate health information, enhance self-management skills, and promote social support. However, few digital psychoeducational interventions for adolescent depression have been robustly developed and evaluated in line with research guidance. Objective: We aimed to evaluate the feasibility, acceptability, and potential impact of a theory-informed, co-designed digital intervention program, MoodHwb. Methods: We used a mixed methods (quantitative and qualitative) approach to evaluate the program and the assessment process. Adolescents with or at elevated risk of depression and their parents and carers were recruited from mental health services, school counselors and nurses, and participants from a previous study. They completed a range of questionnaires before and after the program (related to the feasibility and acceptability of the program and evaluation process, and changes in mood, knowledge, attitudes, and behavior), and their Web usage was monitored. A subsample was also interviewed. A focus group was conducted with professionals from health, education, social, and youth services and charities. Interview and focus group transcripts were analyzed using thematic analysis with NVivo 10 (QSR International Pty Ltd). Results: A total of 44 young people and 31 parents or carers were recruited, of which 36 (82%) young people and 21 (68%) parents or carers completed follow-up questionnaires. In all, 19 young people and 12 parents or carers were interviewed. Overall, 13 professionals from a range of disciplines participated in the focus group. The key themes from the interviews and groups related to the design features, sections and content, and integration and context of the program in the young person’s life. Overall, the participants found the intervention engaging, clear, user-friendly, and comprehensive, and stated that it could be integrated into existing services. Young people found the “Self help” section and “Mood monitor” particularly helpful. The findings provided initial support for the intervention program theory, for example, depression literacy improved after using the intervention (difference in mean literacy score: 1.7, 95% CI 0.8 to 2.6; P<.001 for young people; 1.3, 95% CI 0.4 to 2.2; P=.006 for parents and carers). Conclusions: Findings from this early stage evaluation suggest that MoodHwb and the assessment process were feasible and acceptable, and that the intervention has the potential to be helpful for young people, families and carers as an early intervention program in health, education, social, and youth services and charities. A randomized controlled trial is needed to further evaluate the digital program. %M 32384053 %R 10.2196/14536 %U https://mental.jmir.org/2020/7/e14536 %U https://doi.org/10.2196/14536 %U http://www.ncbi.nlm.nih.gov/pubmed/32384053 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e13650 %T What College Students Post About Depression on Facebook and the Support They Perceive: Content Analysis %A Cash,Scottye %A Schwab-Reese,Laura Marie %A Zipfel,Erin %A Wilt,Megan %A Moreno,Megan %+ College of Social Work, The Ohio State University, 1947 College Rd, Columbus, OH, 43210, United States, 1 614 292 3690, cash.33@osu.edu %K social media %K depression %K college students %K qualitative %D 2020 %7 17.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: College students frequently use social media sites to connect with friends. Increasingly, research suggests college students and other young adults seek mental health-related support on social media, which may present a unique venue for intervention. Objective: The purpose of this study was to examine college students’ perceptions about displaying feelings of depression on Facebook and, in turn, how their social media friends responded. Methods: A primarily quantitative online survey with open response questions was distributed to students at four US universities. Qualitative responses were analyzed using content analysis. Results: A total of 34 students provided qualitative responses for analysis, these students were 85.3% female, mean age 20.2 (SD=1.4) and 20.6% racial/ethnic minority. Students who reported posting about depression often expressed an emotion or feeling but did not use the word “depression” in the post. Approximately 20% posted language about a bad day, and 15% posted a song or music video. Only one person reported posting a statement that directly asked for help. When friends responded to the posts, students generally perceived the responses as supportive or motivating gestures. Nearly 15% of friends contacted the individual outside of Facebook. One individual received a negative response and no responses suggested that the individual seek help. Conclusions: This study found that college students who post about depression often do so without directly referencing depression and that friends were generally supportive. However, no participants reported their social network suggested they seek help, which may suggest increasing mental health literacy, for both support seekers and responders, would be an opportunity to improve online mental health-related support. %M 32706687 %R 10.2196/13650 %U https://formative.jmir.org/2020/7/e13650 %U https://doi.org/10.2196/13650 %U http://www.ncbi.nlm.nih.gov/pubmed/32706687 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16136 %T Adherence to Established Treatment Guidelines Among Unguided Digital Interventions for Depression: Quality Evaluation of 28 Web-Based Programs and Mobile Apps %A Bubolz,Stefan %A Mayer,Gwendolyn %A Gronewold,Nadine %A Hilbel,Thomas %A Schultz,Jobst-Hendrik %+ Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany, 49 6221 56 38176, nadine.gronewold@med.uni-heidelberg.de %K web-based interventions %K depression %K mHealth %K mental health %K telemedicine %K mobile phone %K eHealth %K electronic mental health %K online therapy %D 2020 %7 13.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based interventions for depression have been widely tested for usability and functioning. However, the few studies that have addressed the therapeutic quality of these interventions have mainly focused on general aspects without consideration of specific quality factors related to particular treatment components. Clinicians and scientists are calling for standardized assessment criteria for web-based interventions to enable effective and trustworthy patient care. Therefore, an extensive evaluation of web-based interventions at the level of individual treatment components based on therapeutic guidelines and manuals is needed. Objective: The objective of this study was to evaluate the quality of unguided web-based interventions for depression at the level of individual treatment components based on their adherence to current gold-standard treatment guidelines and manuals. Methods: A comprehensive online search of popular app stores and search engines in January 2018 revealed 11 desktop programs and 17 smartphone apps that met the inclusion criteria. Programs and apps were included if they were available for German users, interactive, unguided, and targeted toward depression. All programs and apps were tested by three independent researchers following a standardized procedure with a predefined symptom trajectory. During the testing, all web-based interventions were rated with a standardized list of criteria based on treatment guidelines and manuals for depression. Results: Overall interrater reliability for all raters was substantial with an intraclass correlation coefficient of 0.73 and Gwet AC1 value of 0.80. The main features of web-based interventions included mood tracking (24/28, 86%), psychoeducation (21/28, 75%), cognitive restructuring (21/28, 75%), crisis management (20/28, 71%), behavioral activation (19/29, 68%), and relaxation training (18/28, 64%). Overall, therapeutic meaningfulness was rated higher for desktop programs (mean 4.13, SD 1.17) than for smartphone apps (mean 2.92, SD 1.46). Conclusions: Although many exercises from manuals are included in web-based interventions, the necessary therapeutic depth of the interventions is often not reached, and risk management is frequently lacking. There is a need for further research targeting general principles for the development and evaluation of therapeutically sound web-based interventions for depression. %M 32673221 %R 10.2196/16136 %U https://www.jmir.org/2020/7/e16136 %U https://doi.org/10.2196/16136 %U http://www.ncbi.nlm.nih.gov/pubmed/32673221 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16021 %T Effectiveness and Safety of Using Chatbots to Improve Mental Health: Systematic Review and Meta-Analysis %A Abd-Alrazaq,Alaa Ali %A Rababeh,Asma %A Alajlani,Mohannad %A Bewick,Bridgette M %A Househ,Mowafa %+ College of Science and Engineering, Hamad Bin Khalifa University, Liberal Arts and Sciences Building, Education City, Ar Rayyan, Doha, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K chatbots %K conversational agents %K mental health %K mental disorders %K depression %K anxiety %K effectiveness %K safety %D 2020 %7 13.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The global shortage of mental health workers has prompted the utilization of technological advancements, such as chatbots, to meet the needs of people with mental health conditions. Chatbots are systems that are able to converse and interact with human users using spoken, written, and visual language. While numerous studies have assessed the effectiveness and safety of using chatbots in mental health, no reviews have pooled the results of those studies. Objective: This study aimed to assess the effectiveness and safety of using chatbots to improve mental health through summarizing and pooling the results of previous studies. Methods: A systematic review was carried out to achieve this objective. The search sources were 7 bibliographic databases (eg, MEDLINE, EMBASE, PsycINFO), the search engine “Google Scholar,” and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently selected the studies, extracted data from the included studies, and assessed the risk of bias. Data extracted from studies were synthesized using narrative and statistical methods, as appropriate. Results: Of 1048 citations retrieved, we identified 12 studies examining the effect of using chatbots on 8 outcomes. Weak evidence demonstrated that chatbots were effective in improving depression, distress, stress, and acrophobia. In contrast, according to similar evidence, there was no statistically significant effect of using chatbots on subjective psychological wellbeing. Results were conflicting regarding the effect of chatbots on the severity of anxiety and positive and negative affect. Only two studies assessed the safety of chatbots and concluded that they are safe in mental health, as no adverse events or harms were reported. Conclusions: Chatbots have the potential to improve mental health. However, the evidence in this review was not sufficient to definitely conclude this due to lack of evidence that their effect is clinically important, a lack of studies assessing each outcome, high risk of bias in those studies, and conflicting results for some outcomes. Further studies are required to draw solid conclusions about the effectiveness and safety of chatbots. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42019141219; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019141219 %M 32673216 %R 10.2196/16021 %U http://www.jmir.org/2020/7/e16021/ %U https://doi.org/10.2196/16021 %U http://www.ncbi.nlm.nih.gov/pubmed/32673216 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 7 %P e14500 %T Identifying the Medical Lethality of Suicide Attempts Using Network Analysis and Deep Learning: Nationwide Study %A Kim,Bora %A Kim,Younghoon %A Park,C Hyung Keun %A Rhee,Sang Jin %A Kim,Young Shin %A Leventhal,Bennett L %A Ahn,Yong Min %A Paik,Hyojung %+ Center for Supercomputing Applications, Division of Supercomputing, Korea Institute of Science and Technology Information (KISTI), 245 Daehak-ro, Yuseong-gu, Daejeon, 305-806, Republic of Korea, 1 82 42 869 1004, hyojungpaik@kisti.re.kr %K suicide %K deep learning %K network %K antecedent behaviors %D 2020 %7 9.7.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Suicide is one of the leading causes of death among young and middle-aged people. However, little is understood about the behaviors leading up to actual suicide attempts and whether these behaviors are specific to the nature of suicide attempts. Objective: The goal of this study was to examine the clusters of behaviors antecedent to suicide attempts to determine if they could be used to assess the potential lethality of the attempt. To accomplish this goal, we developed a deep learning model using the relationships among behaviors antecedent to suicide attempts and the attempts themselves. Methods: This study used data from the Korea National Suicide Survey. We identified 1112 individuals who attempted suicide and completed a psychiatric evaluation in the emergency room. The 15-item Beck Suicide Intent Scale (SIS) was used for assessing antecedent behaviors, and the medical outcomes of the suicide attempts were measured by assessing lethality with the Columbia Suicide Severity Rating Scale (C-SSRS; lethal suicide attempt >3 and nonlethal attempt ≤3). Results: Using scores from the SIS, individuals who had lethal and nonlethal attempts comprised two different network nodes with the edges representing the relationships among nodes. Among the antecedent behaviors, the conception of a method’s lethality predicted suicidal behaviors with severe medical outcomes. The vectorized relationship values among the elements of antecedent behaviors in our deep learning model (E-GONet) increased performances, such as F1 and area under the precision-recall gain curve (AUPRG), for identifying lethal attempts (up to 3% for F1 and 32% for AUPRG), as compared with other models (mean F1: 0.81 for E-GONet, 0.78 for linear regression, and 0.80 for random forest; mean AUPRG: 0.73 for E-GONet, 0.41 for linear regression, and 0.69 for random forest). Conclusions: The relationships among behaviors antecedent to suicide attempts can be used to understand the suicidal intent of individuals and help identify the lethality of potential suicide attempts. Such a model may be useful in prioritizing cases for preventive intervention. %M 32673253 %R 10.2196/14500 %U http://medinform.jmir.org/2020/7/e14500/ %U https://doi.org/10.2196/14500 %U http://www.ncbi.nlm.nih.gov/pubmed/32673253 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e16341 %T Engagement and Clinical Improvement Among Older Adult Primary Care Patients Using a Mobile Intervention for Depression and Anxiety: Case Studies %A Orr,L Casey %A Graham,Andrea K %A Mohr,David C %A Greene,Carolyn J %+ Center for Health Services Research, Psychiatric Research Institute, University of Arkansas for Medical Sciences, 4301 W Markham #554, Little Rock, AR, 72205, United States, 1 5015512880, lcorr@ualr.edu %K mobile health %K older adults %K depression %K anxiety %K primary care %K smartphone %K mobile phone %K text messaging %D 2020 %7 8.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Technology-based mental health interventions are an increasingly attractive option for expanding access to mental health services within the primary care system. Older adults are among the groups that could potentially benefit from the growing ubiquity of technology-based mental health interventions; however, older adults are perceived to be averse to using technology and have reported barriers to use. Objective: The aim of this paper is to present a case study of 3 participants from a clinical trial evaluating IntelliCare, an evidence-based mobile intervention for depression and anxiety, among adults recruited from primary care clinics. Our report of these 3 participants, who were aged 60 years or older, focuses on their engagement with the IntelliCare service (ie, app use, coach communication) and clinical changes in depression or anxiety symptoms over the intervention period. Methods: The 3 case study participants were offered IntelliCare with coaching for 8 weeks. The intervention consisted of 5 treatment intervention apps that support a variety of psychological skills, a Hub app that contained psychoeducational content and administered weekly assessments, and coaching for encouragement, accountability, and technical assistance as needed. The 3 case study participants were selected to reflect the overall demographics of participants within the trial and because their interactions with IntelliCare provided a good illustration of varied experiences regarding engagement with the intervention. Results: The 3 participants’ unique experiences with the intervention are described. Despite potential barriers and experiencing some technical glitches, the participants showed proficient ability to use the apps, high levels of participation through frequent app use and coach interaction, and decreased depression and anxiety scores. At the end of the 8-week intervention, each of these 3 participants expressed great enthusiasm for the benefit of this program through feedback to their coach, and they each identified a number of ways they had seen improvements in themselves. Conclusions: These 3 cases provide examples of older individuals who engaged with and benefitted from the IntelliCare service. Although the results from these 3 cases may not generalize to others, they provide an important, informed perspective of the experiences that can contribute to our understanding of how older adults use and overcome barriers to mental health technologies. The findings also contribute toward the ultimate goal of ensuring that the IntelliCare intervention is appropriate for individuals of all ages. %M 32673236 %R 10.2196/16341 %U https://mental.jmir.org/2020/7/e16341 %U https://doi.org/10.2196/16341 %U http://www.ncbi.nlm.nih.gov/pubmed/32673236 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18220 %T Effectiveness of a Transdiagnostic Guided Internet-Delivered Protocol for Emotional Disorders Versus Treatment as Usual in Specialized Care: Randomized Controlled Trial %A González-Robles,Alberto %A Díaz-García,Amanda %A García-Palacios,Azucena %A Roca,Pablo %A Ramos-Quiroga,Josep Antoni %A Botella,Cristina %+ Department of Basic and Clinical Psychology, and Psychobiology, Universitat Jaume I, Sos Baynat Avenue, Campus del Riu Sec, Research II Building, Labpsitec, Castellón de la Plana, 12071, Spain, 34 964387646 ext 7646, vrobles@uji.es %K transdiagnostic %K internet %K cognitive behavioral therapy %K emotional disorders %K depression %K anxiety %K specialized care %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Anxiety disorders and depression (emotional disorders) are highly prevalent mental disorders. Extensive empirical evidence supports the efficacy of cognitive behavioral therapy (CBT) for the treatment of these disorders. However, there are still some barriers related to their dissemination and implementation, which make it difficult for patients to receive these treatments, especially in public health care settings where resources are limited. Recent advances in improving CBT dissemination encompass different perspectives. One is the transdiagnostic approach, which offers treatment protocols that can be used for a range of emotional disorders. Another approach is the use of the internet to reach a larger number of people who could benefit from CBT. Objective: This study aimed to analyze the effectiveness and acceptability of a transdiagnostic internet-delivered protocol (EmotionRegulation) with human and automated guidance in patients from public specialized mental health care settings. Methods: A 2-armed randomized controlled trial (RCT) was conducted to compare the effectiveness of EmotionRegulation with treatment as usual (TAU) in specialized mental health care. In all, 214 participants were randomly assigned to receive either EmotionRegulation (n=106) or TAU (n=108). Measurement assessments were conducted at pre- and postintervention and at a 3-month follow-up. Results: The results revealed the superiority of EmotionRegulation over TAU on measures of depression (d=0.41), anxiety (d=0.35), and health-related quality of life (d=−0.45) at posttreatment, and these gains were maintained at the 3-month follow-up. Furthermore, the results for expectations and opinions showed that EmotionRegulation was well accepted by participants. Conclusions: EmotionRegulation was more effective than TAU for the treatment of emotional disorders in the Spanish public mental health system. The implications of this RCT, limitations, and suggestions for future research are discussed. Trial Registration: ClinicalTrials.gov NCT02345668; https://clinicaltrials.gov/ct2/show/NCT02345668 %M 32673226 %R 10.2196/18220 %U https://www.jmir.org/2020/7/e18220 %U https://doi.org/10.2196/18220 %U http://www.ncbi.nlm.nih.gov/pubmed/32673226 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17758 %T Detection of Suicidal Ideation on Social Media: Multimodal, Relational, and Behavioral Analysis %A Ramírez-Cifuentes,Diana %A Freire,Ana %A Baeza-Yates,Ricardo %A Puntí,Joaquim %A Medina-Bravo,Pilar %A Velazquez,Diego Alejandro %A Gonfaus,Josep Maria %A Gonzàlez,Jordi %+ Department of Information and Communication Technologies, Universitat Pompeu Fabra, Carrer de Tànger, 122-140, Barcelona, 08018, Spain, 34 643294184, diana.ramirez@upf.edu %K social media %K mental health %K suicidal ideation %K risk assessment %K machine learning %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide risk assessment usually involves an interaction between doctors and patients. However, a significant number of people with mental disorders receive no treatment for their condition due to the limited access to mental health care facilities; the reduced availability of clinicians; the lack of awareness; and stigma, neglect, and discrimination surrounding mental disorders. In contrast, internet access and social media usage have increased significantly, providing experts and patients with a means of communication that may contribute to the development of methods to detect mental health issues among social media users. Objective: This paper aimed to describe an approach for the suicide risk assessment of Spanish-speaking users on social media. We aimed to explore behavioral, relational, and multimodal data extracted from multiple social platforms and develop machine learning models to detect users at risk. Methods: We characterized users based on their writings, posting patterns, relations with other users, and images posted. We also evaluated statistical and deep learning approaches to handle multimodal data for the detection of users with signs of suicidal ideation (suicidal ideation risk group). Our methods were evaluated over a dataset of 252 users annotated by clinicians. To evaluate the performance of our models, we distinguished 2 control groups: users who make use of suicide-related vocabulary (focused control group) and generic random users (generic control group). Results: We identified significant statistical differences between the textual and behavioral attributes of each of the control groups compared with the suicidal ideation risk group. At a 95% CI, when comparing the suicidal ideation risk group and the focused control group, the number of friends (P=.04) and median tweet length (P=.04) were significantly different. The median number of friends for a focused control user (median 578.5) was higher than that for a user at risk (median 372.0). Similarly, the median tweet length was higher for focused control users, with 16 words against 13 words of suicidal ideation risk users. Our findings also show that the combination of textual, visual, relational, and behavioral data outperforms the accuracy of using each modality separately. We defined text-based baseline models based on bag of words and word embeddings, which were outperformed by our models, obtaining an increase in accuracy of up to 8% when distinguishing users at risk from both types of control users. Conclusions: The types of attributes analyzed are significant for detecting users at risk, and their combination outperforms the results provided by generic, exclusively text-based baseline models. After evaluating the contribution of image-based predictive models, we believe that our results can be improved by enhancing the models based on textual and relational features. These methods can be extended and applied to different use cases related to other mental disorders. %M 32673256 %R 10.2196/17758 %U https://www.jmir.org/2020/7/e17758 %U https://doi.org/10.2196/17758 %U http://www.ncbi.nlm.nih.gov/pubmed/32673256 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18723 %T Blended Care-Cognitive Behavioral Therapy for Depression and Anxiety in Real-World Settings: Pragmatic Retrospective Study %A Lungu,Anita %A Jun,Janie Jihee %A Azarmanesh,Okhtay %A Leykin,Yan %A Chen,Connie E-Jean %+ Lyra Health, 287 Lorton Avenue, Burlingame, CA, 94010, United States, 1 6505673136, anita@lyrahealth.com %K cognitive behavior therapy %K blended psychotherapy %K dissemination %K implementation %K depression %K anxiety/anxiety disorders %K internet %K web based %K video psychotherapy %D 2020 %7 6.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The past few decades saw considerable advances in research and dissemination of evidence-based psychotherapies, yet available treatment resources are not able to meet the high need for care for individuals suffering from depression or anxiety. Blended care psychotherapy, which combines the strengths of therapist-led and internet interventions, can narrow this gap and be clinically effective and efficient, but has rarely been evaluated outside of controlled research settings. Objective: This study evaluated the effectiveness of a blended care intervention (video-based cognitive behavior therapy and internet intervention) under real-world conditions. Methods: This is a pragmatic retrospective cohort analysis of 385 participants with clinical range depression and/or anxiety symptoms at baseline, measured using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), who enrolled in blended care psychotherapy treatment. Participants resided in the United States and had access to the blended care intervention as a mental health benefit offered through their employers. Levels of depression and anxiety were tracked throughout treatment. Hierarchical linear modeling was used to examine the change in symptoms over time. The effects of age, gender, and providers on participants’ symptom change trajectories were also evaluated. Paired sample t-tests were also conducted, and rates of positive clinical change and clinically significant improvement were calculated. Results: The average depression and anxiety symptoms at 6 weeks after the start of treatment were 5.94 and 6.57, respectively. There were significant linear effects of time on both symptoms of depression and anxiety (β=–.49, P<.001 and β=–.64, P<.001). The quadratic effect was also significant for both symptoms of depression and anxiety (β=.04, P<.001 for both), suggesting a decelerated decrease in symptoms over time. Approximately 73% (n=283) of all 385 participants demonstrated reliable improvement, and 83% (n=319) recovered on either the PHQ-9 or GAD-7 measures. Large effect sizes were observed on both symptoms of depression (Cohen d=1.08) and of anxiety (d=1.33). Conclusions: Video blended care cognitive behavioral therapy interventions can be effective and efficient in treating symptoms of depression and anxiety in real-world conditions. Future research should investigate the differential and interactive contribution of the therapist-led and digital components of care to patient outcomes to optimize care. %M 32628120 %R 10.2196/18723 %U https://www.jmir.org/2020/7/e18723 %U https://doi.org/10.2196/18723 %U http://www.ncbi.nlm.nih.gov/pubmed/32628120 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16228 %T The Acceptability and Usability of Digital Health Interventions for Adults With Depression, Anxiety, and Somatoform Disorders: Qualitative Systematic Review and Meta-Synthesis %A Patel,Shireen %A Akhtar,Athfah %A Malins,Sam %A Wright,Nicola %A Rowley,Emma %A Young,Emma %A Sampson,Stephanie %A Morriss,Richard %+ Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Institute of Mental Health Building, University of Nottingham Innovation Park, Triumph Road, Nottingham, NG7 2TU, United Kingdom, 44 115 8231434, shireen.patel@nottingham.ac.uk %K digital health interventions %K depression %K anxiety %K somatoform disorders %K smartphone %K mobile phone %D 2020 %7 6.7.2020 %9 Review %J J Med Internet Res %G English %X Background: The prevalence of mental health disorders continues to rise, with almost 4% of the world population having an anxiety disorder and almost 3.5% having depression in 2017. Despite the high prevalence, only one-third of people with depression or anxiety receive treatment. Over the last decade, the use of digital health interventions (DHIs) has risen rapidly as a means of accessing mental health care and continues to increase. Although there is evidence supporting the effectiveness of DHIs for the treatment of mental health conditions, little is known about what aspects are valued by users and how they might be improved. Objective: This systematic review aimed to identify, appraise, and synthesize the qualitative literature available on service users’ views and experiences regarding the acceptability and usability of DHIs for depression, anxiety, and somatoform disorders. Methods: A systematic search strategy was developed, and searches were run in 7 electronic databases. Qualitative and mixed methods studies published in English were included. A meta-synthesis was used to interpret and synthesize the findings from the included studies. Results: A total of 24 studies were included in the meta-synthesis, and 3 key themes emerged with descriptive subthemes. The 3 key themes were initial motivations and approaches to DHIs, personalization of treatment, and the value of receiving personal support in DHIs. The meta-synthesis suggests that participants’ initial beliefs about DHIs can have an important effect on their engagement with these types of interventions. Personal support was valued very highly as a major component of the success of DHIs. The main reason for this was the way it enabled individual personalization of care. Conclusions: Findings from the systematic review have implications for the design of future DHIs to improve uptake, retention, and outcomes in DHIs for depression, anxiety, and somatoform disorders. DHIs need to be personalized to the specific needs of the individual. Future research should explore whether the findings could be generalized to other health conditions. %M 32628116 %R 10.2196/16228 %U https://www.jmir.org/2020/7/e16228 %U https://doi.org/10.2196/16228 %U http://www.ncbi.nlm.nih.gov/pubmed/32628116 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 7 %P e17159 %T Effectiveness of Using Mental Health Mobile Apps as Digital Antidepressants for Reducing Anxiety and Depression: Protocol for a Multiple Baseline Across-Individuals Design %A Marshall,Jamie M %A Dunstan,Debra A %A Bartik,Warren %+ School of Psychology, Faculty of Medicine and Health, University of New England, Armidale, 2351, Australia, 61 2 6773 3012, jmarsh21@une.edu.au %K mHealth %K eHealth %K mobile apps %K mobile phone %K anxiety %K depression %K single-case study %D 2020 %7 5.7.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: The use of mental health mobile apps to treat anxiety and depression is widespread and growing. Several reviews have found that most of these apps do not have published evidence for their effectiveness, and existing research has primarily been undertaken by individuals and institutions that have an association with the app being tested. Another reason for the lack of research is that the execution of the traditional randomized controlled trial is time prohibitive in this profit-driven industry. Consequently, there have been calls for different methodologies to be considered. One such methodology is the single-case design, of which, to the best of our knowledge, no peer-reviewed published example with mental health apps for anxiety and/or depression could be located. Objective: The aim of this study is to examine the effectiveness of 5 apps (Destressify, MoodMission, Smiling Mind, MindShift, and SuperBetter) in reducing symptoms of anxiety and/or depression. These apps were selected because they are publicly available, free to download, and have published evidence of efficacy. Methods: A multiple baseline across-individuals design will be employed. A total of 50 participants will be recruited (10 for each app) who will provide baseline data for 20 days. The sequential introduction of an intervention phase will commence once baseline readings have indicated stability in the measures of participants’ mental health and will proceed for 10 weeks. Postintervention measurements will continue for a further 20 days. Participants will be required to provide daily subjective units of distress (SUDS) ratings via SMS text messages and will complete other measures at 5 different time points, including at 6-month follow-up. SUDS data will be examined via a time series analysis across the experimental phases. Individual analyses of outcome measures will be conducted to detect clinically significant changes in symptoms using the statistical approach proposed by Jacobson and Truax. Participants will rate their app on several domains at the end of the intervention. Results: Participant recruitment commenced in January 2020. The postintervention phase will be completed by June 2020. Data analysis will commence after this. A write-up for publication is expected to be completed after the follow-up phase is finalized in January 2021. Conclusions: If the apps prove to be effective as hypothesized, this will provide collateral evidence of their efficacy. It could also provide the benefits of (1) improved access to mental health services for people in rural areas, lower socioeconomic groups, and children and adolescents and (2) improved capacity to enhance face-to-face therapy through digital homework tasks that can be shared instantly with a therapist. It is also anticipated that this methodology could be used for other mental health apps to bolster the independent evidence base for this mode of treatment. International Registered Report Identifier (IRRID): PRR1-10.2196/17159 %M 32623368 %R 10.2196/17159 %U https://www.researchprotocols.org/2020/7/e17159 %U https://doi.org/10.2196/17159 %U http://www.ncbi.nlm.nih.gov/pubmed/32623368 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e17722 %T Use of a Mobile App to Augment Psychotherapy in a Community Psychiatric Clinic: Feasibility and Fidelity Trial %A Adam,Atif %A Jain,Ameena %A Pletnikova,Alexandra %A Bagga,Rishi %A Vita,Allison %A N Richey,Lisa %A Gould,Neda %A Munshaw,Supriya %A Misrilall,Kavi %A Peters,Matthew E %+ Rose: Smarter Mental Health, 3400 Prospect St NW, Washington, DC, 20007, United States, 1 4103363626, dratif@askrose.com %K mobile app %K mental health %K depression %K anxiety %D 2020 %7 3.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Even though 1 in 5 Americans experience some form of mental illness each year, 80% have been shown to discontinue psychotherapy prematurely. The traditional psychotherapy service delivery model, consisting of isolated clinical sessions, lacks the ability to keep patients engaged outside clinical sessions. Newer digital mental health platforms can address the clinical need for a robust tool that tracks mental well-being and improves engagement in patients with depressive symptoms. Objective: The primary goals of this feasibility study were to (1) assess compliance among providers and their patients with a digital mental health platform protocol, and (2) examine the usability and fidelity of a mobile app through structured participant feedback. Methods: A sample of 30 participants was recruited for a 5-week study from a community-based mental health clinic in Baltimore, Maryland, USA. Inclusion criteria were: aged 18 years or older, having access to a smartphone, and having at least mild-to-moderate depression and/or anxiety as measured by the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scales, respectively. Eligible participants were randomized into one of two study arms: (1) the intervention arm or (2) the waitlist control arm. Participants in the intervention arm were asked to download the Rose app and were prompted to complete clinical assessments (PHQ-9 and GAD-7) every other week, daily mood and anxiety Likert scales, and daily journal entries. The participants in the waitlist arm served as controls for the study and completed the clinical assessments only. Both arms engaged in weekly psychotherapy sessions, with participant in-app input informing the psychotherapy process of the intervention arm, while those in the waitlist control arm continued their standard care. Outcomes of interest included adherence to completion of in-app assessments and usability of the Rose mobile app assessed through the modified Mobile Application Rating Scale. Results: Over the study period, a sample of 30 participants used the Rose app 2834 times to complete clinical assessments. On average, 70% (21; 95% CI 61.14%-77.41%) of participants completed mood and anxiety daily check-ins and journal entries 5 days per week. Nearly all participants (29/30, 97%) completed all PHQ-9 and GAD-7 in-app scales during the study. Subjective impressions showed that 73% (22/30) of participants found the mobile app to be engaging and in line with their needs, and approximately 70% (21/30) of participants reported the app functionality and quality of information to be excellent. Additionally, more than two-thirds of the participants felt that their knowledge and awareness of depression and anxiety management improved through using the app. Conclusions: Steady compliance and high app ratings showcase the utility of the Rose mobile mental health app in augmenting the psychotherapy process for patients with mood disorders and improving mental health knowledge. Future studies are needed to further examine the impact of Rose on treatment outcomes. Trial Registration: ClinicalTrials.gov NCT04200170; https://clinicaltrials.gov/ct2/show/NCT04200170 %M 32618572 %R 10.2196/17722 %U https://formative.jmir.org/2020/7/e17722 %U https://doi.org/10.2196/17722 %U http://www.ncbi.nlm.nih.gov/pubmed/32618572 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e15901 %T Testing Suicide Risk Prediction Algorithms Using Phone Measurements With Patients in Acute Mental Health Settings: Feasibility Study %A Haines-Delmont,Alina %A Chahal,Gurdit %A Bruen,Ashley Jane %A Wall,Abbie %A Khan,Christina Tara %A Sadashiv,Ramesh %A Fearnley,David %+ Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Brooks Building, Nursing Department, 53 Bonsall Street, Manchester, M15 6GX, United Kingdom, 44 01612472461 ext 2461, a.haines@mmu.ac.uk %K suicide %K suicidal ideation %K smartphone %K cell phone %K machine learning %K nearest neighbor algorithm %K digital phenotyping %D 2020 %7 26.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Digital phenotyping and machine learning are currently being used to augment or even replace traditional analytic procedures in many domains, including health care. Given the heavy reliance on smartphones and mobile devices around the world, this readily available source of data is an important and highly underutilized source that has the potential to improve mental health risk prediction and prevention and advance mental health globally. Objective: This study aimed to apply machine learning in an acute mental health setting for suicide risk prediction. This study uses a nascent approach, adding to existing knowledge by using data collected through a smartphone in place of clinical data, which have typically been collected from health care records. Methods: We created a smartphone app called Strength Within Me, which was linked to Fitbit, Apple Health kit, and Facebook, to collect salient clinical information such as sleep behavior and mood, step frequency and count, and engagement patterns with the phone from a cohort of inpatients with acute mental health (n=66). In addition, clinical research interviews were used to assess mood, sleep, and suicide risk. Multiple machine learning algorithms were tested to determine the best fit. Results: K-nearest neighbors (KNN; k=2) with uniform weighting and the Euclidean distance metric emerged as the most promising algorithm, with 68% mean accuracy (averaged over 10,000 simulations of splitting the training and testing data via 10-fold cross-validation) and an average area under the curve of 0.65. We applied a combined 5×2 F test to test the model performance of KNN against the baseline classifier that guesses training majority, random forest, support vector machine and logistic regression, and achieved F statistics of 10.7 (P=.009) and 17.6 (P=.003) for training majority and random forest, respectively, rejecting the null of performance being the same. Therefore, we have taken the first steps in prototyping a system that could continuously and accurately assess the risk of suicide via mobile devices. Conclusions: Predicting for suicidality is an underaddressed area of research to which this paper makes a useful contribution. This is part of the first generation of studies to suggest that it is feasible to utilize smartphone-generated user input and passive sensor data to generate a risk algorithm among inpatients at suicide risk. The model reveals fair concordance between phone-derived and research-generated clinical data, and with iterative development, it has the potential for accurate discriminant risk prediction. However, although full automation and independence of clinical judgment or input would be a worthy development for those individuals who are less likely to access specialist mental health services, and for providing a timely response in a crisis situation, the ethical and legal implications of such advances in the field of psychiatry need to be acknowledged. %M 32442152 %R 10.2196/15901 %U https://mhealth.jmir.org/2020/6/e15901 %U https://doi.org/10.2196/15901 %U http://www.ncbi.nlm.nih.gov/pubmed/32442152 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17365 %T Examining Social Capital, Social Support, and Language Use in an Online Depression Forum: Social Network and Content Analysis %A Pan,Wenjing %A Feng,Bo %A Shen,Cuihua %+ School of Journalism and Communication, Renmin University of China, 507, School of Journalism and Communication, Renmin University of China, 59 Zhongguancun St, Haidian District, Beijing, 100872, China, 86 010 82500855, wenjingpan@ruc.edu.cn %K social capital %K social support %K social network analysis %K computerized text analysis %K communication accommodation %K language style matching %K online support forums %K depression %K mental health %D 2020 %7 24.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The use of peer-to-peer online support groups and communities has grown into a social phenomenon. Many people use online support groups and communities to seek and provide social support. It is essential to examine how users’ participation behaviors may contribute to different outcomes. Objective: This study aimed to (1) use the structural positions of online depression forum users in their reply network to predict received support and (2) examine their language use reflecting their health conditions. Methods: A total of 2061 users and their 62,274 replies posted on a depression forum from July 2004 to July 2014 were extracted using a web crawler written in Python. The content of the forum users’ posts and replies and their reply patterns were examined. A social network analysis method was used to build the reply networks of users. The computerized text analysis method was used to measure features of the forum users’ language styles. Results: Forum users’ bridging social capital (operationalized as network betweenness) was positively associated with the level of communication accommodation in their received replies (P=.04). Forum users’ bonding social capital (operationalized as network constraint) was negatively associated with the level of communication accommodation in their received replies (P<.001). The forum users’ change in their use of self-referent words and words expressing negative emotions were examined as linguistic proxies for their health conditions and mental states. The results revealed a general negative association between the number of received replies and the degree of decrease in the use of words expressing negative emotion (P=.007). Conclusions: The structural positions of online depression forum users in the reply network are associated with different participation outcomes in the users. Thus, receiving replies can be beneficial to online depression forum users. %M 32579125 %R 10.2196/17365 %U https://www.jmir.org/2020/6/e17365 %U https://doi.org/10.2196/17365 %U http://www.ncbi.nlm.nih.gov/pubmed/32579125 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e16525 %T Apps With Maps—Anxiety and Depression Mobile Apps With Evidence-Based Frameworks: Systematic Search of Major App Stores %A Marshall,Jamie M %A Dunstan,Debra A %A Bartik,Warren %+ School of Psychology, Faculty of Medicine and Health, University of New England, Elm Ave, Armidale, 2351, Australia, 61 2 6773 3012, jmarsh21@myune.edu.au %K mHealth %K apps %K app store %K depression %K anxiety %K e-mental health %K smartphone %K mobile mental health %K digital mental health %K mobile phone %D 2020 %7 24.6.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mobile mental health apps have become ubiquitous tools to assist people in managing symptoms of anxiety and depression. However, due to the lack of research and expert input that has accompanied the development of most apps, concerns have been raised by clinicians, researchers, and government authorities about their efficacy. Objective: This review aimed to estimate the proportion of mental health apps offering comprehensive therapeutic treatments for anxiety and/or depression available in the app stores that have been developed using evidence-based frameworks. It also aimed to estimate the proportions of specific frameworks being used in an effort to understand which frameworks are having the most influence on app developers in this area. Methods: A systematic review of the Apple App Store and Google Play store was performed to identify apps offering comprehensive therapeutic interventions that targeted anxiety and/or depression. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist was adapted to guide this approach. Results: Of the 293 apps shortlisted as offering a therapeutic treatment for anxiety and/or depression, 162 (55.3%) mentioned an evidence-based framework in their app store descriptions. Of the 293 apps, 88 (30.0%) claimed to use cognitive behavioral therapy techniques, 46 (15.7%) claimed to use mindfulness, 27 (9.2%) claimed to use positive psychology, 10 (3.4%) claimed to use dialectical behavior therapy, 5 (1.7%) claimed to use acceptance and commitment therapy, and 20 (6.8%) claimed to use other techniques. Of the 162 apps that claimed to use a theoretical framework, only 10 (6.2%) had published evidence for their efficacy. Conclusions: The current proportion of apps developed using evidence-based frameworks is unacceptably low, and those without tested frameworks may be ineffective, or worse, pose a risk of harm to users. Future research should establish what other factors work in conjunction with evidence-based frameworks to produce efficacious mental health apps. %M 32579127 %R 10.2196/16525 %U http://mental.jmir.org/2020/6/e16525/ %U https://doi.org/10.2196/16525 %U http://www.ncbi.nlm.nih.gov/pubmed/32579127 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 6 %P e17650 %T Automatic Construction of a Depression-Domain Lexicon Based on Microblogs: Text Mining Study %A Li,Genghao %A Li,Bing %A Huang,Langlin %A Hou,Sibing %+ School of Information Technology & Management, University of International Business and Economics, Chaoyang District, Huixin East Street, Beijing, 100029, China, 86 1 343 978 8086, 01630@uibe.edu.cn %K depression detection %K depression diagnosis %K social media %K automatic construction %K domain-specific lexicon %K depression lexicon %K label propagation %D 2020 %7 23.6.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: According to a World Health Organization report in 2017, there was almost one patient with depression among every 20 people in China. However, the diagnosis of depression is usually difficult in terms of clinical detection owing to slow observation, high cost, and patient resistance. Meanwhile, with the rapid emergence of social networking sites, people tend to share their daily life and disclose inner feelings online frequently, making it possible to effectively identify mental conditions using the rich text information. There are many achievements regarding an English web-based corpus, but for research in China so far, the extraction of language features from web-related depression signals is still in a relatively primary stage. Objective: The purpose of this study was to propose an effective approach for constructing a depression-domain lexicon. This lexicon will contain language features that could help identify social media users who potentially have depression. Our study also compared the performance of detection with and without our lexicon. Methods: We autoconstructed a depression-domain lexicon using Word2Vec, a semantic relationship graph, and the label propagation algorithm. These two methods combined performed well in a specific corpus during construction. The lexicon was obtained based on 111,052 Weibo microblogs from 1868 users who were depressed or nondepressed. During depression detection, we considered six features, and we used five classification methods to test the detection performance. Results: The experiment results showed that in terms of the F1 value, our autoconstruction method performed 1% to 6% better than baseline approaches and was more effective and steadier. When applied to detection models like logistic regression and support vector machine, our lexicon helped the models outperform by 2% to 9% and was able to improve the final accuracy of potential depression detection. Conclusions: Our depression-domain lexicon was proven to be a meaningful input for classification algorithms, providing linguistic insights on the depressive status of test subjects. We believe that this lexicon will enhance early depression detection in people on social media. Future work will need to be carried out on a larger corpus and with more complex methods. %M 32574151 %R 10.2196/17650 %U http://medinform.jmir.org/2020/6/e17650/ %U https://doi.org/10.2196/17650 %U http://www.ncbi.nlm.nih.gov/pubmed/32574151 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17902 %T Evaluation of an On-Demand Mental Health System for Depression Symptoms: Retrospective Observational Study %A Kunkle,Sarah %A Yip,Manny %A Ξ,Watson %A Hunt,Justin %+ Ginger, 116 New Montgomery St Suite 500, San Francisco, CA, 94105, United States, 1 7175197355, sarah@ginger.io %K mental health %K depression %K digital health %K therapy %K coaching %K behavioral health %K virtual care %D 2020 %7 18.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is an extremely prevalent issue in the United States, with an estimated 7% of adults experiencing at least one major depressive episode in 2017. Although psychotherapy and medication management are effective treatments for depression, significant barriers in accessing care persist. Virtual care can potentially address some of these obstacles. Objective: We conducted a preliminary investigation of utilization characteristics and effectiveness of an on-demand health system for reducing depression symptoms. Methods: Data were analyzed from 1662 users of an on-demand mental health system that includes behavioral health coaching, clinical services (therapy and psychiatry), and self-guided content and assessments primarily via a mobile app platform. Measures included engagement characterized by mobile app data, member satisfaction scores collected via in-app surveys, and depression symptoms via the Patient Health Questionnaire-2 (PHQ-2) at baseline and 8-12 week follow-up. Descriptive statistics are reported for measures, and pre/post-PHQ-2 data were analyzed using the McNemar test. A chi-square test was used to test the association between the proportion of individuals with an improvement in PHQ-2 result and care modality (coaching, therapy, and psychiatry, or hybrid). Results: During the study period, 65.5% of individuals (1089/1662) engaged only in coaching services, 27.6% of individuals (459/1662) were engaged in both coaching and clinical services, 3.3% of individuals (54/1662) engaged only in clinical services, and 3.7% of individuals (61/1662) only used the app. Of the 1662 individuals who completed the PHQ-2 survey, 772 (46.5%) were considered a positive screen at intake, and 890 (53.6%) were considered a negative screen at intake. At follow-up, 477 (28.7%) of individuals screened positive, and 1185 (71.3%) screened negative. A McNemar test showed that there was a statistically significant decrease in the proportion of users experiencing depressed mood and anhedonia more than half the time at follow-up (P<.001). A chi-square test showed there was no significant association between care modality and the proportion of individuals with an improvement in PHQ-2 score. Conclusions: This study provides preliminary insights into which aspects of an on-demand mental health system members are utilizing and levels of engagement and satisfaction over an 8-12 week window. Additionally, there is some signal that this system may be useful for reducing depression symptoms in users over this period. Additional research is required, given the study limitations, and future research directions are discussed. %M 32554387 %R 10.2196/17902 %U http://www.jmir.org/2020/6/e17902/ %U https://doi.org/10.2196/17902 %U http://www.ncbi.nlm.nih.gov/pubmed/32554387 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e16350 %T Optimizing Smartphone-Delivered Cognitive Behavioral Therapy for Body Dysmorphic Disorder Using Passive Smartphone Data: Initial Insights From an Open Pilot Trial %A Weingarden,Hilary %A Matic,Aleksandar %A Calleja,Roger Garriga %A Greenberg,Jennifer L %A Harrison,Oliver %A Wilhelm,Sabine %+ Massachusetts General Hospital/Harvard Medical School, 185 Cambridge Street, Suite 2000, Boston, MA, 02114, United States, 1 6176436206, hilary_weingarden@mgh.harvard.edu %K body dysmorphic disorder %K cognitive behavioral therapy %K mobile health %K mobile phone %K patient engagement %D 2020 %7 18.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Smartphone-delivered cognitive behavioral therapy (CBT) is becoming more common, but research on the topic remains in its infancy. Little is known about how people typically engage with smartphone CBT or which engagement and mobility patterns may optimize treatment. Passive smartphone data offer a unique opportunity to gain insight into these knowledge gaps. Objective: This study aimed to examine passive smartphone data across a pilot course of smartphone CBT for body dysmorphic disorder (BDD), a psychiatric illness characterized by a preoccupation with a perceived defect in physical appearance, to inform hypothesis generation and the design of subsequent, larger trials. Methods: A total of 10 adults with primary diagnoses of BDD were recruited nationally and completed telehealth clinician assessments with a reliable evaluator. In a 12-week open pilot trial of smartphone CBT, we initially characterized natural patterns of engagement with the treatment and tested how engagement and mobility patterns across treatment corresponded with treatment response. Results: Most participants interacted briefly and frequently with smartphone-delivered treatment. More frequent app usage (r=–0.57), as opposed to greater usage duration (r=–0.084), correlated strongly with response. GPS-detected time at home, a potential digital marker of avoidance, decreased across treatment and correlated moderately with BDD severity (r=0.49). Conclusions: The sample was small in this pilot study; thus, results should be used to inform the hypotheses and design of subsequent trials. The results provide initial evidence that frequent (even if brief) practice of CBT skills may optimize response to smartphone CBT and that mobility patterns may serve as useful passive markers of symptom severity. This is one of the first studies to examine the value that passively collected sensor data may contribute to understanding and optimizing users’ response to smartphone CBT. With further validation, the results can inform how to enhance smartphone CBT design. %M 32554382 %R 10.2196/16350 %U http://mhealth.jmir.org/2020/6/e16350/ %U https://doi.org/10.2196/16350 %U http://www.ncbi.nlm.nih.gov/pubmed/32554382 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 6 %P e16372 %T Summarizing Complex Graphical Models of Multiple Chronic Conditions Using the Second Eigenvalue of Graph Laplacian: Algorithm Development and Validation %A Faruqui,Syed Hasib Akhter %A Alaeddini,Adel %A Chang,Mike C %A Shirinkam,Sara %A Jaramillo,Carlos %A NajafiRad,Peyman %A Wang,Jing %A Pugh,Mary Jo %+ Department of Mechanical Engineering, The University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, 78249, United States, 1 210 458 8747, adel.alaeddini@utsa.edu %K graphical models %K graph summarization %K graph Laplacian %K disease network %K multiple chronic conditions %D 2020 %7 17.6.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: It is important but challenging to understand the interactions of multiple chronic conditions (MCC) and how they develop over time in patients and populations. Clinical data on MCC can now be represented using graphical models to study their interaction and identify the path toward the development of MCC. However, the current graphical models representing MCC are often complex and difficult to analyze. Therefore, it is necessary to develop improved methods for generating these models. Objective: This study aimed to summarize the complex graphical models of MCC interactions to improve comprehension and aid analysis. Methods: We examined the emergence of 5 chronic medical conditions (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], depression [Depr], substance abuse [SuAb], and back pain [BaPa]) over 5 years among 257,633 veteran patients. We developed 3 algorithms that utilize the second eigenvalue of the graph Laplacian to summarize the complex graphical models of MCC by removing less significant edges. The first algorithm learns a sparse probabilistic graphical model of MCC interactions directly from the data. The second algorithm summarizes an existing probabilistic graphical model of MCC interactions when a supporting data set is available. The third algorithm, which is a variation of the second algorithm, summarizes the existing graphical model of MCC interactions with no supporting data. Finally, we examined the coappearance of the 100 most common terms in the literature of MCC to validate the performance of the proposed model. Results: The proposed summarization algorithms demonstrate considerable performance in extracting major connections among MCC without reducing the predictive accuracy of the resulting graphical models. For the model learned directly from the data, the area under the curve (AUC) performance for predicting TBI, PTSD, BaPa, SuAb, and Depr, respectively, during the next 4 years is as follows—year 2: 79.91%, 84.04%, 78.83%, 82.50%, and 81.47%; year 3: 76.23%, 80.61%, 73.51%, 79.84%, and 77.13%; year 4: 72.38%, 78.22%, 72.96%, 77.92%, and 72.65%; and year 5: 69.51%, 76.15%, 73.04%, 76.72%, and 69.99%, respectively. This demonstrates an overall 12.07% increase in the cumulative sum of AUC in comparison with the classic multilevel temporal Bayesian network. Conclusions: Using graph summarization can improve the interpretability and the predictive power of the complex graphical models of MCC. %M 32554376 %R 10.2196/16372 %U http://medinform.jmir.org/2020/6/e16372/ %U https://doi.org/10.2196/16372 %U http://www.ncbi.nlm.nih.gov/pubmed/32554376 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 6 %P e18890 %T Adherence of the #Here4U App – Military Version to Criteria for the Development of Rigorous Mental Health Apps %A Linden,Brooke %A Tam-Seto,Linna %A Stuart,Heather %+ Health Services and Policy Research Institute, Queen's University, 21 Arch Street, Kingston, ON, K7L 3L3, Canada, 1 613 533 6387, brooke.linden@queensu.ca %K mental health services %K telemedicine %K mHealth %K chatbot %K e-solutions %K Canadian Armed Forces %K military health %K mobile phone %D 2020 %7 17.6.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Over the past several years, the emergence of mobile mental health apps has increased as a potential solution for populations who may face logistical and social barriers to traditional service delivery, including individuals connected to the military. Objective: The goal of the #Here4U App – Military Version is to provide evidence-informed mental health support to members of Canada’s military community, leveraging artificial intelligence in the form of IBM Canada’s Watson Assistant to carry on unique text-based conversations with users, identify presenting mental health concerns, and refer users to self-help resources or recommend professional health care where appropriate. Methods: As the availability and use of mental health apps has increased, so too has the list of recommendations and guidelines for efficacious development. We describe the development and testing conducted between 2018 and 2020 and assess the quality of the #Here4U App against 16 criteria for rigorous mental health app development, as identified by Bakker and colleagues in 2016. Results: The #Here4U App – Military Version met the majority of Bakker and colleagues’ criteria, with those unmet considered not applicable to this particular product or out of scope for research conducted to date. Notably, a formal evaluation of the efficacy of the app is a major priority moving forward. Conclusions: The #Here4U App – Military Version is a promising new mental health e-solution for members of the Canadian Armed Forces community, filling many of the gaps left by traditional service delivery. %M 32554374 %R 10.2196/18890 %U https://formative.jmir.org/2020/6/e18890 %U https://doi.org/10.2196/18890 %U http://www.ncbi.nlm.nih.gov/pubmed/32554374 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17586 %T Challenges and Benefits of an Internet-Based Intervention With a Peer Support Component for Older Adults With Depression: Qualitative Analysis of Textual Data %A Chen,Annie T %A Slattery,Krystal %A Tomasino,Kathryn N %A Rubanovich,Caryn Kseniya %A Bardsley,Leland R %A Mohr,David C %+ Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, 850 Republican Street, Box 358047, UW Medicine South Lake Union, Seattle, WA, 98109, United States, 1 2062219218, atchen@uw.edu %K aged %K depression %K internet %K peer group %K social support %K qualitative research %D 2020 %7 16.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Technological interventions provide many opportunities for improving the health and quality of life of older adults. However, interaction with new technologies can also cause frustration. Although these themes have been explored in extant research, much remains to be learned with regard to how the challenges of aging and technology use and the experiences of participating in a social and learning environment are interrelated. Objective: This study aimed to perform a qualitative analysis of data collected from MoodTech, a pilot study of an internet-based intervention with a peer support component for older adults with symptoms of depression, to better understand the participants’ experience of using technological interventions, including the challenges and benefits that they experienced over the course of these interventions. Methods: We employed an inductive qualitative analysis method based on grounded theory methodology and interpretative phenomenological analysis to analyze participant textual data. These textual data were of 3 main types: (1) assignments in which participants challenged their negative thoughts, (2) status updates, and (3) comments in the peer support component of the intervention. Results: We have presented the results through 3 main themes: (1) the challenges of aging as seen through the participants’ comments, (2) the difficulties experienced by the participants in using MoodTech, and (3) the benefits they derived from participating. Conclusions: This paper offers several contributions concerning study participants’ experiences with internet-based cognitive behavioral therapy (iCBT) interventions with a peer support component and design considerations for developing complex technological interventions that support the challenges participants experience due to aging and cognitive difficulties. First, technical issues encountered by older adults within the context of the intervention can interact with and exacerbate the insecurities they experience in life, and it is important to consider how intervention components might be designed to mitigate these issues. Second, peer support can be employed as a mechanism to facilitate communication, support, and collaborative problem solving among participants in an intervention. The insights from this paper can inform the design of iCBT interventions for older adults. %M 32543448 %R 10.2196/17586 %U https://www.jmir.org/2020/6/e17586 %U https://doi.org/10.2196/17586 %U http://www.ncbi.nlm.nih.gov/pubmed/32543448 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e18236 %T Prospective Associations Between Working Time Arrangements and Psychiatric Treatment in Denmark: Protocol for a Cohort Study %A Hannerz,Harald %A Albertsen,Karen %A Nielsen,Martin Lindhardt %A Garde,Anne Helene %+ The National Research Center for the Working Environment, Lersø Parkallé 105, Copenhagen, 2100, Denmark, 45 39165460, hha@nrcwe.dk %K occupational health %K long working hours %K night shift work %K mood disorders %K anxiety %K stress-related disorders %K psychiatric hospital treatment %K prescription drugs %K psychotropic medicine %D 2020 %7 15.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: The burden of mental ill health in working-age populations has prompted research on possible links between work-related factors and mental ill health. Long working hours and night shift work are some of the factors that have been studied in relation to the risk of developing mental ill health. Yet, previous studies have not generated conclusive evidence, and further studies of high quality are needed. Objective: This study aims to investigate the prospective association between working time arrangements and mental health in terms of psychotropic drug usage or psychiatric hospital treatment in the general working population of Denmark. Methods: Data on total weekly working hours in any job and night shift work from the Danish Labor Force Survey 2000–2013 will be linked to data from the Psychiatric Central Research Register (expected 2400 cases during 700,000 person years at risk) and National Prescription Registry (expected 17,400 cases during 600,000 person years at risk). Participants will be followed for up to 5 years. We will use Poisson regression to separately analyze incidence rates of redeemed prescriptions for psychotropic medicine and incidence rates of psychiatric hospital treatment due to mood disorders, anxiety disorders, or stress-related disorders as a function of weekly working hours and night shift work. The analyses will be controlled for sex, age, calendar time of the interview, and socioeconomic status. Results: This is a study protocol. Power calculations indicate that the study has sufficient statistical power to detect relatively small differences in risks and minor interactions (eg, ~90% power to detect a rate ratio of 1.1 for psychoactive medication use). We expect the analyses to be completed by the end of 2020 and the results to be published in 2021. Conclusions: In this study protocol, all hypotheses and statistical models of the project have been completely defined before we link the exposure data to the outcome data. The results of the project will indicate to what extent and in what direction the national burden of mental ill health in Denmark has been influenced by long working hours and night shift work. International Registered Report Identifier (IRRID): DERR1-10.2196/18236 %M 32442158 %R 10.2196/18236 %U https://www.researchprotocols.org/2020/6/e18236 %U https://doi.org/10.2196/18236 %U http://www.ncbi.nlm.nih.gov/pubmed/32442158 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17195 %T Therapeutic Alliance in Technology-Based Interventions for the Treatment of Depression: Systematic Review %A Wehmann,Eileen %A Köhnen,Moritz %A Härter,Martin %A Liebherz,Sarah %+ Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany, 49 40 7410 57969, s.liebherz@uke.de %K therapeutic alliance %K depression %K technology-based intervention %K treatment %D 2020 %7 11.6.2020 %9 Review %J J Med Internet Res %G English %X Background: There is growing evidence that technology-based interventions (TBIs) are effective for the treatment of depression. As TBIs are gaining acceptance, a question arises whether good therapeutic alliance, considered a key aspect of psychotherapy, can be established without or with minimal face-to-face contact or rather changes if blended concepts are applied. While therapeutic alliance has been studied extensively in the context of face-to-face therapy, only few studies have reviewed evidence on alliance ratings in TBIs. Objective: The purpose of this study was to examine therapeutic alliance in technology-based psychological interventions for the treatment of depression. Methods: We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PSYNDEX, CINAHL, clinical trial registers, and sources of grey literature for randomized controlled trials on TBIs in the treatment of adults with unipolar depression. All publications were selected according to prespecified criteria. Data were extracted by two independent reviewers. Results: A total of eight out of 98 studies (9.5%) included in the review on TBIs for depression considered therapeutic alliance as part of their evaluation. The available data covered eight different treatment conditions, including four stand-alone treatments (face-to-face psychotherapy, email, telephone, and internet program) and four combined treatments (face-to-face psychotherapy plus a smartphone app and an internet program combined with face-to-face psychotherapy, treatment as usual, or email/telephone). On average, patients rated the alliance positively across all groups. Importantly, no relevant group differences regarding therapeutic alliance sum scores were found in any of the studies. Five studies investigated the relationship between patients’ alliance ratings and treatment outcome, revealing mixed results. Conclusions: Our results suggest that it is possible to establish a positive therapeutic alliance across a variety of different TBIs for depression, but this is based on a small number of studies. Future research needs to determine on what basis therapeutic alliance is formed in settings that do not allow for additional nonverbal cues, perhaps with adapted instruments to measure therapeutic alliance. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413) International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2018-028042 %M 32525484 %R 10.2196/17195 %U http://www.jmir.org/2020/6/e17195/ %U https://doi.org/10.2196/17195 %U http://www.ncbi.nlm.nih.gov/pubmed/32525484 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e16684 %T Causal Factors of Anxiety and Depression in College Students: Longitudinal Ecological Momentary Assessment and Causal Analysis Using Peter and Clark Momentary Conditional Independence %A Huckins,Jeremy F %A DaSilva,Alex W %A Hedlund,Elin L %A Murphy,Eilis I %A Rogers,Courtney %A Wang,Weichen %A Obuchi,Mikio %A Holtzheimer,Paul E %A Wagner,Dylan D %A Campbell,Andrew T %+ Department of Psychological and Brain Sciences, Dartmouth College, HB6207, Hanover, NH, 03755, United States, 1 5086574825, jeremy.f.huckins@dartmouth.edu %K depression %K anxiety %K self-esteem %K stress %K causality %K ecological momentary assessments %K mental health %K network %K college %D 2020 %7 10.6.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Across college campuses, the prevalence of clinically relevant depression or anxiety is affecting more than 27% of the college population at some point between entry to college and graduation. Stress and self-esteem have both been hypothesized to contribute to depression and anxiety levels. Although contemporaneous relationships between these variables have been well-defined, the causal relationship between these mental health factors is not well understood, as frequent sampling can be invasive, and many of the current causal techniques are not well suited to investigate correlated variables. Objective: This study aims to characterize the causal and contemporaneous networks between these critical mental health factors in a cohort of first-year college students and then determine if observed results replicate in a second, distinct cohort. Methods: Ecological momentary assessments of depression, anxiety, stress, and self-esteem were obtained weekly from two cohorts of first-year college students for 40 weeks (1 academic year). We used the Peter and Clark Momentary Conditional Independence algorithm to identify the contemporaneous (t) and causal (t-1) network structures between these mental health metrics. Results: All reported results are significant at P<.001 unless otherwise stated. Depression was causally influenced by self-esteem (t-1 rp, cohort 1 [C1]=–0.082, cohort 2 [C2]=–0.095) and itself (t-1 rp, C1=0.388, C2=0.382) in both cohorts. Anxiety was causally influenced by stress (t-1 rp, C1=0.095, C2=0.104), self-esteem (t-1 rp, C1=–0.067, C2=–0.064, P=.002), and itself (t-1 rp, of C1=0.293, C2=0.339) in both cohorts. A causal link between anxiety and depression was observed in the first cohort (t-1 rp, C1=0.109) and only observed in the second cohort with a more liberal threshold (t-1 rp, C2=0.044, P=.03). Self-esteem was only causally influenced by itself (t-1 rp, C1=0.389, C2=0.393). Stress was only causally influenced by itself (t-1 rp, C1=0.248, C2=0.273). Anxiety had positive contemporaneous links to depression (t rp, C1=0.462, C2=0.444) and stress (t rp, C1=0.354, C2=0.358). Self-esteem had negative contemporaneous links to each of the other three mental health metrics, with the strongest negative relationship being stress (t rp, C1=–0.334, C2=–0.340), followed by depression (t rp, C1=–0.302, C2=–0.274) and anxiety (t rp, C1=–0.256, C2=–0.208). Depression had positive contemporaneous links to anxiety (previously mentioned) and stress (t rp, C1=0.250, C2=0.231). Conclusions: This paper is an initial attempt to describe the contemporaneous and causal relationships among these four mental health metrics in college students. We replicated previous research identifying concurrent relationships between these variables and extended them by identifying causal links among these metrics. These results provide support for the vulnerability model of depression and anxiety. Understanding how causal factors impact the evolution of these mental states over time may provide key information for targeted treatment or, perhaps more importantly, preventative interventions for individuals at risk for depression and anxiety. %M 32519971 %R 10.2196/16684 %U https://mental.jmir.org/2020/6/e16684 %U https://doi.org/10.2196/16684 %U http://www.ncbi.nlm.nih.gov/pubmed/32519971 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e15001 %T Coach-Facilitated Web-Based Therapy Compared With Information About Web-Based Resources in Patients Referred to Secondary Mental Health Care for Depression: Randomized Controlled Trial %A MacLean,Sarah %A Corsi,Daniel J %A Litchfield,Sadie %A Kucharski,Julia %A Genise,Kira %A Selaman,Zeynep %A Testa,Valerie %A Hatcher,Simon %+ Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1919 Riverside Drive, Suite 406, Ottawa, ON, K1H 7W9, Canada, 1 613 737 8899, shatcher@toh.ca %K major depressive disorder %K secondary care %K randomized controlled trial %K telemedicine %K digital health technologies %K Canada %D 2020 %7 9.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is a common mental disorder with a high social burden and significant impact on suicidality and quality of life. Treatment is often limited to drug therapies because of long waiting times to see psychological therapists face to face, despite several guidelines recommending that psychological treatments should be first-line interventions for mild to moderate depression. Objective: We aimed to evaluate, among patients on a waitlist to receive secondary mental health care services for depression, how effective coach-guided web-based therapy (The Journal) is, compared with an information-only waitlist control group, in reducing depression symptoms after 12 weeks. Methods: We conducted a randomized controlled trial with 2 parallel arms and a process evaluation, which included interviews with study participants. Participants assigned to the intervention group received 12 weeks of web-based therapy guided by a coach who had a background in social work. Patients in the control group receive a leaflet of mental health resources they could access. The primary outcome measure was a change in depression scores, as measured by the Patient-Health Questionnaire (PHQ-9). Results: A total of 95 participants were enrolled (intervention, n=47; control, n=48). The mean change in PHQ-9 scores from baseline to week 12 was −3.6 (SD 6.6) in the intervention group and −3.1 (SD 6.2) in the control group, which was not a statistically significant difference with a two-sided alpha of .05 (t91=−0.37; P=.72, 95% CI −3.1 to 2.2). At 12 weeks, participants in the intervention group reported higher health-related quality of life (mean EuroQol 5 dimensions visual analogue scale [EQ-5D-VAS] score 66.8, SD 18.0) compared with the control group (mean EQ-5D VAS score 55.9, SD 19.2; t84=−2.73; P=.01). There were no statistically significant differences between the two groups in health service use following their initial consultation with a psychiatrist. The process evaluation showed that participants in the intervention group completed a mean of 5.0 (SD 2.3) lessons in The Journal and 8.8 (SD 3.1) sessions with the coach. Most participants (29/47, 62%) in the intervention group who completed the full dose of the intervention, by finishing 6 or more lessons in The Journal, were more likely to have a clinically important reduction in depressive symptoms at 12 weeks compared with the control group (Χ21=6.3; P=.01, Φ=0.37). Participants who completed the interviews reported that the role played by the coach was a major factor in adherence to the study intervention. Conclusions: The results demonstrate that the use of guided web-based therapy for the treatment of depression is not more effective than information-only waitlist control. However, it showed that the coach has the potential to increase adherence and engagement with web-based depression treatment protocols. Further research is needed on what makes the coach effective. Trial Registration: ClinicalTrials.gov: NCT02423733; https://clinicaltrials.gov/ct2/show/NCT02423733 %M 32515740 %R 10.2196/15001 %U https://www.jmir.org/2020/6/e15001 %U https://doi.org/10.2196/15001 %U http://www.ncbi.nlm.nih.gov/pubmed/32515740 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e15973 %T Examining the Self-Harm and Suicide Contagion Effects of the Blue Whale Challenge on YouTube and Twitter: Qualitative Study %A Khasawneh,Amro %A Chalil Madathil,Kapil %A Dixon,Emma %A Wiśniewski,Pamela %A Zinzow,Heidi %A Roth,Rebecca %+ Department of Anesthesiology and Critical Care, Johns Hopkins University, 750 E Pratt St, 15th Fl, Baltimore, MD, 21202, United States, 1 410 637 4365, akhasaw1@jhmi.edu %K suicide %K suicidal ideation %K self-mutilation %K mental health %K self-injurious behavior %K behavioral symptoms %D 2020 %7 5.6.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Research suggests that direct exposure to suicidal behaviors and acts of self-harm through social media may increase suicidality through imitation and modeling, particularly in more vulnerable populations. One example of a social media phenomenon that demonstrates how self-harming behavior could potentially be propagated is the blue whale challenge. In this challenge, adolescents and young adults are encouraged to engage in self-harm and eventually kill themselves. Objective: This paper aimed to investigate the way individuals portray the blue whale challenge on social media, with an emphasis on factors that could pose a risk to vulnerable populations. Methods: We first used a thematic analysis approach to code 60 publicly posted YouTube videos, 1112 comments on those videos, and 150 Twitter posts that explicitly referenced the blue whale challenge. We then deductively coded the YouTube videos based on the Suicide Prevention Resource Center (SPRC) safe messaging guidelines as a metric for the contagion risk associated with each video. Results: The thematic analysis revealed that social media users post about the blue whale challenge to raise awareness and discourage participation, express sorrow for the participants, criticize the participants, or describe a relevant experience. The deductive coding of the YouTube videos showed that most of the videos violated at least 50% of the SPRC safe and effective messaging guidelines. Conclusions: These posts might have the problematic effect of normalizing the blue whale challenge through repeated exposure, modeling, and reinforcement of self-harming and suicidal behaviors, especially among vulnerable populations such as adolescents. More effort is needed to educate social media users and content generators on safe messaging guidelines and factors that encourage versus discourage contagion effects. %M 32515741 %R 10.2196/15973 %U https://mental.jmir.org/2020/6/e15973 %U https://doi.org/10.2196/15973 %U http://www.ncbi.nlm.nih.gov/pubmed/32515741 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e17223 %T The Safety, Efficacy, and Tolerability of Microbial Ecosystem Therapeutic-2 in People With Major Depression and/or Generalized Anxiety Disorder: Protocol for a Phase 1, Open-Label Study %A Chinna Meyyappan,Arthi %A Milev,Roumen %+ Providence Care Hospital, 752 King St West, Kingston, ON, K7L 4X3, Canada, 1 6135444900 ext 53326, 14acm@queensu.ca %K depression %K anxiety %K microbial ecosystem therapy %K gut-brain axis %K microbiome %K clinical trial %K protocol %D 2020 %7 4.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: The bidirectional signaling between the gut microbiota and the brain, known as the gut-brain axis, is being heavily explored in current neuropsychiatric research. Analyses of the human gut microbiota have shown considerable individual variability in bacterial content, which is hypothesized to influence brain function, and potentially mood and anxiety symptoms, through gut-brain axis communication. Preclinical and clinical research examining these effects suggests that fecal microbiota transplant (FMT) may aid in improving the severity of depression and anxiety symptoms by recolonizing the gastrointestinal (GI) tract with healthy bacteria. The microbial ecosystem therapeutic (ie, microbial ecosystem therapeutic-2 [MET-2]) used in this study is an alternative treatment to FMT, which comprises 40 different strains of gut bacteria from a healthy donor. Objective: The primary objective of this study is to assess subjective changes in mood and anxiety symptoms before, during, and after administration of MET-2. The secondary objectives of this study are to assess the changes in metabolic functioning and the level of repopulation of healthy gut bacteria, the safety and tolerability of MET-2, and the effects of early stress on biomarkers of depression/anxiety and the response to treatment. Methods: Adults experiencing depressive or anxiety symptoms will be recruited from the Kingston area. These participants will orally consume an encapsulated MET-2 once daily—containing 40 strains of purified and laboratory-grown bacteria from a single healthy donor—for 8 weeks, followed by a 2-week treatment-free follow-up period. Participants will undergo a series of clinical assessments measuring mood, anxiety, and GI symptoms using validated clinical scales and questionnaires. Molecular data will be collected from blood and fecal samples to assess metabolic changes, neurotransmitter levels, inflammatory markers, and the level of engraftment of the fecal samples that may predict outcomes in depression or anxiety. Results: Given the association between the gut bacteria and the risk factors of depression, we expect to observe an improvement in the severity of depressive and anxiety symptoms following treatment, and we expect that this improvement is mediated by the recolonization of the GI tract with healthy bacteria. The recruitment for this study has been completed, and the data obtained are currently being analyzed. Conclusions: This is the first time MET-2 is being tested in psychiatric indications, specifically depression and anxiety. As such, this may be the first study to show the potential effects of microbial therapy in alleviating psychiatric symptoms as well as its safety and tolerability. International Registered Report Identifier (IRRID): DERR1-10.2196/17223 %M 32495743 %R 10.2196/17223 %U https://www.researchprotocols.org/2020/6/e17223 %U https://doi.org/10.2196/17223 %U http://www.ncbi.nlm.nih.gov/pubmed/32495743 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e13247 %T Possible Application of Ecological Momentary Assessment to Older Adults’ Daily Depressive Mood: Integrative Literature Review %A Kim,Heejung %A Kim,Sunah %A Kong,Seong Sook %A Jeong,Yi-Rang %A Kim,Hyein %A Kim,Namhee %+ College of Nursing, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 10 9267 3611, namheekim0316@gmail.com %K ecological momentary assessment %K depression %K aged %K review %D 2020 %7 2.6.2020 %9 Review %J JMIR Ment Health %G English %X Background: Ecological momentary assessment is a method of investigating individuals’ real-time experiences, behaviors, and moods in their natural environment over time. Despite its general usability and clinical value for evaluating daily depressive mood, there are several methodological challenges when applying ecological momentary assessment to older adults. Objective: The aims of this integrative literature review were to examine possible uses of the ecological momentary assessment methodology with older adults and to suggest strategies to increase the feasibility of its application in geriatric depression research and practice. Methods: We searched 4 electronic databases (MEDLINE, CINAHL, PsycINFO, and EMBASE) and gray literature; we also hand searched the retrieved articles’ references. We limited all database searches to articles published in peer-reviewed journals from 2009 to 2019. Search terms were “ecological momentary assessment,” “smartphone assessment,” “real time assessment,” “electronic daily diary,” “mHealth momentary assessment,” “mobile-based app,” and “experience sampling method,” combined with the relevant terms of depression. We included any studies that enrolled older adults even as a subgroup and that reported depressive mood at least once a day for more than 2 days. Results: Of the 38 studies that met the inclusion criteria, only 1 study enrolled adults aged 65 years or older as the entire sample; the remainder of the reviewed studies used mixed samples of both younger and older adults. Most of the analyzed studies (18/38, 47%) were quantitative, exploratory (descriptive, correlational, and predictive), and cohort in design. Ecological momentary assessment was used to describe the fluctuating pattern of participants’ depressive moods primarily and to examine the correlation between mood patterns and other health outcomes as a concurrent symptom. We found 3 key methodological issues: (1) heterogeneity in study design and protocol, (2) issues with definitions of dropout and adherence, and (3) variation in how depressive symptoms were measured with ecological momentary assessment. Some studies (8/38, 21%) examined the age difference of participants with respect to dropout or poor compliance rate. Detailed participant burden was reported, such as technical problems, aging-related health problems, or discomfort while using the device. Conclusions: Ecological momentary assessment has been used for comprehensive assessment of multiple mental health indicators in relation to depressive mood. Our findings provide methodological considerations for further studies that may be implemented using ecological momentary assessment to assess daily depressive mood in older adults. Conducting more feasibility studies focusing on older adults with standardized data collection protocols and mixed-methods research is required to reflect users’ experiences. Further telepsychiatric evaluation and diagnosis based on ecological momentary assessment data should involve standardized and sophisticated strategies to maximize the potential of ecological momentary assessment for older adults with depression in the community setting. %M 32484442 %R 10.2196/13247 %U https://mental.jmir.org/2020/6/e13247 %U https://doi.org/10.2196/13247 %U http://www.ncbi.nlm.nih.gov/pubmed/32484442 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e19347 %T Flattening the Mental Health Curve: COVID-19 Stay-at-Home Orders Are Associated With Alterations in Mental Health Search Behavior in the United States %A Jacobson,Nicholas C %A Lekkas,Damien %A Price,George %A Heinz,Michael V %A Song,Minkeun %A O’Malley,A James %A Barr,Paul J %+ Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, 46 Centerra Parkway, Suite 300, Office #333S, Lebanon, NH, 03766, United States, 1 6036467037, Nicholas.C.Jacobson@dartmouth.edu %K COVID-19 %K coronavirus %K stay-at-home orders %K mental health %K suicide %K anxiety %K infodemiology %K infoveillance %K search trends %K health information needs %D 2020 %7 1.6.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The coronavirus disease (COVID-19) has led to dramatic changes worldwide in people’s everyday lives. To combat the pandemic, many governments have implemented social distancing, quarantine, and stay-at-home orders. There is limited research on the impact of such extreme measures on mental health. Objective: The goal of this study was to examine whether stay-at-home orders produced differential changes in mental health symptoms using internet search queries on a national scale. Methods: In the United States, individual states vary in their adoption of measures to reduce the spread of COVID-19; as of March 23, 2020, 11 of the 50 states had issued stay-at-home orders. The staggered rollout of stay-at-home measures across the United States allows us to investigate whether these measures impact mental health by exploring variations in mental health search queries across the states. This paper examines the changes in mental health search queries on Google between March 16-23, 2020, across each state and Washington, DC. Specifically, this paper examines differential changes in mental health searches based on patterns of search activity following issuance of stay-at-home orders in these states compared to all other states. The participants were all the people who searched mental health terms in Google between March 16-23. Between March 16-23, 11 states underwent stay-at-home orders to prevent the transmission of COVID-19. Outcomes included search terms measuring anxiety, depression, obsessive-compulsive, negative thoughts, irritability, fatigue, anhedonia, concentration, insomnia, and suicidal ideation. Results: Analyzing over 10 million search queries using generalized additive mixed models, the results suggested that the implementation of stay-at-home orders are associated with a significant flattening of the curve for searches for suicidal ideation, anxiety, negative thoughts, and sleep disturbances, with the most prominent flattening associated with suicidal ideation and anxiety. Conclusions: These results suggest that, despite decreased social contact, mental health search queries increased rapidly prior to the issuance of stay-at-home orders, and these changes dissipated following the announcement and enactment of these orders. Although more research is needed to examine sustained effects, these results suggest mental health symptoms were associated with an immediate leveling off following the issuance of stay-at-home orders. %M 32459186 %R 10.2196/19347 %U https://mental.jmir.org/2020/6/e19347 %U https://doi.org/10.2196/19347 %U http://www.ncbi.nlm.nih.gov/pubmed/32459186 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e17458 %T Mobile Apps for Mental Health Issues: Meta-Review of Meta-Analyses %A Lecomte,Tania %A Potvin,Stéphane %A Corbière,Marc %A Guay,Stéphane %A Samson,Crystal %A Cloutier,Briana %A Francoeur,Audrey %A Pennou,Antoine %A Khazaal,Yasser %+ Department of Psychology, University of Montreal, 90 rue Vincent d'Indy, Bur C-358, CP 6128, Succ Centre-Ville, Montreal, QC, H3C 3J7, Canada, 1 343 6274, tania.lecomte@umontreal.ca %K apps %K mental health %K depression %K anxiety %K review %K meta %D 2020 %7 29.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental health apps have great potential to help people needing support to cope with distress or specific symptoms. In fact, there is an exponential increase in the number of mental health apps available on the internet, with less than 5% being actually studied. Objective: This study aimed to assess the quality of the available evidence regarding the use of mental health apps and to summarize the results obtained so far. Methods: Systematic reviews and meta-analyses were searched, specifically for mobile apps on mental health issues or symptoms, and rated using the Grading of Recommendations Assessment, Development and Evaluation system. Results: A total of 7 meta-analyses were carefully reviewed and rated. Although some meta-analyses looked at any mental health issue and analyzed the data together, these studies were of poorer quality and did not offer strong empirical support for the apps. Studies focusing specifically on anxiety symptoms or depressive symptoms were of moderate to high quality and generally had small to medium effect sizes. Similarly, the effects of apps on stress and quality of life tended to offer small to medium effects and were of moderate to high quality. Studies looking at stand-alone apps had smaller effect sizes but better empirical quality than studies looking at apps with guidance. The studies that included follow-ups mostly found a sustained impact of the app at an 11-week follow-up. Conclusions: This meta-review revealed that apps for anxiety and depression hold great promise with clear clinical advantages, either as stand-alone self-management or as adjunctive treatments. More meta-analyses and more quality studies are needed to recommend apps for other mental health issues or for specific populations. %M 32348289 %R 10.2196/17458 %U https://mhealth.jmir.org/2020/5/e17458 %U https://doi.org/10.2196/17458 %U http://www.ncbi.nlm.nih.gov/pubmed/32348289 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 3 %N 1 %P e18043 %T Association of Social Media Use and High-Risk Behaviors in Adolescents: Cross-Sectional Study %A Vente,Teresa %A Daley,Mary %A Killmeyer,Elizabeth %A Grubb,Laura K %+ Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 16, Chicago, IL, United States, 1 518 339 5440, tvente@luriechildrens.org %K self-harm %K social media %K nonsuicidal self-injury %K sexting %D 2020 %7 26.5.2020 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Previous studies have demonstrated the prevalence of social media use and identified the presence of high-risk behaviors among adolescents, including self-harm and sharing of sexually explicit messages. Objective: This study aimed to identify patterns in the amount of time spent on social media by adolescents who engage in high-risk behavior and the extent to which they use social media as a platform for sharing such behaviors. Methods: This was a descriptive cross-sectional study of 179 adolescents seen in a pediatric clinic at an urban medical center. We used an anonymous self-report survey to obtain demographic characteristics, rates of self-harm thoughts and behaviors, sharing of sexually explicit messages, and social media use as determined by total hours spent on social media per day and the number of applications used. Results: Most adolescents reported spending 3 to 5 hours on social media each day and using 3 or more social media applications. Almost 1 in 8 (22/179, 12.3%) adolescents self-reported having ever engaged in self-injury with a mean age of onset of 11.8 years. Over a quarter (49/179, 27.4%) of adolescents reported sharing sexually explicit messages. Relative risk of engaging in self-injury and or sharing sexually explicit messages increased with the use of 4 or more social media applications (1.66; CI 1.11-2.48). Conclusions: Results show a relationship between the number of social media applications used and increased rates of high-risk behaviors. We identified relevant risk factors that clinicians can use to screen for high-risk behavior and parents can monitor to encourage education about healthy online practices. %M 32452820 %R 10.2196/18043 %U http://pediatrics.jmir.org/2020/1/e18043/ %U https://doi.org/10.2196/18043 %U http://www.ncbi.nlm.nih.gov/pubmed/32452820 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 5 %P e17345 %T Augmenting Safety Planning With Text Messaging Support for Adolescents at Elevated Suicide Risk: Development and Acceptability Study %A Czyz,Ewa K %A Arango,Alejandra %A Healy,Nathaniel %A King,Cheryl A %A Walton,Maureen %+ Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Ann Arbor, MI, 48109, United States, 1 7346476727, ewac@umich.edu %K adolescents %K suicide %K text messaging %K safety planning %D 2020 %7 25.5.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide is the second leading cause of death among adolescents. A critical need exists for developing promising interventions for adolescents after psychiatric hospitalization who are at a high risk of experiencing repeated suicidal behaviors and related crises. The high-risk period following psychiatric hospitalization calls for cost-effective and scalable continuity of care approaches to support adolescents’ transition from inpatient care. Text messages have been used to improve a wide range of behavioral and health outcomes and may hold promise as an accessible continuity of care strategy for youth at risk of suicide. Objective: In this study of 40 adolescents at elevated suicide risk, we report on the iterative development and acceptability of a text-based intervention designed to encourage adaptive coping and safety plan adherence in the high-risk period following psychiatric hospitalization. Methods: Adolescents (aged 13-17 years) who were hospitalized because of last-month suicide attempts or last-week suicidal ideation took part in either study phase 1 (n=25; 19/25, 76% female), wherein message content was developed and revised on the basis of feedback obtained during hospitalization, or study phase 2 (n=15; 11/15, 73% female), wherein text messages informed by phase 1 were further tested and refined based on feedback obtained daily over the course of a month after discharge (n=256 observations) and during an end-of-study phone interview. Results: Quantitative and qualitative feedback across the 2 study phases pointed to the acceptability of text-based support. Messages were seen as having the potential to be helpful with the transition after hospitalization, with adolescents indicating that texts may serve as reminders to use coping strategies, contribute to improvement in mood, and provide them with a sense of encouragement and hope. At the same time, some adolescents expressed concerns that messages may be insufficient for all teens or circumstances. In phase 2, the passage of time did not influence adolescents’ perception of messages in the month after discharge (P=.74); however, there were notable daily level associations between the perception of messages and adolescents’ affect. Specifically, higher within-person (relative to adolescents’ own average) anger was negatively related to liking text messages (P=.005), whereas within-person positive affect was associated with the perception of messages as more helpful (P=.04). Conclusions: Text-based support appears to be an acceptable continuity of care strategy to support adolescents’ transition after hospitalization. The implications of study findings are discussed. Future work is needed to evaluate the impact of text-based interventions on suicide-related outcomes. %M 32160150 %R 10.2196/17345 %U http://mental.jmir.org/2020/5/e17345/ %U https://doi.org/10.2196/17345 %U http://www.ncbi.nlm.nih.gov/pubmed/32160150 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e17034 %T Mood and Stress Evaluation of Adult Patients With Moyamoya Disease in Korea: Ecological Momentary Assessment Method Using a Mobile Phone App %A Yang,Yong Sook %A Ryu,Gi Wook %A Park,Chang Gi %A Yeom,Insun %A Shim,Kyu Won %A Choi,Mona %+ Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 222283341, monachoi@yuhs.ac %K affect %K ecological momentary assessment %K mood %K Moyamoya disease %K psychological stress %D 2020 %7 25.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Moyamoya disease (MMD) is a known progressive obstructive cerebrovascular disorder. Monitoring and managing mood and stress are critical for patients with MMD, as they affect clinical outcomes. The ecological momentary assessment (EMA) method is a longitudinal study design by which multiple variable assessments can be performed over time to detect momentary fluctuations and changes in psychological dimensions such as mood and stress over time. Objective: This study aimed to identify predicting factors associated with momentary mood and stress at both the within-person and between-person levels and to examine individual fluctuation of mood over time in the short term using an EMA method combined with a mobile phone app. Methods: Participants aged older than 18 years were recruited from a tertiary hospital in Seoul, Korea, between July 2018 and January 2019. The PsyMate scale for negative affect (NA) and positive affect (PA) and the Trier Inventory for Chronic Stress Scale were uploaded on patient mobile phones. Using a mobile app, data were collected four times a day for 7 days. Pearson correlations and mixed modeling were used to predict relationships between repeatedly measured variables at both the between-person and within-person levels. Results: The mean age of the 93 participants was 40.59 (SD 10.06) years, 66 (71%) were female, and 71 (76%) were married. Participants provided 1929 responses out of a possible 2604 responses (1929/2604, 74.08%). The mean momentary NA and PA values were 2.15 (SD 1.12) and 4.70 (SD 1.31) out of 7, respectively. The momentary stress value was 2.03 (SD 0.98) out of 5. Momentary NA, PA, and stress were correlated (P<.001) and varied over time in relation to momentary variables. Common momentary variables associated with momentary mood and stress at both the within-person (level 1) and between-person (level 2) levels were identified. Momentary NA increased when being alone and being at the hospital at both levels, whereas momentary PA increased when eating or drinking, resting, being at a café, restaurant or a public place but decreased when being alone at both levels. Momentary stress increased when being at the office, at a public place, or as the time of the day went by but decreased when resting or during the weekend. Different factors affecting mood and stress at different levels were identified. Fluctuations in individual momentary mood over time at the within-person level were captured. Conclusions: The EMA method using a mobile phone app demonstrated its ability to capture changes in mood and stress in various environmental contexts in patients with MMD. The results could provide baseline information for developing interventions to manage negative mood and stress of patients with MMD based on the identified predictors affecting mood and stress at two different levels. %M 32449687 %R 10.2196/17034 %U http://mhealth.jmir.org/2020/5/e17034/ %U https://doi.org/10.2196/17034 %U http://www.ncbi.nlm.nih.gov/pubmed/32449687 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 5 %P e14309 %T Effectiveness of Group Cognitive Behavioral Therapy and Exercise in the Management of Major Depressive Disorder: Protocol for a Pilot Randomized Controlled Trial %A Yekrang Safakar,Mojtaba %A Hrabok,Marianne %A Urichuk,Liana %A Juhas,Michal %A Shalaby,Reham %A Parmar,Devashree %A Chue,Pierre %A Snaterse,Mark %A Mason,Judith %A Tchida,Donna %A Kelland,Jill %A Coulson,Pamela %A Sosdjan,Daniella %A Brown,Jason %A Hay,Katherine %A Lesage,Deanna %A Paulsen,Lacey %A Delday,Amy %A Duiker,Sherianna %A Surood,Shireen %A Abba-Aji,Adam %A Agyapong,Vincent Israel Opoku %+ Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Centre, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 7802157771, agyapong@ualberta.ca %K depression %K major depressive disorder %K cognitive behavioral therapy %K group CBT %K exercise %D 2020 %7 25.5.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Despite evidence in scientific literature indicating the effectiveness of both cognitive behavioral therapy (CBT) and physical exercise in the management of major depressive disorder (MDD), few studies have directly compared them. Objective: This study aims to evaluate and compare the effectiveness of group CBT, physical exercise, and only wait-listing to receive treatment-as-usual (TAU) in the management of MDD. The investigators hypothesize that participants with MDD assigned to the group CBT or exercise arms of the study will achieve superior outcomes compared with participants wait-listed to receive TAU only. Methods: This prospective rater-blinded randomized controlled trial assesses the benefits of group CBT and exercise for participants with MDD. A total of 120 patients with MDD referred to addiction and mental health clinics in Edmonton, Canada, will be randomly assigned to one of the three equal-sized arms of the study to receive either weekly sessions of group CBT plus TAU, group exercise three times a week plus TAU, or only TAU for 14 weeks. Participants will be assessed at enrollment, 3 and 6 months post enrollment, midtreatment, and upon treatment completion for primary (functional and symptom variables) and secondary outcomes (service variables and health care utilization). In addition, participants in the intervention groups would be evaluated weekly with one functional measure. The data will be analyzed using repeated measures and effect size analyses, and correlational analyses will be completed between measures at each time point. Results: The study will be conducted in accordance with the Declaration of Helsinki (Hong Kong amendment) and Good Clinical Practice (Canadian guidelines). Written informed consent will be obtained from each subject. The study received ethical clearance from the Health Ethics Research Board of the University of Alberta on September 7, 2018 (Pro 00080975) and operational approval from the provincial health authority (Alberta Health Services 43638). As of October 13, 2019, we have enrolled 32 participants. The results will be disseminated at several levels, including patients, practitioners, academics, researchers, and health care organizations. Conclusions: The results of the pilot trial may inform the implementation of a multicenter clinical trial and provide useful information for administrators and clinicians who are interested in incorporating group CBT and group exercise interventions into existing care. Trial Registration: ClinicalTrials.gov NCT03731728; https://clinicaltrials.gov/ct2/show/NCT03731728 International Registered Report Identifier (IRRID): PRR1-10.2196/14309 %M 32449684 %R 10.2196/14309 %U https://www.researchprotocols.org/2020/5/e14309 %U https://doi.org/10.2196/14309 %U http://www.ncbi.nlm.nih.gov/pubmed/32449684 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 5 %P e16237 %T An Automated Mobile Mood Tracking Technology (Mood 24/7): Validation Study %A Kumar,Anupama %A Wang,Michael %A Riehm,Alison %A Yu,Eileen %A Smith,Ted %A Kaplin,Adam %+ Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Room 121, 600 N Wolfe Street, Meyer Building, Baltimore, MD, 21287-0005, United States, 1 4106143307, akaplin@jhmi.edu %K depression %K text messaging %K patient monitoring %K mobile phone %K short message service %K ecological momentary assessment %K digital health %D 2020 %7 20.5.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Electronic tracking has been utilized for a variety of health conditions. Previous studies have shown that there is higher adherence to electronic methods vs paper-and-pencil tracking modalities. Electronic tracking also ensures that there are no back-filled entries, where patients have—to appear compliant—entered their responses retrospectively just before their visits with their health care provider. On the basis of the recognition of an unmet need for a Web-based automated platform to track psychiatric outcomes, Johns Hopkins University partnered with Health Central (a subsidiary of Remedy Health Media LLC) to develop Mood 24/7, an electronic, mobile, automated, SMS-based mood tracker. This is a pilot study to validate the use of Mood 24/7 in anticipation of clinical trials to demonstrate the therapeutic benefit on patients’ health outcomes of utilizing digital mood-tracking technology. Objective: Mood 24/7 is an electronic mood-monitoring platform developed to accurately and efficiently track mood over time through automated daily SMS texts or emails. This study was designed to assess the accuracy and validity of Mood 24/7 in an outpatient psychiatric setting. Methods: This pilot study involved a retrospective chart review for depressed outpatients (N=9) to compare their self-reported Mood 24/7 daily mood ratings with their psychiatrist’s independent clinical mood assessment at the time of the patient’s visit. Their mood ratings via Mood 24/7 were collected over 36 weeks. In addition, a mixed model analysis was applied to compare the weekly Montgomery-Åsberg Depression Rating Scale (MADRS) scores with Mood 24/7 scores over an average of 3 months. Results: A 97.2% (315/324) digital mood reporting adherence was found over 36 weeks, and a significant correlation (r=0.86, P<.001) was observed between patients’ Mood 24/7 scores and their psychiatrist’s blinded clinical assessment of the patient’s mood when seen in the clinic. In addition, a significant concordance (intraclass correlation of 0.69, 95% CI 0.33-0.91, P<.001) was observed in the mixed model analysis of the clinician-administered MADRS vs Mood 24/7 scores over time. Conclusions: Our chart review and mixed model analyses demonstrate that Mood 24/7 is a valid instrument for convenient, simple, noninvasive, and accurate longitudinal mood assessment in the outpatient clinical setting. %M 32432558 %R 10.2196/16237 %U https://mental.jmir.org/2020/5/e16237 %U https://doi.org/10.2196/16237 %U http://www.ncbi.nlm.nih.gov/pubmed/32432558 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e16604 %T User Experiences of an Internet-Based Stepped-Care Intervention for Individuals With Cancer and Concurrent Symptoms of Anxiety or Depression (the U-CARE AdultCan Trial): Qualitative Study %A Igelström,Helena %A Hauffman,Anna %A Alfonsson,Sven %A Sjöström,Jonas %A Cajander,Åsa %A Johansson,Birgitta %+ Department of Neuroscience, Uppsala University, BMC, Box 593, Uppsala, 75124, Sweden, 46 184714761, helena.igelstrom@neuro.uu.se %K interactive web portal %K stepped care %K user experience %K cancer %K interviews %D 2020 %7 19.5.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The internet-based stepped-care intervention iCAN-DO, used in the multicenter randomized controlled trial AdultCan, was developed for adult patients undergoing treatment for cancer and concurrently experiencing anxiety or depressive symptoms. iCAN-DO aimed to decrease symptoms of anxiety or depression. Step 1 comprises access to a library with psychoeducational material and a peer-support section, as well as the possibility to pose questions to a nurse. Step 2 of the intervention offers treatment consisting of internet-based cognitive behavioral therapy (iCBT) to participants still experiencing anxiety or depression at 1, 4, or 7 months after inclusion. Objective: The study aimed to explore user experiences of delivery, design, and structure of iCAN-DO from the perspective of people with cancer. Methods: We studied user experiences by interviewing 15 informants individually: 10 women with breast cancer (67%), 4 men with prostate cancer (27%), and 1 man with colorectal cancer (7%) with a mean age 58.9 years (SD 8.9). The interviews focused on informants' perceptions of ease of use and of system design and structure. Informants had been included in iCAN-DO for at least 7 months. They were purposefully selected based on activity in Step 1, participation in iCBT (ie, Step 2), gender, and diagnosis. Results: Of the 15 informants, 6 had been offered iCBT (40%). All informants used the internet on a daily basis, but 2 (13%) described themselves as very inexperienced computer users. The analysis revealed three subthemes, concerning how user experiences were affected by disease-specific factors and side effects (User experience in the context of cancer), technical problems (Technical struggles require patience and troubleshooting), and the structure and design of iCAN-DO (Appealing and usable, but rather simple). Conclusions: The results indicate that user experiences were affected by informants’ life situations, the technical aspects and the design of iCAN-DO, and informants’ preferences. The results have generated some developments feasible to launch during the ongoing study, but if iCAN-DO is to be used beyond research interest, a greater level of tailoring of information, features, and design may be needed to improve user experiences. The use of recurrent questionnaires during the treatment period may highlight an individual’s health, but also function as a motivator showing improvements over time. %M 32427108 %R 10.2196/16604 %U http://www.jmir.org/2020/5/e16604/ %U https://doi.org/10.2196/16604 %U http://www.ncbi.nlm.nih.gov/pubmed/32427108 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 5 %P e17520 %T Developing a Suicide Prevention Social Media Campaign With Young People (The #Chatsafe Project): Co-Design Approach %A Thorn,Pinar %A Hill,Nicole TM %A Lamblin,Michelle %A Teh,Zoe %A Battersby-Coulter,Rikki %A Rice,Simon %A Bendall,Sarah %A Gibson,Kerry L %A Finlay,Summer May %A Blandon,Ryan %A de Souza,Libby %A West,Ashlee %A Cooksey,Anita %A Sciglitano,Joe %A Goodrich,Simon %A Robinson,Jo %+ Orygen, 35 Poplar Road, Parkville, VIC, Australia, 61 412 999 140, jo.robinson@orygen.org.au %K suicide %K social media %K health promotion %K co-design %K adolescent %K young adult %K #chatsafe %D 2020 %7 11.5.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Young people commonly use social media platforms to communicate about suicide. Although research indicates that this communication may be helpful, the potential for harm still exists. To facilitate safe communication about suicide on social media, we developed the #chatsafe guidelines, which we sought to implement via a national social media campaign in Australia. Population-wide suicide prevention campaigns have been shown to improve knowledge, awareness, and attitudes toward suicide. However, suicide prevention campaigns will be ineffective if they do not reach and resonate with their target audience. Co-designing suicide prevention campaigns with young people can increase the engagement and usefulness of these youth interventions. Objective: This study aimed to document key elements of the co-design process; to evaluate young people’s experiences of the co-design process; and to capture young people’s recommendations for the #chatsafe suicide prevention social media campaign. Methods: In total, 11 co-design workshops were conducted, with a total of 134 young people aged between 17 and 25 years. The workshops employed commonly used co-design strategies; however, modifications were made to create a safe and comfortable environment, given the population and complexity and sensitivity of the subject matter. Young people’s experiences of the workshops were evaluated through a short survey at the end of each workshop. Recommendations for the campaign strategy were captured through a thematic analysis of the postworkshop discussions with facilitators. Results: The majority of young people reported that the workshops were both safe (116/131, 88.5%) and enjoyable (126/131, 96.2%). They reported feeling better equipped to communicate safely about suicide on the web and feeling better able to identify and support others who may be at risk of suicide. Key recommendations for the campaign strategy were that young people wanted to see bite-sized sections of the guidelines come to life via shareable content such as short videos, animations, photographs, and images. They wanted to feel visible in campaign materials and wanted all materials to be fully inclusive and linked to resources and support services. Conclusions: This is the first study internationally to co-design a suicide prevention social media campaign in partnership with young people. The study demonstrates that it is feasible to safely engage young people in co-designing a suicide prevention intervention and that this process produces recommendations, which can usefully inform suicide prevention campaigns aimed at youth. The fact that young people felt better able to safely communicate about suicide on the web as a result of participation in the study augurs well for youth engagement with the national campaign, which was rolled out across Australia. If effective, the campaign has the potential to better prepare many young people to communicate safely about suicide on the web. %M 32391800 %R 10.2196/17520 %U https://mental.jmir.org/2020/5/e17520 %U https://doi.org/10.2196/17520 %U http://www.ncbi.nlm.nih.gov/pubmed/32391800 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 4 %P e15516 %T Machine Learning Models for the Prediction of Postpartum Depression: Application and Comparison Based on a Cohort Study %A Zhang,Weina %A Liu,Han %A Silenzio,Vincent Michael Bernard %A Qiu,Peiyuan %A Gong,Wenjie %+ XiangYa School of Public Health, Central South University, 238 Shangmayuanling Lane Xiangya Road, Kaifu District, Changsha, 410005, China, 86 13607445252, gongwenjie@csu.edu.cn %K depression %K postpartum %K machine learning %K support vector machine %K random forest %K prediction model %D 2020 %7 30.4.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Postpartum depression (PPD) is a serious public health problem. Building a predictive model for PPD using data during pregnancy can facilitate earlier identification and intervention. Objective: The aims of this study are to compare the effects of four different machine learning models using data during pregnancy to predict PPD and explore which factors in the model are the most important for PPD prediction. Methods: Information on the pregnancy period from a cohort of 508 women, including demographics, social environmental factors, and mental health, was used as predictors in the models. The Edinburgh Postnatal Depression Scale score within 42 days after delivery was used as the outcome indicator. Using two feature selection methods (expert consultation and random forest-based filter feature selection [FFS-RF]) and two algorithms (support vector machine [SVM] and random forest [RF]), we developed four different machine learning PPD prediction models and compared their prediction effects. Results: There was no significant difference in the effectiveness of the two feature selection methods in terms of model prediction performance, but 10 fewer factors were selected with the FFS-RF than with the expert consultation method. The model based on SVM and FFS-RF had the best prediction effects (sensitivity=0.69, area under the curve=0.78). In the feature importance ranking output by the RF algorithm, psychological elasticity, depression during the third trimester, and income level were the most important predictors. Conclusions: In contrast to the expert consultation method, FFS-RF was important in dimension reduction. When the sample size is small, the SVM algorithm is suitable for predicting PPD. In the prevention of PPD, more attention should be paid to the psychological resilience of mothers. %M 32352387 %R 10.2196/15516 %U http://medinform.jmir.org/2020/4/e15516/ %U https://doi.org/10.2196/15516 %U http://www.ncbi.nlm.nih.gov/pubmed/32352387 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e14940 %T Mediation Effect of Suicide-Related Social Media Use Behaviors on the Association Between Suicidal Ideation and Suicide Attempt: Cross-Sectional Questionnaire Study %A Liu,Xingyun %A Huang,Jiasheng %A Yu,Nancy Xiaonan %A Li,Qing %A Zhu,Tingshao %+ Institute of Psychology, Chinese Academy of Sciences, No 16, Lincui Road, Beijing, , China, 86 15010965509, tszhu@psych.ac.cn %K suicidal ideation %K suicide %K attempted %K social media %K suicide-related social media use behaviors %D 2020 %7 28.4.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: A limited number of studies have examined the differences in suicide-related social media use behaviors between suicide ideators and suicide attempters or have sought to elucidate how these social media usage behaviors contributed to the transition from suicidal ideation to suicide attempt. Objective: Suicide attempts can be acquired through suicide-related social media use behaviors. This study aimed to propose 3 suicide-related social media use behaviors (ie, attending to suicide information, commenting on or reposting suicide information, or talking about suicide) based on social cognitive theory, which proposes that successive processes governing behavior transition include attentional, retention, production, and motivational processes. Methods: We aimed to examine the mediating role of suicide-related social media use behaviors in Chinese social media users with suicidal risks. A sample of 569 Chinese social media users with suicidal ideation completed measures on suicidal ideation, suicide attempt, and suicide-related social media use behaviors. Results: The results demonstrated that suicide attempters showed a significantly higher level of suicidal ideation (t563.64=5.04; P<.001; two-tailed) and more suicide-related social media use behaviors, which included attending to suicide information (t567=1.94; P=.05; two-tailed), commenting on or reposting suicide information (t567=2.12; P=.03; two-tailed), or talking about suicide (t542.22=5.12; P<.001; two-tailed). Suicidal ideation also affected suicide attempts through the mediational chains. Conclusions: Our findings thus support the social cognitive theory, and there are implications for population-based suicide prevention that can be achieved by identifying behavioral signals. %M 32343249 %R 10.2196/14940 %U http://www.jmir.org/2020/4/e14940/ %U https://doi.org/10.2196/14940 %U http://www.ncbi.nlm.nih.gov/pubmed/32343249 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 4 %P e17071 %T Temporal Associations of Daily Changes in Sleep and Depression Core Symptoms in Patients Suffering From Major Depressive Disorder: Idiographic Time-Series Analysis %A Lorenz,Noah %A Sander,Christian %A Ivanova,Galina %A Hegerl,Ulrich %+ Research Centre of the German Depression Foundation, Goerdelerring 9, Leipzig, 04109, Germany, 49 341 2238740, noah.lorenz@medizin.uni-leipzig.de %K depression %K sleep %K time series %K idiographic %K self-management %D 2020 %7 23.4.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is a strong link between sleep and major depression; however, the causal relationship remains unclear. In particular, it is unknown whether changes in depression core symptoms precede or follow changes in sleep, and whether a longer or shorter sleep duration is related to improvements of depression core symptoms. Objective: The aim of this study was to investigate temporal associations between sleep and depression in patients suffering from major depressive disorder using an idiographic research approach. Methods: Time-series data of daily sleep assessments (time in bed and total sleep time) and self-rated depression core symptoms for an average of 173 days per patient were analyzed in 22 patients diagnosed with recurrent major depressive disorder using a vector autoregression model. Granger causality tests were conducted to test for possible causality. Impulse response analysis and forecast error variance decomposition were performed to quantify the temporal mutual impact of sleep and depression. Results: Overall, 11 positive and 5 negative associations were identified between time in bed/total sleep time and depression core symptoms. Granger analysis showed that time in bed/total sleep time caused depression core symptoms in 9 associations, whereas this temporal order was reversed for the other 7 associations. Most of the variance (10%) concerning depression core symptoms could be explained by time in bed. Changes in sleep or depressive symptoms of 1 SD had the greatest impact on the other variable in the following 2 to 4 days. Conclusions: Longer rather than shorter bedtimes were associated with more depression core symptoms. However, the temporal orders of the associations were heterogeneous. %M 32324147 %R 10.2196/17071 %U http://mental.jmir.org/2020/4/e17071/ %U https://doi.org/10.2196/17071 %U http://www.ncbi.nlm.nih.gov/pubmed/32324147 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e17330 %T Patients’ Perspective on Mental Health Specialist Video Consultations in Primary Care: Qualitative Preimplementation Study of Anticipated Benefits and Barriers %A Bleyel,Caroline %A Hoffmann,Mariell %A Wensing,Michel %A Hartmann,Mechthild %A Friederich,Hans-Christoph %A Haun,Markus W %+ Department of General Internal Medicine and Psychosomatics, Heidelberg University, Im Neuenheimer Feld 410, Heidelberg, D-69120, Germany, 49 622156 ext 38396, markus.haun@med.uni-heidelberg.de %K telemedicine %K remote consultation %K implementation %K primary health care %K mental health services %K thematic analysis %K integrated behavioral health %K health services research %D 2020 %7 20.4.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Due to limited access to specialist services, most patients with common mental disorders (depression or anxiety, or both) usually receive treatment in primary care. More recently, innovative technology-based care models (eg, video consultations) have been proposed to facilitate access to specialist services. Against this background, the PROVIDE (Improving Cross-Sectoral Collaboration Between Primary and Psychosocial Care: An Implementation Study on Video Consultations) project aims to improve the provision of psychosocial care through implementing video consultations integrated into routine primary care. Objective: From the patients’ perspective, this qualitative preimplementation study explored (1) anticipated benefits from and (2) barriers to implementing mental health specialist video consultations embedded in primary care services and (3) prerequisites for interacting with therapists via video consultations. Methods: Using a purposive (ie, stratified) sampling strategy, we recruited 13 patients from primary care practices and a tertiary care hospital (psychosomatic outpatient clinic) for one-off semistructured interviews. In a computer-assisted thematic analysis, we inductively (bottom-up) derived key themes concerning the practicability of mental health specialist video consultations. To validate our results, we discussed our findings with the interviewees as part of a systematic member checking. Results: Overall, we derived 3 key themes and 10 subthemes. Participants identified specific benefits in 2 areas: the accessibility of mental health specialist care (shorter waiting times: 11/13, 85%; lower threshold for seeking specialist mental health care: 6/13, 46%; shorter travel distances: 3/13, 23%); and the environment in primary care (familiar travel modalities, premises, and employees: 5/13, 38%). The main barriers to the implementation of mental health video consultations from the patients’ perspective were the lack of face-to-face contact (13/13, 100%) and technical challenges (12/13, 92%). Notably, participants’ prerequisites for interacting with therapists (12/13, 92%) did not seem to differ much from those concerning face-to-face contacts. Conclusions: Mental health service users mostly welcomed mental health specialist video consultations in primary care. Taking a pragmatic stance, service users, who are often frustrated about uncoordinated care, particularly valued the embedment of the consultations in the familiar environment of the primary care practice. With respect to interventional studies and implementation, our findings underscore the need to minimize technical disruptions during video consultations and to ensure optimal resemblance to face-to-face settings (eg, by training therapists in consistently reacting to nonverbal cues). Trial Registration: German Clinical Trials Register DRKS00012487; https://tinyurl.com/uhg2one %M 32310139 %R 10.2196/17330 %U http://www.jmir.org/2020/4/e17330/ %U https://doi.org/10.2196/17330 %U http://www.ncbi.nlm.nih.gov/pubmed/32310139 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 4 %P e16398 %T A Web- and Mobile-Based Intervention for Comorbid, Recurrent Depression in Patients With Chronic Back Pain on Sick Leave (Get.Back): Pilot Randomized Controlled Trial on Feasibility, User Satisfaction, and Effectiveness %A Schlicker,Sandra %A Baumeister,Harald %A Buntrock,Claudia %A Sander,Lasse %A Paganini,Sarah %A Lin,Jiaxi %A Berking,Matthias %A Lehr,Dirk %A Ebert,David Daniel %+ Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Nägelsbachstraße 25a, Erlangen, 91052, Germany, 49 91318567564, Sandra.Schlicker@fau.de %K pilot project %K low back pain %K depressive disorder %K mental health %K sick leave %D 2020 %7 15.4.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Chronic back pain (CBP) is linked to a higher prevalence and higher occurrence of major depressive disorder (MDD) and can lead to reduced quality of life. Unfortunately, individuals with both CBP and recurrent MDD are underidentified. Utilizing health care insurance data may provide a possibility to better identify this complex population. In addition, internet- and mobile-based interventions might enhance the availability of existing treatments and provide help to those highly burdened individuals. Objective: This pilot randomized controlled trial investigated the feasibility of recruitment via the health records of a German health insurance company. The study also examined user satisfaction and effectiveness of a 9-week cognitive behavioral therapy and Web- and mobile-based guided self-help intervention Get.Back in CBP patients with recurrent MDD on sick leave compared with a waitlist control condition. Methods: Health records from a German health insurance company were used to identify and recruit participants (N=76) via invitation letters. Study outcomes were measured using Web-based self-report assessments at baseline, posttreatment (9 weeks), and a 6-month follow-up. The primary outcome was depressive symptom severity (Center for Epidemiological Studies–Depression); secondary outcomes included anxiety (Hamilton Anxiety and Depression Scale), quality of life (Assessment of Quality of Life), pain-related variables (Oswestry Disability Index, Pain Self-Efficacy Questionnaire, and pain intensity), and negative effects (Inventory for the Assessment of Negative Effects of Psychotherapy). Results: The total enrollment rate with the recruitment strategy used was 1.26% (76/6000). Participants completed 4.8 modules (SD 2.6, range 0-7) of Get.Back. The overall user satisfaction was favorable (mean Client Satisfaction Questionnaire score=24.5, SD 5.2). Covariance analyses showed a small but statistically significant reduction in depressive symptom severity in the intervention group (n=40) at posttreatment compared with the waitlist control group (n=36; F1,76=3.62, P=.03; d=0.28, 95% CI −0.17 to 0.74). Similar findings were noted for the reduction of anxiety symptoms (F1,76=10.45; P=.001; d=0.14, 95% CI −0.31 to 0.60) at posttreatment. Other secondary outcomes were nonsignificant (.06≤P≤.44). At the 6-month follow-up, the difference between the groups with regard to reduction in depressive symptom severity was no longer statistically significant (F1,76=1.50, P=.11; d=0.10, 95% CI −0.34 to 0.46). The between-group difference in anxiety at posttreatment was maintained to follow-up (F1,76=2.94, P=.04; d=0.38, 95% CI −0.07 to 0.83). There were no statistically significant differences across groups regarding other secondary outcomes at the 6-month follow-up (.08≤P≤.42). Conclusions: These results suggest that participants with comorbid depression and CBP on sick leave may benefit from internet- and mobile-based interventions, as exemplified with the positive user satisfaction ratings. The recruitment strategy via health insurance letter invitations appeared feasible, but more research is needed to understand how response rates in untreated individuals with CBP and comorbid depression can be increased. Trial Registration: German Clinical Trials Register DRKS00010820; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00010820. %M 32293577 %R 10.2196/16398 %U http://mental.jmir.org/2020/4/e16398/ %U https://doi.org/10.2196/16398 %U http://www.ncbi.nlm.nih.gov/pubmed/32293577 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 6 %N 1 %P e16476 %T Use of Mental Health Apps by Patients With Breast Cancer in the United States: Pilot Pre-Post Study %A Chow,Philip I %A Showalter,Shayna L %A Gerber,Matthew %A Kennedy,Erin M %A Brenin,David %A Mohr,David C %A Lattie,Emily G %A Gupta,Alisha %A Ocker,Gabrielle %A Cohn,Wendy F %+ Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, 560 Ray C Hunt Dr, Charlottesville, VA, United States, 1 4349245401, philip.i.chow@gmail.com %K breast cancer %K mental health %K mHealth %D 2020 %7 15.4.2020 %9 Original Paper %J JMIR Cancer %G English %X Background: Nearly half of the patients with breast cancer experience clinically significant mental distress within the first year of receiving their cancer diagnosis. There is an urgent need to identify scalable and cost-efficient ways of delivering empirically supported mental health interventions to patients with breast cancer. Objective: The aim of this study was to evaluate the feasibility of in-clinic recruitment for a mobile phone app study and to evaluate the usability and preliminary impact of a suite of mental health apps (IntelliCare) with phone coaching on psychosocial distress symptoms in patients recently diagnosed with breast cancer. Methods: This pilot study adopted a within-subject, 7-week pre-post study design. A total of 40 patients with breast cancer were recruited at a US National Cancer Institute–designated clinical cancer center. Self-reported distress (Patient Health Questionnaire-4) and mood symptoms (Patient-Reported Outcomes Measurement Information System depression and anxiety scales) were assessed at baseline and postintervention. App usability was assessed at postintervention. Results: The minimum recruitment threshold was met. There was a significant decrease in general distress symptoms, as well as symptoms of depression and anxiety, from baseline to postintervention. Overall, participants reported high levels of ease of app use and learning. Scores for app usefulness and satisfaction were reinforced by some qualitative feedback suggesting that tailoring the apps more for patients with breast cancer could enhance engagement. Conclusions: There is a dire need for scalable, supportive interventions in cancer. The results from this study inform how scalable mobile phone–delivered programs with additional phone support can be used to support patients with breast cancer. International Registered Report Identifier (IRRID): RR2-10.2196/11452 %M 32293570 %R 10.2196/16476 %U http://cancer.jmir.org/2020/1/e16476/ %U https://doi.org/10.2196/16476 %U http://www.ncbi.nlm.nih.gov/pubmed/32293570 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e17011 %T Mobile Health for Perinatal Depression and Anxiety: Scoping Review %A Hussain-Shamsy,Neesha %A Shah,Amika %A Vigod,Simone N %A Zaheer,Juveria %A Seto,Emily %+ Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street 4th Floor, Toronto, ON, M5T 3M6, Canada, 1 416 978 4326, neesha.hussainshamsy@mail.utoronto.ca %K mental health %K depression %K anxiety %K pregnancy %K postpartum %K smartphone %K mobile phone %K text message %K mHealth %D 2020 %7 13.4.2020 %9 Review %J J Med Internet Res %G English %X Background: The perinatal period is a vulnerable time during which depression and anxiety commonly occur. If left untreated or undertreated, there may be significant adverse effects; therefore, access to rapid, effective treatment is essential. Treatments for mild-to-moderate symptoms according to a stepped-care approach involve psychoeducation, peer support, and psychological therapy, all of which have been shown to be efficaciously delivered through digital means. Women experience significant barriers to care because of system- and individual-level factors, such as cost, accessibility, and availability of childcare. The use of mobile phones is widespread in this population, and the delivery of mental health services via mobile phones has been suggested as a means of reducing barriers. Objective: This study aimed to understand the extent, range, and nature of mobile health (mHealth) tools for prevention, screening, and treatment of perinatal depression and anxiety in order to identify gaps and inform opportunities for future work. Methods: Using a scoping review framework, 4 databases were searched for terms related to mobile phones, perinatal period, and either depression or anxiety. A total of 477 unique records were retrieved, 81 of which were reviewed by full text. Peer-reviewed publications were included if they described the population as women pregnant or up to 1 year postpartum and a tool explicitly delivered via a mobile phone for preventing, screening, or treating depression or anxiety. Studies published in 2007 or earlier, not in English, or as case reports were excluded. Results: A total of 26 publications describing 22 unique studies were included (77% published after 2017). mHealth apps were slightly more common than texting-based interventions (12/22, 54% vs 10/22, 45%). Most tools were for either depression (12/22, 54%) or anxiety and depression (9/22, 41%); 1 tool was for anxiety only (1/22, 4%). Interventions starting in pregnancy and continuing into the postpartum period were rare (2/22, 9%). Tools were for prevention (10/22, 45%), screening (6/22, 27%), and treatment (6/22, 27%). Interventions delivered included psychoeducation (16/22, 73%), peer support (4/22, 18%), and psychological therapy (4/22, 18%). Cost was measured in 14% (3/22) studies. Conclusions: Future work in this growing area should incorporate active psychological treatment, address continuity of care across the perinatal period, and consider clinical sustainability to realize the potential of mHealth. %M 32281939 %R 10.2196/17011 %U http://www.jmir.org/2020/4/e17011/ %U https://doi.org/10.2196/17011 %U http://www.ncbi.nlm.nih.gov/pubmed/32281939 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 4 %P e15164 %T Gamified Mobile Computerized Cognitive Behavioral Therapy for Japanese University Students With Depressive Symptoms: Protocol for a Randomized Controlled Trial %A Yokomitsu,Kengo %A Irie,Tomonari %A Sekiguchi,Mayu %A Shimizu,Ayako %A Matsuoka,Hirofumi %A Merry,Sally Nicola %A Stasiak,Karolina %+ College of Comprehensive Psychology, Ritsumeikan University, 2-150 Iwakura-cho, Ibaraki, Osaka, 567-8570, Japan, 81 72 665 2490, k-yoko@fc.ritsumei.ac.jp %K SPARX %K Japan %K university students %K depressive symptoms %D 2020 %7 7.4.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Evidence shows that computerized self-help interventions are effective for reducing symptoms of depression. One such intervention, SPARX, is a gamified mobile computerized cognitive behavioral therapy (cCBT) developed for adolescents in New Zealand, which was shown to be as effective as usual care for young people with mild-to-moderate symptoms of depression. However, gamified cCBT has not yet been tested in Japan. Objective: This trial is designed to investigate whether a Japanese-adapted version of SPARX improves depressive symptoms in Japanese university students with mild-to-moderate depressive symptoms. Methods: In this 7-week, multicenter, stratified, parallel-group, superiority randomized trial, participants will be allocated to either a treatment condition (SPARX) or a wait-list control condition. SPARX is a fully automated program, which will be delivered to the mobile phone or tablet device of the participants. SPARX is designed as an interactive fantasy game to guide the user through seven modules that teach key CBT strategies. All participants will be recruited from universities via advertisements on online bulletin boards, the campus newspaper, and posters. Participants in the treatment condition will use the SPARX program weekly. The primary outcome is the reduction of depressive symptoms (using Patient Health Questionnaires-9) measured at baseline and weekly: once after the 7-week intervention and once at a 1-month follow-up. Secondary outcomes include satisfaction with the program and satisfaction with life, measured by the Satisfaction With Life Scale; positive and negative moods, measured by the Profile of Mood States Second Edition; social functioning, measured by the EuroQol Instrument; rumination, measured by the Ruminative Responses Scale; and coping, measured by the Brief Coping Orientation to Problem Experienced Inventory. Results: This study received funding from The Research Institute of Personalized Health Sciences, Health Sciences University of Hokkaido, and obtained institutional review board approval in September 2019. Data collection began in April 2019. Conclusions: Results of this trial may provide further evidence for the efficacy of gamified cCBT for the treatment of depression and, specifically, provide support for using SPARX with Japanese university students. Trial Registration: Japan Primary Registries Network UMIN000034354; https://tinyurl.com/uu7xd77 International Registered Report Identifier (IRRID): DERR1-10.2196/15164 %M 32254045 %R 10.2196/15164 %U https://www.researchprotocols.org/2020/4/e15164 %U https://doi.org/10.2196/15164 %U http://www.ncbi.nlm.nih.gov/pubmed/32254045 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e17767 %T Efficacy of the Digital Therapeutic Mobile App BioBase to Reduce Stress and Improve Mental Well-Being Among University Students: Randomized Controlled Trial %A Ponzo,Sonia %A Morelli,Davide %A Kawadler,Jamie M %A Hemmings,Nicola Rose %A Bird,Geoffrey %A Plans,David %+ Initiative in the Digital Economy, Department of Science, Innovation, Technology, and Entrepreneurship, University of Exeter, Stocker Road, Exeter, EX4 4PY, United Kingdom, 44 7527016574, D.Plans@exeter.ac.uk %K anxiety %K depression %K mobile apps %K biofeedback %K mental health %K mobile phones %K technology %D 2020 %7 6.4.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: University students in the United Kingdom are experiencing increasing levels of anxiety. A program designed to increase awareness of one’s present levels of well-being and suggest personalized health behaviors may reduce anxiety and improve mental well-being in students. The efficacy of a digital version of such a program, providing biofeedback and therapeutic content based on personalized well-being metrics, is reported here. Objective: The aim of this study was to test the efficacy and sustained effects of using a mobile app (BioBase) and paired wearable device (BioBeam), compared with a waitlist control group, on anxiety and well-being in university students with elevated levels of anxiety and stress. Methods: The study employed a randomized, waitlist-controlled trial with assessments at baseline, 2 weeks, postintervention (4 weeks), and follow-up (6 weeks). Participants were eligible if they were current full-time undergraduate students and (1) at least 18 years of age, (2) scored >14 points on the Depression, Anxiety, and Stress Scale-21 items (DASS-21) stress subscale or >7 points on the DASS-21 anxiety subscale, (3) owned an iOS mobile phone, (4) did not have any previous psychiatric or neurological conditions, (6) were not pregnant at the time of testing, and (7) were able to read and understand English. Participants were encouraged to use BioBase daily and complete at least one course of therapeutic content. A P value ≤.05 was considered statistically significant. Results: We found that a 4-week intervention with the BioBase program significantly reduced anxiety and increased perceived well-being, with sustained effects at a 2-week follow-up. Furthermore, a significant reduction in depression levels was found following the 4-week usage of BioBase. Conclusions: This study shows the efficacy of a biofeedback digital intervention in reducing self-reported anxiety and increasing perceived well-being in UK university students. Results suggest that digital mental health interventions could constitute a novel approach to treat stress and anxiety in students, which could be combined or integrated with existing therapeutic pathways. Trial Registration: Open Science Framework (OSF.io) 2zd45; https://osf.io/2zd45/ %M 31926063 %R 10.2196/17767 %U https://mhealth.jmir.org/2020/4/e17767 %U https://doi.org/10.2196/17767 %U http://www.ncbi.nlm.nih.gov/pubmed/31926063 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 4 %P e14278 %T Critical Predictors for the Early Detection of Conversion From Unipolar Major Depressive Disorder to Bipolar Disorder: Nationwide Population-Based Retrospective Cohort Study %A Hu,Ya-Han %A Chen,Kuanchin %A Chang,I-Chiu %A Shen,Cheng-Che %+ Department of Psychiatry, Chiayi Branch, Taichung Veterans General Hospital, No. 600, Sec 2, Shixian Road, West District, Chiayi City, 60090, Taiwan, 886 52359630, pures1000@yahoo.com.tw %K major depressive disorder %K bipolar disorder %K National Health Insurance Database %K data mining %K classification and regression tree %D 2020 %7 3.4.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Unipolar major depressive disorder (MDD) and bipolar disorder are two major mood disorders. The two disorders have different treatment strategies and prognoses. However, bipolar disorder may begin with depression and could be diagnosed as MDD in the initial stage, which may later contribute to treatment failure. Previous studies indicated that a high proportion of patients diagnosed with MDD will develop bipolar disorder over time. This kind of hidden bipolar disorder may contribute to the treatment resistance observed in patients with MDD. Objective: In this population-based study, our aim was to investigate the rate and risk factors of a diagnostic change from unipolar MDD to bipolar disorder during a 10-year follow-up. Furthermore, a risk stratification model was developed for MDD-to-bipolar disorder conversion. Methods: We conducted a retrospective cohort study involving patients who were newly diagnosed with MDD between January 1, 2000, and December 31, 2004, by using the Taiwan National Health Insurance Research Database. All patients with depression were observed until (1) diagnosis of bipolar disorder by a psychiatrist, (2) death, or (3) December 31, 2013. All patients with depression were divided into the following two groups, according to whether bipolar disorder was diagnosed during the follow-up period: converted group and nonconverted group. Six groups of variables within the first 6 months of enrollment, including personal characteristics, physical comorbidities, psychiatric comorbidities, health care usage behaviors, disorder severity, and psychotropic use, were extracted and were included in a classification and regression tree (CART) analysis to generate a risk stratification model for MDD-to-bipolar disorder conversion. Results: Our study enrolled 2820 patients with MDD. During the follow-up period, 536 patients were diagnosed with bipolar disorder (conversion rate=19.0%). The CART method identified five variables (kinds of antipsychotics used within the first 6 months of enrollment, kinds of antidepressants used within the first 6 months of enrollment, total psychiatric outpatient visits, kinds of benzodiazepines used within one visit, and use of mood stabilizers) as significant predictors of the risk of bipolar disorder conversion. This risk CART was able to stratify patients into high-, medium-, and low-risk groups with regard to bipolar disorder conversion. In the high-risk group, 61.5%-100% of patients with depression eventually developed bipolar disorder. On the other hand, in the low-risk group, only 6.4%-14.3% of patients with depression developed bipolar disorder. Conclusions: The CART method identified five variables as significant predictors of bipolar disorder conversion. In a simple two- to four-step process, these variables permit the identification of patients with low, intermediate, or high risk of bipolar disorder conversion. The developed model can be applied to routine clinical practice for the early diagnosis of bipolar disorder. %M 32242821 %R 10.2196/14278 %U https://medinform.jmir.org/2020/4/e14278 %U https://doi.org/10.2196/14278 %U http://www.ncbi.nlm.nih.gov/pubmed/32242821 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e15033 %T Assessing Real-Time Moderation for Developing Adaptive Mobile Health Interventions for Medical Interns: Micro-Randomized Trial %A NeCamp,Timothy %A Sen,Srijan %A Frank,Elena %A Walton,Maureen A %A Ionides,Edward L %A Fang,Yu %A Tewari,Ambuj %A Wu,Zhenke %+ Department of Statistics, University of Michigan, 1085 South University Ave, Ann Arbor, MI, 48109, United States, 1 7346474820, tnecamp@umich.edu %K mobile health %K digital health %K smartphone %K mobile phone %K wearable devices %K ecological momentary assessment %K depression %K mood %K physical activity %K sleep %K moderator variables %D 2020 %7 31.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Individuals in stressful work environments often experience mental health issues, such as depression. Reducing depression rates is difficult because of persistently stressful work environments and inadequate time or resources to access traditional mental health care services. Mobile health (mHealth) interventions provide an opportunity to deliver real-time interventions in the real world. In addition, the delivery times of interventions can be based on real-time data collected with a mobile device. To date, data and analyses informing the timing of delivery of mHealth interventions are generally lacking. Objective: This study aimed to investigate when to provide mHealth interventions to individuals in stressful work environments to improve their behavior and mental health. The mHealth interventions targeted 3 categories of behavior: mood, activity, and sleep. The interventions aimed to improve 3 different outcomes: weekly mood (assessed through a daily survey), weekly step count, and weekly sleep time. We explored when these interventions were most effective, based on previous mood, step, and sleep scores. Methods: We conducted a 6-month micro-randomized trial on 1565 medical interns. Medical internship, during the first year of physician residency training, is highly stressful, resulting in depression rates several folds higher than those of the general population. Every week, interns were randomly assigned to receive push notifications related to a particular category (mood, activity, sleep, or no notifications). Every day, we collected interns’ daily mood valence, sleep, and step data. We assessed the causal effect moderation by the previous week’s mood, steps, and sleep. Specifically, we examined changes in the effect of notifications containing mood, activity, and sleep messages based on the previous week’s mood, step, and sleep scores. Moderation was assessed with a weighted and centered least-squares estimator. Results: We found that the previous week’s mood negatively moderated the effect of notifications on the current week’s mood with an estimated moderation of −0.052 (P=.001). That is, notifications had a better impact on mood when the studied interns had a low mood in the previous week. Similarly, we found that the previous week’s step count negatively moderated the effect of activity notifications on the current week’s step count, with an estimated moderation of −0.039 (P=.01) and that the previous week’s sleep negatively moderated the effect of sleep notifications on the current week’s sleep with an estimated moderation of −0.075 (P<.001). For all three of these moderators, we estimated that the treatment effect was positive (beneficial) when the moderator was low, and negative (harmful) when the moderator was high. Conclusions: These findings suggest that an individual’s current state meaningfully influences their receptivity to mHealth interventions for mental health. Timing interventions to match an individual’s state may be critical to maximizing the efficacy of interventions. Trial Registration: ClinicalTrials.gov NCT03972293; http://clinicaltrials.gov/ct2/show/NCT03972293 %M 32229469 %R 10.2196/15033 %U http://www.jmir.org/2020/3/e15033/ %U https://doi.org/10.2196/15033 %U http://www.ncbi.nlm.nih.gov/pubmed/32229469 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e18047 %T Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression: Randomized Controlled Trial %A Lindqvist,Karin %A Mechler,Jakob %A Carlbring,Per %A Lilliengren,Peter %A Falkenström,Fredrik %A Andersson,Gerhard %A Johansson,Robert %A Edbrooke-Childs,Julian %A Dahl,Hanne-Sofie J %A Lindert Bergsten,Katja %A Midgley,Nick %A Sandell,Rolf %A Thorén,Agneta %A Topooco,Naira %A Ulberg,Randi %A Philips,Björn %+ Department of Psychology, Stockholm University, SE-106 91, Stockholm, Sweden, 46 (0)8 16 20 10, bjorn.philips@psychology.su.se %K depressive disorder %K adolescents %K psychodynamic %K internet-based treatment %K treatment outcome %K mobile phone %D 2020 %7 30.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Adolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments. Objective: This trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents. Methods: The trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment. Results: IPDT was significantly more effective than the control condition in reducing depression (d=0.82, P=.01), the result of which was corroborated by the second depression measure (d=0.80, P<.001). IPDT was also significantly more effective in reducing anxiety (d=0.78, P<.001) and increasing emotion regulation (d=0.97, P<.001) and self-compassion (d=0.65, P=.003). Significantly more patients in the IPDT group compared to the control group met criteria for response (56% vs 21%, respectively) and remission (35% vs 8%, respectively). Results on depression and anxiety symptoms were stable at 6 months follow-up. On average, participants completed 5.8 (SD 2.4) of the 8 modules. Conclusions: IPDT may be an effective intervention to reduce adolescent depression. Further research is needed, including comparisons with other treatments. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 16206254; http://www.isrctn.com/ISRCTN16206254 %M 32224489 %R 10.2196/18047 %U http://www.jmir.org/2020/3/e18047/ %U https://doi.org/10.2196/18047 %U http://www.ncbi.nlm.nih.gov/pubmed/32224489 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e16547 %T Experiences of Internet-Based Stepped Care in Individuals With Cancer and Concurrent Symptoms of Anxiety and Depression: Qualitative Exploration Conducted Alongside the U-CARE AdultCan Randomized Controlled Trial %A Hauffman,Anna %A Alfonsson,Sven %A Igelström,Helena %A Johansson,Birgitta %+ Department of Immunology, Genetics and Pathology, Section of Experimental and Clinical Oncology, Uppsala University, Akademiska University Hospital ing 100 D, Uppsala, SE-751 85, Sweden, 46 18 611 00 00, anna.hauffman@igp.uu.se %K internet-based stepped care %K internet-based interactive health communication application %K internet-based intervention %K telemedicine %K patient portals %K oncology nursing %K self care %K psychoeducation %D 2020 %7 30.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Individuals with newly diagnosed cancer may experience impaired health in several aspects and often have a large need for information and support. About 30% will experience symptoms of anxiety and depression, with varying needs of knowledge and support. Despite this, many of these patients lack appropriate support. Internet-based support programs may offer a supplement to standard care services, but must be carefully explored from a user perspective. Objective: The purpose of this study was to explore the participants’ perceptions of the relevance and benefits of an internet-based stepped care program (iCAN-DO) targeting individuals with cancer and concurrent symptoms of anxiety and depression. Methods: We performed a qualitative study with an inductive approach, in which we used semistructured questions to interview 15 individuals using iCAN-DO. We analyzed the interviews using content analysis. Results: The analysis found 17 subcategories regarding the stepped care intervention, resulting in 4 categories. Participants described the need for information as large and looked upon finding information almost as a survival strategy when receiving the cancer diagnosis. iCAN-DO was seen as a useful, reliable source of information and support. It was used as a complement to standard care and as a means to inform next of kin. Increased knowledge was a foundation for continued processing of participants’ own feelings. The optimal time to gain access to iCAN-DO would have been when being informed of the diagnosis. The most common denominator was feeling acknowledged and supported, but with a desire for further adaptation of the system to each individual’s own situation and needs. Conclusions: Users saw the internet-based stepped care program as safe and reliable and used it as a complement to standard care. Similar interventions may gain from more personalized contents, being integrated into standard care, or using symptom tracking to adjust the contents. Offering this type of program close to diagnosis may provide benefits to users. Trial Registration: ClincalTrials.gov NCT-01630681; https://clinicaltrials.gov/ct2/show/NCT01630681 %M 32224483 %R 10.2196/16547 %U http://www.jmir.org/2020/3/e16547/ %U https://doi.org/10.2196/16547 %U http://www.ncbi.nlm.nih.gov/pubmed/32224483 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e17282 %T Text Messaging as a Screening Tool for Depression and Related Conditions in Underserved, Predominantly Minority Safety Net Primary Care Patients: Validity Study %A Jin,Haomiao %A Wu,Shinyi %+ Suzanne Dworak-Peck School of Social Work, University of Southern California, 1150 S Olive Street, Suite 1400, Los Angeles, CA, 90015, United States, 1 2138216441, haomiaoj@usc.edu %K depression %K diabetes mellitus %K comorbidity %K screening %K primary care %K health information technology %K mobile health %K text messaging %K patient reported outcome measures %D 2020 %7 26.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: SMS text messaging is an inexpensive, private, and scalable technology-mediated assessment mode that can alleviate many barriers faced by the safety net population to receive depression screening. Some existing studies suggest that technology-mediated assessment encourages self-disclosure of sensitive health information such as depressive symptoms while other studies show the opposite effect. Objective: This study aimed to evaluate the validity of using SMS text messaging to screen depression and related conditions, including anxiety and functional disability, in a low-income, culturally diverse safety net primary care population. Methods: This study used a randomized design with 4 study groups that permuted the order of SMS text messaging and the gold standard interview (INTW) assessment. The participants for this study were recruited from the participants of the prior Diabetes-Depression Care-management Adoption Trial (DCAT). Depression was screened by using the 2-item and 8-item Patient Health Questionnaire (PHQ-2 and PHQ-8, respectively). Anxiety was screened by using the 2-item Generalized Anxiety Disorder scale (GAD-2), and functional disability was assessed by using the Sheehan Disability Scale (SDS). Participants chose to take up the assessment in English or Spanish. Internal consistency and test-retest reliability were evaluated by using Cronbach alpha and intraclass correlation coefficient (ICC), respectively. Concordance was evaluated by using an ICC, a kappa statistic, an area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. A regression analysis was conducted to examine the association between the participant characteristics and the differences in the scores between the SMS text messaging and INTW assessment modes. Results: Overall, 206 participants (average age 57.1 [SD 9.18] years; females: 119/206, 57.8%) were enrolled. All measurements except the SMS text messaging–assessed PHQ-2 showed Cronbach alpha values ≥.70, indicating acceptable to good internal consistency. All measurements except the INTW-assessed SDS had ICC values ≥0.75, indicating good to excellent test-retest reliability. For concordance, the PHQ-8 had an ICC of 0.73 and AUROC of 0.93, indicating good concordance. The kappa statistic, sensitivity, and specificity for major depression (PHQ-8 ≥8) were 0.43, 0.60, and 0.86, respectively. The concordance of the shorter PHQ-2, GAD-2, and SDS scales was poor to fair. The regression analysis revealed that a higher level of personal depression stigma was associated with reporting higher SMS text messaging–assessed PHQ-8 and GAD-2 scores than the INTW-assessed scores. The analysis also determined that the differences in the scores were associated with marital status and personality traits. Conclusions: Depression screening conducted using the longer PHQ-8 scale via SMS text messaging demonstrated good internal consistency, test-retest reliability, and concordance with the gold standard INTW assessment mode. However, care must be taken when deploying shorter scales via SMS text messaging. Further regression analysis supported that a technology-mediated assessment, such as SMS text messaging, may create a private space with less pressure from the personal depression stigma and therefore encourage self-disclosure of depressive symptoms. Trial Registration: ClinicalTrials.gov NCT01781013; https://clinicaltrials.gov/ct2/show/NCT01781013 International Registered Report Identifier (IRRID): RR2-10.2196/12392 %M 32213473 %R 10.2196/17282 %U http://www.jmir.org/2020/3/e17282/ %U https://doi.org/10.2196/17282 %U http://www.ncbi.nlm.nih.gov/pubmed/32213473 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e15312 %T Brief Web-Based Intervention for Depression: Randomized Controlled Trial on Behavioral Activation %A Jelinek,Lena %A Arlt,Sönke %A Moritz,Steffen %A Schröder,Johanna %A Westermann,Stefan %A Cludius,Barbara %+ Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany, 49 407410 ext 58087, ljelinek@uke.de %K affective disorders %K depressive symptoms %K brief psychotherapy %K internet %K world wide web %D 2020 %7 26.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based interventions have been shown to be effective for the treatment of depression. However, interventions are often complex and include a variety of elements, making it difficult to identify the most effective component(s). Objective: The aim of this pilot study was to shed light on mechanisms in the online treatment of depression by comparing a single-module, fully automated intervention for depression (internet-based behavioral activation [iBA]) to a nonoverlapping active control intervention and a nonactive control group. Methods: We assessed 104 people with at least mild depressive symptoms (Patient Health Questionnaire-9, >4) via the internet at baseline (t0) and 2 weeks (t1) and 4 weeks (t2) later. After the t0 assessment, participants were randomly allocated to one of three groups: (1) iBA (n=37), (2) active control using a brief internet-based mindfulness intervention (iMBI, n=32), or (3) care as usual (CAU, n=35). The primary outcome was improvement in depressive symptoms, as measured using the Patient Health Questionnaire-9. Secondary parameters included changes in activity, dysfunctional attitudes, and quality of life Results: While groups did not differ regarding the change in depression from t0 to t1 (ηp2=.007, P=.746) or t0 to t2 (ηp2=.008, P=.735), iBA was associated with a larger decrease in dysfunctional attitudes from t0 to t2 in comparison to CAU (ηp2=.053, P=.04) and a larger increase in activity from t0 to t1 than the pooled control groups (ηp2=.060, P=.02). A change in depression from t0 to t2 was mediated by a change in activity from t0 to t1. At t1, 22% (6/27) of the participants in the iBA group and 12% (3/25) of the participants in the iMBI group indicated that they did not use the intervention. Conclusions: Although we did not find support for the short-term efficacy of the single-module iBA regarding depression, long-term effects are still conceivable, potentially initiated by changes in secondary outcomes. Future studies should use a longer intervention and follow-up interval. Trial Registration: DKRS (#DRKS00011562) %M 32213470 %R 10.2196/15312 %U http://www.jmir.org/2020/3/e15312/ %U https://doi.org/10.2196/15312 %U http://www.ncbi.nlm.nih.gov/pubmed/32213470 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e15824 %T The Association of Therapeutic Alliance With Long-Term Outcome in a Guided Internet Intervention for Depression: Secondary Analysis From a Randomized Control Trial %A Gómez Penedo,Juan Martín %A Babl,Anna Margarete %A grosse Holtforth,Martin %A Hohagen,Fritz %A Krieger,Tobias %A Lutz,Wolfgang %A Meyer,Björn %A Moritz,Steffen %A Klein,Jan Philipp %A Berger,Thomas %+ Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, Bern, 3012, Switzerland, 41 31 631 5424, jmgomezpenedo@gmail.com %K internet interventions %K guidance %K alliance %K Working Alliance Inventory for Guided Internet Intervention %K only interventions %K tasks and goals %K bond %D 2020 %7 24.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Therapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes. Objective: The aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties. Methods: A sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment. Results: We found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ02=−1.74, standard error [SE]=0.40, 95% CI −2.52 to −0.96, t206=−4.37, P<.001) and patient well-being (γ02=3.10, SE=1.14, 95% CI 0.87-5.33, t198=2.72, P=.007) at the end of follow-up. A greater score in this subscale was related to lower levels of residual depressive symptoms and a higher level of well-being. However, there were no significant effects of the tasks and goals subscale on the rate of change in these variables during follow-up (depressive symptoms, P=.48; patient well-being, P=.26). The effects of the bond subscale were also nonsignificant when predicting the estimated values of depressive symptoms and well-being at the end of follow-up and the rate of change during that period (depressive symptoms, P=.08; patient well-being, P=.68). Conclusions: The results of this study point out the importance of attuning internet interventions to patients’ expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient’s individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats. %M 32207689 %R 10.2196/15824 %U https://www.jmir.org/2020/3/e15824 %U https://doi.org/10.2196/15824 %U http://www.ncbi.nlm.nih.gov/pubmed/32207689 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 3 %P e14860 %T Three Decades of Internet- and Computer-Based Interventions for the Treatment of Depression: Protocol for a Systematic Review and Meta-Analysis %A Moshe,Isaac %A Terhorst,Yannik %A Cuijpers,Pim %A Cristea,Ioana %A Pulkki-Råback,Laura %A Sander,Lasse %+ Department of Rehabilitation Psychology and Psychotherapy, University of Freiburg, Engelbergerstrasse 41, Freiburg, 79085, Germany, 49 761 203 3049, lasse.sander@psychologie.uni-freiburg.de %K depression %K internet-based interventions %K meta-analysis %K review %D 2020 %7 24.3.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is one of the leading causes of disability worldwide. Internet- and computer-based interventions (IBIs) have been shown to provide effective, scalable forms of treatment. More than 100 controlled trials and a growing number of meta-analyses published over the past 30 years have demonstrated the efficacy of IBIs in reducing symptoms in the short and long term. Despite the large body of research, no comprehensive review or meta-analysis has been conducted to date that evaluates how the effectiveness of IBIs has evolved over time. Objective: This systematic review and meta-analysis aims to evaluate whether there has been a change in the effectiveness of IBIs on the treatment of depression over the past 30 years and to identify potential variables moderating the effect size. Methods: A sensitive search strategy will be executed across the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO. Data extraction and evaluation will be conducted by two independent researchers. Risk of bias will be assessed. A multilevel meta-regression model will be used to analyze the data and estimate effect size. Results: The search was completed in mid-2019. We expect the results to be submitted for publication in early 2020. Conclusions: The year 2020 will mark 30 years since the first paper was published on the use of IBIs for the treatment of depression. Despite the large and rapidly growing body of research in the field, evaluations of effectiveness to date are missing the temporal dimension. This review will address that gap and provide valuable analysis of how the effectiveness of interventions has evolved over the past three decades; which participant-, intervention-, and study-related variables moderate changes in effectiveness; and where research in the field may benefit from increased focus. Trial Registration: PROSPERO CRD42019136554; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=136554 International Registered Report Identifier (IRRID): PRR1-10.2196/14860 %M 32207695 %R 10.2196/14860 %U http://www.researchprotocols.org/2020/3/e14860/ %U https://doi.org/10.2196/14860 %U http://www.ncbi.nlm.nih.gov/pubmed/32207695 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e15172 %T The Effectiveness of a Guided Internet-Based Tool for the Treatment of Depression and Anxiety in Pregnancy (MamaKits Online): Randomized Controlled Trial %A Heller,Hanna M %A Hoogendoorn,Adriaan W %A Honig,Adriaan %A Broekman,Birit F P %A van Straten,Annemieke %+ Department of Psychiatry, Amsterdam Universitair Medische Centra, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, 1081 HV, Netherlands, 31 204440196, hm.heller@amsterdamumc.nl %K pregnancy %K depression %K anxiety %K internet %K pregnancy outcome %K treatment %D 2020 %7 23.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Pregnant women with symptoms of depression or anxiety often do not receive adequate treatment. In view of the high incidence of these symptoms in pregnancy and their impact on pregnancy outcomes, getting treatment is of the utmost importance. A guided internet self-help intervention may help to provide more women with appropriate treatment. Objective: This study aimed to examine the effectiveness of a guided internet intervention (MamaKits online) for pregnant women with moderate to severe symptoms of anxiety or depression. Assessments took place before randomization (T0), post intervention (T1), at 36 weeks of pregnancy (T2), and 6 weeks postpartum (T3). We also explored effects on perinatal child outcomes 6 weeks postpartum. Methods: This randomized controlled trial included pregnant women (<30 weeks) with depressive symptoms above threshold (ie, Center for Epidemiological Studies Depression scale [CES-D] >16) or anxiety above threshold (ie, Hospital Anxiety and Depression Scale-Anxiety subscale [HADS-A] >8) or both of them. Participants were recruited via general media and flyers in prenatal care waiting rooms or via obstetricians and midwives. After initial assessment, women were randomized to (1) MamaKits online in addition to treatment as usual or (2) treatment as usual (control condition). MamaKits online is a 5-week guided internet intervention based on problem solving treatment. Guidance was was provided by trained students pursuing a Master's in Psychology. Outcomes were based on a Web-based self-report. Women in the control condition were allowed to receive the intervention after the last assessment (6 weeks postpartum). Results: Of the 159 included women, 79 were randomized to MamaKits online, 47% (79/37) of whom completed the intervention. Both groups showed a substantial decrease in affective symptoms on the CES-D, HADS-A, and Edinburgh Postnatal Depression Scale over time. In the intervention group, affective symptoms decreased more than that in the control group, but between-group effect sizes were small to medium (Cohen d at T3=0.45, 0.21, and 0.23 for the 3 questionnaires, respectively) and statistically not significant. Negative perinatal child outcomes did not differ between the 2 groups (χ21=0.1; P=.78). Completer analysis revealed no differences in outcome between the treatment completers and the control group. The trial was terminated early for reasons of futility based on the results of an interim analysis, which we performed because of inclusion problems. Conclusions: Our study did show a significant reduction in affective symptoms in both groups, but the differences in reduction of affective symptoms between the intervention and control groups were not significant. There were also no differences in perinatal child outcomes. Future research should examine for which women these interventions might be effective or if changes in the internet intervention might make the intervention more effective. Trial Registration: Netherlands Trial Register NL4162; https://tinyurl.com/sdckjek %M 32202505 %R 10.2196/15172 %U http://www.jmir.org/2020/3/e15172/ %U https://doi.org/10.2196/15172 %U http://www.ncbi.nlm.nih.gov/pubmed/32202505 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 3 %P e14842 %T Digital Cognitive Behavioral Therapy for Insomnia for Adolescents With Mental Health Problems: Feasibility Open Trial %A Cliffe,Bethany %A Croker,Abigail %A Denne,Megan %A Smith,Jacqueline %A Stallard,Paul %+ Department of Health, University of Bath, 1 West, Claverton Down, Bath, BA2 7AY, United Kingdom, 44 01225 388388, p.stallard@bath.ac.uk %K insomnia %K internet-based intervention %K cognitive therapy %K mental health %D 2020 %7 3.3.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Insomnia in adolescents is common, persistent, and associated with poor mental health including anxiety and depression. Insomnia in adolescents attending child mental health services is seldom directly treated, and the effects of digital cognitive behavioral therapy (CBT) for insomnia (CBTi) on the mental health of adolescents with significant mental health problems are unknown. Objective: This open study aimed to assess the feasibility of adding supported Web-based CBT for insomnia to the usual care of young people aged 14 to 17 years attending specialist child and adolescent mental health services (CAMHS). Methods: A total of 39 adolescents with insomnia aged 14 to 17 years attending specialist CAMHS were assessed and offered digital CBTi. The digital intervention was Sleepio, an evidence-based, self-directed, fully automated CBTi that has proven effective in multiple randomized controlled trials with adults. Self-report assessments of sleep (Sleep Condition Indicator [SCI], Insomnia Severity Scale, and Web- or app-based sleep diaries), anxiety (Revised Child Anxiety and Depression Scale [RCADS]), and depression (Mood and Feelings Questionnaire [MFQ]) were completed at baseline and post intervention. Postuse interviews assessed satisfaction with digital CBTi. Results: Average baseline sleep efficiency was very poor (53%), with participants spending an average of 9.6 hours in bed but only 5.1 hours asleep. All participants scored less than 17 on the SCI, with 92% (36/39) participants scoring 15 or greater on the Insomnia Severity Scale, suggesting clinical insomnia. Of the 39 participants, 36 (92%) scored 27 or greater on the MFQ for major depression and 20 (51%) had clinically elevated symptoms of anxiety. The majority of participants (38/49, 78%) were not having any treatment for their insomnia, with the remaining 25% (12/49) receiving medication. Sleepio was acceptable, with 77% (30/39) of the participants activating their account and 54% (21/39) completing the program. Satisfaction was high, with 84% (16/19) of the participants finding Sleepio helpful, 95% (18/19) indicating that they would recommend it to a friend, and 37% (7/19) expressing a definite preference for a digital intervention. Statistically significant pre-post improvements were found in weekly diaries of sleep efficiency (P=.005) and sleep quality (P=.001) and on measures of sleep (SCI: P=.001 and Insomnia Severity Index: P=.001), low mood (MFQ: P=.03), and anxiety (RCADS: P=.005). Conclusions: Our study has a number of methodological limitations, particularly the small sample size, absence of a comparison group and no follow-up assessment. Nonetheless, our findings are encouraging and suggest that digital CBTi for young people with mental health problems might offer an acceptable and an effective way to improve both sleep and mental health. International Registered Report Identifier (IRRID): RR2-10.2196/11324 %M 32134720 %R 10.2196/14842 %U https://mental.jmir.org/2020/3/e14842 %U https://doi.org/10.2196/14842 %U http://www.ncbi.nlm.nih.gov/pubmed/32134720 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 2 %P e16105 %T Evaluating the Effect of Daily Diary Instructional Phrases on Respondents’ Recall Time Frames: Survey Experiment %A Stone,Arthur A %A Wen,Cheng K Fred %A Schneider,Stefan %A Junghaenel,Doerte U %+ Center for Self-Report Science and Center for Economic and Social Research, University of Southern California, 635 Downey Way 405H, Los Angeles, CA, 90089, United States, 1 2138212894, chengkuw@usc.edu %K end-of-day dairy %K daily diary study %K recall time frame %D 2020 %7 21.2.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Daily diaries are extensively used for examining participants’ daily experience in behavioral and medical science. However, little attention is paid to whether participants recall their experiences within the time frames prescribed by the task. Objective: This study aimed to describe survey respondents’ self-reported recall time frames and to evaluate the impact of different daily diary items on respondents’ reported affective states. Methods: In this study, 577 participants completed a mood survey with one of the following 4 time frame instructions: (1) today, (2) since waking up today, (3) during the last 24 hours, or (4) in the last day. They were also asked to indicate the periods they considered when answering these items and to recall the instructional phrases associated with the items. Results: Almost all participants in the today (141/146, 96.6%) and since waking up today (136/145, 93.8%) conditions reported using periods consistent with our expectations, whereas a lower proportion was observed in the during the last 24 hours (100/145, 69.0%) condition. A diverse range of responses was observed in the in the last day condition. Furthermore, the instructions influenced the levels of some self-reported affects, although exploratory analyses were not able to identify the mechanism underlying this finding. Conclusions: Overall, these results indicate that today and since waking up today are the most effective instructional phrases for inquiring about daily experience and that investigators should use caution when using the other 2 instructional phrases. %M 32130129 %R 10.2196/16105 %U http://www.jmir.org/2020/2/e16105/ %U https://doi.org/10.2196/16105 %U http://www.ncbi.nlm.nih.gov/pubmed/32130129 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 2 %P e15520 %T An Eight-Week, Web-Based Mindfulness Virtual Community Intervention for Students’ Mental Health: Randomized Controlled Trial %A Ahmad,Farah %A El Morr,Christo %A Ritvo,Paul %A Othman,Nasih %A Moineddin,Rahim %A , %+ School of Health Policy and Management, York University, Stong 350, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada, 1 4167362100 ext 22053, Elmorr@yorku.ca %K mindfulness %K CBT %K depression %K anxiety %K students %K universities %K randomized controlled trial %K Canada %D 2020 %7 18.2.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Innovative interventions are needed to address the increasing mental health needs of university students. Given the demonstrated anxiolytic and antidepressant benefits of mindfulness training, we developed an 8-week, Web-based Mindfulness Virtual Community (MVC) intervention informed by cognitive behavioral therapy (CBT) constructs. Objective: This study investigated the efficacy of the MVC intervention in reducing symptoms of depression, anxiety, and stress among undergraduate students in Toronto, Canada. The secondary outcomes included quality of life, life satisfaction, and mindfulness. Methods: The first 4 weeks of the full MVC intervention (F-MVC) comprised: (1) 12 video-based modules with psycho-education on students’ preidentified stressful topics and topically applied mindfulness practice; (2) anonymous peer-to-peer discussion forums; and (3) anonymous, group-based, professionally guided, 20-min live videoconferences. The second 4 weeks of F-MVC involved access only to video-based modules. The 8-week partial MVC (P-MVC) comprised 12 video-based modules. A randomized controlled trial was conducted with 4 parallel arms: F-MVC, P-MVC, waitlist control (WLC), and group-based face-to-face CBT; results for the latter group are presented elsewhere. Students recruited through multiple strategies consented and were randomized: WLC=40; F-MVC=40, P-MVC=39; all learned about allocation after consenting. The online surveys at baseline (T1), 4 weeks (T2), and 8 weeks (T3) included the Patient Health Questionnaire-9 item, Beck Anxiety Inventory, Perceived Stress Scale, Quality of Life Scale, Brief Multi-Dimensional Students Life Satisfaction Scale, and Five-Facet Mindfulness Questionnaire. Analyses employed generalized estimation equation methods with AR(1) covariance structures and were adjusted for possible confounders (gender, age, birth country, paid work, unpaid work, physical activities, self-rated health, and mental health counseling access). Results: Of the 113 students who provided T1 data, 28 were males and 85 were females with a mean age of 24.8 years. Participants in F-MVC (n=39), P-MVC (n=35), and WLC (n=39) groups were similar in sociodemographic characteristics at T1. At T3 follow-up, per adjusted comparisons, there were statistically significant reductions in depression scores for F-MVC (score change −4.03; P<.001) and P-MVC (score change −4.82; P<.001) when compared with WLC. At T3, there was a statistically significant reduction in anxiety scores only for P-MVC (score change −7.35; P=.01) when compared with WLC. There was a statistically significant reduction in scores for perceived stress for both F-MVC (score change −5.32; P<.001) and P-MVC (score change −5.61; P=.005) compared with WLC. There were statistically significant changes at T3 for quality of life and mindfulness for F-MVC and P-MVC vs WLC but not for life satisfaction. Conclusions: Internet-based mindfulness CBT–based interventions, such as F-MVC and P-MVC, can result in significant reductions in symptoms of depression, anxiety, and stress in a student population. Future research with a larger sample from multiple universities would more precisely test generalizability. Trial Registration: International Standard Randomized Controlled Trial Number ISRCTN92827275; https://www.isrctn.com/ISRCTN92827275 %M 32074061 %R 10.2196/15520 %U https://mental.jmir.org/2020/2/e15520 %U https://doi.org/10.2196/15520 %U http://www.ncbi.nlm.nih.gov/pubmed/32074061 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 2 %P e16715 %T Effect of a WeChat-Based Intervention (Run4Love) on Depressive Symptoms Among People Living With HIV in China: Randomized Controlled Trial %A Guo,Yan %A Hong,Y Alicia %A Cai,Weiping %A Li,Linghua %A Hao,Yuantao %A Qiao,Jiaying %A Xu,Zhimeng %A Zhang,Hanxi %A Zeng,Chengbo %A Liu,Cong %A Li,Yiran %A Zhu,Mengting %A Zeng,Yu %A Penedo,Frank J %+ Department of Health Administration and Policy, College of Health and Human Services, George Mason University, 4400 University Dr MS 1J3, Fairfax, VA, United States, 1 7039931929, yhong22@gmu.edu %K HIV %K depression %K mHealth %K WeChat %K randomized controlled trial %D 2020 %7 11.2.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: People living with HIV (PLWH) have high rates of depressive symptoms. However, only a few effective mental health interventions exist for this vulnerable population. Objective: The aim of this study was to assess the efficacy of a WeChat-based intervention, Run4Love, with a randomized controlled trial among 300 people living with HIV and depression (PLWHD) in China. Methods: We recruited PLWH from the HIV outpatient clinic in South China. Participants were screened based on the Center for Epidemiologic Studies-Depression (CES-D) scale. Those who scored 16 or higher were eligible to participate. A total of 300 eligible patients were enrolled. After obtaining informed consent from the participants, completion of a baseline survey, and collection of participants’ hair samples for measuring cortisol, the participants were randomly assigned to an intervention or a control group in a 1:1 ratio. The intervention group received the Run4Love program, delivered via the popular social media app WeChat. Cognitive behavioral stress management courses and weekly reminders of exercise were delivered in a multimedia format. Participants’ progress was monitored with timely and tailored feedback. The control group received usual care and a brochure on nutrition for PLWH. Data were collected at 3, 6, and 9 months. The primary outcome was depression, which was measured by a validated instrument. Results: Participants in the intervention and control groups were comparable at baseline; about 91.3% (139/150), 88.3% (132/150), and 86.7% (130/150) participants completed the 3-, 6-, and 9-month follow-ups, respectively. At the 3-month follow-up, a significant reduction in CES-D score was observed in the intervention group (from 23.9 to 17.7 vs from 24.3 to 23.8; mean difference=−5.77, 95% CI −7.82 to −3.71; P<.001; standard effect size d=0.66). The mean changes in CES-D score from baseline to the 6- and 9-month follow-ups between the two groups remained statistically significant. No adverse events were reported. Conclusions: The WeChat-based mobile health (mHealth) intervention Run4Love significantly reduced depressive symptoms among PLWHD, and the effect was sustained. An app-based mHealth intervention could provide a feasible therapeutic option for many PLWHD in resource-limited settings. Further research is needed to assess generalizability and cost-effectiveness of this intervention. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IPR-17012606; http://www.chictr.org.cn/showproj.aspx?proj=21019 (Archived by WebCite at https://www.webcitation.org/78Bw2vouF) %R 10.2196/16715 %U https://www.jmir.org/2020/2/e16715 %U https://doi.org/10.2196/16715 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 2 %P e16267 %T Willingness to Seek Help for Depression in Young African American Adults: Protocol for a Mixed Methods Study %A Bamgbade,Benita A %A Barner,Jamie C %A Ford,Kentya H %A Brown,Carolyn M %A Lawson,William B %A Burdine,Kimberly %+ Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, 140 The Fenway, Room R218X, 360 Huntington Avenue, Boston, MA, 02115, United States, 1 6173737973, b.bamgbade@northeastern.edu %K African American young adults %K depression %K willingness to seek help %K Theory of Planned Behavior %D 2020 %7 11.2.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: In the United States, among those living with mental illness, 81% of African American (AA) young adults do not seek treatment compared with 66% of their white counterparts. Although the literature has identified unique culturally related factors that impact help seeking among AAs, limited information exists regarding the development and evaluation of interventions that incorporate these unique factors. Objective: This study aims to describe a study protocol designed to develop a culturally relevant, theory-based, psychoeducational intervention for AA young adults; to determine if exposure to the intervention impacts AA young adults’ willingness to seek help; and to determine whether cultural factors and stigma add to the prediction of willingness to seek help. Methods: The Theory of Planned Behavior (TPB) and Barrera and Castro’s framework for cultural adaptation of interventions were used as guiding frameworks. In stage 1 (information gathering), a literature review and three focus groups were conducted to identify salient cultural beliefs. Using stage 1 results, the intervention was designed in stage 2 (preliminary adaptation design), and in stage 3 (preliminary adaptation tests), the intervention was tested using pretest, posttest, and 3-month follow-up surveys. An experimental, mixed methods, prospective one-group intervention design was employed, and the primary outcomes were participants’ willingness and intention to seek help for depression and actual help-seeking behavior. Results: This study was funded in May 2016 and approved by the University of Texas at Austin institutional review board. Data were collected from November 2016 to March 2016. Of the 103 students who signed up to participate in the study, 70 (67.9%) completed the pre- and posttest surveys. The findings are expected to be submitted for publication in 2020. Conclusions: The findings from this research are expected to improve clinical practice by providing empirical evidence as to whether a culturally relevant psychoeducational intervention is useful for improving help seeking among young AAs. It will also inform future research and intervention development involving the TPB and willingness to seek help by identifying the important factors related to willingness to seek help. Advancing this field of research may facilitate improvements in help-seeking behavior among AA young people and reduce the associated mental health disparities that apparently manifest early on. International Registered Report Identifier (IRRID): DERR1-10.2196/16267 %R 10.2196/16267 %U https://www.researchprotocols.org/2020/2/e16267 %U https://doi.org/10.2196/16267 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 6 %N 1 %P e15750 %T A Novel Mobile Phone App Intervention With Phone Coaching to Reduce Symptoms of Depression in Survivors of Women’s Cancer: Pre-Post Pilot Study %A Chow,Philip I %A Drago,Fabrizio %A Kennedy,Erin M %A Cohn,Wendy F %+ University of Virginia, 560 Ray C Hunt Dr, Charlottesville, VA, 22903, United States, 1 9244345401, philip.i.chow@gmail.com %K mobile apps %K mental health %K mHealth %K women %K cancer survivors %D 2020 %7 6.2.2020 %9 Original Paper %J JMIR Cancer %G English %X Background: Psychological distress is a major issue among survivors of women’s cancer who face numerous barriers to accessing in-person mental health treatments. Mobile phone app–based interventions are scalable and have the potential to increase access to mental health care among survivors of women’s cancer worldwide. Objective: This study aimed to evaluate the acceptability and preliminary efficacy of a novel app-based intervention with phone coaching in a sample of survivors of women’s cancer. Methods: In a single-group, pre-post, 6-week pilot study in the United States, 28 survivors of women’s cancer used iCanThrive, a novel app intervention that teaches skills for coping with stress and enhancing well-being, with added phone coaching. The primary outcome was self-reported symptoms of depression (Center for Epidemiologic Studies Depression Scale). Emotional self-efficacy and sleep disruption were also assessed at baseline, 6-week postintervention, and 4 weeks after the intervention period. Feedback obtained at the end of the study focused on user experience of the intervention. Results: There were significant decreases in symptoms of depression and sleep disruption from baseline to postintervention. Sleep disruption remained significantly lower at 4-week postintervention compared with baseline. The iCanThrive app was launched a median of 20.5 times over the intervention period. The median length of use was 2.1 min. Of the individuals who initiated the intervention, 87% (20/23) completed the 6-week intervention. Conclusions: This pilot study provides support for the acceptability and preliminary efficacy of the iCanThrive intervention. Future work should validate the intervention in a larger randomized controlled study. It is important to develop scalable interventions that meet the psychosocial needs of different cancer populations. The modular structure of the iCanThrive app and phone coaching could impact a large population of survivors of women’s cancer. %R 10.2196/15750 %U http://cancer.jmir.org/2020/1/e15750/ %U https://doi.org/10.2196/15750 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 2 %P e16005 %T An Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety Among Clients Referred and Funded by Insurance Companies Compared With Those Who Are Publicly Funded: Longitudinal Observational Study %A Hadjistavropoulos,Heather D %A Peynenburg,Vanessa %A Mehta,Swati %A Adlam,Kelly %A Nugent,Marcie %A Gullickson,Kirsten M %A Titov,Nickolai %A Dear,Blake %+ Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK, , Canada, 1 3065855133, heather.hadjistavropoulos@uregina.ca %K internet %K disability %K depression %K anxiety %K insurance %K cognitive behavior therapy %D 2020 %7 4.2.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Anxiety and depression are leading causes of disability but are often undertreated. Internet-delivered cognitive behavioral therapy (ICBT) improves access to treatment by overcoming barriers to obtaining care. ICBT has been found to be efficacious in research trials and routine care, but there is limited research of ICBT when it is recommended and funded by insurance companies for clients on or recently in receipt of disability benefits or accommodations. Objective: The aim of this study was to examine ICBT engagement, treatment satisfaction, and effectiveness among individuals involved with 2 insurance companies. The 2 samples were benchmarked against published outcomes from a publicly funded (PF) ICBT clinic. Methods: Individuals who were on or recently in receipt of disability benefits and were either insurance company (IC) employees (n=21) or IC plan members (n=19) were referred to ICBT funded by the respective insurance companies. Outcomes were benchmarked against outcomes of ICBT obtained in a PF ICBT clinic, with clients in the clinic divided into those who reported no involvement with insurance companies (n=414) and those who were on short-term disability (n=44). All clients received the same 8-week, therapist-assisted, transdiagnostic ICBT course targeting anxiety and depression. Engagement was assessed using completion rates, log-ins, and emails exchanged. Treatment satisfaction was assessed posttreatment. Depression, anxiety, and disability measures were administered pretreatment, posttreatment, and at 3 months. Results: All samples showed high levels of ICBT engagement and treatment satisfaction. IC employees experienced significant improvement at posttreatment (depression d=0.77; anxiety d=1.13; and disability d=0.91) with outcomes maintained at 3 months. IC plan members, who notably had greater pretreatment disability than the other samples, experienced significant moderate effects at posttreatment (depression d=0.58; anxiety d=0.54; and disability d=0.60), but gains were not maintained at 3 months. Effect sizes at posttreatment in both IC samples were significantly smaller than in the PF sample who reported no insurance benefits (depression d=1.14 and anxiety d=1.30) and the PF sample who reported having short-term disability benefits (depression d=0.95 and anxiety d=1.07). No difference was seen in effect sizes among IC employees and the PF samples on disability. However, IC plan members experienced significantly smaller effects on disability d=0.60) compared with the PF sample with no disability benefits d=0.90) and those on short-term disability benefits d=0.94). Conclusions: Many clients referred and funded by insurance companies were engaged with ICBT and found it acceptable and effective. Results, however, were not maintained among those with very high levels of pretreatment disability. Small sample sizes in the IC groups are a limitation. Directions for research related to ICBT funded by insurance companies have been described. %M 32014840 %R 10.2196/16005 %U https://mental.jmir.org/2020/2/e16005 %U https://doi.org/10.2196/16005 %U http://www.ncbi.nlm.nih.gov/pubmed/32014840 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 2 %P e15801 %T The Acceptability of Text Messaging to Help African American Women Manage Anxiety and Depression: Cross-Sectional Survey Study %A McCall,Terika %A Schwartz,Todd A %A Khairat,Saif %+ School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall, CB #7460, Chapel Hill, NC, 27599-7460, United States, 1 9198435413, saif@unc.edu %K African Americans %K women %K anxiety %K depression %K mHealth %K text messaging %D 2020 %7 3.2.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The rates of mental illness among African American women are comparable with the general population; however, they significantly underutilize mental health services compared with their white counterparts. Previous studies revealed that interventions delivered via text messaging are effective and can be used to increase access to services and resources. More insight into whether or not this modality is acceptable for use to deliver mental health care to help African American women manage anxiety and depression is needed. Objective: This exploratory study aimed to gain insight into the acceptability of using text messaging to help African American women manage anxiety and depression. Methods: A self-administered Web-based survey was launched in June 2018 and closed in August 2018. Eligible participants were African American women (18 years or older) who reside in the United States. Participants were recruited through convenience sampling (eg, email sent via listservs and social media posts). Respondents were provided an anonymous link to the questionnaire. The survey consisted of 53 questions on the following subjects: sociodemographic characteristics, attitudes toward seeking professional psychological help, mobile phone use, and acceptability of using a mobile phone to receive mental health care. Results: The results of this exploratory study (N=101) showed that fewer than half of respondents endorsed the use of text messaging to communicate with a professional to receive help to manage anxiety (49/101, 48.5%) and depression (43/101, 42.6%). Approximately 51.4% (52/101) agreed that having the option to use text messaging to communicate with a professional if they are dealing with anxiety would be helpful. Similarly, 48.5% (49/101) agreed that having the option to use text messaging to communicate with a professional if they are dealing with depression would be helpful. Among participants who agreed that text messaging would be helpful, more than 80% noted being comfortable with its use to receive help for managing anxiety (approximately 86%, 45/52) and depression (approximately 82%, 40/49; highly significant positive association, all P<.001). More than 50% of respondents (56/101, 55.4%) indicated having concerns about using text messaging. No statistically significant associations were found between age and agreement with the use of text messaging to communicate with a professional to receive help for managing anxiety (P=.26) or depression (P=.27). Conclusions: The use of text messaging was not highly endorsed by African American women as an acceptable mode of communication with a professional to help them manage anxiety or depression. Concerns around privacy, confidentiality, and the impersonal feel of communicating about sensitive issues via text messages must be addressed for this modality to be a viable option. The findings of this study demonstrated the need for further research into the use of mobile technology to provide this population with more accessible and convenient options for mental health care. %M 31909720 %R 10.2196/15801 %U https://mental.jmir.org/2020/2/e15801 %U https://doi.org/10.2196/15801 %U http://www.ncbi.nlm.nih.gov/pubmed/31909720 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 7 %N 1 %P e14146 %T Engagement and Usability of a Cognitive Behavioral Therapy Mobile App Compared With Web-Based Cognitive Behavioral Therapy Among College Students: Randomized Heuristic Trial %A Purkayastha,Saptarshi %A Addepally,Siva Abhishek %A Bucher,Sherri %+ Indiana University - Purdue University Indianapolis, 719 Indiana Avenue, WK 119, Indianapolis, IN, , United States, 1 3172740439, saptpurk@iupui.edu %K cognitive behavioral therapy %K mHealth %K mental health %K heuristics %K usability %D 2020 %7 3.2.2020 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Recent evidence in mobile health has demonstrated that, in some cases, apps are an effective way to improve health care delivery. Health care interventions delivered via mobile technology have demonstrated both practicality and affordability. Lately, cognitive behavioral therapy (CBT) interventions delivered over the internet have also shown a meaningful impact on patients with anxiety and depression. Objective: Given the growing proliferation of smartphones and the trust in apps to support improved health behaviors and outcomes, we were interested in comparing a mobile app with Web-based methods for the delivery of CBT. This study aimed to compare the usability of a CBT mobile app called MoodTrainer with an evidence-based website called MoodGYM. Methods: We used convenience sampling to recruit 30 students from a large Midwestern university and randomly assigned them to either the MoodGYM or MoodTrainer user group. The trial period ran for 2 weeks, after which the students completed a self-assessment survey based on Nielsen heuristics. Statistical analysis was performed to compare the survey results from the 2 groups. We also compared the number of modules attempted or completed and the time spent on CBT strategies. Results: The results indicate that the MoodTrainer app received a higher usability score when compared with MoodGYM. Overall, 87% (13/15) of the participants felt that it was easy to navigate through the MoodTrainer app compared with 80% (12/15) of the MoodGYM participants. All MoodTrainer participants agreed that the app was easy to use and did not require any external assistance, whereas only 67% (10/15) had the same opinion for MoodGYM. Furthermore, 67% (10/15) of the MoodTrainer participants found that the navigation controls were easy to locate compared with 80% (12/15) of the MoodGYM participants. MoodTrainer users, on average, completed 2.5 modules compared with 1 module completed by MoodGYM users. Conclusions: As among the first studies to directly compare the usability of a mobile app–based CBT with smartphone-specific features against a Web-based CBT, there is an opportunity for app-based CBT as, at least in our limited trial, it was more usable and engaging. The study was limited to evaluate usability only and not the clinical effectiveness of the app. %M 32012043 %R 10.2196/14146 %U http://humanfactors.jmir.org/2020/1/e14146/ %U https://doi.org/10.2196/14146 %U http://www.ncbi.nlm.nih.gov/pubmed/32012043 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 2 %P e14200 %T Nurse-Delivered Cognitive Behavioral Therapy for Adherence and Depression Among People Living With HIV (the Ziphamandla Study): Protocol for a Randomized Controlled Trial %A Joska,John A %A Andersen,Lena S %A Smith-Alvarez,Rosana %A Magidson,Jessica %A Lee,Jasper S %A O’Cleirigh,Conall %A Safren,Steven A %+ HIV Mental Health Research Unit, Neuroscience Institute, Department of Psychiatry and Mental Health, University of Cape Town, Groote Schuur Hospital, OPD Building, H-Floor, Rm 30, Groote Schuur Drive, Observatory, Cape Town, 7925, South Africa, 27 21 404 2164, John.Joska@uct.ac.za %K major depressive disorder %K cognitive behavioral therapy %K HIV %K medication adherence %K integrated treatment %K task shifting %D 2020 %7 3.2.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is an unmet need to develop effective, feasible, and scalable interventions for poor adherence and depression in persons living with HIV in low- and middle-income countries (LMIC). Objective: This study aims to investigate the effectiveness of a nurse-delivered cognitive behavioral therapy (CBT) intervention for adherence and depression (CBT-AD) among persons living with HIV who are failing first-line antiretroviral therapy (ART) in Cape Town, South Africa. Methods: This study is a 2-arm randomized controlled trial of CBT-AD integrated into the HIV primary care setting in South Africa. A total of 160 participants who did not achieve viral suppression from their first-line ART and have a unipolar depressive mood disorder will be randomized to receive either 8 sessions of CBT-AD or enhanced treatment as usual. Participants will be assessed for major depressive disorder using the Mini International Neuropsychiatric Interview at baseline and 4, 8, and 12 months. The primary outcomes are depression on the Hamilton Depression Scale (HAM-D; as assessed by a blinded assessor) at the 4-month assessment and changes in ART adherence (assessed via real-time, electronic monitoring with Wisepill) between baseline and the 4-month assessment. Secondary outcomes are HIV viral load and CD4 cell count at the 12-month assessment as well as ART adherence (Wisepill) and depression (HAM-D) over follow-up (4-, 8-, and 12-month assessments). Results: The trial commenced in August 2015 and recruitment began in July 2016. Enrollment was completed in June 2019. Conclusions: Results of this study will inform whether an existing intervention (CBT-AD) can be effectively administered in LMIC by nurses with training and ongoing supervision. This will present unique opportunities to further explore the scale-up of a behavioral intervention to enhance ART adherence among persons living with HIV with major depression in a high-prevalence setting, to move toward achieving The Joint United Nations Programme on HIV/AIDS 90-90-90 goals. Trial Registration: ClincialTrials.gov NCT02696824; https://clinicaltrials.gov/ct2/show/NCT02696824 International Registered Report Identifier (IRRID): DERR1-10.2196/14200 %M 32012114 %R 10.2196/14200 %U https://www.researchprotocols.org/2020/2/e14200 %U https://doi.org/10.2196/14200 %U http://www.ncbi.nlm.nih.gov/pubmed/32012114 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e13392 %T A Culturally Adapted Cognitive Behavioral Internet-Delivered Intervention for Depressive Symptoms: Randomized Controlled Trial %A Salamanca-Sanabria,Alicia %A Richards,Derek %A Timulak,Ladislav %A Connell,Sarah %A Mojica Perilla,Monica %A Parra-Villa,Yamilena %A Castro-Camacho,Leonidas %+ SilverCloud Health, Clinical Research & Innovation, 1 Stephen St Upper, Dublin 8, DR9P, Ireland, 353 87 9343678, drichard@tcd.ie %K culture %K internet %K cognitive behavioral therapy %K depressive symptoms %K students %K South America %D 2020 %7 31.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Internet-delivered treatments for depressive symptoms have proved to be successful in high-income Western countries. There may be potential for implementing such treatments in low- and middle-income countries such as Colombia, where access to mental health services is limited. Objective: The objective of this study was to assess the efficacy of a culturally adapted cognitive behavioral internet-delivered treatment for college students with depressive symptoms in Colombia. Methods: This was a randomized controlled trial with a 3-month follow-up. The program comprised seven modules. A total of 214 Colombian college students were recruited. They were assessed and randomly assigned to either the treatment group (n=107) or a waiting list (WL) control group (n=107). Participants received weekly support from a trained supporter. The primary outcome was symptoms of depression, as measured by the Patient Health Questionnaire - 9, and the secondary outcomes were anxiety symptoms assessed by the Generalized Anxiety Disorder questionnaire - 7. Other measures, including satisfaction with treatment, were evaluated after 7 weeks. Results: Research attrition and treatment dropouts were high in this study. On average, 7.6 sessions were completed per user. The mean time spent on the program was 3 hours and 18 min. The linear mixed model (LMM) showed significant effects after treatment (t197.54=−5.189; P<.001) for the treatment group, and these effects were maintained at the 3-month follow-up (t39.62=4.668; P<.001). Within-group results for the treatment group yielded a large effect size post treatment (d=1.44; P<.001), and this was maintained at the 3-month follow-up (d=1.81; P<.001). In addition, the LMM showed significant differences between the groups (t197.54=−5.189; P<.001). The results showed a large effect size between the groups (d=0.91; P<.001). In the treatment group, 76.0% (16/107) achieved a reliable change, compared with 32.0% (17/107) in the WL control group. The difference between groups was statistically significant (X22=10.5; P=.001). Conclusions: This study was the first contribution to investigating the potential impact of a culturally adapted internet-delivered treatment on depressive symptoms for college students as compared with a WL control group in South America. Future research should focus on identifying variables associated both with premature dropout and treatment withdrawal at follow-up. Trial Registration: ClinicalTrials.gov NCT03062215; https://clinicaltrials.gov/ct2/show/NCT03062215 %M 32003749 %R 10.2196/13392 %U https://mental.jmir.org/2020/1/e13392 %U https://doi.org/10.2196/13392 %U http://www.ncbi.nlm.nih.gov/pubmed/32003749 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e16919 %T Web-Based Graphic Representation of the Life Course of Mental Health: Cross-Sectional Study Across the Spectrum of Mood, Anxiety, Eating, and Substance Use Disorders %A Aupperle,Robin Leora %A Paulus,Martin P %A Kuplicki,Rayus %A Touthang,James %A Victor,Teresa %A Yeh,Hung-Wen %A , %A Khalsa,Sahib S %+ Laureate Institute for Brain Research, 6655 S Yale Ave, Tulsa, OK, 74136, United States, 1 9137084766, raupperle@laureateinstitute.org %K mental health %K life history %K psychosocial factors %K depression %K anxiety %K substance use disorders %K eating disorders %D 2020 %7 28.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Although patient history is essential for informing mental health assessment, diagnosis, and prognosis, there is a dearth of standardized instruments measuring time-dependent factors relevant to psychiatric disorders. Previous research has demonstrated the potential utility of graphical representations, termed life charts, for depicting the complexity of the course of mental illness. However, the implementation of these assessments is limited by the exclusive focus on specific mental illnesses (ie, bipolar disorder) and the lack of intuitive graphical interfaces for data collection and visualization. Objective: This study aimed to develop and test the utility of the Tulsa Life Chart (TLC) as a Web-based, structured approach for obtaining and graphically representing historical information on psychosocial and mental health events relevant across a spectrum of psychiatric disorders. Methods: The TLC interview was completed at baseline by 499 participants of the Tulsa 1000, a longitudinal study of individuals with depressive, anxiety, substance use, or eating disorders and healthy comparisons (HCs). All data were entered electronically, and a 1-page electronic and interactive graphical representation was developed using the Google Visualization Application Programming Interface. For 8 distinct life epochs (periods of approximately 5-10 years), the TLC assessed the following factors: school attendance, hobbies, jobs, social support, substance use, mental health treatment, family structure changes, negative and positive events, and epoch and event-related mood ratings. We used generalized linear mixed models (GLMMs) to evaluate trajectories of each domain over time and by sex, age, and diagnosis, using case examples and Web-based interactive graphs to visualize data. Results: GLMM analyses revealed main or interaction effects of epoch and diagnosis for all domains. Epoch by diagnosis interactions were identified for mood ratings and the number of negative-versus-positive events (all P values <.001), with all psychiatric groups reporting worse mood and greater negative-versus-positive events than HCs. These differences were most robust at different epochs, depending on diagnosis. There were also diagnosis and epoch main effects for substance use, mental health treatment received, social support, and hobbies (P<.001). User experience ratings (each on a 1-5 scale) revealed that participants found the TLC pleasant to complete (mean 3.07, SD 1.26) and useful for understanding their mental health (mean 3.07, SD 1.26), and that they were likely to recommend it to others (mean 3.42, SD 0.85). Conclusions: The TLC provides a structured, Web-based transdiagnostic assessment of psychosocial history relevant for the diagnosis and treatment of psychiatric disorders. Interactive, 1-page graphical representations of the TLC allow for the efficient communication of historical life information that would be useful for clinicians, patients, and family members. %M 32012081 %R 10.2196/16919 %U http://mental.jmir.org/2020/1/e16919/ %U https://doi.org/10.2196/16919 %U http://www.ncbi.nlm.nih.gov/pubmed/32012081 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e12503 %T The Role of Campus Data in Representing Depression Among College Students: Exploratory Research %A Mei,Guang %A Xu,Weisheng %A Li,Li %A Zhao,Zhen %A Li,Hao %A Liu,Wenqing %A Jiao,Yueming %+ Department of Control Science and Engineering, College of Electronic and Information Engineering, Tongji University, Zhixin Bldg, 6th Fl, 4800 Caoan Rd, Shanghai, China, 86 18916087269, lili@tongji.edu.cn %K depression %K mental health %K behavior analysis %D 2020 %7 27.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is a predominant feature of many psychological problems leading to extreme behaviors and, in some cases, suicide. Campus information systems keep detailed and reliable student behavioral data; however, whether these data can reflect depression and we know the differences in behavior between depressive and nondepressive students are still research problems. Objective: The purpose of this paper is to investigate the behavioral patterns of depressed students by using multisource campus data and exploring the link between behavioral preferences and depressive symptoms. The campus data described in this paper include basic personal information, academic performance, poverty subsidy, consumption habit, daily routine, library behavior, and meal habit, totaling 121 features. Methods: To identify potentially depressive students, we developed an online questionnaire system based on a standard psychometric instrument, the Zung Self-Rating Depression Scale (SDS). To explore the differences in behavior of depressive and nondepressive students, the Mann-Whitney U test was applied. In order to investigate the behavioral features of different depressive symptoms, factor analysis was used to divide the questionnaire items into different symptom groups and then correlation analysis was employed to study the extrinsic characteristics of each depressive symptom. Results: The correlation between these factors and the features were computed. The results indicated that there were 25 features correlated with either 4 factors or SDS score. The statistical results indicated that depressive students were more likely to fail exams, have poor meal habits, have increased night activities and decreased morning activities, and engage less in social activities (eg, avoiding meal times with friends). Correlation analysis showed that the somatic factor 2 (F4) was negatively correlated with the number of library visits (r=–.179, P<.001), and, compared with other factors, had the greatest impact on students’ daily schedule, eating and social habits. The biggest influencing factor to poor academic performance was cognitive factor F1, and its score was found to be significantly positively correlated with fail rate (r=.185, P=.02). Conclusions: The results presented in this study indicate that campus data can reflect depression and its symptoms. By collecting a large amount of questionnaire data and combining machine learning algorithms, it is possible to realize an identification method of depression and depressive symptoms based on campus data. %M 32012070 %R 10.2196/12503 %U http://mental.jmir.org/2020/1/e12503/ %U https://doi.org/10.2196/12503 %U http://www.ncbi.nlm.nih.gov/pubmed/32012070 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e15321 %T Functionality of Top-Rated Mobile Apps for Depression: Systematic Search and Evaluation %A Qu,Chengcheng %A Sas,Corina %A Daudén Roquet,Claudia %A Doherty,Gavin %+ School of Computing and Communications, Lancaster University, Bailrigg, Lancaster, LA1 4YW, United Kingdom, 44 01524510321, c.qu3@lancaster.ac.uk %K mobile apps %K depression %K review %K ethics %K mHealth %D 2020 %7 24.1.2020 %9 Review %J JMIR Ment Health %G English %X Background: In the last decade, there has been a proliferation of mobile apps claiming to support the needs of people living with depression. However, it is unclear what functionality is actually provided by apps for depression, or for whom they are intended. Objective: This paper aimed to explore the key features of top-rated apps for depression, including descriptive characteristics, functionality, and ethical concerns, to better inform the design of apps for depression. Methods: We reviewed top-rated iPhone OS (iOS) and Android mobile apps for depression retrieved from app marketplaces in spring 2019. We applied a systematic analysis to review the selected apps, for which data were gathered from the 2 marketplaces and through direct use of the apps. We report an in-depth analysis of app functionality, namely, screening, tracking, and provision of interventions. Of the initially identified 482 apps, 29 apps met the criteria for inclusion in this review. Apps were included if they remained accessible at the moment of evaluation, were offered in mental health–relevant categories, received a review score greater than 4.0 out of 5.0 by more than 100 reviewers, and had depression as a primary target. Results: The analysis revealed that a majority of apps specify the evidence base for their intervention (18/29, 62%), whereas a smaller proportion describes receiving clinical input into their design (12/29, 41%). All the selected apps are rated as suitable for children and adolescents on the marketplace, but 83% (24/29) do not provide a privacy policy consistent with their rating. The findings also show that most apps provide multiple functions. The most commonly implemented functions include provision of interventions (24/29, 83%) either as a digitalized therapeutic intervention or as support for mood expression; tracking (19/29, 66%) of moods, thoughts, or behaviors for supporting the intervention; and screening (9/29, 31%) to inform the decision to use the app and its intervention. Some apps include overtly negative content. Conclusions: Currently available top-ranked apps for depression on the major marketplaces provide diverse functionality to benefit users across a range of age groups; however, guidelines and frameworks are still needed to ensure users’ privacy and safety while using them. Suggestions include clearly defining the age of the target population and explicit disclosure of the sharing of users’ sensitive data with third parties. In addition, we found an opportunity for apps to better leverage digital affordances for mitigating harm, for personalizing interventions, and for tracking multimodal content. The study further demonstrated the need to consider potential risks while using depression apps, including the use of nonvalidated screening tools, tracking negative moods or thinking patterns, and exposing users to negative emotional expression content. %M 32012079 %R 10.2196/15321 %U https://mental.jmir.org/2020/1/e15321 %U https://doi.org/10.2196/15321 %U http://www.ncbi.nlm.nih.gov/pubmed/32012079 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e14045 %T Tracking and Predicting Depressive Symptoms of Adolescents Using Smartphone-Based Self-Reports, Parental Evaluations, and Passive Phone Sensor Data: Development and Usability Study %A Cao,Jian %A Truong,Anh Lan %A Banu,Sophia %A Shah,Asim A %A Sabharwal,Ashutosh %A Moukaddam,Nidal %+ Menninger Department of Psychiatry, Baylor College of Medicine, 1504 Taub Loop, NPC Bldg, Houston, TX, 77030, United States, 1 7138735270, nidalm@bcm.edu %K SOLVD-Teen and SOLVD-Parent App %K adolescent depression %K smartphone monitoring %K self-evaluation %K parental input %K sensory data %D 2020 %7 24.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression carries significant financial, medical, and emotional burden on modern society. Various proof-of-concept studies have highlighted how apps can link dynamic mental health status changes to fluctuations in smartphone usage in adult patients with major depressive disorder (MDD). However, the use of such apps to monitor adolescents remains a challenge. Objective: This study aimed to investigate whether smartphone apps are useful in evaluating and monitoring depression symptoms in a clinically depressed adolescent population compared with the following gold-standard clinical psychometric instruments: Patient Health Questionnaire (PHQ-9), Hamilton Rating Scale for Depression (HAM-D), and Hamilton Anxiety Rating Scale (HAM-A). Methods: We recruited 13 families with adolescent patients diagnosed with MDD with or without comorbid anxiety disorder. Over an 8-week period, daily self-reported moods and smartphone sensor data were collected by using the Smartphone- and OnLine usage–based eValuation for Depression (SOLVD) app. The evaluations from teens’ parents were also collected. Baseline depression and anxiety symptoms were measured biweekly using PHQ-9, HAM-D, and HAM-A. Results: We observed a significant correlation between the self-evaluated mood averaged over a 2-week period and the biweekly psychometric scores from PHQ-9, HAM-D, and HAM-A (0.45≤|r|≤0.63; P=.009, P=.01, and P=.003, respectively). The daily steps taken, SMS frequency, and average call duration were also highly correlated with clinical scores (0.44≤|r|≤0.72; all P<.05). By combining self-evaluations and smartphone sensor data of the teens, we could predict the PHQ-9 score with an accuracy of 88% (23.77/27). When adding the evaluations from the teens’ parents, the prediction accuracy was further increased to 90% (24.35/27). Conclusions: Smartphone apps such as SOLVD represent a useful way to monitor depressive symptoms in clinically depressed adolescents, and these apps correlate well with current gold-standard psychometric instruments. This is a first study of its kind that was conducted on the adolescent population, and it included inputs from both teens and their parents as observers. The results are preliminary because of the small sample size, and we plan to expand the study to a larger population. %M 32012072 %R 10.2196/14045 %U http://mental.jmir.org/2020/1/e14045/ %U https://doi.org/10.2196/14045 %U http://www.ncbi.nlm.nih.gov/pubmed/32012072 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e14623 %T E-Learning to Improve Suicide Prevention Practice Skills Among Undergraduate Psychology Students: Randomized Controlled Trial %A Kullberg,Marie-Louise J %A Mouthaan,Joanne %A Schoorl,Maartje %A de Beurs,Derek %A Kenter,Robin Maria Francisca %A Kerkhof,Ad JFM %+ Department of Clinical Psychology, Leiden University, Wassenaarseweg 52, Leiden, 2333 AK, Netherlands, 31 715276676, m.j.kullberg@fsw.leidenuniv.nl %K e-learning %K suicide prevention %K digital learning %K skills training %K randomized controlled trial %K undergraduate students %D 2020 %7 22.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Despite increasing evidence of the effectiveness of digital learning solutions in higher vocational education, including the training of allied health professionals, the impact of Web-based training on the development of practical skills in psychiatry and psychology, in general, and in suicide prevention, specifically, remains largely understudied. Objective: This study aimed to determine the effectiveness of an electronic learning (e-learning) module on the adherence to suicide prevention guidelines, knowledge of practical skills, and provider’s confidence to have a conversation about suicidal behavior with undergraduate psychology students. Methods: The e-learning module, comprising video recordings of therapist-patient interactions, was designed with the aim of transferring knowledge about suicide prevention guideline recommendations. The program’s effects on guideline adherence, self-evaluated knowledge, and provider’s confidence were assessed using online questionnaires before the program (baseline and at 1 month [T1] and 3 months after baseline). The eligible third- and fourth-year undergraduate psychology students were randomly allocated to the e-learning (n=211) or to a waitlist control condition (n=187), with access to the intervention after T1. Results: Overall, the students evaluated e-learning in a fairly positive manner. The intention-to-treat analysis showed that the students in the intervention condition (n=211) reported higher levels of self-evaluated knowledge, provider’s confidence, and guideline adherence than those in the waitlist control condition (n=187) after receiving the e-learning module (all P values<.001). When comparing the scores at the 1- and 3-month follow-up, after both groups had received access to the e-learning module, the completers-only analysis showed that the levels of knowledge, guideline adherence, and confidence remained constant (all P values>.05) within the intervention group, whereas a significant improvement was observed in the waitlist control group (all P values<.05). Conclusions: An e-learning intervention on suicide prevention could be an effective first step toward improved knowledge of clinical skills. The learning outcomes of a stand-alone module were found to be similar to those of a training that combined e-learning with a face-to-face training, with the advantages of flexibility and low costs. %M 32012076 %R 10.2196/14623 %U http://mental.jmir.org/2020/1/e14623/ %U https://doi.org/10.2196/14623 %U http://www.ncbi.nlm.nih.gov/pubmed/32012076 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 1 %P e14949 %T Assessing the Usability, Appeal, and Impact of a Web-Based Training for Adults Responding to Concerning Posts on Social Media: Pilot Suicide Prevention Study %A Kerr,Bradley %A Stephens,David %A Pham,Daniel %A Ghost Dog,Thomas %A McCray,Celena %A Caughlan,Colbie %A Gaston,Amanda %A Gritton,Jesse %A Jenkins,Marina %A Craig Rushing,Stephanie %A Moreno,Megan A %+ Department of Pediatrics, University of Wisconsin-Madison, 2870 University Avenue, Suite 200, Madison, WI, 53705, United States, 1 6082624440, bkerr@wisc.edu %K community health education %K mental health %K social networking %D 2020 %7 20.1.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide prevention remains challenging among youth, as many do not disclose suicidal ideation. Nearly one-third of American Indian and Alaska Native (AI and AN, tribal, or native) youth see concerning messages on social media at least weekly. Objective: To prepare adults to support AI and AN youth who post or view concerning messages, our team designed an hour-long training: Responding to Concerning Posts on Social Media. This study tested the usability, appeal, and impact of the training. Methods: A purposive sample of 70 adults was recruited to participate in the pilot, which included 2 study arms. Arm 1 participants completed a 30-min training video and reviewed accompanying handouts, including the Viewer Care Plan (VCP). The VCP provided a 3-step planning and response tool: (1) Start the Conversation, (2) Listen, Gather Information, and Assess Viewer Experience, and (3) Plan and Act. The intent of the VCP was to support and connect AI and AN youth who either view or post concerning messages on social media to life-saving resources. Those enrolled in arm 2 participated in an additional interactive role-play scenario with a coach that took place after the training, via text message. Participants provided qualitative and quantitative feedback on the training’s relevance, appeal, and utility. Paired t tests were used to assess confidence in addressing concerning posts between pre- and postsurveys. Content analysis of the role-play transcripts was used to assess the quality and completion of the coached role-plays, in relation to the recommended VCP. Results: Altogether, 35 participants finished the training and completed pre- and postsurveys; 22 participants completed the 6-month follow-up survey. Pre-post analyses of differences in means found significant improvement across several efficacy measures, including confidence starting a conversation about social media (P=.003), confidence contacting the person who posted something concerning (P<.001), and confidence recommending support services to youth who view (P=.001) or youth who post concerning messages (P<.001). Similarly, pre- to 6-month analyses found significant positive improvement across multiple measures, including confidence contacting the youth who posted (P<.001), confidence starting a conversation about social media with youth (P=.003), and an increase in the number of experiences recommending resources for youth who viewed concerning social media posts (P=.02). Of the 3 steps of the VCP, the least followed step in coached role-plays was sharing tools and resources, which is a part of the third Plan and Act step. Conclusions: Findings indicate that the Responding to Concerning Posts on Social Media training is a promising tool to prepare adults to intervene and complete the VCP. Additional evaluation with a larger cohort of participants is needed to determine the unique impact of the role-play scenario and changes in mental health referral rates, behaviors, and skills. %M 31958066 %R 10.2196/14949 %U https://mental.jmir.org/2020/1/e14949 %U https://doi.org/10.2196/14949 %U http://www.ncbi.nlm.nih.gov/pubmed/31958066 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 1 %P e12599 %T Technological State of the Art of Electronic Mental Health Interventions for Major Depressive Disorder: Systematic Literature Review %A Burger,Franziska %A Neerincx,Mark A %A Brinkman,Willem-Paul %+ Delft University of Technology, van Mourik Broekmanweg 6, Delft, 2628XE, Netherlands, 31 0645340352, f.v.burger@tudelft.nl %K eHealth %K major depressive disorder %K technology %K systematic review %D 2020 %7 20.1.2020 %9 Review %J J Med Internet Res %G English %X Background: Electronic mental (e-mental) health care for depression aims to overcome barriers to and limitations of face-to-face treatment. Owing to the high and growing demand for mental health care, a large number of such information and communication technology systems have been developed in recent years. Consequently, a diverse system landscape formed. Objective: This literature review aims to give an overview of this landscape of e-mental health systems for the prevention and treatment of major depressive disorder, focusing on three main research questions: (1) What types of systems exist? (2) How technologically advanced are these systems? (3) How has the system landscape evolved between 2000 and 2017? Methods: Publications eligible for inclusion described e-mental health software for the prevention or treatment of major depressive disorder. Additionally, the software had to have been evaluated with end users and developed since 2000. After screening, 270 records remained for inclusion. We constructed a taxonomy concerning software systems, their functions, how technologized these were in their realization, and how systems were evaluated, and then, we extracted this information from the included records. We define here as functions any component of the system that delivers either treatment or adherence support to the user. For this coding process, an elaborate classification hierarchy for functions was developed yielding a total of 133 systems with 2163 functions. The systems and their functions were analyzed quantitatively, with a focus on technological realization. Results: There are various types of systems. However, most are delivered on the World Wide Web (76%), and most implement cognitive behavioral therapy techniques (85%). In terms of content, systems contain twice as many treatment functions as adherence support functions, on average. Furthermore, autonomous systems, those not including human guidance, are equally as technologized and have one-third less functions than guided ones. Therefore, lack of guidance is neither compensated with additional functions nor compensated by technologizing functions to a greater degree. Although several high-tech solutions could be found, the average system falls between a purely informational system and one that allows for data entry but without automatically processing these data. Moreover, no clear increase in the technological capabilities of systems showed in the field, between 2000 and 2017, despite a marked growth in system quantity. Finally, more sophisticated systems were evaluated less often in comparative trials than less sophisticated ones (OR 0.59). Conclusions: The findings indicate that when developers create systems, there is a greater focus on implementing therapeutic treatment than adherence support. Although the field is very active, as evidenced by the growing number of systems developed per year, the technological possibilities explored are limited. In addition to allowing developers to compare their system with others, we anticipate that this review will help researchers identify opportunities in the field. %M 31958063 %R 10.2196/12599 %U https://www.jmir.org/2020/1/e12599 %U https://doi.org/10.2196/12599 %U http://www.ncbi.nlm.nih.gov/pubmed/31958063 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 1 %P e15188 %T The True Colours Remote Symptom Monitoring System: A Decade of Evolution %A Goodday,Sarah M %A Atkinson,Lauren %A Goodwin,Guy %A Saunders,Kate %A South,Matthew %A Mackay,Clare %A Denis,Mike %A Hinds,Chris %A Attenburrow,Mary-Jane %A Davies,Jim %A Welch,James %A Stevens,William %A Mansfield,Karen %A Suvilehto,Juulia %A Geddes,John %+ Department of Psychiatry, University of Oxford, Warneford Lane, Oxford, OX3 7JX, United Kingdom, 44 (0)1865 618200, sarah.goodday@psych.ox.ac.uk %K symptom assessment %K signs and symptoms %K digital health %K ecological momentary assessment %K mood disorders %D 2020 %7 15.1.2020 %9 Viewpoint %J J Med Internet Res %G English %X The True Colours remote mood monitoring system was developed over a decade ago by researchers, psychiatrists, and software engineers at the University of Oxford to allow patients to report on a range of symptoms via text messages, Web interfaces, or mobile phone apps. The system has evolved to encompass a wide range of measures, including psychiatric symptoms, quality of life, and medication. Patients are prompted to provide data according to an agreed personal schedule: weekly, daily, or at specific times during the day. The system has been applied across a number of different populations, for the reporting of mood, anxiety, substance use, eating and personality disorders, psychosis, self-harm, and inflammatory bowel disease, and it has shown good compliance. Over the past decade, there have been over 36,000 registered True Colours patients and participants in the United Kingdom, with more than 20 deployments of the system supporting clinical service and research delivery. The system has been adopted for routine clinical care in mental health services, supporting more than 3000 adult patients in secondary care, and 27,263 adolescent patients are currently registered within Oxfordshire and Buckinghamshire. The system has also proven to be an invaluable scientific resource as a platform for research into mood instability and as an electronic outcome measure in randomized controlled trials. This paper aimed to report on the existing applications of the system, setting out lessons learned, and to discuss the implications for tailored symptom monitoring, as well as the barriers to implementation at a larger scale. %M 31939746 %R 10.2196/15188 %U https://www.jmir.org/2020/1/e15188 %U https://doi.org/10.2196/15188 %U http://www.ncbi.nlm.nih.gov/pubmed/31939746 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 1 %P e12516 %T Mobile Health Technology Interventions for Suicide Prevention: Systematic Review %A Melia,Ruth %A Francis,Kady %A Hickey,Emma %A Bogue,John %A Duggan,Jim %A O'Sullivan,Mary %A Young,Karen %+ School of Psychology, National University of Ireland Galway, Arts Millennium Building, Galway, H91 TK33, Ireland, 353 877710431, ruth.melia@hse.ie %K mHealth %K systematic review %D 2020 %7 15.1.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Digital interventions are proposed as one way by which effective treatments for self-harm and suicidal ideation may be improved and their scalability enhanced. Mobile devices offer a potentially powerful medium to deliver evidence-based interventions with greater specificity to the individual when the intervention is needed. The recent proliferation of publicly available mobile apps designed for suicide prevention underlines the need for robust evidence to promote safe practice. Objective: This review aimed to examine the effectiveness of currently available mobile health (mHealth) technology tools in reducing suicide-specific outcomes. Methods: The following databases were searched: Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, and relevant sources of gray literature. All published and unpublished randomized controlled trials (RCTs), pseudo-RCTs, and pre-post observational studies that evaluated the effectiveness of mHealth technology in suicide prevention delivered via mobile computing and communication technology were included. Studies were included if they measured at least one suicide outcome variable (ie, suicidal ideation, suicidal intent, nonsuicidal self-injurious behavior, and suicidal behavior). A total of 2 review authors independently extracted data and assessed study suitability, in accordance with the Cochrane Collaboration Risk of Bias Tool, on July 31, 2018. Owing to the heterogeneity of outcomes found across studies, results were not amenable for pooled synthesis, and a meta-analysis was not performed. A narrative synthesis of the available research is presented here. Results: A total of 7 studies met criteria for inclusion . Four published articles that reported on the effectiveness of the following mobile phone apps were included: iBobbly, Virtual Hope Box, BlueIce, and Therapeutic Evaluative Conditioning. Results demonstrated some positive impacts for individuals at elevated risk of suicide or self-harm, including reductions in depression, psychological distress, and self-harm and increases in coping self-efficacy. None of the apps evaluated demonstrated the ability to significantly decrease suicidal ideation compared with a control condition. In addition, 3 unpublished and recently completed trials also met criteria for inclusion in the review. Conclusions: Further research is needed to evaluate the efficacy of stand-alone mHealth technology–based interventions in suicide prevention. The small number of studies reported in this review tentatively indicate that such tools may have a positive impact on suicide-specific outcomes. Future mHealth intervention evaluations would benefit from addressing the following 3 main methodological limitations : (1) heterogeneity of outcomes: a lack of standardized measurement of suicide outcomes across studies; (2) ecological validity: the tendency to exclude potential participants because of the elevated suicide risk may reduce generalizability within clinical settings; and (3) app regulation and definition: the lack of a standardized classification system for mHealth intervention type points to the need for better definition of the scope of such technologies to promote safe practice. Trial Registration: PROSPERO CRD42017072899; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=72899 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.8635 %M 31939744 %R 10.2196/12516 %U https://mhealth.jmir.org/2020/1/e12516 %U https://doi.org/10.2196/12516 %U http://www.ncbi.nlm.nih.gov/pubmed/31939744 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 12 %P e15644 %T Clinically Meaningful Use of Mental Health Apps and its Effects on Depression: Mixed Methods Study %A Zhang,Renwen %A Nicholas,Jennifer %A Knapp,Ashley A %A Graham,Andrea K %A Gray,Elizabeth %A Kwasny,Mary J %A Reddy,Madhu %A Mohr,David C %+ Department of Communication Studies, Northwestern University, 2240 Campus Dr, MTS Program, Evanston, IL, 60208, United States, 1 8479976596, alicezhang@u.northwestern.edu %K mHealth %K mobile apps %K mental health %K engagement %D 2019 %7 20.12.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: User engagement is key to the effectiveness of digital mental health interventions. Considerable research has examined the clinical outcomes of overall engagement with mental health apps (eg, frequency and duration of app use). However, few studies have examined how specific app use behaviors can drive change in outcomes. Understanding the clinical outcomes of more nuanced app use could inform the design of mental health apps that are more clinically effective to users. Objective: This study aimed to classify user behaviors in a suite of mental health apps and examine how different types of app use are related to depression and anxiety outcomes. We also compare the clinical outcomes of specific types of app use with those of generic app use (ie, intensity and duration of app use) to understand what aspects of app use may drive symptom improvement. Methods: We conducted a secondary analysis of system use data from an 8-week randomized trial of a suite of 13 mental health apps. We categorized app use behaviors through a mixed methods analysis combining qualitative content analysis and principal component analysis. Regression analyses were used to assess the association between app use and levels of depression and anxiety at the end of treatment. Results: A total of 3 distinct clusters of app use behaviors were identified: learning, goal setting, and self-tracking. Each specific behavior had varied effects on outcomes. Participants who engaged in self-tracking experienced reduced depression symptoms, and those who engaged with learning and goal setting at a moderate level (ie, not too much or not too little) also had an improvement in depression. Notably, the combination of these 3 types of behaviors, what we termed “clinically meaningful use,” accounted for roughly the same amount of variance as explained by the overall intensity of app use (ie, total number of app use sessions). This suggests that our categorization of app use behaviors succeeded in capturing app use associated with better outcomes. However, anxiety outcomes were neither associated with specific behaviors nor generic app use. Conclusions: This study presents the first granular examination of user interactions with mental health apps and their effects on mental health outcomes. It has important implications for the design of mobile health interventions that aim to achieve greater user engagement and improved clinical efficacy. %M 31859682 %R 10.2196/15644 %U http://www.jmir.org/2019/12/e15644/ %U https://doi.org/10.2196/15644 %U http://www.ncbi.nlm.nih.gov/pubmed/31859682 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 12 %P e13911 %T Comparison of YouthCHAT, an Electronic Composite Psychosocial Screener, With a Clinician Interview Assessment for Young People: Randomized Trial %A Thabrew,Hiran %A D'Silva,Simona %A Darragh,Margot %A Goldfinch,Mary %A Meads,Jake %A Goodyear-Smith,Felicity %+ Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Department of Psychological Medicine, University of Auckland, Level 12, Support Block, Auckland Hospital, 2 Park Road, Grafton, Auckland, 1142, New Zealand, 64 21402055, h.thabrew@auckland.ac.nz %K mass screening %K adolescents %K anxiety %K depression %K substance-related disorders %K primary health care %K school health services %K eHealth %D 2019 %7 3.12.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Psychosocial problems such as depression, anxiety, and substance abuse are common and burdensome in young people. In New Zealand, screening for such problems is undertaken routinely only with year 9 students in low-decile schools and opportunistically in pediatric settings using a nonvalidated and time-consuming clinician-administered Home, Education, Eating, Activities, Drugs and Alcohol, Sexuality, Suicide and Depression, Safety (HEEADSSS) interview. The Youth version, Case-finding and Help Assessment Tool (YouthCHAT) is a relatively new, locally developed, electronic tablet–based composite screener for identifying similar psychosocial issues to HEEADSSS Objective: This study aimed to compare the performance and acceptability of YouthCHAT with face-to-face HEEADSSS assessment among 13-year-old high school students. Methods: A counterbalanced randomized trial of YouthCHAT screening either before or after face-to-face HEEADSSS assessment was undertaken with 129 13-year-old New Zealand high school students of predominantly Māori and Pacific Island ethnicity. Main outcome measures were comparability of YouthCHAT and HEEADSSS completion times, detection rates, and acceptability to students and school nurses. Results: YouthCHAT screening was more than twice as fast as HEEADSSS assessment (mean 8.57 min vs mean 17.22 min; mean difference 8 min 25 seconds [range 6 min 20 seconds to 11 min 10 seconds]; P<.01) and detected more issues overall on comparable domains. For substance misuse and problems at home, both instruments were roughly comparable. YouthCHAT detected significantly more problems with eating or body image perception (70/110, 63.6% vs 25/110, 22.7%; P<.01), sexual health (24/110, 21.8% vs 10/110, 9.1%; P=.01), safety (65/110, 59.1% vs 17/110, 15.5%; P<.01), and physical inactivity (43/110, 39.1% vs 21/110, 19.1%; P<.01). HEEADSSS had a greater rate of detection for a broader set of mental health issues (30/110, 27%) than YouthCHAT (11/110, 10%; P=.001), which only assessed clinically relevant anxiety and depression. Assessment order made no significant difference to the duration of assessment or to the rates of YouthCHAT-detected positive screens for anxiety and depression. There were no significant differences in student acceptability survey results between the two assessments. Nurses identified that students found YouthCHAT easy to answer and that it helped students answer face-to-face questions, especially those of a sensitive nature. Difficulties encountered with YouthCHAT included occasional Wi-Fi connectivity and student literacy issues. Conclusions: This study provides preliminary evidence regarding the shorter administration time, detection rates, and acceptability of YouthCHAT as a school-based psychosocial screener for young people. Although further research is needed to confirm its effectiveness in other age and ethnic groups, YouthCHAT shows promise for aiding earlier identification and treatment of common psychosocial problems in young people, including possible use as part of an annual, school-based, holistic health check. Trial Registration: Australian New Zealand Clinical Trials Network Registry (ACTRN) ACTRN12616001243404p; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371422. %M 31793890 %R 10.2196/13911 %U https://www.jmir.org/2019/12/e13911 %U https://doi.org/10.2196/13911 %U http://www.ncbi.nlm.nih.gov/pubmed/31793890 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 12 %P e14119 %T Effects of a 12-Minute Smartphone-Based Mindful Breathing Task on Heart Rate Variability for Students With Clinically Relevant Chronic Pain, Depression, and Anxiety: Protocol for a Randomized Controlled Trial %A Azam,Muhammad Abid %A Latman,Vered Valeria %A Katz,Joel %+ York University, 4700 Keele Street, Toronto, ON, MJ3 1P3, Canada, 1 4163129252, abid.azam1@gmail.com %K mindfulness %K mobile apps %K heart rate variability %K chronic pain %K depression %K anxiety %D 2019 %7 2.12.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mindfulness meditation (MM) is a commonly used psychological intervention for pain, mood, and anxiety conditions, but can be challenging to practice with severe symptoms without proper training. The Mindfulness Meditation app (MMA) is a supportive training tool specifically developed for this study to aid in the practice of mindful breathing using a smartphone. Objective: This study aims to evaluate the psychophysiological effects of the MMA. Specifically, the study will assess parasympathetic functioning using heart rate variability (HRV; primary outcome), pain and mood symptoms, mind-wandering and present moment awareness, and breath focus in groups of undergraduate participants who self-report clinically-relevant symptoms of chronic pain (CP) and depression or anxiety (DA) and condition-free (CF) participants who do not meet either criteria. We hypothesize that use of the MMA by study groups will lead to improved HRV, pain, and mood symptoms compared with groups who do not use the app. Methods: This study is a two-arm randomized controlled trial (RCT) recruiting through a Web-based research participation pool at York University in Toronto, Canada. We are aiming for minimum 60 participants in each of CP, DA, and CF groups. Upon arriving to the laboratory, participants will be prescreened for classification into groups of CP, DA, or CF. Groups will be randomly assigned by a 1:1 ratio to an MMA (MMA+) condition or MM condition without the app (MMA−) after a brief stress induction procedure. In MMA+, participants will practice mindful breathing with a smartphone and press breath or other buttons at the sound of audio tones if their awareness was on breathing or another experience, respectively. HRV and respiration data will be obtained during rest (5 min), stress induction (5 min), and meditation conditions (12 min). Participants will complete psychological self-report inventories before and after the stress induction and after the meditation condition. Separate linear mixed models will be used to examine HRV and self-report inventories comparing groups and treatment conditions. Results: Recruitment for the study began in November 2017 and is expected to be completed in winter of 2019-2020. As of July 2019, 189 participants have been recruited. The study’s main findings are expected to reveal a positive pattern of HRV responses in the CP, DA, and CF groups, such that a significant increase in HRV (P<.05) is detected in those randomized to the MMA+ condition in comparison with those randomized to the MMA− condition. Conclusions: This RCT will contribute to the burgeoning health psychology literature regarding the clinical relevance of HRV in assessment and treatment of psychological and medical conditions. Furthermore, possible ways to inform designs of MM training tools delivered by apps and Web platforms for CP, depression, and anxiety conditions’ treatment will be discussed. Trial Registration: Clinicaltrials.gov NCT03296007; https://clinicaltrials.gov/ct2/show/NCT03296007. International Registered Report Identifier (IRRID): DERR1-10.2196/14119 %M 31789601 %R 10.2196/14119 %U https://www.researchprotocols.org/2019/12/e14119 %U https://doi.org/10.2196/14119 %U http://www.ncbi.nlm.nih.gov/pubmed/31789601 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e14728 %T Using Cluster Analysis to Explore Engagement and e-Attainment as Emergent Behavior in Electronic Mental Health %A Sanatkar,Samineh %A Baldwin,Peter Andrew %A Huckvale,Kit %A Clarke,Janine %A Christensen,Helen %A Harvey,Samuel %A Proudfoot,Judy %+ Black Dog Institute, School of Psychiatry, University of New South Wales, Hospital Road, Sydney 2031, , Australia, 61 2 9382 ext 4368, s.sanatkar@unsw.edu.au %K eHealth %K engagement %K adherence %K Web-based intervention %K depression %K anxiety %D 2019 %7 28.11.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: In most e-mental health (eMH) research to date, adherence is defined according to a trial protocol. However, adherence to a study protocol may not completely capture a key aspect of why participants engage with eMH tools, namely, to achieve personal mental health goals. As a consequence, trial attrition reported as non-adherence or dropout may reflect e-attainment, the discontinuation of eMH engagement after personal goals have been met. Clarifying engagement patterns, such as e-attainment, and how these align with mental health trajectories, may help optimize eMH design and implementation science. Objective: This study aimed to use clustering techniques to identify real-world engagement profiles in a community of eMH users and examine if such engagement profiles are associated with different mental health outcomes. The novelty of this approach was our attempt to identify actual user engagement behaviors, as opposed to employing engagement benchmarks derived from a trial protocol. The potential of this approach is to link naturalistic behaviors to beneficial mental health outcomes, which would be especially informative when designing eMH programs for the general public. Methods: Between May 2013 and June 2018, Australian adults (N=43,631) signed up to myCompass, a self-guided eMH program designed to help alleviate mild to moderate symptoms of depression, anxiety, and stress. Recorded usage data included number of logins, frequency of mood tracking, number of started and completed learning activities, and number of tracking reminders set. A subset of users (n=168) completed optional self-assessment mental health questionnaires (Patient Health Questionnaire-9 item, PHQ-9; Generalized Anxiety Disorder Questionnaire-7 item, GAD-7) at registration and at 28 and 56 days after sign-up. Another subset of users (n=861) completed the PHQ-9 and GAD-7 at registration and at 28 days. Results: Two-step cluster analyses revealed 3 distinct usage patterns across both subsamples: moderates, trackers, and super users, signifying differences both in the frequency of use as well as differences in preferences for program functionalities. For both subsamples, repeated measures analysis of variances showed significant decreases over time in PHQ-9 and GAD-7 scores. Time-by-cluster interactions, however, did not yield statistical significance in both subsamples, indicating that clusters did not predict symptom reduction over time. Interestingly, users who completed the self-assessment questionnaires twice had slightly but significantly lower depression and anxiety levels at sign-up compared with users who completed the questionnaires a third time at 56 days. Conclusions: Findings suggested that although users engaged with myCompass in different but measurable ways, those different usage patterns evoked equivalent mental health benefits. Furthermore, the randomized controlled trial paradigm may unintentionally limit the scope of eMH engagement research by mislabeling early mental health goal achievers as dropouts. More detailed and naturalistic approaches to study engagement with eMH technologies may improve program design and, ultimately, program effectiveness. %M 31778115 %R 10.2196/14728 %U http://www.jmir.org/2019/11/e14728/ %U https://doi.org/10.2196/14728 %U http://www.ncbi.nlm.nih.gov/pubmed/31778115 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e14729 %T Mechanisms and Effects of a WeChat-Based Intervention on Suicide Among People Living With HIV and Depression: Path Model Analysis of a Randomized Controlled Trial %A Li,Yiran %A Guo,Yan %A Hong,Y Alicia %A Zhu,Mengting %A Zeng,Chengbo %A Qiao,Jiaying %A Xu,Zhimeng %A Zhang,Hanxi %A Zeng,Yu %A Cai,Weiping %A Li,Linghua %A Liu,Cong %+ Department of Epidemiology and Biostatistics, School of Public Health, Sun Yat-sen University, #74 Zhongshan 2nd Road, Guangzhou, , China, 86 020 87334202, guoy8@mail.sysu.edu.cn %K HIV %K mHealth %K depression %K suicide %D 2019 %7 27.11.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: People living with HIV and depression have high rates of suicide. Studies of mobile health (mHealth) interventions have shown feasibility, acceptability, and efficacy in improving mental health in people living with HIV and depression. However, few studies have examined the mechanisms and effects of mHealth interventions on suicide. Objective: This study was designed to examine the mechanisms and effects of a WeChat-based intervention, Run4Love, on suicide among people living with HIV and depression in China, while considering perceived stress and depressive symptoms as mediators. Methods: A sample of 300 People living with HIV and depression was recruited from the outpatient clinic of a large HIV or AIDS treatment hospital and was randomized to the Run4Love group or a control group. Data were collected at baseline, 3-, 6-, and 9-month follow-ups. Path analysis modeling, with longitudinal data, was used in data analyses. Results: The Run4Love mHealth intervention had a direct effect on reducing suicide rate at the 6-month follow-up (beta=−.18, P=.02) and indirect effect through reducing perceived stress and depressive symptoms at the 3-month follow-up (beta=−.09, P=.001). A partial mediating effect between perceived stress and depressive symptoms accounted for 33% (–0.09/–0.27) of the total effect. Conclusions: Through path analyses, we understood the mechanisms and effects of an mHealth intervention on suicide prevention. The findings underscored the importance of stress reduction and depression treatment in such a program. We call for more effective suicide prevention, especially mHealth interventions targeting the vulnerable population of people living with HIV and depression. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IPR-17012606; http://www.chictr.org.cn/showprojen.aspx?proj=21019 %M 31774411 %R 10.2196/14729 %U https://www.jmir.org/2019/11/e14729 %U https://doi.org/10.2196/14729 %U http://www.ncbi.nlm.nih.gov/pubmed/31774411 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e14946 %T Mood Monitoring Over One Year for People With Chronic Obstructive Pulmonary Disease Using a Mobile Health System: Retrospective Analysis of a Randomized Controlled Trial %A Whelan,Maxine E %A Velardo,Carmelo %A Rutter,Heather %A Tarassenko,Lionel %A Farmer,Andrew J %+ Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom, 44 7435330992, maxine.whelan@phc.ox.ac.uk %K pulmonary disease, chronic obstructive %K self-management %K telemedicine %K computers %K handheld %K anxiety %K depression %D 2019 %7 22.11.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Comorbid anxiety and depression can add to the complexity of managing treatment for people living with chronic obstructive pulmonary disease (COPD). Monitoring mood has the potential to identify individuals who might benefit from additional support and treatment. Objective: We used data from the sElf-management anD support proGrammE (EDGE) trial to examine: (1) the extent to which the mood-monitoring components of a mobile health system for patients with COPD were used by participants; (2) the levels of anxiety and depression symptoms among study participants; (3) the extent to which videos providing advice about coping with low mood were viewed; and (4) the characteristics of participants with differing levels of mood and utilization of mood monitoring. Methods: A total of 107 men and women with a clinical diagnosis of COPD, aged ≥40 years old, were recruited to the intervention arm of the EDGE trial. Participants were invited to complete the Patient Health Questionnaire-8 and the Generalized Anxiety Disorder-7 test every four weeks using a tablet computer. Mood disturbance based on these measures was defined as a score ≥5 on either scale. Participants reporting a mood disturbance were automatically directed (signposted) to a stress or mood management video. Study outcomes included measures of health status, respiratory quality of life, and symptoms of anxiety and depression. Results: Overall, 94 (87.9%) participants completed the 12-month study. A total of 80 participants entered at least one response each month for at least ten months. On average, 16 participants (range 8-38 participants) entered ≥2 responses each month. Of all the participants, 47 (50%) gave responses indicating a mood disturbance. Participants with a mood disturbance score for both scales (n=47) compared with those without (n=20) had lower health status (P=.008), lower quality of life (P=.009), and greater anxiety (P<.001) and increased depression symptoms (P<.001). Videos were viewed by 64 (68%) people over 12 months. Of the 220 viewing visualizations, 70 (34.7%) began after being signposted. Participants signposted to the stress management video (100%; IQR 23.3-100%) watched a greater proportion of it compared to those not signposted (38.4%; IQR 16.0-68.1%; P=.03), whereas duration of viewing was not significantly different for the mood management video. Conclusions: Monitoring of anxiety and depression symptoms for people with COPD is feasible. More than half of trial participants reported scores indicating a mood disturbance during the study. Signposting participants to an advisory video when reporting increased symptoms of a mood disturbance resulted in a longer view-time for the stress management video. The opportunity to elicit measures of mood regularly as part of a health monitoring system could contribute to better care for people with COPD. %M 31755872 %R 10.2196/14946 %U http://mhealth.jmir.org/2019/11/e14946/ %U https://doi.org/10.2196/14946 %U http://www.ncbi.nlm.nih.gov/pubmed/31755872 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e14754 %T Use of a Fully Automated Internet-Based Cognitive Behavior Therapy Intervention in a Community Population of Adults With Depression Symptoms: Randomized Controlled Trial %A Schure,Mark B %A Lindow,Janet C %A Greist,John H %A Nakonezny,Paul A %A Bailey,Sandra J %A Bryan,William L %A Byerly,Matthew J %+ Department of Health & Human Development, Montana State University, 305 Herrick Hall, Bozeman, MT, United States, 1 406 994 3248, mark.schure@montana.edu %K internet-based cognitive behavior therapy %K iCBT %K depression symptoms %K rural populations %K RCT %K randomized controlled trial %K CBT %D 2019 %7 18.11.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Although internet-based cognitive behavior therapy (iCBT) interventions can reduce depression symptoms, large differences in their effectiveness exist. Objective: The aim of this study was to evaluate the effectiveness of an iCBT intervention called Thrive, which was designed to enhance engagement when delivered as a fully automated, stand-alone intervention to a rural community population of adults with depression symptoms. Methods: Using no diagnostic or treatment exclusions, 343 adults with depression symptoms were recruited from communities using an open-access website and randomized 1:1 to the Thrive intervention group or the control group. Using self-reports, participants were evaluated at baseline and 4 and 8 weeks for the primary outcome of depression symptom severity and secondary outcome measures of anxiety symptoms, work and social adjustment, psychological resilience, and suicidal ideation. Results: Over the 8-week follow-up period, the intervention group (n=181) had significantly lower depression symptom severity than the control group (n=162; P<.001), with a moderate treatment effect size (d=0.63). Moderate to near-moderate effect sizes favoring the intervention group were observed for anxiety symptoms (P<.001; d=0.47), work/social functioning (P<.001; d=0.39), and resilience (P<.001; d=0.55). Although not significant, the intervention group was 45% less likely than the control group to experience increased suicidal ideation (odds ratio 0.55). Conclusions: These findings suggest that the Thrive intervention was effective in reducing depression and anxiety symptom severity and improving functioning and resilience among a mostly rural community population of US adults. The effect sizes associated with Thrive were generally larger than those of other iCBT interventions delivered as a fully automated, stand-alone intervention. Trial Registration: ClinicalTrials.gov NCT03244878; https://clinicaltrials.gov/ct2/show/NCT03244878 %M 31738173 %R 10.2196/14754 %U http://www.jmir.org/2019/11/e14754/ %U https://doi.org/10.2196/14754 %U http://www.ncbi.nlm.nih.gov/pubmed/31738173 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 11 %P e12814 %T Wearable Technology for High-Frequency Cognitive and Mood Assessment in Major Depressive Disorder: Longitudinal Observational Study %A Cormack,Francesca %A McCue,Maggie %A Taptiklis,Nick %A Skirrow,Caroline %A Glazer,Emilie %A Panagopoulos,Elli %A van Schaik,Tempest A %A Fehnert,Ben %A King,James %A Barnett,Jennifer H %+ Cambridge Cognition, Tunbridge Court, Bottisham, Cambridge, CB25 9TU, United Kingdom, 44 1223 810700 ext 686, Francesca.Cormack@camcog.com %K depression %K cognition %K mood %K mobile health %K mHealth %K mobile apps %K ecological momentary assessment %K digital phenotyping %K digital biomarkers %D 2019 %7 18.11.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Cognitive symptoms are common in major depressive disorder and may help to identify patients who need treatment or who are not experiencing adequate treatment response. Digital tools providing real-time data assessing cognitive function could help support patient treatment and remediation of cognitive and mood symptoms. Objective: The aim of this study was to examine feasibility and validity of a wearable high-frequency cognitive and mood assessment app over 6 weeks, corresponding to when antidepressant pharmacotherapy begins to show efficacy. Methods: A total of 30 patients (aged 19-63 years; 19 women) with mild-to-moderate depression participated in the study. The new Cognition Kit app was delivered via the Apple Watch, providing a high-resolution touch screen display for task presentation and logging responses. Cognition was assessed by the n-back task up to 3 times daily and depressed mood by 3 short questions once daily. Adherence was defined as participants completing at least 1 assessment daily. Selected tests sensitive to depression from the Cambridge Neuropsychological Test Automated Battery and validated questionnaires of depression symptom severity were administered on 3 occasions (weeks 1, 3, and 6). Exploratory analyses examined the relationship between mood and cognitive measures acquired in low- and high-frequency assessment. Results: Adherence was excellent for mood and cognitive assessments (95% and 96%, respectively), did not deteriorate over time, and was not influenced by depression symptom severity or cognitive function at study onset. Analyses examining the relationship between high-frequency cognitive and mood assessment and validated measures showed good correspondence. Daily mood assessments correlated moderately with validated depression questionnaires (r=0.45-0.69 for total daily mood score), and daily cognitive assessments correlated moderately with validated cognitive tests sensitive to depression (r=0.37-0.50 for mean n-back). Conclusions: This study supports the feasibility and validity of high-frequency assessment of cognition and mood using wearable devices over an extended period in patients with major depressive disorder. %M 31738172 %R 10.2196/12814 %U https://mental.jmir.org/2019/11/e12814 %U https://doi.org/10.2196/12814 %U http://www.ncbi.nlm.nih.gov/pubmed/31738172 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e15489 %T Mediators of Intervention Effects on Depressive Symptoms Among People Living With HIV: Secondary Analysis of a Mobile Health Randomized Controlled Trial Using Latent Growth Curve Modeling %A Zhu,Mengting %A Cai,Weiping %A Li,Linghua %A Guo,Yan %A Monroe-Wise,Aliza %A Li,Yiran %A Zeng,Chengbo %A Qiao,Jiaying %A Xu,Zhimeng %A Zhang,Hanxi %A Zeng,Yu %A Liu,Cong %+ Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, 74 Zhong Shan 2nd Road, Guangzhou, China, 86 1 350 150 2582, guoy8@mail.sysu.edu.cn %K mobile health %K depression %K HIV %K randomized controlled trial %K longitudinal studies %D 2019 %7 15.11.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although several studies have investigated the effects of mobile health (mHealth) interventions on depression among people living with HIV, few studies have explored mediators of mHealth-based interventions to improve mental health in people living with HIV. Identifying influential mediators may enhance and refine effective components of mHealth interventions to improve mental health of people living with HIV. Objective: This study aimed to examine mediating factors of the effects of a mHealth intervention, Run4Love, designed to reduce depression among people living with HIV using 4 time-point measurement data. Methods: This study used data from a randomized controlled trial of a mHealth intervention among people living with HIV with elevated depressive symptoms in Guangzhou, China. A total of 300 patients were assigned to receive either the mHealth intervention (n=150) or a waitlist control group (n=150) through computer-generated block randomization. Depressive symptoms, coping, and HIV-related stigma were measured at baseline, 3-, 6-, and 9-month follow-ups. The latent growth curve model was used to examine the effects of the intervention on depressive symptoms via potential mediators. Mediating effects were estimated using bias-corrected 95% bootstrapped CIs (BCIs) with resampling of 5000. Results: Enhanced positive coping and reduced HIV-related stigma served as effective treatment mediators in the mHealth intervention. Specially, there was a significant indirect effect of the mHealth intervention on the slope of depressive symptoms via the slope of positive coping (beta=–2.86; 95% BCI –4.78 to –0.94). The indirect effect of the mHealth intervention on the slope of depressive symptoms via the slope of HIV-related stigma was also statistically significant (beta=–1.71; 95% BCI –3.03 to –0.40). These findings indicated that enhancement of positive coping and reduction of HIV-related stigma were important mediating factors of the mHealth intervention in reducing depression among people living with HIV. Conclusions: This study revealed the underlying mediators of a mHealth intervention to reduce depression among people living with HIV using latent growth curve model and 4 time-point longitudinal measurement data. The study results underscored the importance of improving positive coping skills and mitigating HIV-related stigma in mHealth interventions to reduce depression among people living with HIV. %M 31730042 %R 10.2196/15489 %U http://mhealth.jmir.org/2019/11/e15489/ %U https://doi.org/10.2196/15489 %U http://www.ncbi.nlm.nih.gov/pubmed/31730042 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 11 %P e12942 %T Public Opinions on Using Social Media Content to Identify Users With Depression and Target Mental Health Care Advertising: Mixed Methods Survey %A Ford,Elizabeth %A Curlewis,Keegan %A Wongkoblap,Akkapon %A Curcin,Vasa %+ Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Village Way, Falmer, Brighton, BN1 9PH, United Kingdom, 44 +441273641974, e.m.ford@bsms.ac.uk %K social media %K depression %K mental health %K machine learning %K public opinion %K social license %K survey %D 2019 %7 13.11.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is a common disorder that still remains underdiagnosed and undertreated in the UK National Health Service. Charities and voluntary organizations offer mental health services, but they are still struggling to promote these services to the individuals who need them. By analyzing social media (SM) content using machine learning techniques, it may be possible to identify which SM users are currently experiencing low mood, thus enabling the targeted advertising of mental health services to the individuals who would benefit from them. Objective: This study aimed to understand SM users’ opinions of analysis of SM content for depression and targeted advertising on SM for mental health services. Methods: A Web-based, mixed methods, cross-sectional survey was administered to SM users aged 16 years or older within the United Kingdom. It asked participants about their demographics, their usage of SM, and their history of depression and presented structured and open-ended questions on views of SM content being analyzed for depression and views on receiving targeted advertising for mental health services. Results: A total of 183 participants completed the survey, and 114 (62.3%) of them had previously experienced depression. Participants indicated that they posted less during low moods, and they believed that their SM content would not reflect their depression. They could see the possible benefits of identifying depression from SM content but did not believe that the risks to privacy outweighed these benefits. A majority of the participants would not provide consent for such analysis to be conducted on their data and considered it to be intrusive and exposing. Conclusions: In a climate of distrust of SM platforms’ usage of personal data, participants in this survey did not perceive that the benefits of targeting advertisements for mental health services to individuals analyzed as having depression would outweigh the risks to privacy. Future work in this area should proceed with caution and should engage stakeholders at all stages to maximize the transparency and trustworthiness of such research endeavors. %M 31719022 %R 10.2196/12942 %U http://mental.jmir.org/2019/11/e12942/ %U https://doi.org/10.2196/12942 %U http://www.ncbi.nlm.nih.gov/pubmed/31719022 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e13393 %T Evaluating the Efficacy of Internet-Delivered Cognitive Behavioral Therapy Blended With Synchronous Chat Sessions to Treat Adolescent Depression: Randomized Controlled Trial %A Topooco,Naira %A Byléhn,Sandra %A Dahlström Nysäter,Ellen %A Holmlund,Jenny %A Lindegaard,Johanna %A Johansson,Sanna %A Åberg,Linnea %A Bergman Nordgren,Lise %A Zetterqvist,Maria %A Andersson,Gerhard %+ Department of Behavioural Sciences and Learning, Linköping University, Campus Valla, Linköping, SE-581 83, Sweden, 46 13281000, naira.topooco@liu.se %K adolescent %K depression %K cognitive behavioral therapy %K randomized controlled trial %K internet %K digital health %K technology %K mental health %K text messaging %K instant messaging %D 2019 %7 1.11.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is a common and serious problem among adolescents, but few seek or have access to therapy. Internet-delivered cognitive behavioral therapies (ICBTs), developed to increase treatment access, show promise in reducing depression. The inclusion of coach support in treatment is desired and may be needed. Objective: The aim of this study was to determine the efficacy of an ICBT protocol blended with weekly real-time therapist sessions via chat; blended treatment, for adolescent depression, including major depressive episode (MDE). The protocol has previously been evaluated in a controlled study. Methods: In a two-arm randomized controlled trial, adolescents 15 to 19 years of age were recruited through a community setting at the national level in Sweden (n=70) and allocated to either 8 weeks of treatment or to minimal attention control. Depression was assessed at baseline, at posttreatment, and at 12 months following treatment (in the intervention group). The primary outcome was self-reported depression level as measured with the Beck Depression Inventory II at posttreatment. The intervention was offered without the need for parental consent. Results: Over two weeks, 162 adolescents registered and completed the baseline screening. Eligible participants (n=70) were on average 17.5 years of age (SD 1.15), female (96%, 67/70), suffered from MDE (76%, 53/70), had no previous treatment experience (64%, 45/70), and reported guardian(s) to be aware about their depression state (71%, 50/70). The average intervention completion was 74% (11.8 of 16 modules and sessions). Following the treatment, ICBT participants demonstrated a significant decrease in depression symptoms compared with controls (P<.001), corresponding to a large between-group effect (intention-to-treat analysis: d=0.86, 95% CI 0.37-1.35; of completer analysis: d=0.99, 95% CI 0.48-1.51). A significant between-group effect was observed in the secondary depression outcome (P=.003); clinically significant improvement was found in 46% (16/35) of ICBT participants compared with 11% (4/35) in the control group (P=.001). Conclusions: The results are in line with our previous study, further demonstrating that adolescents with depression can successfully be engaged in and experience significant improvement following ICBT blended with therapist chat sessions. Findings on participants’ age and baseline depression severity are of interest in relation to used study methods. Trial Registration: ClinicalTrials.gov NCT02363205; https://clinicaltrials.gov/ct2/show/NCT02363205 %M 31682572 %R 10.2196/13393 %U https://www.jmir.org/2019/11/e13393 %U https://doi.org/10.2196/13393 %U http://www.ncbi.nlm.nih.gov/pubmed/31682572 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e12514 %T Difficulties Encountered by People With Depression and Anxiety on the Web: Qualitative Study and Web-Based Expert Survey %A Bernard,Renaldo %A Sabariego,Carla %A Cieza,Alarcos %+ Chair for Public Health and Health Services Research, Research Unit for Biopsychosocial Health, Department of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, Munich, 81377, Germany, 49 49 89 2180 7822, renaldo.bernard@med.lmu.de %K World Wide Web %K depression %K anxiety %K accessibility %K interview %K persona %K expert study %K eHealth %K usability %K user experience %K facilitators %K barriers %K mental disorders %D 2019 %7 31.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression and anxiety are the most common mental health conditions, and they were identified as leading contributors to global disability in 2016. People with these conditions rely on Web-based resources as a source of accurate health information, convenient and effective treatment, and essential social support. However, a recent systematic review revealed several potentially limiting difficulties that this group experiences online and also suggested that there is a partial understanding of these difficulties as only difficulties associated with neurocognitive, but not sociocognitive, deficits were identified. Therefore, this study fills this knowledge gap and contributes to a more robust and fuller understanding of the difficulties this group experiences online. Objective: The objective of this study was to identify the difficulties people with depression and anxiety experience when using the Web and the Web activities that are most associated with the experience of difficulties. Methods: The study employed data triangulation using face-to-face semistructured interviews with 21 participants affected by depression and anxiety and a comparison group (7 participants) without mental disorders (study 1) as well as a persona-based expert online survey with 21 mental health practitioners (MHPs) who treated people with depression and anxiety (study 2). Framework analysis for both studies proceeded through 5 stages: (1) familiarization, (2) identifying a thematic framework, (3) indexing, (4) charting, and (5) mapping and interpretation. Results: In study 1, 167 difficulties were identified from the experiences of participants in the depression and anxiety group were discussed within the context of 81 Web activities, services, and features. From these, 4 themes and 12 subthemes describing the difficulties people with depression and anxiety experienced online were identified. Difficulties relating to the subtheme lack of control over access and usage were the most common difficulties experienced by participants in the depression and anxiety group (19/21). Sixteen difficulties identified from the experiences of participants in the comparison group were discussed within the context of 11 Web activities, services, and features. Most participants in the comparison group (6/7) contributed to the subtheme describing difficulties with unexpected and irrelevant content. In study 2, researchers identified 3 themes and 10 subthemes that described the perceived difficulties people with depression and anxiety might experience online as reported by MHPs. Practitioners linked these difficulties with 22 common impairments, limitations in activities of daily life, and diagnostic criteria associated with depression and anxiety. Conclusions: People with depression and anxiety also experience difficulties when using the Web that are related to the sociocognitive deficits associated with their conditions. MHPs have a good awareness of the difficulties that people with depression and anxiety are likely to experience when using the Web. This investigation has contributed to a fuller understanding of these difficulties and provides innovative guidance on how to remove and reduce them for people with depression and anxiety when using the Web. International Registered Report Identifier (IRRID): RR2-10.1007/978-3-319-21006-3_3 %M 31674915 %R 10.2196/12514 %U http://www.jmir.org/2019/10/e12514/ %U https://doi.org/10.2196/12514 %U http://www.ncbi.nlm.nih.gov/pubmed/31674915 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e14261 %T Cost and Effectiveness of Blended Versus Standard Cognitive Behavioral Therapy for Outpatients With Depression in Routine Specialized Mental Health Care: Pilot Randomized Controlled Trial %A Kooistra,Lisa Catharine %A Wiersma,Jenneke Elize %A Ruwaard,Jeroen %A Neijenhuijs,Koen %A Lokkerbol,Joran %A van Oppen,Patricia %A Smit,Filip %A Riper,Heleen %+ Department of Research and Innovation, GGZ in Geest/Amsterdam University Medical Center, VU University Medical Center, Postbus 74077, Amsterdam, 1070 BB, Netherlands, 31 204448180, l.kooistra@ggzingeest.nl %K depression %K blended cognitive behavioral therapy %K specialized mental health care %K cost-effectiveness %K randomized controlled trial %D 2019 %7 29.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive behavioral therapy (CBT) is an effective treatment, but access is often restricted due to costs and limited availability of trained therapists. Blending online and face-to-face CBT for depression might improve cost-effectiveness and treatment availability. Objective: This pilot study aimed to examine the costs and effectiveness of blended CBT compared with standard CBT for depressed patients in specialized mental health care to guide further research and development of blended CBT. Methods: Patients were randomly allocated to blended CBT (n=53) or standard CBT (n=49). Blended CBT consisted of 10 weekly face-to-face sessions and 9 Web-based sessions. Standard CBT consisted of 15 to 20 weekly face-to-face sessions. At baseline and 10, 20, and 30 weeks after start of treatment, self-assessed depression severity, quality-adjusted life-years (QALYs), and costs were measured. Clinicians, blinded to treatment allocation, assessed psychopathology at all time points. Data were analyzed using linear mixed models. Uncertainty intervals around cost and effect estimates were estimated with 5000 Monte Carlo simulations. Results: Blended CBT treatment duration was mean 19.0 (SD 12.6) weeks versus mean 33.2 (SD 23.0) weeks in standard CBT (P<.001). No significant differences were found between groups for depressive episodes (risk difference [RD] 0.06, 95% CI −0.05 to 0.19), response to treatment (RD 0.03, 95% CI −0.10 to 0.15), and QALYs (mean difference 0.01, 95% CI −0.03 to 0.04). Mean societal costs for blended CBT were €1183 higher than standard CBT. This difference was not significant (95% CI −399 to 2765). Blended CBT had a probability of being cost-effective compared with standard CBT of 0.02 per extra QALY and 0.37 for an additional treatment response, at a ceiling ratio of €25,000. For health care providers, mean costs for blended CBT were €176 lower than standard CBT. This difference was not significant (95% CI −659 to 343). At €0 per additional unit of effect, the probability of blended CBT being cost-effective compared with standard CBT was 0.75. The probability increased to 0.88 at a ceiling ratio of €5000 for an added treatment response, and to 0.85 at €10,000 per QALY gained. For avoiding new depressive episodes, blended CBT was deemed not cost-effective compared with standard CBT because the increase in costs was associated with negative effects. Conclusions: This pilot study shows that blended CBT might be a promising way to engage depressed patients in specialized mental health care. Compared with standard CBT, blended CBT was not considered cost-effective from a societal perspective but had an acceptable probability of being cost-effective from the health care provider perspective. Results should be carefully interpreted due to the small sample size. Further research in larger replication studies focused on optimizing the clinical effects of blended CBT and its budget impact is warranted. Trial Registration: Netherlands Trial Register NTR4650; https://www.trialregister.nl/trial/4408 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-014-0290-z %M 31663855 %R 10.2196/14261 %U http://www.jmir.org/2019/10/e14261/ %U https://doi.org/10.2196/14261 %U http://www.ncbi.nlm.nih.gov/pubmed/31663855 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e13655 %T Improving the Course of Depressive Symptoms After Inpatient Psychotherapy Using Adjunct Web-Based Self-Help: Follow-Up Results of a Randomized Controlled Trial %A Zwerenz,Rüdiger %A Baumgarten,Carlotta %A Becker,Jan %A Tibubos,Ana %A Siepmann,Martin %A Knickenberg,Rudolf J %A Beutel,Manfred E %+ Department of Psychosomatic Medicine and Psychotherapy, University Medical Center, Johannes Gutenberg-University, Untere Zahlbacher Str 8, Mainz, 55131, Germany, 49 61311 75981, ruediger.zwerenz@unimedizin-mainz.de %K depression %K mental health %K internet %K aftercare %K psychotherapy %K psychology, clinical %K inpatients %D 2019 %7 24.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: We recently showed in a randomized controlled trial that Web-based self-help as an adjunct improved the effectiveness of multimodal inpatient psychotherapy for depression. Objective: The aims of this study were (1) to determine whether a Web-based self-help adjunctive to multimodal inpatient psychotherapeutic treatment could also improve the course of depressive symptoms and (2) to identify predictors of residual depressive symptoms at follow-up. Methods: Overall, 229 patients were randomized either to the Web-based self-help intervention group (Deprexis) or an active control group (Web-based information about depression and depressive symptoms) in addition to multimodal inpatient psychotherapy. Participants in both groups were able to access their respective Web-based programs for 12 weeks, which meant that they typically had access after discharge from the inpatient unit (mean hospitalization duration: 40 days, T1). Follow-up was performed 6 months after study intake (T3). Results: At follow-up, participants of the Web-based self-help group had considerably lower symptom load regarding depressive symptoms (d=0.58) and anxiety (d=0.46) as well as a better quality of life (d=0.43) and self-esteem (d=0.31) than participants of the control group. Nearly 3 times as many participants of the intervention group compared with the control group achieved remission in accordance with less deterioration. The number needed to treat based on the Beck Depression Inventory-II (BDI-II) improved over time (T1: 7.84, T2: 7.09, and T3: 5.12). Significant outcome predictors were BDI at discharge and treatment group. Conclusions: Web-based self-help as an add-on to multimodal inpatient psychotherapy improved the short-term course of depressive symptoms beyond termination. Residual symptoms at discharge from inpatient treatment and utilization of the Web-based self-help were the major predictors of depressive symptoms at follow-up. Challenges and barriers (eg, costs, therapists’ concerns, or technical barriers) of adding Web-based interventions to inpatient treatment have to be addressed. Trial Registration: ClinicalTrials.gov NCT02196896; https://clinicaltrials.gov/ct2/show/NCT02196896. %M 31651403 %R 10.2196/13655 %U https://www.jmir.org/2019/10/e13655 %U https://doi.org/10.2196/13655 %U http://www.ncbi.nlm.nih.gov/pubmed/31651403 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e14065 %T Development of the Therapeutic Alliance and its Association With Internet-Based Mindfulness-Based Cognitive Therapy for Distressed Cancer Patients: Secondary Analysis of a Multicenter Randomized Controlled Trial %A Bisseling,Else %A Cillessen,Linda %A Spinhoven,Philip %A Schellekens,Melanie %A Compen,Félix %A van der Lee,Marije %A Speckens,Anne %+ Radboudumc for Mindfulness, Department of Psychiatry, Radboud University Medical Center, 966/CvM, Postbus 9101, Nijmegen, 6500HB, Netherlands, 31 243615445, else.bisseling@radboudumc.nl %K therapeutic alliance %K telemedicine %K mindfulness %K cancer %K patient dropouts %D 2019 %7 18.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Mindfulness-based cognitive therapy (MBCT) is an evidence-based group-based psychological treatment in oncology, resulting in reduction of depressive and anxiety symptoms. Internet-based MBCT (eMBCT) has been found to be an effective alternative for MBCT. The therapeutic alliance (the bond between therapist and patient,) is known to have a significant impact on psychological treatment outcomes, including MBCT. A primary concern in the practice of eMBCT is whether a good therapeutic alliance can develop. Although evidence for the beneficial effect of therapist assistance on treatment outcome in internet-based interventions (IBIs) is accumulating, it is still unclear whether the therapeutic alliance is related to outcome in IBIs. Objective: This study aimed to (1) explore whether early therapeutic alliance predicts treatment dropout in MBCT or eMBCT, (2) compare the development of the therapeutic alliance during eMBCT and MBCT, and (3) examine whether early therapeutic alliance is a predictor of the reduction of psychological distress and the increase of mental well-being at posttreatment in both conditions. Methods: This study was part of a multicenter randomized controlled trial (n=245) on the effectiveness of MBCT or eMBCT for distressed cancer patients. The therapeutic alliance was measured at the start of week 2 (ie, early therapeutic alliance), week 5, and week 9. Outcome measures were psychological distress, measured with the Hospital Anxiety and Depression Scale, and mental well-being, measured with the Mental Health Continuum-Short Form. Results: The strength of early therapeutic alliance did not predict treatment dropout in MBCT or eMBCT (B=−.39; P=.21). Therapeutic alliance increased over time in both conditions (F2,90=16.46; Wilks λ=0.732; P<.001). This increase did not differ between eMBCT and MBCT (F1,91=0.114; P=.74). Therapeutic alliance at week 2 predicted a decrease in psychological distress (B=−.12; t114=−2.656; P=.01) and an increase in mental well-being (B=.23; t113=2.651; P=.01) at posttreatment. The relationship with reduction of psychological distress differed between treatments: a weaker early therapeutic alliance predicted higher psychological distress at posttreatment in MBCT but not in eMBCT (B=.22; t113=2.261; P=.03). Conclusions: A therapeutic alliance can develop in both eMBCT and MBCT. Findings revealed that the strength of early alliance did not predict treatment dropout. Furthermore, the level of therapeutic alliance predicted reduced psychological distress and increased mental well-being at posttreatment in both conditions. Interestingly, the strength of therapeutic alliance appeared to be more related to treatment outcome in group-based MBCT than in eMBCT. Trial Registration: ClinicalTrials.gov NCT02138513; https://clinicaltrials.gov/ct2/show/NCT02138513 %M 31628791 %R 10.2196/14065 %U https://www.jmir.org/2019/10/e14065 %U https://doi.org/10.2196/14065 %U http://www.ncbi.nlm.nih.gov/pubmed/31628791 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e13440 %T A Protocol-Driven, Bedside Digital Conversational Agent to Support Nurse Teams and Mitigate Risks of Hospitalization in Older Adults: Case Control Pre-Post Study %A Bott,Nicholas %A Wexler,Sharon %A Drury,Lin %A Pollak,Chava %A Wang,Victor %A Scher,Kathleen %A Narducci,Sharon %+ Clinical Excellence Research Center, Department of Medicine, Stanford University School of Medicine, 75 Alta Road, Stanford, CA, 94305, United States, 1 650 814 9383, nbott@stanford.edu %K digital health %K older adults %K loneliness %K delirium %K falls %K embodied conversational agent %K chatbot %K relational agent %K information and communication technology %D 2019 %7 17.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Hospitalized older adults often experience isolation and disorientation while receiving care, placing them at risk for many inpatient complications, including loneliness, depression, delirium, and falls. Embodied conversational agents (ECAs) are technological entities that can interact with people through spoken conversation. Some ECAs are also relational agents, which build and maintain socioemotional relationships with people across multiple interactions. This study utilized a novel form of relational ECA, provided by Care Coach (care.coach, inc): an animated animal avatar on a tablet device, monitored and controlled by live health advocates. The ECA implemented algorithm-based clinical protocols for hospitalized older adults, such as reorienting patients to mitigate delirium risk, eliciting toileting needs to prevent falls, and engaging patients in social interaction to facilitate social engagement. Previous pilot studies of the Care Coach avatar have demonstrated the ECA’s usability and efficacy in home-dwelling older adults. Further study among hospitalized older adults in a larger experimental trial is needed to demonstrate its effectiveness. Objective: The aim of the study was to examine the effect of a human-in-the-loop, protocol-driven relational ECA on loneliness, depression, delirium, and falls among diverse hospitalized older adults. Methods: This was a clinical trial of 95 adults over the age of 65 years, hospitalized at an inner-city community hospital. Intervention participants received an avatar for the duration of their hospital stay; participants on a control unit received a daily 15-min visit from a nursing student. Measures of loneliness (3-item University of California, Los Angeles Loneliness Scale), depression (15-item Geriatric Depression Scale), and delirium (confusion assessment method) were administered upon study enrollment and before discharge. Results: Participants who received the avatar during hospitalization had lower frequency of delirium at discharge (P<.001), reported fewer symptoms of loneliness (P=.01), and experienced fewer falls than control participants. There were no significant differences in self-reported depressive symptoms. Conclusions: The study findings validate the use of human-in-the-loop, relational ECAs among diverse hospitalized older adults. %M 31625949 %R 10.2196/13440 %U http://www.jmir.org/2019/10/e13440/ %U https://doi.org/10.2196/13440 %U http://www.ncbi.nlm.nih.gov/pubmed/31625949 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 10 %P e14149 %T Depression Prediction by Using Ecological Momentary Assessment, Actiwatch Data, and Machine Learning: Observational Study on Older Adults Living Alone %A Kim,Heejung %A Lee,SungHee %A Lee,SangEun %A Hong,Soyun %A Kang,HeeJae %A Kim,Namhee %+ College of Nursing, Yonsei University, Room #603, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2 2228 3273, hkim80@yuhs.ac %K elderly %K one-person household %K depression %K ecological momentary assessment %K actigraphy %K machine learning %D 2019 %7 16.10.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although geriatric depression is prevalent, diagnosis using self-reporting instruments has limitations when measuring the depressed mood of older adults in a community setting. Ecological momentary assessment (EMA) by using wearable devices could be used to collect data to classify older adults into depression groups. Objective: The objective of this study was to develop a machine learning algorithm to predict the classification of depression groups among older adults living alone. We focused on utilizing diverse data collected through a survey, an Actiwatch, and an EMA report related to depression. Methods: The prediction model using machine learning was developed in 4 steps: (1) data collection, (2) data processing and representation, (3) data modeling (feature engineering and selection), and (4) training and validation to test the prediction model. Older adults (N=47), living alone in community settings, completed an EMA to report depressed moods 4 times a day for 2 weeks between May 2017 and January 2018. Participants wore an Actiwatch that measured their activity and ambient light exposure every 30 seconds for 2 weeks. At baseline and the end of the 2-week observation, depressive symptoms were assessed using the Korean versions of the Short Geriatric Depression Scale (SGDS-K) and the Hamilton Depression Rating Scale (K-HDRS). Conventional classification based on binary logistic regression was built and compared with 4 machine learning models (the logit, decision tree, boosted trees, and random forest models). Results: On the basis of the SGDS-K and K-HDRS, 38% (18/47) of the participants were classified into the probable depression group. They reported significantly lower scores of normal mood and physical activity and higher levels of white and red, green, and blue (RGB) light exposures at different degrees of various 4-hour time frames (all P<.05). Sleep efficiency was chosen for modeling through feature selection. Comparing diverse combinations of the selected variables, daily mean EMA score, daily mean activity level, white and RGB light at 4:00 pm to 8:00 pm exposure, and daily sleep efficiency were selected for modeling. Conventional classification based on binary logistic regression had a good model fit (accuracy: 0.705; precision: 0.770; specificity: 0.859; and area under receiver operating characteristic curve or AUC: 0.754). Among the 4 machine learning models, the logit model had the best fit compared with the others (accuracy: 0.910; precision: 0.929; specificity: 0.940; and AUC: 0.960). Conclusions: This study provides preliminary evidence for developing a machine learning program to predict the classification of depression groups in older adults living alone. Clinicians should consider using this method to identify underdiagnosed subgroups and monitor daily progression regarding treatment or therapeutic intervention in the community setting. Furthermore, more efforts are needed for researchers and clinicians to diversify data collection methods by using a survey, EMA, and a sensor. %M 31621642 %R 10.2196/14149 %U http://mhealth.jmir.org/2019/10/e14149/ %U https://doi.org/10.2196/14149 %U http://www.ncbi.nlm.nih.gov/pubmed/31621642 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 10 %P e13434 %T Effectiveness and Cost-Effectiveness of Blended Cognitive Behavioral Therapy in Clinically Depressed Adolescents: Protocol for a Pragmatic Quasi-Experimental Controlled Trial %A Rasing,Sanne P A %A Stikkelbroek,Yvonne A J %A Riper,Heleen %A Dekovic,Maja %A Nauta,Maaike H %A Dirksen,Carmen D %A Creemers,Daan H M %A Bodden,Denise H M %+ Child and Adolescent Studies, Utrecht University, PO Box 80140, Utrecht, 3508 TC, Netherlands, 31 30 253 47 00, s.p.a.rasing1@uu.nl %K depression %K major depressive disorder %K cognitive behavioral therapy %K blended %K eHealth %K online %K adolescents %K effectiveness %K cost-effectiveness %D 2019 %7 7.10.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Cognitive behavioral therapy (CBT) is an effective intervention to treat depressive disorders in youth. However, 50% of adolescents still have depressive symptoms after treatment, and 57% drop out during treatment. Online CBT interventions have proven to be effective in reducing depressive symptoms and seem promising as a treatment for depressed adolescents. However, combining online programs with face-to-face sessions seems necessary to increase their effectiveness and monitor for suicide risk. Objective: In this study, we examine the effectiveness and cost-effectiveness of a blended CBT treatment protocol, a mixture of online and face-to-face CBT, as a treatment for clinically depressed adolescents. Methods: A pragmatic quasi-experimental controlled trial will be conducted to study the effectiveness of a blended CBT treatment protocol, in which blended CBT is compared with face-to-face CBT (n=44) and treatment as usual (n=44); the latter two were collected in a previous randomized controlled trial. The same inclusion and exclusion criteria will be used: adolescents aged between 12 and 21 years, with a clinical diagnosis of a depressive disorder, and referred to one of the participating mental health institutions. Assessments will be conducted at the same time points: before the start of the intervention, during the intervention (after 5 and 10 weeks), postintervention, and at 6- and 12-month follow-ups. Results: The primary outcome is the presence of a depression diagnosis at 12-month follow-up. Several secondary outcomes will be measured, such as depressive symptoms, quality of life, and suicide risk. Costs and effects in both conditions will be compared to analyze cost-effectiveness. Further, moderating (age, gender, alcohol and drug use, parental depression, and other psychopathology) and mediating effects (negative automatic thoughts, cognitive emotion regulation, attributional style) will be analyzed. Also, treatment characteristics will be studied, such as characteristics of the therapists, treatment expectancy, and therapeutic alliance. Dropout rates and treatment characteristics will be measured to study the feasibility of blended CBT. Conclusions: This study will examine the effectiveness and cost-effectiveness of a blended CBT program in which depressed adolescents are treated in mental health care. Results of blended CBT will be compared with face-to-face CBT and treatment as usual, and implications for implementation will be reviewed. Trial Registration: Dutch Trial Register (NTR6759); http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6759 International Registered Report Identifier (IRRID): DERR1-10.2196/13434 RR1-10.2196/12654 %M 31593538 %R 10.2196/13434 %U https://www.researchprotocols.org/2019/10/e13434 %U https://doi.org/10.2196/13434 %U http://www.ncbi.nlm.nih.gov/pubmed/31593538 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 10 %P e14648 %T An Internet-Based Cognitive Behavioral Therapy Program Adapted to Patients With Cardiovascular Disease and Depression: Randomized Controlled Trial %A Johansson,Peter %A Westas,Mats %A Andersson,Gerhard %A Alehagen,Urban %A Broström,Anders %A Jaarsma,Tiny %A Mourad,Ghassan %A Lundgren,Johan %+ Department of Social and Welfare Studies, Linköping University, 601 74, Norrköping, Sweden, 46 11 36 31 85, peter.b.johansson@liu.se %K cardiovascular disease %K depression %K cognitive behavior therapy %K internet %K randomized controlled trial %D 2019 %7 3.10.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is a common cause of reduced well-being and prognosis in patients with cardiovascular disease (CVD). However, there is a lack of effective intervention strategies targeting depression. Objective: The study aimed to evaluate the effects of a nurse-delivered and adapted internet-based cognitive behavioral therapy (iCBT) program aimed at reducing depression in patients with CVD. Methods: A randomized controlled trial was conducted. A total of 144 patients with CVD with at least mild depression (Patient Health Questionnaire–9 [PHQ-9] score ≥5) were randomized 1:1 to a 9-week program of iCBT (n=72) or an active control participating in a Web-based discussion forum (online discussion forum [ODF], n=72). The iCBT program, which included 7 modules, was adapted to fit patients with CVD. Nurses with an experience of CVD care provided feedback and a short introduction to cognitive behavioral therapy. The primary outcome, depression, was measured using PHQ-9. Secondary outcomes were depression measured using the Montgomery-Åsberg Depression Rating Scale–self-rating version (MADRS-S), health-related quality of life (HRQoL) measured using Short Form 12 (SF-12) survey and EuroQol Visual Analogue Scale (EQ-VAS), and the level of adherence. An intention-to-treat analysis with multiple imputations was used. Between-group differences in the primary and secondary outcomes were determined by the analysis of covariance, and a sensitivity analysis was performed using mixed models. Results: Compared with ODF, iCBT had a significant and moderate treatment effect on the primary outcome depression (ie, PHQ-9; mean group difference=−2.34 [95% CI −3.58 to −1.10], P<.001, Cohen d=0.62). In the secondary outcomes, compared with ODF, iCBT had a significant and large effect on depression (ie, MADRS-S; P<.001, Cohen d=0.86) and a significant and moderate effect on the mental component scale of the SF-12 (P<.001, Cohen d=0.66) and the EQ-VAS (P<.001, Cohen d=0.62). Overall, 60% (n=43) of the iCBT group completed all 7 modules, whereas 82% (n=59) completed at least half of the modules. No patients were discontinued from the study owing to a high risk of suicide or deterioration in depression. Conclusions: Nurse-delivered iCBT can reduce depression and improve HRQoL in patients with CVD, enabling treatment for depression in their own homes and at their preferred time. Trial Registration: ClinicalTrials.gov NCT02778074; https://clinicaltrials.gov/ct2/show/NCT02778074 %M 31584000 %R 10.2196/14648 %U https://mental.jmir.org/2019/10/e14648 %U https://doi.org/10.2196/14648 %U http://www.ncbi.nlm.nih.gov/pubmed/31584000 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e14240 %T Diminishing Effects After Recurrent Use of Self-Guided Internet-Based Interventions in Depression: Randomized Controlled Trial %A Bücker,Lara %A Schnakenberg,Patricia %A Karyotaki,Eirini %A Moritz,Steffen %A Westermann,Stefan %+ Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr 52, Hamburg, 20246, Germany, 49 40 7410 55868, l.buecker@uke.de %K eHealth %K self-management %K depressive symptoms %K randomized controlled trial %D 2019 %7 2.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Self-guided internet-based interventions have several advantages over guided interventions and are generally effective in treating psychiatric symptoms. Objective: We aimed to investigate whether the use of a new self-guided internet-based intervention (MOOD) would lead to a significant reduction in depressive symptoms compared with a care-as-usual (CAU) control group in a sample of individuals with depressive symptoms, most of whom had already used a different self-guided internet-based intervention in a previous trial. Methods: A total of 125 individuals were randomized to the intervention condition (MOOD) and received access to the intervention for a period of six weeks or a CAU group. After six weeks, all participants were invited to take part in the post assessment. The Beck Depression Inventory-II served as the primary outcome. Results: Both intention-to-treat as well as per-protocol analyses indicated that the depressive symptomatology decreased in both conditions but showed no advantage for those who had used MOOD. Subsequent moderation analyses suggested that those individuals who had less experience with psychotherapy benefitted to a greater extent compared with those with more experience. Conclusions: Self-guided internet-based interventions are deemed a suitable first-step approach to the treatment of depression. However, our results indicate that they are more efficacious in those with less psychotherapy experience. Trial Registration: ClinicalTrials.gov NCT03795480; http://clinicaltrials.gov/ct2/show/NCT03795480 %M 31579014 %R 10.2196/14240 %U https://www.jmir.org/2019/10/e14240 %U https://doi.org/10.2196/14240 %U http://www.ncbi.nlm.nih.gov/pubmed/31579014 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 4 %P e13610 %T Use of Patient-Reported Data to Match Depression Screening Intervals With Depression Risk Profiles in Primary Care Patients With Diabetes: Development and Validation of Prediction Models for Major Depression %A Jin,Haomiao %A Wu,Shinyi %+ Suzanne Dworak-Peck School of Social Work, University of Southern California, 1150 S Olive St, Suite 1400, Los Angeles, CA, 90015, United States, 1 213 821 6441, haomiaoj@usc.edu %K patient-reported data %K patient-centered decision making %K depression screening %K depression %K diabetes %K health information technology %K data analytics %K predictive modeling %K machine learning %K data mining %D 2019 %7 1.10.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Clinical guidelines recommend screening for depression in the general adult population but recognizes that the optimum interval for screening is unknown. Ideal screening intervals should match the patient risk profiles. Objective: This study describes a predictive analytics approach for mining clinical and patient-reported data from a large clinical study for the identification of primary care patients at high risk for depression to match depression screening intervals with patient risk profiles. Methods: This paper analyzed data from a large safety-net primary care study for diabetes and depression. A regression-based data mining technique was used to examine 53 demographics, clinical variables, and patient-reported variables to develop three prediction models for major depression at 6, 12, and 18 months from baseline. Predictors with the strongest predictive power that require low information collection efforts were selected to develop the prediction models. Predictive accuracy was measured by the area under the receiver operating curve (AUROC) and was evaluated by 10-fold cross-validation. The effectiveness of the prediction algorithms in supporting clinical decision making for six “typical” types of patients was demonstrated. Results: The analysis included 923 patients who were nondepressed at the study baseline. Five patient-reported variables were selected in the prediction models to predict major depression at 6, 12, and 18 months: (1) Patient Health Questionnaire 2-item score; (2) the Sheehan Disability Scale; (3) previous problems with depression; (4) the diabetes symptoms scale; and (5) emotional burden of diabetes. All three depression prediction models had an AUROC>0.80, comparable with published depression prediction studies. Among the 6 “typical” types of patients, the algorithms suggest that patients who reported impaired daily functioning by health status are at an elevated risk for depression in all three periods. Conclusions: This study demonstrated that leveraging patient-reported data and prediction models can help improve identification of high-risk patients and clinical decisions about the depression screening interval for diabetes patients. Implementation of this approach can be coupled with application of modern technologies such as telehealth and mobile health assessment for collecting patient-reported data to improve privacy, reducing stigma and costs, and promoting a personalized depression screening that matches screening intervals with patient risk profiles. %M 31573900 %R 10.2196/13610 %U https://formative.jmir.org/2019/4/e13610 %U https://doi.org/10.2196/13610 %U http://www.ncbi.nlm.nih.gov/pubmed/31573900 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 9 %P e13467 %T Role of Moderators on Engagement of Adolescents With Depression or Anxiety in a Social Media Intervention: Content Analysis of Web-Based Interactions %A Windler,Carolyn %A Clair,Maeve %A Long,Cassandra %A Boyle,Leah %A Radovic,Ana %+ University of Pittsburgh School of Medicine, 3550 Terrace St, Pittsburgh, PA, 15261, United States, 1 310 699 2025, cmw185@pitt.edu %K moderator %K social media %K engagement %K adolescents %K mental health %D 2019 %7 26.9.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: The Supporting Our Valued Adolescents (SOVA) intervention aims to use a moderated social media website to encourage peer discussion about negative health beliefs, which may prevent treatment uptake. Web moderators with a background in behavioral health are used to facilitate peer conversation to promote a sense of community, provide social support, and ensure safety. Objective: Although moderation is a core component of this intervention, little is known on best practices for moderators to ensure safety while encouraging engagement. This study sought to describe interactions between moderators and peer users and understand moderator experiences through individual interviews. Methods: Adolescents and young adults aged 14 to 26 years with depression or anxiety history were recruited for a usability study of the SOVA intervention. During this study, 14 moderators were trained to regularly review comments to blog posts for safety, facilitate conversation, and correct misinformation. A total of 110 blog posts and their associated comments were extracted and coded using a codebook based on items from the supportive accountability model and a peer social support analysis. Closing interviews with 12 moderators assessing their experience of moderating were conducted, recorded, and transcribed. Blog post text and comments as well as transcripts of moderator interviews were assessed using a thematic analysis approach, and blog posts were examined for trends in content of moderator comments comparing blog posts with differences in comment contributor order. Results: There were no safety concerns during the study, and moderators only intervened to remove identifiable information. Web moderators exhibited elements of supportive accountability (such as being perceived as experts and using verbal rewards as well as offering informational and emotional support). When the moderators provided the last comment under a blog post, thereby potentially ending contribution by users, they were at times found to be commenting about their own experiences. Moderators interviewed after completing their role expressed challenges in engaging users. A cohort of moderators who received more extensive training on supportive accountability and peer social support felt their ability to engage users improved because of the training. Conclusions: Moderators of a Web-based support site for adolescents with depression or anxiety were able to ensure safety while promoting user engagement. Moderators can elicit user engagement by offering gratitude and encouragement to users, asking users follow-up questions, and limiting their own opinions and experiences when responding to comments. %M 31573923 %R 10.2196/13467 %U http://mental.jmir.org/2019/9/e13467/ %U https://doi.org/10.2196/13467 %U http://www.ncbi.nlm.nih.gov/pubmed/31573923 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 9 %P e13725 %T Using Wearable Physiological Monitors With Suicidal Adolescent Inpatients: Feasibility and Acceptability Study %A Kleiman,Evan %A Millner,Alexander J %A Joyce,Victoria W %A Nash,Carol C %A Buonopane,Ralph J %A Nock,Matthew K %+ Rutgers, The State University of New Jersey, Department of Psychology, 53 Avenue E, Room 627, Piscataway, NJ, 08854, United States, 1 8484452345, evan.kleiman@rutgers.edu %K feasibility studies %K wearable electronic devices %K adolescent, hospitalized %K self-injurious behavior %K qualitative research %D 2019 %7 24.09.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Wearable physiological monitoring devices enable the continuous measurement of human behavior and psychophysiology in the real world. Although such monitors are promising, their availability does not guarantee that participants will continuously wear and interact with them, especially during times of psychological distress. Objective: This study aimed to evaluate the feasibility and acceptability of using a wearable behavioral and physiological monitor, the Empatica E4, to continuously assess a group of suicidal adolescent inpatients. Methods: Participants (n=50 adolescent inpatients) were asked to wear an Empatica E4 on their wrist for the duration of their inpatient stay. In addition to assessing behavioral metadata (eg, hours worn per day), we also used qualitative interviews and self-report measures to assess participants’ experience of wearing the monitor. Results: Results supported the feasibility and acceptability of this approach. Participants wore the monitor for an average of 18 hours a day and reported that despite sometimes finding the monitor uncomfortable, they did not mind wearing it. Many of the participants noted that the part of the study they enjoyed most was contributing to scientific understanding, especially if it could help people similar to them in the future. Conclusions: These findings provide promising support for using wearable monitors in clinical samples in future studies, especially if participants are invested in being part of a research study. %M 31586364 %R 10.2196/13725 %U http://mhealth.jmir.org/2019/9/e13725/ %U https://doi.org/10.2196/13725 %U http://www.ncbi.nlm.nih.gov/pubmed/31586364 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 9 %P e12051 %T Validation of an mHealth App for Depression Screening and Monitoring (Psychologist in a Pocket): Correlational Study and Concurrence Analysis %A Ramos,Roann Munoz %A Cheng,Paula Glenda Ferrer %A Jonas,Stephan Michael %+ Department of Medical Informatics, RWTH Aachen University Hospital, Pauwelstrasse 30, Aachen, 52074, Germany, 49 2418080352, rramos@mi.rwth-aachen.de %K mobile health %K depression %K validation %K Psychologist in a Pocket %K PiaP %D 2019 %7 16.09.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) is a fast-growing professional sector. As of 2016, there were more than 259,000 mHealth apps available internationally. Although mHealth apps are growing in acceptance, relatively little attention and limited efforts have been invested to establish their scientific integrity through statistical validation. This paper presents the external validation of Psychologist in a Pocket (PiaP), an Android-based mental mHealth app which supports traditional approaches in depression screening and monitoring through the analysis of electronic text inputs in communication apps. Objective: The main objectives of the study were (1) to externally validate the construct of the depression lexicon of PiaP with standardized psychological paper-and-pencil tools and (2) to determine the comparability of PiaP, a new depression measure, with a psychological gold standard in identifying depression. Methods: College participants downloaded PiaP for a 2-week administration. Afterward, they were asked to complete 4 psychological depression instruments. Furthermore, 1-week and 2-week PiaP total scores (PTS) were correlated with (1) Beck Depression Index (BDI)-II and Center for Epidemiological Studies–Depression (CES-D) Scale for congruent construct validation, (2) Affect Balance Scale (ABS)–Negative Affect for convergent construct validation, and (3) Satisfaction With Life Scale (SWLS) and ABS–Positive Affect for divergent construct validation. In addition, concordance analysis between PiaP and BDI-II was performed. Results: On the basis of the Pearson product-moment correlation, significant positive correlations exist between (1) 1-week PTS and CES-D Scale, (2) 2-week PTS and BDI-II, and (3) PiaP 2-week PTS and SWLS. Concordance analysis (Bland-Altman plot and analysis) suggested that PiaP’s approach to depression screening is comparable with the gold standard (BDI-II). Conclusions: The evaluation of mental health has historically relied on subjective measurements. With the integration of novel approaches using mobile technology (and, by extension, mHealth apps) in mental health care, the validation process becomes more compelling to ensure their accuracy and credibility. This study suggests that PiaP’s approach to depression screening by analyzing electronic data is comparable with traditional and well-established depression instruments and can be used to augment the process of measuring depression symptoms. %M 31538946 %R 10.2196/12051 %U https://mhealth.jmir.org/2019/9/e12051/ %U https://doi.org/10.2196/12051 %U http://www.ncbi.nlm.nih.gov/pubmed/31538946 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 9 %P e14657 %T Response Time as an Implicit Self-Schema Indicator for Depression Among Undergraduate Students: Preliminary Findings From a Mobile App–Based Depression Assessment %A Chung,Kyungmi %A Park,Jin Young %A Joung,DaYoung %A Jhung,Kyungun %+ Department of Psychiatry, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Simgokro 100gil 25 Seo-gu, Incheon, 22711, Republic of Korea, 82 32 290 3878, kyungun12@gmail.com %K depressive symptoms %K response time %K self-concept %K mobile phone %K mobile apps %K diagnostic screening programs %K self-assessment %K treatment adherence %K compliance %D 2019 %7 13.09.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Response times to depressive symptom items in a mobile-based depression screening instrument has potential as an implicit self-schema indicator for depression but has yet to be determined; the instrument was designed to readily record depressive symptoms experienced on a daily basis. In this study, the well-validated Korean version of the Center for Epidemiologic Studies Depression Scale-Revised (K-CESD-R) was adopted. Objective: The purpose of this study was to investigate the relationship between depression severity (ie, explicit measure: total K-CESD-R Mobile scores) and the latent trait of interest in schematic self-referent processing of depressive symptom items (ie, implicit measure: response times to items in the K-CESD-R Mobile scale). The purpose was to investigate this relationship among undergraduate students who had never been diagnosed with, but were at risk for, major depressive disorder (MDD) or comorbid MDD with other neurological or psychiatric disorders. Methods: A total of 70 participants—36 males (51%) and 34 females (49%)—aged 19-29 years (mean 22.66, SD 2.11), were asked to complete both mobile and standard K-CESD-R assessments via their own mobile phones. The mobile K-CESD-R sessions (binary scale: yes or no) were administered on a daily basis for 2 weeks. The standard K-CESD-R assessment (5-point scale) was administered on the final day of the 2-week study period; the assessment was delivered via text message, including a link to the survey, directly to participants’ mobile phones. Results: A total of 5 participants were excluded from data analysis. The result of polynomial regression analysis showed that the relationship between total K-CESD-R Mobile scores and the reaction times to the depressive symptom items was better explained by a quadratic trend—F (2, 62)=21.16, P<.001, R2=.41—than by a linear trend—F (1, 63)=25.43, P<.001, R2=.29. It was further revealed that the K-CESD-R Mobile app had excellent internal consistency (Cronbach alpha=.94); at least moderate concurrent validity with other depression scales, such as the Korean version of the Quick Inventory for Depressive Symptomatology-Self Report (ρ=.38, P=.002) and the Patient Health Questionnaire-9 (ρ=.48, P<.001); a high adherence rate for all participants (65/70, 93%); and a high follow-up rate for 10 participants whose mobile or standard K-CESD-R score was 13 or greater (8/10, 80%). Conclusions: As hypothesized, based on a self-schema model for depression that represented both item and person characteristics, the inverted U-shaped relationship between the explicit and implicit self-schema measures for depression showed the potential of an organizational breakdown; this also showed the potential for a subsequent return to efficient processing of schema-consistent information along a continuum, ranging from nondepression through mild depression to severe depression. Further, it is expected that the updated K-CESD-R Mobile app can play an important role in encouraging people at risk for depression to seek professional follow-up for mental health care. %M 31586362 %R 10.2196/14657 %U https://mhealth.jmir.org/2019/9/e14657/ %U https://doi.org/10.2196/14657 %U http://www.ncbi.nlm.nih.gov/pubmed/31586362 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 8 %P e14734 %T Wearable Digital Sensors to Identify Risks of Postpartum Depression and Personalize Psychological Treatment for Adolescent Mothers: Protocol for a Mixed Methods Exploratory Study in Rural Nepal %A Poudyal,Anubhuti %A van Heerden,Alastair %A Hagaman,Ashley %A Maharjan,Sujen Man %A Byanjankar,Prabin %A Subba,Prasansa %A Kohrt,Brandon A %+ Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington School of Medicine and Health Sciences, 2120 L Street, Suite 600, Washington, DC, 20037, United States, 1 (202) 741 2888, bkohrt@gwu.edu %K developing countries %K feasibility studies %K mobile health %K mother-child interaction %K postpartum depression %K psychotherapy %D 2019 %7 11.09.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is a high prevalence of untreated postpartum depression among adolescent mothers with the greatest gap in services in low- and middle-income countries. Recent studies have demonstrated the potential of nonspecialists to provide mental health services for postpartum depression in these low-resource settings. However, there is inconsistency in short-term and long-term benefits from the interventions. Passive sensing data generated from wearable digital devices can be used to more accurately distinguish which mothers will benefit from psychological services. In addition, wearable digital sensors can be used to passively collect data to personalize care for mothers. Therefore, wearable passive sensing technology has the potential to improve outcomes from psychological treatments for postpartum depression. Objective: This study will explore the use of wearable digital sensors for two objectives: First, we will pilot test using wearable sensors to generate passive sensing data that distinguish adolescent mothers with depression from those without depression. Second, we will explore how nonspecialists can integrate data from passive sensing technologies to better personalize psychological treatment. Methods: This study will be conducted in rural Nepal with participatory involvement of adolescent mothers and health care stakeholders through a community advisory board. The first study objective will be addressed by comparing behavioral patterns of adolescent mothers without depression (n=20) and with depression (n=20). The behavioral patterns will be generated by wearable digital devices collecting data in 4 domains: (1) the physical activity of mothers using accelerometer data on mobile phones, (2) the geographic range and routine of mothers using GPS (Global Positioning System) data collected from mobile phones, (3) the time and routine of adolescent mothers with their infants using proximity data collected from Bluetooth beacons, and (4) the verbal stimulation and auditory environment for mothers and infants using episodic audio recordings on mobile phones. For the second objective, the same 4 domains of data will be collected and shared with nonspecialists who are delivering an evidence-based behavioral activation intervention to the depressed adolescent mothers. Over 5 weeks of the intervention, we will document how passive sensing data are used by nonspecialists to personalize the intervention. In addition, qualitative data on feasibility and acceptability of passive data collection will be collected for both objectives. Results: To date, a community advisory board comprising young women and health workers engaged with adolescent mothers has been established. The study is open for recruitment, and data collection is anticipated to be completed in November 2019. Conclusions: Integration of passive sensing data in public health and clinical programs for mothers at risk of perinatal mental health problems has the potential to more accurately identify who will benefit from services and increase the effectiveness by personalizing psychological interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/14734 %M 31512581 %R 10.2196/14734 %U http://www.researchprotocols.org/2019/8/e14734/ %U https://doi.org/10.2196/14734 %U http://www.ncbi.nlm.nih.gov/pubmed/31512581 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e12915 %T Evaluation of a Technology-Based Peer-Support Intervention Program for Preventing Postnatal Depression (Part 2): Qualitative Study %A Shorey,Shefaly %A Ng,Esperanza Debby %+ Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Clinical Research Centre, MD 11, Level 2, 10 Medical Drive, Singapore, 117597, Singapore, 65 6601 1294, nurssh@nus.edu.sg %K depression %K mothers %K postpartum %K qualitative %K social support %K telecommunication %K digital health %K peer support %K peer-to-peer support %K online support groups %K internet %D 2019 %7 29.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Social support is known to reduce risks of postnatal depression (PND) and improve maternal emotional well-being. However, the Asian cultural context is often neglected when appraising maternal needs and mothers’ preferences for social support. While many preventive efforts have experimented with technology, professionals, and paraprofessionals in providing social support to mothers in need, most studies determined the effectiveness of their interventions through quantitative measurements of maternal outcomes. Experiences and feedback from both participants and administrators are rarely discussed, especially in an Asian setting. Objective: The goal of the research was to evaluate the postnatal experiences of Asian mothers at risk of PND and the perceptions of peer volunteers regarding a technology-based peer-support intervention program (PIP). Methods: A qualitative semistructured interview was conducted with 20 Asian mothers at risk of depression (10 from the control group and 10 from the intervention group) and 19 peer volunteers from a randomized controlled trial. The PIP included weekly correspondence between peer volunteers and mothers through any telecommunication means over 4 weeks. All interviews were approximately 30 to 60 minutes long, audiotaped, transcribed verbatim, and analyzed using thematic analysis. Study findings were reported according to the Consolidated Standards of Reporting Trials checklist. Results: Two overarching themes comprising five subthemes were generated: postnatal experience (a bouncy ride, a way forward) and evaluation of the PIP (valuable, flexible, and supportive program; building blocks of a good relationship; and lessons learned and the road ahead). Mothers from both the control and interventions groups were generally satisfied with hospital care and the support received from family. They also shared similar breastfeeding challenges and needs for more informed decisions and follow-up support from the hospital. However, mothers who received the PIP tended to have more positive outlooks of their birth experiences. Overall, peer volunteers and mothers involved in the PIP found the PIP useful and expressed satisfaction with the program’s flexibility. They also shared their personal takeaways, the qualities of their friendships, and the need for extended correspondence time and recommended outreach to non–at-risk mothers. Conclusions: The positive endorsement of the PIP by peer volunteers and mothers suggests the success of the PIP in maintaining positive maternal emotional well-being during the postpartum period. With the help of technology, hospitals can easily provide additional peer support to at-risk mothers in addition to existing standard care offered to these mothers. Trial Registration: ISRCTN Registry ISRCTN14864807; http://www.isrctn.com/ISRCTN14864807 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.9416 %M 31469080 %R 10.2196/12915 %U http://www.jmir.org/2019/8/e12915/ %U https://doi.org/10.2196/12915 %U http://www.ncbi.nlm.nih.gov/pubmed/31469080 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e12410 %T Evaluation of a Technology-Based Peer-Support Intervention Program for Preventing Postnatal Depression (Part 1): Randomized Controlled Trial %A Shorey,Shefaly %A Chee,Cornelia Yin Ing %A Ng,Esperanza Debby %A Lau,Ying %A Dennis,Cindy-Lee %A Chan,Yiong Huak %+ Alice Lee Centre for Nursing Studies, Yong Loo Lin School Of Medicine, National University of Singapore, Clinical Research Centre, MD 11, Level 2, 10 Medical Drive, Singapore, 117597, Singapore, 65 6601 1294, nurssh@nus.edu.sg %K anxiety %K loneliness %K postpartum depression %K social support %K technology %K digital health %K peer support %K peer-to-peer support %K online support groups %K internet %D 2019 %7 29.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The frenzy of postbirth events often takes a toll on mothers’ mental well-being, leaving them susceptible to postpartum psychological disorders such as postnatal depression (PND). Social support has been found to be effective in restoring the emotional well-being of new mothers. Therefore, mothers need to be supported during the crucial postpartum period to buffer the negative after effects of childbirth and to promote healthier maternal well-being. Objective: This study aimed to evaluate the effectiveness of a technology-based peer-support intervention program (PIP) on maternal outcomes during the early postpartum period. Methods: A randomized, parallel-armed controlled trial was conducted. The study recruited 138 mothers (69 in intervention group, 69 in control group) at risk of PND from a tertiary hospital in Singapore. To support these mothers, 20 peer volunteers were recruited by word of mouth and trained by a psychiatrist in social support skills before the intervention commenced. The 4-week–long intervention included a weekly follow-up with a peer volunteer through phone calls or text messages. The intervention group received peer support in addition to the standard care offered by the hospital. The control group only received postnatal standard care. Maternal outcomes (PND, postnatal anxiety [PNA], loneliness, and perceived social support) were measured with reliable and valid instruments. Data were collected immediately postpartum, at 1 month postpartum and at 3 months postpartum. The general linear model was used to compare the groups for postpartum percentage changes in the outcome variables at first and third months, and the linear mixed model was used to compare the trend over the study period. Results: There was a statistically significant difference in Edinburgh Postnatal Depression Scale scores (d=–2.11; 95% CI −4.0 to −0.3; P=.03) between the intervention and control groups at 3 months postpartum after adjusting for covariates. The intervention group had a significant change over time compared with the control group. Conclusions: The technology-based PIP was found to be effective in reducing the risk of PND among new mothers and showed a generally positive trend in reducing PNA and loneliness and increasing perceived social support. This study highlights the importance of training paraprofessionals to provide needed support for new mothers postpartum. A further long-term evaluation of the PIP on maternal and family outcomes and its cost-effectiveness is needed to inform clinical practices. Trial Registration: ISRCTN Registry ISRCTN14864807; https://www.isrctn.com/ISRCTN14864807 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.9416 %M 31469084 %R 10.2196/12410 %U http://www.jmir.org/2019/8/e12410/ %U https://doi.org/10.2196/12410 %U http://www.ncbi.nlm.nih.gov/pubmed/31469084 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e13609 %T Comparison of the Effects of Coaching and Receipt of App Recommendations on Depression, Anxiety, and Engagement in the IntelliCare Platform: Factorial Randomized Controlled Trial %A Mohr,David C %A Schueller,Stephen M %A Tomasino,Kathryn Noth %A Kaiser,Susan M %A Alam,Nameyeh %A Karr,Chris %A Vergara,Jessica L %A Gray,Elizabeth L %A Kwasny,Mary J %A Lattie,Emily G %+ Center for Behavioral Intervention Technologies, Northwestern University, 750 N Lakeshore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 312 503 1403, d-mohr@northwestern.edu %K depression %K anxiety %K mHealth %K clinical trial %D 2019 %7 28.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: IntelliCare is a modular platform that includes 12 simple apps targeting specific psychological strategies for common mental health problems. Objective: This study aimed to examine the effect of 2 methods of maintaining engagement with the IntelliCare platform, coaching, and receipt of weekly recommendations to try different apps on depression, anxiety, and app use. Methods: A total of 301 participants with depression or anxiety were randomized to 1 of 4 treatments lasting 8 weeks and were followed for 6 months posttreatment. The trial used a 2X2 factorial design (coached vs self-guided treatment and weekly app recommendations vs no recommendations) to compare engagement metrics. Results: The median time to last use of any app during treatment was 56 days (interquartile range 54-57), with 253 participants (84.0%, 253/301) continuing to use the apps over a median of 92 days posttreatment. Receipt of weekly recommendations resulted in a significantly higher number of app use sessions during treatment (overall median=216; P=.04) but only marginal effects for time to last use (P=.06) and number of app downloads (P=.08). Coaching resulted in significantly more app downloads (P<.001), but there were no significant effects for time to last download or number of app sessions (P=.36) or time to last download (P=.08). Participants showed significant reductions in the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) across all treatment arms (P s<.001). Coached treatment led to larger GAD-7 reductions than those observed for self-guided treatment (P=.03), but the effects for the PHQ-9 did not reach significance (P=.06). Significant interaction was observed between receiving recommendations and time for the PHQ-9 (P=.04), but there were no significant effects for GAD-7 (P=.58). Conclusions: IntelliCare produced strong engagement with apps across all treatment arms. Coaching was associated with stronger anxiety outcomes, and receipt of recommendations enhanced depression outcomes. Trial Registration: ClinicalTrials.gov NCT02801877; https://clinicaltrials.gov/ct2/show/NCT02801877 %M 31464192 %R 10.2196/13609 %U http://www.jmir.org/2019/8/e13609/ %U https://doi.org/10.2196/13609 %U http://www.ncbi.nlm.nih.gov/pubmed/31464192 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e14284 %T Long-Term Outcomes of a Therapist-Supported, Smartphone-Based Intervention for Elevated Symptoms of Depression and Anxiety: Quasiexperimental, Pre-Postintervention Study %A Economides,Marcos %A Ranta,Kristian %A Nazander,Albert %A Hilgert,Outi %A Goldin,Philippe R %A Raevuori,Anu %A Forman-Hoffman,Valerie %+ Meru Health Inc, 470 Ramona Street, Palo Alto, CA, 94301, United States, 1 (650) 740 9404, marcos@mhealthoutcomes.com %K digital health %K depression %K anxiety %K mindfulness %K CBT %K online intervention %K smartphone intervention %D 2019 %7 26.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depression is one of the most common mental health disorders and severely impacts one’s physical, psychological, and social functioning. To address access barriers to care, we developed Ascend—a smartphone-delivered, therapist-supported, 8-week intervention based on several evidence-based psychological treatments for depression and anxiety. A previous feasibility study with 102 adults with elevated depression reported that Ascend is associated with a postintervention reduction in depression symptoms. Objective: We aimed to examine whether Ascend is associated with a reduction in symptoms of anxiety, and importantly, whether reductions in symptoms of depression and anxiety are maintained up to 12-months postintervention. Methods: We assessed whether the previously reported, end-of-treatment improvements seen in the 102 adults with elevated symptoms of depression extended up to 12 months posttreatment for depression symptoms (measured by the Patient Health Questionnaire-9 [PHQ-9]) and up to 6 months posttreatment for anxiety symptoms (added to the intervention later and measured using the Generalized Anxiety Disorder-7 [GAD-7] scale). We used linear mixed effects models with Tukey contrasts to compare time points and reported intention-to-treat statistics with a sensitivity analysis. Results: The intervention was associated with reductions in symptoms of depression that were maintained 12 months after the program (6.67-point reduction in PHQ-9 score, 95% CI 5.59-7.75; P<.001; Hedges g=1.14, 95% CI 0.78-1.49). A total of 60% of the participants with PHQ-9 scores above the cutoff for major depression at baseline (PHQ≥10) reported clinically significant improvement at the 12-month follow-up (at least 50% reduction in PHQ-9 score and postprogram score <10). Participants also reported reductions in symptoms of anxiety that were maintained for at least 6 months after the program (4.26-point reduction in GAD-7 score, 95% CI 3.14-5.38; P<.001; Hedges g=0.91, 95% CI 0.54-1.28). Conclusions: There is limited evidence on whether outcomes associated with smartphone-based interventions for common mental health problems are maintained posttreatment. Participants who enrolled in Ascend experienced clinically significant reductions in symptoms of depression and anxiety that were maintained for up to 1 year and 6 months after the intervention, respectively. Future randomized trials are warranted to test Ascend as a scalable solution to the treatment of depression and anxiety. %M 31452521 %R 10.2196/14284 %U http://mhealth.jmir.org/2019/8/e14284/ %U https://doi.org/10.2196/14284 %U http://www.ncbi.nlm.nih.gov/pubmed/31452521 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 8 %P e12711 %T Exploring Mediators of a Guided Web-Based Self-Help Intervention for People With HIV and Depressive Symptoms: Randomized Controlled Trial %A van Luenen,Sanne %A Kraaij,Vivian %A Spinhoven,Philip %A Wilderjans,Tom F %A Garnefski,Nadia %+ Section of Clinical Psychology, Institute of Psychology, Faculty of Social and Behavioural Sciences, Leiden University, Wassenaarseweg 52, Leiden, 2333 AK, Netherlands, 31 715277957, s.van.luenen@fsw.leidenuniv.nl %K HIV %K depression %K internet %K cognitive behavioral therapy %K coaching %K randomized controlled trial %K mediators %D 2019 %7 23.08.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Cognitive behavioral therapy (CBT) is frequently used to treat depressive symptoms in people living with HIV. We developed an internet-based cognitive behavioral intervention for people with HIV and depressive symptoms, which was based on an effective self-help booklet. The Web-based intervention was previously found to be effective. Objective: The objective of this study was to investigate potential mediators of the Web-based intervention. Methods: This study was part of a randomized controlled trial, in which the intervention was compared with an attention-only waiting list control condition. Participants were 188 (97 in intervention group and 91 in control group) people with HIV and mild to moderate depressive symptoms recruited in HIV treatment centers in the Netherlands. A total of 22 participants (22/188, 11.7%) in the study were female and 166 (166/188, 88.3%) were male. The average age of the participants was 46.30 years (SD 10.63). The intervention comprised Web-based self-help CBT for 8 weeks, 1 to 2 hours a week, including minimal telephone support from a coach. The participants received Web-based questionnaires at pretest, 3 times during the intervention/or waiting period, and post intervention. The outcome was depressive symptoms. Factors tested as potential mediators were changes in behavioral activation, relaxation, the cognitive coping strategies catastrophizing and positive refocusing, goal re-engagement, and coping self-efficacy. Results: Using multilevel structural equation modeling, changes in behavioral activation (P=.006) and goal re-engagement (P=.009) were found to be significant mediators of the intervention effect. The mediation effect seemed to occur between weeks 3 and 5 for behavioral activation and weeks 1 and 3 for goal re-engagement. Using (bivariate) autoregressive latent trajectory analysis, we found a return effect (from the dependent variable to the mediator) for goal re-engagement but not for behavioral activation, which suggested that the mediation effect of changes in behavioral activation was stronger than that in goal re-engagement. Conclusions: The results suggest that changes in behavioral activation and goal re-engagement may mediate the effect of the Web-based intervention for people with HIV and depressive symptoms. The results may lead to possible mechanisms of change of the intervention and improvement of therapy outcomes. Clinical Trial: Netherlands Trial Register NTR5407; https://www.trialregister.nl/trial/5298 %M 31444873 %R 10.2196/12711 %U http://mental.jmir.org/2019/8/e12711/ %U https://doi.org/10.2196/12711 %U http://www.ncbi.nlm.nih.gov/pubmed/31444873 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 8 %P e13271 %T Improving Mental Health in Pregnancy for Refugee Women: Protocol for the Implementation and Evaluation of a Screening Program in Melbourne, Australia %A Boyle,Jacqueline Anne %A Willey,Suzanne %A Blackmore,Rebecca %A East,Christine %A McBride,Jacqueline %A Gray,Kylie %A Melvin,Glenn %A Fradkin,Rebecca %A Ball,Natahl %A Highet,Nicole %A Gibson-Helm,Melanie %+ Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, 43-51 Kanooka Gve, Clayton, Melbourne, 3168, Australia, 61 (613) 85722670, jacqueline.boyle@monash.edu %K mental health %K refugees %K transients and migrants %K pregnancy %K prenatal care %K mass screening %D 2019 %7 19.08.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Identifying mental health disorders in migrant and refugee women during pregnancy provides an opportunity for interventions that may benefit women and their families. Evidence suggests that perinatal mental health disorders impact mother-infant attachment at critical times, which can affect child development. Postnatal depression resulting in suicide is one of the leading causes of maternal mortality postpartum. Routine screening of perinatal mental health is recommended to improve the identification of depression and anxiety and to facilitate early management. However, screening is poorly implemented into routine practice. This study is the first to investigate routine screening for perinatal mental health in a maternity setting designed for refugee women. This study will determine whether symptoms of depression and anxiety are more likely to be detected by the screening program compared with routine care and will evaluate the screening program’s feasibility and acceptability to women and health care providers (HCPs). Objective: The objectives of this study are (1) to assess if refugee women are more likely to screen risk-positive for depression and anxiety than nonrefugee women, using the Edinburgh Postnatal Depression Scale (EPDS); (2) to assess if screening in pregnancy using the EPDS enables better detection of symptoms of depression and anxiety in refugee women than current routine care; (3) to determine if a screening program for perinatal mental health in a maternity setting designed for refugee women is acceptable to women; and (4) to evaluate the feasibility and acceptability of the perinatal mental health screening program from the perspective of HCPs (including the barriers and enablers to implementation). Methods: This study uses an internationally recommended screening measure, the EPDS, and a locally developed psychosocial questionnaire, both administered in early pregnancy and again in the third trimester. These measures have been translated into the most common languages used by the women attending the clinic and are administered via an electronic platform (iCOPE). This platform automatically calculates the EPDS score and generates reports for the HCP and woman. A total of 119 refugee women and 155 nonrefugee women have been recruited to evaluate the screening program’s ability to detect depression and anxiety symptoms and will be compared with 34 refugee women receiving routine care. A subsample of women will participate in a qualitative assessment of the screening program’s acceptability and feasibility. Health service staff have been recruited to evaluate the integration of screening into maternity care. Results: The recruitment is complete, and data collection and analysis are underway. Conclusions: It is anticipated that screening will increase the identification and management of depression and anxiety symptoms in pregnancy. New information will be generated on how to implement such a program in feasible and acceptable ways that will improve health outcomes for refugee women. International Registered Report Identifier (IRRID): DERR1-10.2196/13271 %M 31429411 %R 10.2196/13271 %U http://www.researchprotocols.org/2019/8/e13271/ %U https://doi.org/10.2196/13271 %U http://www.ncbi.nlm.nih.gov/pubmed/31429411 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e14318 %T Counseling With Guided Use of a Mobile Well-Being App for Students Experiencing Anxiety or Depression: Clinical Outcomes of a Feasibility Trial Embedded in a Student Counseling Service %A Broglia,Emma %A Millings,Abigail %A Barkham,Michael %+ Research Department, British Association for Counselling and Psychotherapy, 15 St John's Business Park, Lutterworth, Leicestershire,, United Kingdom, 44 1455 883318, emma.broglia@bacp.co.uk %K counseling %K students %K mental health %K mobile app %K feasibility studies %K outcome measures %K depressive symptoms %K generalized anxiety %K universities %D 2019 %7 15.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Anxiety and depression continue to be prominent experiences of students approaching their university counseling service. These services face unique challenges to ensure that they continue to offer quality support with fewer resources to a growing student population. The convenience and availability of mobile phone apps offer innovative solutions to address therapeutic challenges and expand the reach of traditional support. Objective: The primary aim of this study was to establish the feasibility of a trial in which guided use of a mobile phone well-being app was introduced into a student counseling service and offered as an adjunct to face-to-face counseling. Methods: The feasibility trial used a two-arm, parallel nonrandomized design comparing counseling alone (treatment as usual, or TAU) versus counseling supplemented with guided use of a mobile phone well-being app (intervention) for 38 university students experiencing moderate anxiety or depression. Students in both conditions received up to 6 sessions of face-to-face counseling within a 3-month period. Students who approached the counseling service and were accepted for counseling were invited to join the trial. Feasibility factors evaluated include recruitment duration, treatment preference, randomization acceptability, and intervention fidelity. Clinical outcomes and clinical change were assessed with routine clinical outcome measures administered every counseling session and follow-up phases at 3 and 6 months after recruitment. Results: Both groups demonstrated reduced clinical severity by the end of counseling. This was particularly noticeable for depression, social anxiety, and hostility, whereby clients moved from elevated clinical to low clinical or from low clinical to nonclinical by the end of the intervention. By the 6-month follow-up, TAU clients’ (n=18) anxiety had increased whereas intervention clients’ (n=20) anxiety continued to decrease, and this group difference was significant (Generalized Anxiety Disorder–7: t22=3.46, P=.002). This group difference was not replicated for levels of depression: students in both groups continued to decrease their levels of depression by a similar amount at the 6-month follow-up (Physical Health Questionnaire–9: t22=1.30, P=.21). Conclusion: Supplementing face-to-face counseling with guided use of a well-being app is a feasible and acceptable treatment option for university students experiencing moderate anxiety or depression. The feasibility trial was successfully embedded into a university counseling service without denying access to treatment and with minimal disruption to the service. This study provides preliminary evidence for using a well-being app to maintain clinical improvements for anxiety following the completion of counseling. The design of the feasibility trial provides the groundwork for the development of future pilot trials and definitive trials embedded in a student counseling service. Trial registration: ISRCTN registry ISRCTN55102899; http://www.isrctn.com/ISRCTN55102899 %M 31418424 %R 10.2196/14318 %U http://mhealth.jmir.org/2019/8/e14318/ %U https://doi.org/10.2196/14318 %U http://www.ncbi.nlm.nih.gov/pubmed/31418424 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e13885 %T Suicide Prevention Mobile Apps: Descriptive Analysis of Apps from the Most Popular Virtual Stores %A Castillo-Sánchez,Gema %A Camargo-Henríquez,Ismael %A Muñoz-Sánchez,Juan Luis %A Franco-Martín,Manuel %A de la Torre-Díez,Isabel %+ Department of Signal Theory and Communications, and Telematics Engineering, University of Valladolid, Paseo de Belén 15, Valladolid, 47011, Spain, 34 983423000 ext 3703, isator@tel.uva.es %K apps %K prevention %K suicide %K virtual store %K analysis %D 2019 %7 13.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Provision of follow-up and care during treatment of people with suicidal intentions is a challenge for health professionals and experts in information and communications technology (ICT). Therefore, health professionals and ICT experts are making efforts to carry out these activities in collaboration by using mobile apps as a technological resource. Objective: This study aimed to descriptively analyze mobile apps aimed at suicide prevention and to determine relevant factors in their design and development. In addition, it sought to analyze their impact on the support of treatment for patients at risk for suicide. Methods: We considered 20 apps previously listed in the article “Mobile Apps for Suicide Prevention: Review of Virtual Stores and Literature” (de la Torre et al, JMIR mHealth uHealth 2017;5[10]:e130). To find the apps in this list, the most popular app stores (Android and iOS) were searched using the keyword “suicide prevention.” The research focused on publicly available app information: language, platform, and user ratings. The results obtained were statistically evaluated using 16 parameters that establish various factors that may affect the choice of the user, and the consequent support that the app can offer to a person at risk for suicide. Results: Of the 20 mobile apps, 4 no longer appeared in the app stores and were therefore excluded. Analysis of the remaining 16 apps sampled showed the following: (1) a high percentage of the apps analyzed in the study (n=13, 82%) are provided in English language; (2) the sampled apps were last updated in 2017, when only 45% of them were updated, but the constant and progressive update of treatments should be reflected in the apps; and (3) the technical quality of these apps cannot be determined on the basis of the distribution of scores, because their popularity indices can be subjective (according to the users). User preference for a particular operating system would require further, more specific research, including study of the differences in the technical and usability aspects between both platforms and the design of medical apps. Conclusions: Although there are positive approaches to the use of apps for suicide prevention and follow-up, the technical and human aspects are yet to be explored and defined. For example, the design and development of apps that support suicide prevention should be strongly supported by health personnel to humanize these apps, so that the effectiveness of the treatments supported by them can be improved. %M 31411144 %R 10.2196/13885 %U http://mhealth.jmir.org/2019/8/e13885/ %U https://doi.org/10.2196/13885 %U http://www.ncbi.nlm.nih.gov/pubmed/31411144 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 8 %P e13797 %T Family Members’ Perspectives of Health Care System Interactions With Suicidal Patients and Responses to Suicides: Protocol for a Qualitative Research Study %A Bryksa,Erin %A Shalaby,Reham %A Friesen,Laura %A Klingle,Kirsten %A Gaine,Graham %A Urichuk,Liana %A Surood,Shireen %A Agyapong,Vincent %+ Department of Psychiatry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Centre, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 (780) 407 6504, agyapong@ualberta.ca %K suicide %K family members %K public health systems research %D 2019 %7 09.08.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is a major cause of preventable death globally and a leading cause of death by injury in Canada. To support people who experience suicidal thoughts and behaviors and ultimately prevent people from dying by suicide, it is important to understand the individual and familial experiences with the health care system. Objective: This study aims to explore how suicide victims, and their family members, interacted with the health care system. Methods: We will invite family members of 6 to 8 suicide victims to participate in the study by sharing their perspectives on both their relative’s as well as their own interactions with the health care system. Interviews will take place in-person and will be audio recorded, transcribed, and analyzed thematically. Results: The results of the study are expected to be available in 12 months. We expect the results to shed light on the experiences of suicide victims and their family members with the health care system. Conclusions: Our study results may inform practice, policy, and further research. They may shape how members of the health care system respond to people who are at risk of suicide and their families. International Registered Report Identifier (IRRID): PRR1-10.2196/13797 %M 31400108 %R 10.2196/13797 %U https://www.researchprotocols.org/2019/8/e13797/ %U https://doi.org/10.2196/13797 %U http://www.ncbi.nlm.nih.gov/pubmed/31400108 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e12775 %T Exploring the Relationship Between Usage and Outcomes of an Internet-Based Intervention for Individuals With Depressive Symptoms: Secondary Analysis of Data From a Randomized Controlled Trial %A Enrique,Angel %A Palacios,Jorge E %A Ryan,Holly %A Richards,Derek %+ E-mental Health Research Group, School of Psychology, University of Dublin Trinity College, Dublin, 2, Ireland, 353 1 554 9771, enriquea@tcd.ie %K Web-based intervention %K depression %K adherence %K engagement %K eHealth %K internet %D 2019 %7 01.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet interventions can easily generate objective data about program usage. Increasingly, more studies explore the relationship between usage and outcomes, but they often report different metrics of use, and the findings are mixed. Thus, current evaluations fail to demonstrate which metrics should be considered and how these metrics are related to clinically meaningful change. Objective: This study aimed to explore the relationship between several usage metrics and outcomes of an internet-based intervention for depression. Methods: This is a secondary analysis of data from a randomized controlled trial that examined the efficacy of an internet-based cognitive behavioral therapy for depression (Space from Depression) in an adult community sample. All participants who enrolled in the intervention, regardless of meeting the inclusion criteria, were included in this study. Space from Depression is a 7-module supported intervention, delivered over a period of 8 weeks. Different usage metrics (ie, time spent, modules and activities completed, and percentage of program completion) were automatically collected by the platform, and composite variables from these (eg, activities per session) were computed. A breakdown of the usage metrics was obtained by weeks. For the analysis, the sample was divided into those who obtained a reliable change (RC)—and those who did not. Results: Data from 216 users who completed pre- and posttreatment outcomes were included in the analyses. A total of 89 participants obtained an RC, and 127 participants did not obtain an RC. Those in the RC group significantly spent more time, had more log-ins, used more tools, viewed a higher percentage of the program, and got more reviews from their supporter compared with those who did not obtain an RC. Differences between groups in usage were observed from the first week in advance across the different metrics, although they vanished over time. In the RC group, the usage was higher during the first 4 weeks, and then a significant decrease was observed. Our results showed that specific levels of platform usage, 7 hours total time spent, 15 sessions, 30 tools used, and 50% of program completion, were associated with RC. Conclusions: Overall, the results showed that those individuals who obtained an RC after the intervention had higher levels of exposure to the platform. The usage during the first half of the intervention was higher, and differences between groups were observed from the first week. This study also showed specific usage levels associated with outcomes that could be tested in controlled studies to inform the minimal usage to establish adherence. These results will help to better understand how to use internet-based interventions and what optimal level of engagement can most affect outcomes. Trial Registration: ISRCTN Registry ISRCTN03704676; http://www.isrctn.com/ISRCTN03704676 International Registered Report Identifier (IRRID): RR2-10.1186/1471-244X-14-147 %M 31373272 %R 10.2196/12775 %U https://www.jmir.org/2019/8/e12775/ %U https://doi.org/10.2196/12775 %U http://www.ncbi.nlm.nih.gov/pubmed/31373272 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 7 %P e14174 %T The Effectiveness of Internet-Based Self-Help Interventions to Reduce Suicidal Ideation: Protocol for a Systematic Review and Meta-Analysis %A Büscher,Rebekka %A Torok,Michelle %A Sander,Lasse %+ Department of Rehabilitation Psychology and Psychotherapy, University of Freiburg, Engelbergerstraße 41, Freiburg, 79085, Germany, 49 761 203 3049, lasse.sander@psychologie.uni-freiburg.de %K suicide %K suicidal ideation %K internet %K computer-assisted therapy %K randomized controlled trial %K systematic review %K meta-analysis %D 2019 %7 29.07.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicidal ideation is a highly prevalent condition. There are several barriers for individuals to seek treatment that may be addressed by providing internet-based self-help interventions (ISIs). Current evidence suggests that ISIs for mental disorders may only be effective in reducing suicidal ideation if they specifically target suicidal thoughts or behaviors. Objective: The aim of this systematic review and meta-analysis is to investigate the effectiveness of ISIs that directly target suicidal thoughts or behaviors. Methods: We will conduct a sensitive systematic literature search in PsycINFO, MEDLINE, the Cochrane Central Register of Controlled Trials, and the Centre for Research Excellence of Suicide Prevention databases. Only randomized controlled trials evaluating the effectiveness of ISIs for suicide prevention will be included. Interventions must be delivered primarily in a Web-based setting; mobile-based interventions and interventions targeting gatekeepers will be excluded. Suicide ideation will be the primary outcome; secondary outcomes will be completed suicides, suicide attempts, depressiveness, anxiety, and hopelessness. Study quality will be assessed using the Cochrane Risk of Bias tool. We will provide a narrative synthesis of included studies. If studies are sufficiently homogenous, we will conduct a meta-analysis of the effectiveness on suicide ideation and, if possible, we will evaluate publication bias using funnel plots. We will evaluate the cumulative evidence in accordance with the Grading of Recommendations Assessment, Development and Evaluation framework. Results: This review is in progress, with findings expected by August 2019. Conclusions: This systematic review and meta-analysis focuses on the effectiveness of ISIs for suicidal thoughts and behaviors. It will provide guidance to clinical practice and encourage further research by synthesizing the best available evidence. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019130253; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130253 International Registered Report Identifier (IRRID): PRR1-10.2196/14174 %M 31359868 %R 10.2196/14174 %U https://www.researchprotocols.org/2019/7/e14174/ %U https://doi.org/10.2196/14174 %U http://www.ncbi.nlm.nih.gov/pubmed/31359868 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 7 %P e11591 %T An Online Mindfulness-Based Cognitive Behavioral Therapy Intervention for Youth Diagnosed With Major Depressive Disorders: Protocol for a Randomized Controlled Trial %A Ritvo,Paul %A Daskalakis,Zafiris J %A Tomlinson,George %A Ravindran,Arun %A Linklater,Renee %A Kirk Chang,Megan %A Knyahnytska,Yuliya %A Lee,Jonathan %A Alavi,Nazanin %A Bai,Shari %A Harber,Lillian %A Jain,Tania %A Katz,Joel %+ School of Kinesiology and Health Science, York University, Bethune Building, 4700 Keele St, Toronto, ON, M3J 1P3, Canada, 1 4165808021, pritvo@yorku.ca %K intervention study %K telemedicine %K mobile phone %K mhealth %K fitbit %K depression %K cognitive behavioral therapy %D 2019 %7 29.07.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: About 70% of all mental health disorders appear before the age of 25 years. When untreated, these disorders can become long-standing and impair multiple life domains. When compared with all Canadian youth (of different ages), individuals aged between 15 and 25 years are significantly more likely to experience mental health disorders, substance dependencies, and risks for suicidal ideation and death by suicide. Progress in the treatment of youth, capitalizing on their online responsivity, can strategically address depressive disorders. Objective: We will conduct a randomized controlled trial to compare online mindfulness-oriented cognitive behavioral therapy (CBT-M) combined with standard psychiatric care versus psychiatric care alone in youth diagnosed with major depressive disorder. We will enroll 168 subjects in the age range of 18 to 30 years; 50% of subjects will be from First Nations (FN) backgrounds, whereas the other 50% will be from all other ethnic backgrounds. There will be equal stratification into 2 intervention groups (INT1 and INT2) and 2 wait-list control groups (CTL1 and CTL2) with 42 subjects per group, resulting in an equal number of INT1 and CTL1 of FN background and INT2 and CTL2 of non-FN background. Methods: The inclusion criteria are: (1) age 18 to 30 years, FN background or other ethnicity; (2) Beck Depression Inventory (BDI)-II of at least mild severity (BDI-II score ≥14) and no upper limit; (3) Mini-International Neuropsychiatric Interview (MINI)–confirmed psychiatric diagnosis of major depressive disorder; and (4) fluent in English. All patients are diagnosed by a Centre for Addiction and Mental Health psychiatrist, with diagnoses confirmed using the MINI interview. The exclusion criteria are: (1) individuals receiving weekly structured psychotherapy; (2) individuals who meet the Diagnostic and Statistical Manual of Mental Disorders criteria for severe alcohol/substance use disorder in the past 3 months, or who demonstrate clinically significant suicidal ideation defined as imminent intent, or who have attempted suicide in the past 6 months; and (3) individuals with comorbid diagnoses of borderline personality, schizophrenia, bipolar disorder, and/or obsessive compulsive disorder. All subjects are provided standard psychiatric care defined as 1 monthly session that focuses on appropriate medication, with session durations of 15 to 30 min. Experimental subjects receive an additional intervention consisting of the CBT-M online software program (in collaboration with Nex J Health, Inc). Exposure to and interaction with the online workbooks are combined with navigation-coaching delivered by phone and secure text message interactions. Results: The outcomes selected, combined with measurement blinding, are key features in assessing whether significant benefits regarding depression and anxiety symptoms occur. Conclusions: If results confirm the hypothesis that youth can be effectively treated with online CBT-M, effective services may be widely delivered with less geographic restriction. International Registered Report Identifier (IRRID): PRR1-10.2196/11591 %M 31359869 %R 10.2196/11591 %U http://www.researchprotocols.org/2019/7/e11591/ %U https://doi.org/10.2196/11591 %U http://www.ncbi.nlm.nih.gov/pubmed/31359869 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 7 %P e12707 %T Unraveling the Black Box: Exploring Usage Patterns of a Blended Treatment for Depression in a Multicenter Study %A Kemmeren,Lise L %A van Schaik,Anneke %A Smit,Johannes H %A Ruwaard,Jeroen %A Rocha,Artur %A Henriques,Mário %A Ebert,David Daniel %A Titzler,Ingrid %A Hazo,Jean-Baptiste %A Dorsey,Maya %A Zukowska,Katarzyna %A Riper,Heleen %+ Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, Amsterdam, 1081 HJ, Netherlands, 31 207884527, l.kemmeren@ggzingeest.nl %K cognitive behavior therapy %K internet %K combined modality therapy %K depression %K routine mental healthcare %K treatment compliance %K logfile analysis %D 2019 %7 25.07.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Blended treatments, combining digital components with face-to-face (FTF) therapy, are starting to find their way into mental health care. Knowledge on how blended treatments should be set up is, however, still limited. To further explore and optimize blended treatment protocols, it is important to obtain a full picture of what actually happens during treatments when applied in routine mental health care. Objective: The aims of this study were to gain insight into the usage of the different components of a blended cognitive behavioral therapy (bCBT) for depression and reflect on actual engagement as compared with intended application, compare bCBT usage between primary and specialized care, and explore different usage patterns. Methods: Data used were collected from participants of the European Comparative Effectiveness Research on Internet-Based Depression Treatment project, a European multisite randomized controlled trial comparing bCBT with regular care for depression. Patients were recruited in primary and specialized routine mental health care settings between February 2015 and December 2017. Analyses were performed on the group of participants allocated to the bCBT condition who made use of the Moodbuster platform and for whom data from all blended components were available (n=200). Included patients were from Germany, Poland, the Netherlands, and France; 64.5% (129/200) were female and the average age was 42 years (range 18-74 years). Results: Overall, there was a large variability in the usage of the blended treatment. A clear distinction between care settings was observed, with longer treatment duration and more FTF sessions in specialized care and a more active and intensive usage of the Web-based component by the patients in primary care. Of the patients who started the bCBT, 89.5% (179/200) also continued with this treatment format. Treatment preference, educational level, and the number of comorbid disorders were associated with bCBT engagement. Conclusions: Blended treatments can be applied to a group of patients being treated for depression in routine mental health care. Rather than striving for an optimal blend, a more personalized blended care approach seems to be the most suitable. The next step is to gain more insight into the clinical and cost-effectiveness of blended treatments and to further facilitate uptake in routine mental health care. %M 31344670 %R 10.2196/12707 %U http://mental.jmir.org/2019/7/e12707/ %U https://doi.org/10.2196/12707 %U http://www.ncbi.nlm.nih.gov/pubmed/31344670 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e13809 %T Identification of Patients in Need of Advanced Care for Depression Using Data Extracted From a Statewide Health Information Exchange: A Machine Learning Approach %A Kasthurirathne,Suranga N %A Biondich,Paul G %A Grannis,Shaun J %A Purkayastha,Saptarshi %A Vest,Joshua R %A Jones,Josette F %+ Center for Biomedical Informatics, Regenstrief Institute, 1101 W 10th St, Indianapolis, IN, 46202, United States, 1 3173323480, snkasthu@iupui.edu %K depression %K supervised machine learning %K delivery of health care %D 2019 %7 22.07.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: As the most commonly occurring form of mental illness worldwide, depression poses significant health and economic burdens to both the individual and community. Different types of depression pose different levels of risk. Individuals who suffer from mild forms of depression may recover without any assistance or be effectively managed by primary care or family practitioners. However, other forms of depression are far more severe and require advanced care by certified mental health providers. However, identifying cases of depression that require advanced care may be challenging to primary care providers and health care team members whose skill sets run broad rather than deep. Objective: This study aimed to leverage a comprehensive range of patient-level diagnostic, behavioral, and demographic data, as well as past visit history data from a statewide health information exchange to build decision models capable of predicting the need of advanced care for depression across patients presenting at Eskenazi Health, the public safety net health system for Marion County, Indianapolis, Indiana. Methods: Patient-level diagnostic, behavioral, demographic, and past visit history data extracted from structured datasets were merged with outcome variables extracted from unstructured free-text datasets and were used to train random forest decision models that predicted the need of advanced care for depression across (1) the overall patient population and (2) various subsets of patients at higher risk for depression-related adverse events; patients with a past diagnosis of depression; patients with a Charlson comorbidity index of ≥1; patients with a Charlson comorbidity index of ≥2; and all unique patients identified across the 3 above-mentioned high-risk groups. Results: The overall patient population consisted of 84,317 adult (aged ≥18 years) patients. A total of 6992 (8.29%) of these patients were in need of advanced care for depression. Decision models for high-risk patient groups yielded area under the curve (AUC) scores between 86.31% and 94.43%. The decision model for the overall patient population yielded a comparatively lower AUC score of 78.87%. The variance of optimal sensitivity and specificity for all decision models, as identified using Youden J Index, is as follows: sensitivity=68.79% to 83.91% and specificity=76.03% to 92.18%. Conclusions: This study demonstrates the ability to automate screening for patients in need of advanced care for depression across (1) an overall patient population or (2) various high-risk patient groups using structured datasets covering acute and chronic conditions, patient demographics, behaviors, and past visit history. Furthermore, these results show considerable potential to enable preventative care and can be easily integrated into existing clinical workflows to improve access to wraparound health care services. %M 31333196 %R 10.2196/13809 %U http://www.jmir.org/2019/7/e13809/ %U https://doi.org/10.2196/13809 %U http://www.ncbi.nlm.nih.gov/pubmed/31333196 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e12869 %T Digital Mental Health Interventions for Depression, Anxiety, and Enhancement of Psychological Well-Being Among College Students: Systematic Review %A Lattie,Emily G %A Adkins,Elizabeth C %A Winquist,Nathan %A Stiles-Shields,Colleen %A Wafford,Q Eileen %A Graham,Andrea K %+ Center for Behavioral Intervention Technologies, Northwestern University, 750 N Lake Shore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 3125033741, emily.lattie@northwestern.edu %K eHealth %K mHealth %K mental health %K students %K universities %D 2019 %7 22.07.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: College students are increasingly reporting common mental health problems, such as depression and anxiety, and they frequently encounter barriers to seeking traditional mental health treatments. Digital mental health interventions, such as those delivered via the Web and apps, offer the potential to improve access to mental health treatment. Objective: This study aimed to review the literature on digital mental health interventions focused on depression, anxiety, and enhancement of psychological well-being among samples of college students to identify the effectiveness, usability, acceptability, uptake, and adoption of such programs. Methods: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration number CRD42018092800), and the search strategy was conducted by a medical research librarian in the following databases: MEDLINE (Ovid), EMBASE (Elsevier), PsycINFO (EbscoHost), the Cochrane Library (Wiley), and Web of Science (Thomson Reuters) from the date of inception to April 2019. Data were synthesized using a systematic narrative synthesis framework, and formal quality assessments were conducted to address the risk of bias. Results: A total of 89 studies met the inclusion criteria. The majority of interventions (71/89, 80%) were delivered via a website, and the most common intervention was internet-based cognitive behavioral therapy (28, 31%). Many programs (33, 37%) featured human support in the form of coaching. The majority of programs were either effective (42, 47%) or partially effective (30, 34%) in producing beneficial changes in the main psychological outcome variables. Approximately half of the studies (45, 51%) did not present any usability or acceptability outcomes, and few studies (4, 4%) examined a broad implementation of digital mental health interventions on college campuses. Quality assessments revealed a moderate-to-severe risk of bias in many of the studies. Conclusions: Results suggest that digital mental health interventions can be effective for improving depression, anxiety, and psychological well-being among college students, but more rigorous studies are needed to ascertain the effective elements of these interventions. Continued research on improving the user experience of, and thus user engagement with, these programs appears vital for the sustainable implementation of digital mental health interventions on college campuses. %M 31333198 %R 10.2196/12869 %U http://www.jmir.org/2019/7/e12869/ %U https://doi.org/10.2196/12869 %U http://www.ncbi.nlm.nih.gov/pubmed/31333198 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e10876 %T Internet-Based Interventions for Carers of Individuals With Psychiatric Disorders, Neurological Disorders, or Brain Injuries: Systematic Review %A Spencer,Lucy %A Potterton,Rachel %A Allen,Karina %A Musiat,Peter %A Schmidt,Ulrike %+ Section of Eating Disorders, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF, United Kingdom, 44 2078485608, lucy.spencer@kcl.ac.uk %K internet %K carers %K mental health %K technology %K review %D 2019 %7 09.07.2019 %9 Review %J J Med Internet Res %G English %X Background: Nonprofessional carers who provide support to an individual with a psychiatric or neurological disorder will often themselves experience symptoms of stress, anxiety, or low mood, and they perceive that they receive little support. Internet-based interventions have previously been found to be effective in the prevention and treatment of a range of mental health difficulties in carers. Objective: This review seeks to establish the status of internet-based interventions for informal (nonprofessional) carers of people with psychiatric or neurological disorders by investigating (1) the number and quality of studies evaluating the efficacy or effectiveness of internet-based carer interventions and (2) the impact that such interventions have on carer mental health, as well as (3) how internet-based interventions compare with other intervention types (eg, face-to-face treatment). Methods: A systematic literature search was conducted in January 2019 using the EMBASE (1974-present), Ovid MEDLINE (1946-present), PsychARTICLES, PsychINFO (1806-present), and Global Health (1973-present) databases, via the Ovid Technologies database. Search terms included carer, caregiver, online, technology, internet-based, internet, interactive, intervention, and evaluation. Studies selected for inclusion in this review met the following predetermined criteria: (1) delivering an intervention aimed primarily at informal carers, (2) carers supporting individuals with psychiatric disorders, stroke, dementia, or brain injury, (3) the intervention delivered to the carers was primarily internet based, (4) the study reported a pre- and postquantitative measure of carer depression, anxiety, stress, burden, or quality of life, (5) appeared in a peer-reviewed journal, and (6) was accessible in English. Results: A total of 46 studies were identified for inclusion through the detailed search strategy. The search was conducted, and data were extracted independently by 2 researchers. The majority of studies reported that 1 or more measures relating to carer mental health improved following receipt of a relevant intervention, with interventions for carers of people with traumatic brain injury showing a consistent link with improved outcomes. Conclusions: Studies investigating internet-based interventions for carers of individuals with diverse psychiatric or neurological difficulties show some evidence in support of the effectiveness of these interventions. In addition, such interventions are acceptable to carers. Available evidence is of varying quality, and more high-quality trials are needed. Further research should also establish how specific intervention components, such as structure or interactivity, contribute to their overall efficacy with regard to carer mental health. %M 31290399 %R 10.2196/10876 %U https://www.jmir.org/2019/7/e10876/ %U https://doi.org/10.2196/10876 %U http://www.ncbi.nlm.nih.gov/pubmed/31290399 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 7 %P e13368 %T Virtual Reality and Web-Based Growth Mindset Interventions for Adolescent Depression: Protocol for a Three-Arm Randomized Trial %A Schleider,Jessica Lee %A Mullarkey,Michael C %A Weisz,John R %+ Department of Psychology, Stony Brook University, Psychology B 340, Stony Brook, NY,, United States, 1 631 632 4131, jessica.schleider@stonybrook.edu %K mental health %K depression %K virtual reality %K adolescence %K ehealth %D 2019 %7 09.07.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is the leading cause of disability in youth, with a global economic burden of US >$210 billion annually. However, up to 70% of youth with depression do not receive services. Even among those who do access treatment, 30% to 65% fail to respond and many dropout prematurely, demonstrating a need for more potent, accessible interventions. In a previous trial, a single-session Web-based growth mindset (GM) intervention significantly reduced depressive symptoms in high-symptom adolescents; however, this intervention did not benefit adolescents uniformly. For instance, the intervention reduced depression in adolescents who reported post intervention increases in perceived control, but it did not lead to significant depression reductions in adolescents who reported no significant post intervention increases in perceived control. Objective: The goal of this project is to test the acceptability and efficacy of a novel, single-session, virtual reality (VR) depression intervention—the VR Personality Project—teaching GM, the belief that personal attributes are malleable rather than fixed. The VR Personality Project was designed to systematically target and increase adolescents’ perceived control by offering a more immersive, engaging, user-directed intervention experience than the Web-based intervention can provide. By targeting an identified predictor of intervention response, the VR Personality Project may lead to larger reductions in depressive symptoms than existing Web-based mindset interventions. Methods: Adolescents with elevated depressive symptoms or a recent history of depression (N=159; ages 12 to 16 years) will be randomized to one of 3 intervention conditions: the VR Personality Project; the Web-based GM intervention tested previously; or an active, Web-based control. Adolescents and their parents will report on the adolescents’ depression symptoms, perceived control, and related domains of functioning at preintervention, postintervention, and at 3- and 9-month follow-up assessments. Results: We predict that the VR and Web-based mindset interventions will both lead to larger reductions in adolescent symptoms than the control intervention. Additionally, we predict that the VR-based single session intervention will lead to larger reductions in depression than the online mindset intervention and that these symptom reductions will be mediated by increases in adolescents’ perceived control from pre- to postintervention. Conclusions: The results may suggest an efficient strategy for reducing adolescent depressive symptoms: One that is mechanism-targeted, relatively affordable (less than US $200 for a commercially available VR headset, a fraction of the cost of long-term psychotherapy) and potentially engaging to adolescents experiencing mood-related distress. Trial Registration: ClinicalTrials.gov NCT0385881; https://clinicaltrials.gov/ct2/show/NCT03858881 (Archived by WebCite at http://www.webcitation.org/78C3roDgA). International Registered Report Identifier (IRRID): DERR1-10.2196/13368 %M 31290406 %R 10.2196/13368 %U https://www.researchprotocols.org/2019/7/e13368/ %U https://doi.org/10.2196/13368 %U http://www.ncbi.nlm.nih.gov/pubmed/31290406 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e13664 %T Reducing Patient Loneliness With Artificial Agents: Design Insights From Evolutionary Neuropsychiatry %A Loveys,Kate %A Fricchione,Gregory %A Kolappa,Kavitha %A Sagar,Mark %A Broadbent,Elizabeth %+ Department of Psychological Medicine, The University of Auckland, Auckland City Hospital, Level 12 Support Building, 85 Park Road, Grafton, Auckland, 1023, New Zealand, 64 9 373 7599 ext 84340, k.loveys@auckland.ac.nz %K loneliness %K neuropsychiatry %K biological evolution %K psychological bonding %K interpersonal relations %K artificial intelligence %K social support %K eHealth %D 2019 %7 08.07.2019 %9 Viewpoint %J J Med Internet Res %G English %X Loneliness is a growing public health issue that substantially increases the risk of morbidity and mortality. Artificial agents, such as robots, embodied conversational agents, and chatbots, present an innovation in care delivery and have been shown to reduce patient loneliness by providing social support. However, similar to doctor and patient relationships, the quality of a patient’s relationship with an artificial agent can impact support effectiveness as well as care engagement. Incorporating mammalian attachment-building behavior in neural network processing as part of an agent’s capabilities may improve relationship quality and engagement between patients and artificial agents. We encourage developers of artificial agents intended to relieve patient loneliness to incorporate design insights from evolutionary neuropsychiatry. %M 31287067 %R 10.2196/13664 %U https://www.jmir.org/2019/7/e13664/ %U https://doi.org/10.2196/13664 %U http://www.ncbi.nlm.nih.gov/pubmed/31287067 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e14199 %T Detecting Signs of Depression in Tweets in Spanish: Behavioral and Linguistic Analysis %A Leis,Angela %A Ronzano,Francesco %A Mayer,Miguel A %A Furlong,Laura I %A Sanz,Ferran %+ Research Programme on Biomedical Informatics, Hospital del Mar Medical Research Institute, Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Carrer Dr Aiguader 88, Barcelona, 08003, Spain, 34 933 160 540, ferran.sanz@upf.edu %K depression %K social media %K mental health %K text mining %D 2019 %7 27.06.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental disorders have become a major concern in public health, and they are one of the main causes of the overall disease burden worldwide. Social media platforms allow us to observe the activities, thoughts, and feelings of people’s daily lives, including those of patients suffering from mental disorders. There are studies that have analyzed the influence of mental disorders, including depression, in the behavior of social media users, but they have been usually focused on messages written in English. Objective: The study aimed to identify the linguistic features of tweets in Spanish and the behavioral patterns of Twitter users who generate them, which could suggest signs of depression. Methods: This study was developed in 2 steps. In the first step, the selection of users and the compilation of tweets were performed. A total of 3 datasets of tweets were created, a depressive users dataset (made up of the timeline of 90 users who explicitly mentioned that they suffer from depression), a depressive tweets dataset (a manual selection of tweets from the previous users, which included expressions indicative of depression), and a control dataset (made up of the timeline of 450 randomly selected users). In the second step, the comparison and analysis of the 3 datasets of tweets were carried out. Results: In comparison with the control dataset, the depressive users are less active in posting tweets, doing it more frequently between 23:00 and 6:00 (P<.001). The percentage of nouns used by the control dataset almost doubles that of the depressive users (P<.001). By contrast, the use of verbs is more common in the depressive users dataset (P<.001). The first-person singular pronoun was by far the most used in the depressive users dataset (80%), and the first- and the second-person plural pronouns were the least frequent (0.4% in both cases), this distribution being different from that of the control dataset (P<.001). Emotions related to sadness, anger, and disgust were more common in the depressive users and depressive tweets datasets, with significant differences when comparing these datasets with the control dataset (P<.001). As for negation words, they were detected in 34% and 46% of tweets in among depressive users and in depressive tweets, respectively, which are significantly different from the control dataset (P<.001). Negative polarity was more frequent in the depressive users (54%) and depressive tweets (65%) datasets than in the control dataset (43.5%; P<.001). Conclusions: Twitter users who are potentially suffering from depression modify the general characteristics of their language and the way they interact on social media. On the basis of these changes, these users can be monitored and supported, thus introducing new opportunities for studying depression and providing additional health care services to people with this disorder. %M 31250832 %R 10.2196/14199 %U http://www.jmir.org/2019/6/e14199/ %U https://doi.org/10.2196/14199 %U http://www.ncbi.nlm.nih.gov/pubmed/31250832 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 6 %P e13230 %T Teens Using Screens for Help: Impact of Suicidal Ideation, Anxiety, and Depression Levels on Youth Preferences for Telemental Health Resources %A Toscos,Tammy %A Coupe,Amanda %A Flanagan,Mindy %A Drouin,Michelle %A Carpenter,Maria %A Reining,Lauren %A Roebuck,Amelia %A Mirro,Michael J %+ Parkview Research Center, Parkview Health, 10622 Parkview Plaza Drive, Fort Wayne, IN, 46845, United States, 1 260 266 5586, tammy.toscos@parkview.com %K adolescent %K students %K telemedicine %K mental health %K suicidal ideation %K depression %K anxiety %K health resources %K online social networking %K mental health services %K help-seeking behavior %D 2019 %7 21.6.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: High rates of mental illness, stress, and suicidality among teens constitute a major public health concern in the United States. However, treatment rates remain low, partially because of barriers that could be mitigated with tech-based telemental health (TMH) resources, separate from or in addition to traditional care. Objective: This study aimed to analyze TMH resource usage by high school students to establish current user characteristics and provide a framework for future development. Methods: A total of 2789 students were surveyed regarding demographics, recent anxiety and depression symptoms, suicidality, and stress; people with whom they could openly and honestly discuss stress or problems, and prior TMH use. Logistic regression models and a general linear model were used to test relationships between variables. Results: Overall, 30.58% (853/2789) and 22.91% (639/2789) of students reported moderate to severe anxiety and depression symptoms, respectively, in the past 2 weeks; 16.24% (414/2550) had seriously considered suicide in the past year, consistent with national averages. Meanwhile, 16.03% (447/2789) of students had previously used at least 1 of 4 types of TMH resources (ie, self-help, anonymous chat, online counselor, or crisis text line). Teens reporting depression symptoms, higher stress, or suicidality were less likely to talk to a parent about stress or problems and more likely to tell no one. Suicidality was related to the use of all 4 types of TMH resources. Depression symptoms were related to the use of anonymous chat and crisis text line, and those with higher stress were more likely to have used an online counselor. Those reporting anxiety symptoms were less likely to have no one to talk to and more likely to have used a self-help resource. Conclusions: Youth struggling with mental health symptoms, some of whom lack real-life confidants, are using existing TMH support, with resource preferences related to symptoms. Future research should consider these preferences and assist in the creation of specialized, evidence-based TMH resources. %M 31228179 %R 10.2196/13230 %U http://mental.jmir.org/2019/6/e13230/ %U https://doi.org/10.2196/13230 %U http://www.ncbi.nlm.nih.gov/pubmed/31228179 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e13500 %T Comparing Treatment Acceptability and 12-Month Cessation Rates in Response to Web-Based Smoking Interventions Among Smokers Who Do and Do Not Screen Positive for Affective Disorders: Secondary Analysis %A Watson,Noreen L %A Heffner,Jaimee L %A Mull,Kristin E %A McClure,Jennifer B %A Bricker,Jonathan B %+ Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M3-B232, Seattle, WA,, United States, 1 206 667 2942, nlwatson@fredhutch.org %K smoking %K smoking cessation %K affective disorders %K anxiety %K depression %K eHealth %K Web intervention %K co-occurring disorders %D 2019 %7 19.06.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based cessation programs are now common for intervening with smokers. However, it remains unclear how acceptable or effective these interventions are among people with affective disorders and symptoms (ADS; eg, depression and anxiety). Research examining this is extremely limited, with mixed results on cessation rates. Additional large studies are needed to more fully understand whether Web-based interventions are similarly used and equally effective among people with and without affective disorder symptomology. If not, more targeted Web-based interventions may be required. Objective: The goal of the research was to compare Web-based treatment acceptability (defined by satisfaction and use) and 12-month cessation outcomes between smokers with and without ADS. Methods: Participants (N=2512) were adult smokers enrolled in a randomized, comparative effectiveness trial of two Web-based smoking interventions designed for the general population of smokers. At baseline, participants reported demographic and smoking characteristics and completed measures assessing ADS. Participants were then classified into subgroups based on their self-reported ADS—either into a no ADS group or into six nonmutually exclusive subgroups: depression, posttraumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and more than one ADS. Surveys at 12 months postrandomization included subjective ratings of treatment acceptability and self-reported smoking cessation. Treatment use (ie, number of log-ins and total duration of exposure) was assessed via automated records. Results: Relative to the no ADS group, all six ADS subgroups reported significantly greater satisfaction with their assigned Web treatment program, but they spent less time logged in than those with no ADS. For number of log-ins, a treatment arm by ADS group interaction was observed across all ADS subgroups except GAD, suggesting that relative to the no ADS group, they logged in less to one website but not the other. At the 12-month follow-up, abstinence rates in the no ADS group (153/520, 29.42%) were significantly higher than for participants who screened positive for depression (306/1267, 24.15%; P=.03), PTSD (294/1215, 24.19%; P=.03), PD (229/1003, 23.83%; P=.009), and two or more ADS (323/1332, 24.25%; P=.03). Post hoc analyses suggest the lower quit rates may be associated with differences in baseline nicotine dependence and levels of commitment to resist smoking in difficult situations. Website use did not explain the differential abstinence rates. Conclusions: Despite reporting higher levels of treatment satisfaction, most smokers with ADS used their assigned intervention less often and had lower quit rates than smokers with no ADS at treatment onset. The results support the need for developing more targeted interventions for smokers with ADS. Trial registration: Clinical Trials.gov NCT01812278; https://clinicaltrials.gov/ct2/show/NCT01812278 (Archived by WebCite at http://www.webcitation.org/78L9cNdG4) %M 31219052 %R 10.2196/13500 %U https://www.jmir.org/2019/6/e13500/ %U https://doi.org/10.2196/13500 %U http://www.ncbi.nlm.nih.gov/pubmed/31219052 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 6 %P e11701 %T Addressing Depression Comorbid With Diabetes or Hypertension in Resource-Poor Settings: A Qualitative Study About User Perception of a Nurse-Supported Smartphone App in Peru %A Brandt,Lena R %A Hidalgo,Liliana %A Diez-Canseco,Francisco %A Araya,Ricardo %A Mohr,David C %A Menezes,Paulo R %A Miranda,J Jaime %+ CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Avenida Armendariz 497, Miraflores, Lima, Peru, 51 12416978, fdiezcanseco@gmail.com %K mental health %K depression %K noncommunicable diseases %K mHealth %K smartphone %K developing countries %D 2019 %7 18.06.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Smartphone apps could constitute a cost-effective strategy to overcome health care system access barriers to mental health services for people in low- and middle-income countries. Objective: The aim of this paper was to explore the patients’ perspectives of CONEMO (Emotional Control, in Spanish: Control Emocional), a technology-driven, psychoeducational, and nurse-supported intervention delivered via a smartphone app aimed at reducing depressive symptoms in people with diabetes, hypertension or both who attend public health care centers, as well as the nurses’ feedback about their role and its feasibility to be scaled up. Methods: This study combines data from 2 pilot studies performed in Lima, Peru, between 2015 and 2016, to test the feasibility of CONEMO. Interviews were conducted with 29 patients with diabetes, hypertension or both with comorbid depressive symptoms who used CONEMO and 6 staff nurses who accompanied the intervention. Using a content analysis approach, interview notes from patient interviews were transferred to a digital format, coded, and categorized into 6 main domains: the perceived health benefit, usability, adherence, user satisfaction with the app, nurse’s support, and suggestions to improve the intervention. Interviews with nurses were analyzed by the same approach and categorized into 4 domains: general feedback, evaluation of training, evaluation of study activities, and feasibility of implementing this intervention within the existing structures of health system. Results: Patients perceived improvement in their emotional health because of CONEMO, whereas some also reported better physical health. Many encountered some difficulties with using CONEMO, but resolved them with time and practice. However, the interactive elements of the app, such as short message service, android notifications, and pop-up messages were mostly perceived as challenging. Satisfaction with CONEMO was high, as was the self-reported adherence. Overall, patients evaluated the nurse accompaniment positively, but they suggested improvements in the technological training and an increase in the amount of contact. Nurses reported some difficulties in completing their tasks and explained that the CONEMO intervention activities competed with their everyday work routine. Conclusions: Using a nurse-supported smartphone app to reduce depressive symptoms among people with chronic diseases is possible and mostly perceived beneficial by the patients, but it requires context-specific adaptations regarding the implementation of a task shifting approach within the public health care system. These results provide valuable information about user feedback for those building mobile health interventions for depression. %M 31215511 %R 10.2196/11701 %U https://mental.jmir.org/2019/6/e11701/ %U https://doi.org/10.2196/11701 %U http://www.ncbi.nlm.nih.gov/pubmed/31215511 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e12554 %T Early Detection of Depression: Social Network Analysis and Random Forest Techniques %A Cacheda,Fidel %A Fernandez,Diego %A Novoa,Francisco J %A Carneiro,Victor %+ Department of Computer Science, Faculty of Computer Science, University of A Coruna, Campus de Elvina, A Coruna, 15071, Spain, 34 881011213, diego.fernandez@udc.es %K depression %K major depressive disorder %K social media %K artificial intelligence %K machine learning %D 2019 %7 10.6.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Major depressive disorder (MDD) or depression is among the most prevalent psychiatric disorders, affecting more than 300 million people globally. Early detection is critical for rapid intervention, which can potentially reduce the escalation of the disorder. Objective: This study used data from social media networks to explore various methods of early detection of MDDs based on machine learning. We performed a thorough analysis of the dataset to characterize the subjects’ behavior based on different aspects of their writings: textual spreading, time gap, and time span. Methods: We proposed 2 different approaches based on machine learning singleton and dual. The former uses 1 random forest (RF) classifier with 2 threshold functions, whereas the latter uses 2 independent RF classifiers, one to detect depressed subjects and another to identify nondepressed individuals. In both cases, features are defined from textual, semantic, and writing similarities. Results: The evaluation follows a time-aware approach that rewards early detections and penalizes late detections. The results show how a dual model performs significantly better than the singleton model and is able to improve current state-of-the-art detection models by more than 10%. Conclusions: Given the results, we consider that this study can help in the development of new solutions to deal with the early detection of depression on social networks. %M 31199323 %R 10.2196/12554 %U http://www.jmir.org/2019/6/e12554/ %U https://doi.org/10.2196/12554 %U http://www.ncbi.nlm.nih.gov/pubmed/31199323 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e12556 %T Guided Self-Help Works: Randomized Waitlist Controlled Trial of Pacifica, a Mobile App Integrating Cognitive Behavioral Therapy and Mindfulness for Stress, Anxiety, and Depression %A Moberg,Christine %A Niles,Andrea %A Beermann,Dale %+ Pacifica Labs, Inc, 150 S 5th Street, Suite 825, Minneapolis, MN, 55402, United States, 1 6083470325, christine.moberg@gmail.com %K mHealth %K anxiety %K depression %K stress %K cognitive behavioral therapy %K smartphone app %D 2019 %7 8.6.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite substantial improvements in technology and the increased demand for technology-enabled behavioral health tools among consumers, little progress has been made in easing the burden of mental illness. This may be because of the inherent challenges of conducting traditional clinical trials in a rapidly evolving technology landscape. Objective: This study sought to validate the effectiveness of Pacifica, a popular commercially available app for the self-management of mild-to-moderate stress, anxiety, and depression. Methods: A total of 500 adults with mild-to-moderate anxiety or depression were recruited from in-app onboarding to participate in a randomized waitlist controlled trial of Pacifica. We conducted an all-virtual study, recruiting, screening, and randomizing participants through a Web-based participant portal. Study participants used the app for 1 month, with no level of use required, closely mimicking real-world app usage. Participants in the waitlist group were given access to the app after 1 month. Measurements included self-reported symptoms of stress, anxiety, depression, and self-efficacy. We performed an intent-to-treat analysis to examine the interactive effects of time and condition. Results: We found significant interactions between time and group. Participants in the active condition demonstrated significantly greater decreases in depression, anxiety, and stress and increases in self-efficacy. Although we did not find a relationship between overall engagement with the app and symptom improvement, participants who completed relatively more thought record exercises sustained improvements in their symptoms through the 2-month follow-up to a greater degree than those who completed fewer. In addition, we found that participants who reported concomitantly taking psychiatric medications during the trial benefitted less from the app, as measured by the symptoms of anxiety and stress. Conclusions: This study provides evidence that Pacifica, a popular commercially available self-help app, is effective in reducing self-reported symptoms of depression, anxiety, and stress, particularly among individuals who utilize thought records and are not taking psychiatric medication. Trial Registration: ClinicalTrials.gov NCT03333707; https://clinicaltrials.gov/ct2/show/NCT03333707 (Archived by WebCite at http://www.webcitation.org/78YE07ADB) %M 31199319 %R 10.2196/12556 %U https://www.jmir.org/2019/6/e12556/ %U https://doi.org/10.2196/12556 %U http://www.ncbi.nlm.nih.gov/pubmed/31199319 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e13172 %T Optional Web-Based Videoconferencing Added to Office-Based Care for Women Receiving Psychotherapy During the Postpartum Period: Pilot Randomized Controlled Trial %A Yang,Rebecca %A Vigod,Simone N %A Hensel,Jennifer M %+ Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, 76 Grenville Street, 6th Floor, Toronto, ON, M5S 1B2, Canada, 1 416 323 6400 ext 5989, rebecca.yang@wchospital.ca %K mental health %K psychotherapy %K postpartum period %K videoconferencing %D 2019 %7 20.5.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression and anxiety during the postpartum period are common, with psychotherapy often being the preferred method of treatment. However, psychological, physical, and social barriers prevent women from receiving appropriate and timely psychotherapy. The option of receiving psychotherapy through videoconferencing (VC) during the postpartum period presents an opportunity for more accessible and flexible care. Objective: The aim of this study was to assess the feasibility, acceptability, and preliminary effectiveness of optional VC added to usual office-based psychotherapy, with a psychotherapist during the postpartum period. Methods: We conducted a pilot randomized controlled trial with 1:1 randomization to office-based care (treatment as usual; TAU) or office-based care with the option of VC (treatment as usual plus videoconferencing; TAU-VC) for psychotherapy during the postpartum period. We assessed the ability to recruit and retain postpartum women into the study from an urban perinatal mental health program offering postpartum psychotherapy, and we evaluated the uptake, acceptability, and satisfaction with VC as an addition to in-person psychotherapy. We also compared therapy attendance using therapist logs and symptoms between treatment groups. Symptoms were assessed at baseline and 3 months postrandomization with the Edinburgh Postnatal Depression Scale, Generalized Anxiety Disorder 7-item, and Parental Stress Scale. Furthermore, 3-month scores were compared between groups with intention-to-treat linear mixed-effects models controlling for baseline score. Results: We enrolled 38 participants into the study, with 19 participants in each treatment group. Attendance data were available for all participants, with follow-up symptom measures available for 25 out of 38 participants (66%). Among the 19 TAU-VC participants, 14 participants (74%) utilized VC at least once. Most participants were highly satisfied with the VC option, and they reported average savings of Can $26 and 2.5 hours in travel and childcare expenses and time per appointment. There were no significant differences between the 2 groups for psychotherapy attendance or symptoms. Conclusions: The option of VC appears to be an acceptable method of receiving psychotherapy for postpartum women, with benefits described in costs and time savings. On the basis of this small pilot sample, there were no significant differences in outcomes between office-based care with or without the option of VC. This study has demonstrated the feasibility of such a program in an urban center, which suggests that a larger study would be beneficial to provide evidence that is more conclusive. %M 31199291 %R 10.2196/13172 %U https://www.jmir.org/2019/6/e13172/ %U https://doi.org/10.2196/13172 %U http://www.ncbi.nlm.nih.gov/pubmed/31199291 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e10838 %T A Web-Based Mental Health Platform for Individuals Seeking Specialized Mental Health Care Services: Multicenter Pragmatic Randomized Controlled Trial %A Hensel,Jennifer M %A Shaw,James %A Ivers,Noah M %A Desveaux,Laura %A Vigod,Simone N %A Cohen,Ashley %A Onabajo,Nike %A Agarwal,Payal %A Mukerji,Geetha %A Yang,Rebecca %A Nguyen,Megan %A Bouck,Zachary %A Wong,Ivy %A Jeffs,Lianne %A Jamieson,Trevor %A Bhatia,R Sacha %+ Women's College Institute for Health Systems Solutions and Virtual Care, 76 Grenville St, Toronto, ON, M5S 1B2, Canada, 1 416 323 6400 ext 5126, jennifer.hensel@wchospital.ca %K internet %K mental health %K anxiety %K depression %D 2019 %7 04.06.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based self-directed mental health applications are rapidly emerging to address health service gaps and unmet needs for information and support. Objective: The aim of this study was to determine if a multicomponent, moderated Web-based mental health application could benefit individuals with mental health symptoms severe enough to warrant specialized mental health care. Methods: A multicenter, pragmatic randomized controlled trial was conducted across several outpatient mental health programs affiliated with 3 hospital programs in Ontario, Canada. Individuals referred to or receiving treatment, aged 16 years or older, with access to the internet and an email address, and having the ability to navigate a Web-based mental health application were eligible. A total of 812 participants were randomized 2:1 to receive immediate (immediate treatment group, ITG) or delayed (delayed treatment group, DTG) access for 3 months to the Big White Wall (BWW), a multicomponent Web-based mental health intervention based in the United Kingdom and New Zealand. The primary outcome was the total score on the Recovery Assessment Scale, revised (RAS-r) which measures mental health recovery. Secondary outcomes were total scores on the Patient Health Questionnaire-9 item (PHQ-9), the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7), the EuroQOL 5-dimension quality of life questionnaire (EQ-5D-5L), and the Community Integration Questionnaire. An exploratory analysis examined the association between actual BWW use (categorized into quartiles) and outcomes among study completers. Results: Intervention participants achieved small, statistically significant increases in adjusted RAS-r score (4.97 points, 95% CI 2.90 to 7.05), and decreases in PHQ-9 score (−1.83 points, 95% CI −2.85 to −0.82) and GAD-7 score (−1.55 points, 95% CI −2.42 to −0.70). Follow-up was achieved for 55% (446/812) at 3 months, 48% (260/542) of ITG participants and 69% (186/270) of DTG participants. Only 58% (312/542) of ITG participants logged on more than once. Some higher BWW user groups had significantly greater improvements in PHQ-9 and GAD-7 relative to the lowest use group. Conclusions: The Web-based application may be beneficial; however, many participants did not engage in an ongoing way. This has implications for patient selection and engagement as well as delivery and funding structures for similar Web-based interventions. Trial Registration: ClinicalTrials.gov NCT02896894; https://clinicaltrials.gov/ct2/show/NCT02896894 (Archived by WebCite at http://www.webcitation.org/78LIpnuRO) %M 31165710 %R 10.2196/10838 %U https://www.jmir.org/2019/6/e10838/ %U https://doi.org/10.2196/10838 %U http://www.ncbi.nlm.nih.gov/pubmed/31165710 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e13689 %T The Effectiveness of an App-Based Nurse-Moderated Program for New Mothers With Depression and Parenting Problems (eMums Plus): Pragmatic Randomized Controlled Trial %A Sawyer,Alyssa %A Kaim,Amy %A Le,Huynh-Nhu %A McDonald,Denise %A Mittinty,Murthy %A Lynch,John %A Sawyer,Michael %+ School of Public Health, University of Adelaide, Adelaide Health & Medical Sciences Building, 57 North Terrace, Mail Drop DX 650 550, Adelaide, 5005, Australia, 61 8 81617207, alyssa.sawyer@adelaide.edu.au %K mobile phone %K infant %K mother-child relations %K postnatal depression %K randomized controlled trial %D 2019 %7 04.06.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Postnatal depression and caregiving difficulties adversely affect mothers, infants, and later childhood development. In many countries, resources to help mothers and infants are limited. Online group–based nurse-led interventions have the potential to help address this problem by providing large numbers of mothers with access to professional and peer support during the postnatal period. Objective: This study tested the effectiveness of a 4-month online group–based nurse-led intervention delivered when infants were aged 2 to 6 months as compared with standard care outcomes. Methods: The study was a block randomized control trial. Mothers were recruited at the time they were contacted for the postnatal health check offered to all mothers in South Australia. Those who agreed to participate were randomly assigned to the intervention or standard care. The overall response rate was 63.3% (133/210). Primary outcomes were the level of maternal depressive symptoms assessed with the Edinburgh Postnatal Depression Scale (EPDS) and quality of maternal caregiving assessed using the Parenting Stress Index (PSI; competence and attachment subscales), the Parenting Sense of Competence Scale (PSCS), and the Nursing Child Assessment Satellite Training Scale. Assessments were completed at baseline (mean child age 4.9 weeks [SD 1.4]) and again when infants were aged 8 and 12 months. Results: Outcomes were evaluated using linear generalized estimating equations adjusting for postrandomization group differences in demographic characteristics and the outcome score at baseline. There were no significant differences in the intervention and standard care groups in scores on the PSI competence subscale (P=.69) nor in the PSCS (P=.11). Although the group by time interaction suggested there were differences over time between the EPDS and PSI attachment subscale scores in the intervention and standard care groups (P=.001 and P=.04, respectively), these arose largely because the intervention group had stable scores over time whereas the standard care group showed some improvements between baseline and 12 months. Mothers engaged well with the intervention with at least 60% (43/72) of mothers logging-in once per week during the first 11 weeks of the intervention. The majority of mothers also rated the intervention as helpful and user-friendly. Conclusions: Mothers reported that the intervention was helpful, and the app was described as easy to use. As such, it appears that support for mothers during the postnatal period, provided using mobile phone technology, has the potential to be an important addition to existing services. Possible explanations for the lack of differences in outcomes for the 2 groups in this study are the failure of many mothers to use key components of the intervention and residual differences between the intervention and standard care groups post randomization. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616001732471; http://www.ANZCTR.org.au/ACTRN12616001732471.aspx (archived on WebCite as http://www.webcitation.org/77zo30GDw) %M 31165715 %R 10.2196/13689 %U https://www.jmir.org/2019/6/e13689/ %U https://doi.org/10.2196/13689 %U http://www.ncbi.nlm.nih.gov/pubmed/31165715 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 5 %P e10778 %T A Group-Based Online Intervention to Prevent Postpartum Depression (Sunnyside): Feasibility Randomized Controlled Trial %A Duffecy,Jennifer %A Grekin,Rebecca %A Hinkel,Hannah %A Gallivan,Nicholas %A Nelson,Graham %A O'Hara,Michael W %+ Department of Psychiatry, College of Medicine, University of Illinois at Chicago, 912 S Wood, Chicago, IL, 60612, United States, 1 3124131225, jduffecy@gmail.com %K postpartum depression %K cognitive behavioral therapy %K internet %K social support %D 2019 %7 28.05.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Postpartum depression (PPD) has a 20% 3-month prevalence rate. The consequences of PPD are significant for the mother, infant, and the family. There is a need for preventive interventions for PPD, which are effective and accessible; however, many barriers exist for women who attempt to access perinatal depression prevention programs. Internet interventions for the treatment and prevention of depression are widely accepted as efficacious and may overcome some of the issues pertaining to access to treatment barriers perinatal women face. However, internet interventions offered without any human support tend to have low adherence but positive outcomes for those who do complete treatment. Internet support groups often have high levels of adherence but minimal data supporting efficacy as a treatment for depression. Taken together, these findings suggest that combining the treatment components of individual interventions with the support provided by an internet support group might create an intervention with the scalability and cost-effectiveness of an individual intervention and the better outcomes typically found in supported interventions. Objectives: This study aimed to describe the development of a cognitive behavioral therapy (CBT) internet intervention with peer support to prevent PPD and examine preliminary depression and site usage outcomes. Methods: User-centered design groups were used to develop the internet intervention. Once the intervention was developed, women who were 20 to 28 weeks pregnant with symptoms of depression (Patient Health Questionnaire-8 scores of 5-14) but who had no major depression diagnosis were enrolled in a randomized controlled trial (RCT) to compare 8 weeks of a CBT-based internet intervention with peer support to an individual internet intervention designed to prevent PPD. Assessments took place at baseline, 4 weeks, 8 weeks (end of treatment), and then 4 weeks and 6 weeks postpartum. Results: A total of 25 women were randomized. Of these, 24 women completed the RCT. Patient Health Questionnaire-9 scores at 6 weeks postpartum remained below the clinical threshold for referral for treatment in both groups, with depression measures showing a decrease in symptoms from baseline to postpartum. At 6 weeks postpartum, only 4% (1/24) met the criteria for PPD. There was no difference between groups in adherence to the intervention, with an average of 14.55 log-ins over the course of treatment. Conclusions: Results suggest women were responsive to both peer support and individual internet interventions to prevent PPD and that peer support may be a useful feature to keep participants adherent. Trial Registration: ClinicalTrials.gov NCT02121015; https://clinicaltrials.gov/ct2/show/NCT02121015 (archived by WebCite at http://www.webcitation.org/765a7qBKy) %M 31140443 %R 10.2196/10778 %U http://mental.jmir.org/2019/5/e10778/ %U https://doi.org/10.2196/10778 %U http://www.ncbi.nlm.nih.gov/pubmed/31140443 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e12793 %T Recruiting to a Randomized Controlled Trial of a Web-Based Program for People With Type 2 Diabetes and Depression: Lessons Learned at the Intersection of e-Mental Health and Primary Care %A Fletcher,Susan %A Clarke,Janine %A Sanatkar,Samineh %A Baldwin,Peter %A Gunn,Jane %A Zwar,Nick %A Campbell,Lesley %A Wilhelm,Kay %A Harris,Mark %A Lapsley,Helen %A Hadzi-Pavlovic,Dusan %A Proudfoot,Judy %+ Department of General Practice, University of Melbourne, Ground Floor, 200 Berkeley Street, Carlton, 3052, Australia, 61 390354872, susanlf@unimelb.edu.au %K e-mental health %K primary care %K patient recruitment %K depression %K type 2 diabetes %K learning %D 2019 %7 24.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: E-mental health (eMH) interventions are now widely available and they have the potential to revolutionize the way that health care is delivered. As most health care is currently delivered by primary care, there is enormous potential for eMH interventions to support, or in some cases substitute, services currently delivered face to face in the community setting. However, randomized trials of eMH interventions have tended to recruit participants using online recruitment methods. Consequently, it is difficult to know whether participants who are recruited online differ from those who attend primary care. Objective: This paper aimed to document the experience of recruiting to an eMH trial through primary care and compare the characteristics of participants recruited through this and other recruitment methods. Methods: Recruitment to the SpringboarD randomized controlled trial was initially focused on general practices in 2 states of Australia. Over 15 months, we employed a comprehensive approach to engaging practice staff and supporting them to recruit patients, including face-to-face site visits, regular contact via telephone and trial newsletters, and development of a Web-based patient registration portal. Nevertheless, it became apparent that these efforts would not yield the required sample size, and we therefore supplemented recruitment through national online advertising and promoted the study through existing networks. Baseline characteristics of participants recruited to the trial through general practice, online, or other sources were compared using the analysis of variance and chi square tests. Results: Between November 2015 and October 2017, 780 people enrolled in SpringboarD, of whom 740 provided information on the recruitment source. Of these, only 24 were recruited through general practice, whereas 520 were recruited online and 196 through existing networks. Key barriers to general practice recruitment included perceived mismatch between trial design and diabetes population, prioritization of acute health issues, and disruptions posed by events at the practice and community level. Participants recruited through the 3 different approaches differed in age, gender, employment status, depressive symptoms, and diabetes distress, with online participants being distinguished from those recruited through general practice or other sources. However, most differences reached only a small effect size and are unlikely to be of clinical importance. Conclusions: Time, labor, and cost-intensive efforts did not translate into successful recruitment through general practice in this instance, with barriers identified at several different levels. Online recruitment yielded more participants, who were broadly similar to those recruited via general practice. %M 31127718 %R 10.2196/12793 %U https://www.jmir.org/2019/5/e12793/ %U https://doi.org/10.2196/12793 %U http://www.ncbi.nlm.nih.gov/pubmed/31127718 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e12246 %T A Web-Based Cognitive Behavior Therapy Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The SpringboarD Trial): Randomized Controlled Trial %A Clarke,Janine %A Sanatkar,Samineh %A Baldwin,Peter Andrew %A Fletcher,Susan %A Gunn,Jane %A Wilhelm,Kay %A Campbell,Lesley %A Zwar,Nicholas %A Harris,Mark %A Lapsley,Helen %A Hadzi-Pavlovic,Dusan %A Christensen,Helen %A Proudfoot,Judy %+ Black Dog Institute, Hospital Road, Randwick, Sydney,, Australia, 61 0293824521, p.baldwin@unsw.edu.au %K type 2 diabetes %K depression %K internet %D 2019 %7 21.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Depressive symptoms are common in people with type 2 diabetes mellitus (T2DM). Effective depression treatments exist; however, access to psychological support is characteristically low. Web-based cognitive behavioral therapy (CBT) is accessible, nonstigmatizing, and may help address substantial personal and public health impact of comorbid T2DM and depression. Objective: The aim of this study was to evaluate the Web-based CBT program, myCompass, for improving social and occupational functioning in adults with T2DM and mild-to-moderate depressive symptoms. myCompass is a fully automated, self-guided public health treatment program for common mental health problems. The impact of treatment on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior was also examined. Methods: Participants with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited online via Google and Facebook advertisements targeting adults with T2DM and via community and general practice settings. Screening, consent, and self-report scales were all self-administered online. Participants were randomized using double-blind computerized block randomization to either myCompass (n=391) for 8 weeks plus a 4-week tailing-off period or an active placebo intervention (n=379). At baseline and postintervention (3 months), participants completed the Work and Social Adjustment Scale, the primary outcome measure. Secondary outcome measures included the Patient Health Questionnaire-9 item, Diabetes Distress Scale, Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes. Results: myCompass users logged in an average of 6 times and completed an average of .29 modules. Healthy Lifestyles users logged in an average of 4 times and completed an average of 1.37 modules. At baseline, mean scores on several outcome measures, including the primary outcome of work and social functioning, were near to the normal range, despite an extensive recruitment process. Approximately 61.6% (473/780) of participants completed the postintervention assessment. Intention-to-treat analyses revealed improvement in functioning, depression, anxiety, diabetes distress, and healthy eating over time in both groups. Except for blood glucose monitoring and medication adherence, there were no specific between-group effects. Follow-up analyses suggested the outcomes did not depend on age, morbidity, or treatment engagement. Conclusions: Improvement in social and occupational functioning and the secondary outcomes was generally no greater for myCompass users than for users of the control program at 3 months postintervention. These findings should be interpreted in light of near-normal mean baseline scores on several variables, the self-selected study sample, and sample attrition. Further attention to factors influencing uptake and engagement with mental health treatments by people with T2DM, and the impact of illness comorbidity on patient conceptualization and experience of mental health symptoms, is essential to reduce the burden of T2DM. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109&isReview=true (Archived by WebCite at http://www.webcitation.org/7850eg8pi) %M 31115345 %R 10.2196/12246 %U http://www.jmir.org/2019/5/e12246/ %U https://doi.org/10.2196/12246 %U http://www.ncbi.nlm.nih.gov/pubmed/31115345 %0 Journal Article %@ 2152-7202 %I JMIR Publications %V 11 %N 2 %P e11167 %T Patient Perspective of Cognitive Symptoms in Major Depressive Disorder: Retrospective Database and Prospective Survey Analyses %A Chiauzzi,Emil %A Drahos,Jennifer %A Sarkey,Sara %A Curran,Christopher %A Wang,Victor %A Tomori,Dapo %+ PatientsLikeMe, 160 Second Street, Cambridge, MA, 02142, United States, 1 617 499 4003, echiauzzi@patientslikeme.com %K cognition %K cognitive function %K depression %K major depressive disorder %K patient-centered care %K patient preference %K relapse %K remission %K symptoms %D 2019 %7 16.05.2019 %9 Original Paper %J J Participat Med %G English %X Background: Major depressive disorder (MDD) is a common and burdensome condition. The clinical understanding of MDD is shaped by current research, which lacks insight into the patient perspective. Objective: This two-part study aimed to generate data from PatientsLikeMe, an online patient network, on the perception of cognitive symptoms and their prioritization in MDD. Methods: A retrospective data analysis (study 1) was used to analyze data from the PatientsLikeMe community with self-reported MDD. Information on patient demographics, comorbidities, self-rated severity of MDD, treatment effectiveness, and specific symptoms of MDD was analyzed. A prospective electronic survey (study 2) was emailed to longstanding and recently active members of the PatientsLikeMe MDD community. Study 1 analysis informed the objectives of the study 2 survey, which were to determine symptom perception and prioritization, cognitive symptoms of MDD, residual symptoms, and medication effectiveness. Results: In study 1 (N=17,166), cognitive symptoms were frequently reported, including “severe” difficulty in concentrating (28%). Difficulty in concentrating was reported even among patients with no/mild depression (80%) and those who considered their treatment successful (17%). In study 2 (N=2525), 23% (118/508) of patients cited cognitive symptoms as a treatment priority. Cognitive symptoms correlated with depression severity, including difficulty in making decisions, concentrating, and thinking clearly (rs=0.32, 0.36, and 0.34, respectively). Cognitive symptoms interfered with meaningful relationships and daily life tasks and had a profound impact on patients’ ability to work and recover from depression. Conclusions: Patients acknowledge that cognitive dysfunction in MDD limits their ability to recover fully and return to a normal level of social and occupational functioning. Further clinical understanding and characterization of MDD for symptom prioritization and relapse risk due to residual cognitive impairment are required to help patients return to normal cognitive function and aid their overall recovery. %R 10.2196/11167 %U https://jopm.jmir.org/2019/2/e11167/ %U https://doi.org/10.2196/11167 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 5 %P e12794 %T Using Smartphone-Based Psychoeducation to Reduce Postnatal Depression Among First-Time Mothers: Randomized Controlled Trial %A Chan,Ko Ling %A Leung,Wing Cheong %A Tiwari,Agnes %A Or,Ka Lun %A Ip,Patrick %+ Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong,, China (Hong Kong), 852 2766 5709, koling.chan@polyu.edu.hk %K smartphone technology %K postnatal depression %K psychoeducation %K randomized controlled trial %D 2019 %7 14.05.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Smartphone-based psychoeducation interventions may be a low-cost, user-friendly alternative to resource-consuming, face-to-face antenatal classes to educate expectant mothers. Objective: This study aimed to empirically examine whether such an intervention would lead to reduced postnatal depression, anxiety, or stress and result in a better health-related quality of life. Methods: A single-blind randomized controlled trial was conducted in Hong Kong. All first-time expectant mothers with less than 24 weeks of gestation remaining and attending the antenatal clinic at a public hospital were included. Participants were assigned to the intervention group or the control group by drawing lots. The lots, presented in sealed opaque envelopes, were randomly designated as “intervention” or “control” by stratified randomization. The intervention, a psychoeducational mobile app, was provided in addition to the treatment as usual (TAU) services from the hospital. Follow up with participants took place at 4 weeks postpartum. The primary outcome was the difference in the levels of antenatal and postnatal depression, assessed by the Edinburgh Postnatal Depression Scale (EPDS). The intention-to-treat approach was employed in the analyses. Results: The final sample was 660 expectant mothers (nintervention=330 and ncontrol=330). The mean difference in EPDS scores between the two groups was −0.65 (95% CI −1.29 to 0.00; P=.049) after adjusting for confounding factors. Associations were found between participation in the intervention and reduced depression, and attendance in TAU classes and increased stress levels. Conclusions: The smartphone-based intervention plus TAU services was effective in reducing postnatal depression at 4 weeks postpartum compared with a control condition of TAU only, making this a cost-effective alternative to TAU education for expectant mothers. Limitations of the study included the short postpartum period after which the follow-up assessment was conducted and the inclusion of first-time mothers rather than all mothers. Trial Registration: HKU Clinical Trials Registry HKUCTR-2024; http://www.hkuctr.com/Study/Show/ 34f62a2f6d594273a290491827206384 %M 31094354 %R 10.2196/12794 %U http://mhealth.jmir.org/2019/5/e12794/ %U https://doi.org/10.2196/12794 %U http://www.ncbi.nlm.nih.gov/pubmed/31094354 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e11349 %T Reducing Stress and Preventing Depression (RESPOND): Randomized Controlled Trial of Web-Based Rumination-Focused Cognitive Behavioral Therapy for High-Ruminating University Students %A Cook,Lorna %A Mostazir,Mohammod %A Watkins,Edward %+ SMART Lab, Mood Disorders Centre, School of Psychology, University of Exeter, Sir Henry Wellcome Building for Mood Disorders Research, Queens Drive, Exeter, EX4 4QG, United Kingdom, 44 (0) 139272 ext 4692, E.R.Watkins@exeter.ac.uk %K cognitive behavioral therapy %K depression %K prevention %K rumination, cognitive %K stress, psychological %K student health services %D 2019 %7 13.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Prevention of depression is a priority to reduce its global disease burden. Targeting specific risk factors, such as rumination, may improve prevention. Rumination-focused Cognitive Behavioral Therapy (RFCBT) was developed to specifically target depressive rumination. Objective: The primary objective of this study was to test whether guided Web-based RFCBT (i-RFCBT) would prevent the incidence of major depression relative to usual care in UK university students. The secondary objective was to test the feasibility and estimated effect sizes of unguided i-RFCBT. Methods: To address the primary objective, a phase III randomized controlled trial was designed and powered to compare high risk university students (N=235), selected with elevated worry/rumination, recruited via an open access website in response to circulars within universities and internet advertisements, randomized to receive either guided i-RFCBT (interactive Web-based RFCBT, supported by asynchronous written Web-based support from qualified therapists) or usual care control. To address the secondary objective, participants were also randomized to an adjunct arm of unguided (self-administered) i-RFCBT. The primary outcome was the onset of a major depressive episode over 15 months, assessed with structured diagnostic interviews at 3 (postintervention), 6, and 15 months post randomization, conducted by telephone, blind to the condition. Secondary outcomes of symptoms of depression and anxiety and levels of worry and rumination were self-assessed through questionnaires at baseline and the same follow-up intervals. Results: Participants were randomized to guided i-RFCBT (n=82), unguided i-RFCBT (n=76), or usual care (n=77). Guided i-RFCBT reduced the risk of depression by 34% relative to usual care (hazard ratio [HR] 0.66, 95% CI 0.35 to 1.25; P=.20). Participants with higher levels of baseline stress benefited most from the intervention (HR 0.43, 95% CI 0.21 to 0.87; P=.02). Significant improvements in rumination, worry, and depressive symptoms were found in the short-to-medium term. Of the 6 modules, guided participants completed a mean of 3.46 modules (SD 2.25), with 46% (38/82) being compliant (completing ≥4 modules). Similar effect sizes and compliance rates were found for unguided i-RFCBT. Conclusions: Guided i-RFCBT can reduce the onset of depression in high-risk young people reporting high levels of worry/rumination and stress. The feasibility study argues for formally testing unguided i-RFCBT for prevention: if the observed effect sizes are robustly replicated in a phase III trial, it has potential as a scalable prevention intervention. Trial Registration: ISRCTN Registry ISRCTN12683436; https://www.isrctn.com/ISRCTN12683436 (Archived by WebCite at http://www.webcitation.org/77fqycyBX) International Registered Report Identifier (IRRID): RR2-10.1186/s13063-015-1128-9 %M 31094331 %R 10.2196/11349 %U https://www.jmir.org/2019/5/e11349/ %U https://doi.org/10.2196/11349 %U http://www.ncbi.nlm.nih.gov/pubmed/31094331 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e11705 %T Proactive Suicide Prevention Online (PSPO): Machine Identification and Crisis Management for Chinese Social Media Users With Suicidal Thoughts and Behaviors %A Liu,Xingyun %A Liu,Xiaoqian %A Sun,Jiumo %A Yu,Nancy Xiaonan %A Sun,Bingli %A Li,Qing %A Zhu,Tingshao %+ Institute of Psychology, Chinese Academy of Sciences, No.16, Lincui Road, Beijing,, China, 86 150 1096 5509, tszhu@psych.ac.cn %K suicide identification %K crisis management %K machine learning %K microblog direct message %K social network %K Chinese young people %D 2019 %7 08.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is a great public health challenge. Two hundred million people attempt suicide in China annually. Existing suicide prevention programs require the help-seeking initiative of suicidal individuals, but many of them have a low motivation to seek the required help. We propose that a proactive and targeted suicide prevention strategy can prompt more people with suicidal thoughts and behaviors to seek help. Objective: The goal of the research was to test the feasibility and acceptability of Proactive Suicide Prevention Online (PSPO), a new approach based on social media that combines proactive identification of suicide-prone individuals with specialized crisis management. Methods: We first located a microblog group online. Their comments on a suicide note were analyzed by experts to provide a training set for the machine learning models for suicide identification. The best-performing model was used to automatically identify posts that suggested suicidal thoughts and behaviors. Next, a microblog direct message containing crisis management information, including measures that covered suicide-related issues, depression, help-seeking behavior and an acceptability test, was sent to users who had been identified by the model to be at risk of suicide. For those who replied to the message, trained counselors provided tailored crisis management. The Simplified Chinese Linguistic Inquiry and Word Count was also used to analyze the users’ psycholinguistic texts in 1-month time slots prior to and postconsultation. Results: A total of 27,007 comments made in April 2017 were analyzed. Among these, 2786 (10.32%) were classified as indicative of suicidal thoughts and behaviors. The performance of the detection model was good, with high precision (.86), recall (.78), F-measure (.86), and accuracy (.88). Between July 3, 2017, and July 3, 2018, we sent out a total of 24,727 direct messages to 12,486 social media users, and 5542 (44.39%) responded. Over one-third of the users who were contacted completed the questionnaires included in the direct message. Of the valid responses, 89.73% (1259/1403) reported suicidal ideation, but more than half (725/1403, 51.67%) reported that they had not sought help. The 9-Item Patient Health Questionnaire (PHQ-9) mean score was 17.40 (SD 5.98). More than two-thirds of the participants (968/1403, 69.00%) thought the PSPO approach was acceptable. Moreover, 2321 users replied to the direct message. In a comparison of the frequency of word usage in their microblog posts 1-month before and after the consultation, we found that the frequency of death-oriented words significantly declined while the frequency of future-oriented words significantly increased. Conclusions: The PSPO model is suitable for identifying populations that are at risk of suicide. When followed up with proactive crisis management, it may be a useful supplement to existing prevention programs because it has the potential to increase the accessibility of antisuicide information to people with suicidal thoughts and behaviors but a low motivation to seek help. %M 31344675 %R 10.2196/11705 %U https://www.jmir.org/2019/5/e11705/ %U https://doi.org/10.2196/11705 %U http://www.ncbi.nlm.nih.gov/pubmed/31344675 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 5 %P e9766 %T An Approach for Data Mining of Electronic Health Record Data for Suicide Risk Management: Database Analysis for Clinical Decision Support %A Berrouiguet,Sofian %A Billot,Romain %A Larsen,Mark Erik %A Lopez-Castroman,Jorge %A Jaussent,Isabelle %A Walter,Michel %A Lenca,Philippe %A Baca-García,Enrique %A Courtet,Philippe %+ Adult Psychiatry, Brest Medical University Hospital at Bohars, Route de Ploudalmezeau, Brest, 29200, France, 33 668204178, sofian.berrouiguet@gmail.com %K clinical decision support system %K data mining %K electronic health %K mobile phone %K prevention %K suicide %K suicide attempts %D 2019 %7 07.05.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: In an electronic health context, combining traditional structured clinical assessment methods and routine electronic health–based data capture may be a reliable method to build a dynamic clinical decision-support system (CDSS) for suicide prevention. Objective: The aim of this study was to describe the data mining module of a Web-based CDSS and to identify suicide repetition risk in a sample of suicide attempters. Methods: We analyzed a database of 2802 suicide attempters. Clustering methods were used to identify groups of similar patients, and regression trees were applied to estimate the number of suicide attempts among these patients. Results: We identified 3 groups of patients using clustering methods. In addition, relevant risk factors explaining the number of suicide attempts were highlighted by regression trees. Conclusions: Data mining techniques can help to identify different groups of patients at risk of suicide reattempt. The findings of this study can be combined with Web-based and smartphone-based data to improve dynamic decision making for clinicians. %M 31066693 %R 10.2196/mental.9766 %U https://mental.jmir.org/2019/5/e9766/ %U https://doi.org/10.2196/mental.9766 %U http://www.ncbi.nlm.nih.gov/pubmed/31066693 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e11860 %T Effects, Adherence, and Therapists’ Perceptions of Web- and Mobile-Supported Group Therapy for Depression: Mixed-Methods Study %A Schuster,Raphael %A Kalthoff,Inanna %A Walther,Alexandra %A Köhldorfer,Lena %A Partinger,Edith %A Berger,Thomas %A Laireiter,Anton-Rupert %+ Center for Clinical Psychology, Psychotherapy and Health Psychology, Department of Psychology, University of Salzburg, Hellbrunnerstraße 34, Salzburg, 5020, Austria, 43 6644156146, raphael.schuster@stud.sbg.ac.at %K eHealth %K mobile phone %K computer-assisted therapy %K monitoring %K group therapy %K depression %K professional-patient relations %D 2019 %7 06.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Blended group therapy (bGT) has been investigated a several times for anxiety and depression, but information on patients’ adherence to and therapists’ perception of the novel format is nonexistent. Furthermore, many studies investigated mainly female and highly educated populations, limiting the validity of previous findings. Objective: This study aimed to reduce the gaps and limitations of the previous findings by evaluating an integrated internet- and mobile-supported bGT format. Methods: A total of 27 patients diagnosed with major depression (14/27, 52% female and 7/27, 25.9% compulsory education) participated in a 7-week treatment at a university outpatient clinic. Furthermore, 8 novice therapists participated in semistructured interviews and a subsequent cross-validation survey. Results: Primary symptom reduction was high (d=1.31 to 1.51) and remained stable for the follow-up period. Therapists identified advantages (eg, patient engagement, treatment intensification, and improved therapeutic relation) and disadvantages (eg, increased workload, data issues, and undesired effects) of bGT. The required online guidance time was 10.3 min per patient and week, including guidance on exercises (67% or 6.9 min) and intimate communication (33% or 3.4 min). Concerning patients’ adherence to bGT, tracked completion of all Web-based and mobile tasks was high and comparable with group attendance. Conclusions: Results suggest high feasibility of bGT in a gender-balanced, moderately educated sample. bGT provides group therapists with tools for individual care, resulting in an optimization of the therapy process, and high completion rates of the implemented bGT elements. The limited work experience of the involved therapists restricts the study findings, and potential drawbacks need to be regarded in the development of future bGT interventions. %M 31066700 %R 10.2196/11860 %U https://www.jmir.org/2019/5/e11860/ %U https://doi.org/10.2196/11860 %U http://www.ncbi.nlm.nih.gov/pubmed/31066700 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e13183 %T Development and Evaluation of a Web-Based Resource for Suicidal Thoughts: NowMattersNow.org %A Whiteside,Ursula %A Richards,Julie %A Huh,David %A Hidalgo,Rianna %A Nordhauser,Rebecca %A Wong,Albert J %A Zhang,Xiaoshan %A Luxton,David D %A Ellsworth,Michael %A Lezine,DeQuincy %+ NowMattersNow.org, 2331 E Madison St, Seattle, WA, 98112, United States, 1 206 679 6349, ursulawhiteside@gmail.com %K dialectical behavior therapy %K suicide %K internet %K help-seeking behavior %K behavior therapy %K crisis intervention %K primary care %K integrated health care systems %D 2019 %7 02.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Nearly half of people who die by suicide see a health care provider in the month before their death. With the release of new care guidelines, detection of suicidal patients will likely increase. Providers need access to suicide-specific resources that can be used as part of immediate, brief interventions with a suicidal patient. Web-based suicide prevention resources have the potential to address this need. Objective: This study aimed to describe the development of the NowMattersNow.org website as a resource for individuals with suicidal thoughts and to evaluate the utility of the site via user experience surveys. Methods: NowMattersNow.org is an online video-based free public resource that provides evidence-based teachings, examples, and resources for managing suicidal thoughts and intense emotions focused largely around skills from dialectical behavior therapy. Developed with assistance from mental health consumers, it is intended to address gaps in access to services for suicidal patients in health care systems. Visitors stay an average of a minute and a half on the website. From March 2015 to December 2017, a user experience survey measured self-reported changes on a 1 (not at all) to 5 (completely overwhelming) scale regarding intensity of suicidal thoughts and negative emotions while on the website. Longitudinal regression analyses using generalized estimating equations evaluated the magnitude and statistical significance of user-reported changes in suicidal ideation and negative emotion. In secondary analyses, user-reported changes specific to subgroups, including men aged 36 to 64 years, mental health care providers, and other health care providers were evaluated. Results: During the period of analysis, there were 138,386 unique website visitors. We analyzed surveys (N=3670) collected during that time. Subsamples included men aged 36 to 64 years (n=512), mental health providers (n=460), and other health care providers (n=308). A total of 28% (1028/3670) of survey completers rated their suicidal thoughts as a 5 or “completely overwhelming” when they entered the website. We observed significant reductions in self-reported intensity of suicidal thoughts (–0.21, P<.001) and negative emotions (–0.32, P<.001), including decreases for users with the most severe suicidal thoughts (–6.4%, P<.001), most severe negative emotions (–10.9%, P<.001), and for middle-aged men (–0.13, P<001). Results remained significant after controlling for length of visit to website (before the survey) and technology type (mobile, desktop, and tablet). Conclusions: Survey respondents reported measurable reductions in intensity of suicidal thoughts and emotions, including those rating their suicidal thoughts as completely or almost completely overwhelming and among middle-aged men. Although results from this user-experience survey administered at one point in time to a convenience sample of users must be interpreted with caution, results provide preliminary support for the potential effectiveness of the NowMattersNow.org website as a tool for short-term management of suicidal thoughts and negative emotions. %M 31045498 %R 10.2196/13183 %U http://www.jmir.org/2019/5/e13183/ %U https://doi.org/10.2196/13183 %U http://www.ncbi.nlm.nih.gov/pubmed/31045498 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 4 %P e11800 %T Expanding Access to Depression Treatment in Kenya Through Automated Psychological Support: Protocol for a Single-Case Experimental Design Pilot Study %A Green,Eric P %A Pearson,Nicholas %A Rajasekharan,Sathyanath %A Rauws,Michiel %A Joerin,Angela %A Kwobah,Edith %A Musyimi,Christine %A Bhat,Chaya %A Jones,Rachel M %A Lai,Yihuan %+ Duke Global Health Institute, Duke University, Box 90519, Durham, NC, 27708, United States, 1 919 681 7289, eric.green@duke.edu %K telemedicine %K mental health %K depression %K artificial intelligence %K Kenya %K text messaging %K chatbot %K conversational agent %D 2019 %7 29.04.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression during pregnancy and in the postpartum period is associated with a number of poor outcomes for women and their children. Although effective interventions exist for common mental disorders that occur during pregnancy and the postpartum period, most cases in low- and middle-income countries go untreated because of a lack of trained professionals. Task-sharing models such as the Thinking Healthy Program have shown great potential in feasibility and efficacy trials as a strategy for expanding access to treatment in low-resource settings, but there are significant barriers to scale-up. We are addressing this gap by adapting Thinking Healthy for automated delivery via a mobile phone. This new intervention, Healthy Moms, uses an existing artificial intelligence system called Tess (Zuri in Kenya) to drive conversations with users. Objective: The objective of this pilot study is to test the Healthy Moms perinatal depression intervention using a single-case experimental design with pregnant women and new mothers recruited from public hospitals outside of Nairobi, Kenya. Methods: We will invite patients to complete a brief, automated screening delivered via text messages to determine their eligibility. Enrolled participants will be randomized to a 1- or 2-week baseline period and then invited to begin using Zuri. Participants will be prompted to rate their mood via short message service every 3 days during the baseline and intervention periods. We will review system logs and conduct in-depth interviews with participants to study engagement with the intervention, feasibility, and acceptability. We will use visual inspection, in-depth interviews, and Bayesian estimation to generate preliminary data about the potential response to treatment. Results: Our team adapted the intervention content in April and May 2018 and completed an initial prepilot round of formative testing with 10 women from a private maternity hospital in May and June. In preparation for this pilot study, we used feedback from these users to revise the structure and content of the intervention. Recruitment for this protocol began in early 2019. Results are expected toward the end of 2019. Conclusions: The main limitation of this pilot study is that we will recruit women who live in urban and periurban centers in one part of Kenya. The results of this study may not generalize to the broader population of Kenyan women, but that is not an objective of this phase of work. Our primary objective is to gather preliminary data to know how to build and test a more robust service. We are working toward a larger study with a more diverse population. International Registered Report Identifier (IRRID): DERR1-10.2196/11800 %M 31033448 %R 10.2196/11800 %U http://www.researchprotocols.org/2019/4/e11800/ %U https://doi.org/10.2196/11800 %U http://www.ncbi.nlm.nih.gov/pubmed/31033448 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e11698 %T Use of a Mobile Phone App to Treat Depression Comorbid With Hypertension or Diabetes: A Pilot Study in Brazil and Peru %A Menezes,Paulo %A Quayle,Julieta %A Garcia Claro,Heloísa %A da Silva,Simone %A Brandt,Lena R %A Diez-Canseco,Francisco %A Miranda,J Jaime %A Price,LeShawndra N %A Mohr,David C %A Araya,Ricardo %+ Department of Preventive Medicine, University of São Paulo, Rua Doutor Arnaldo 455, Cerqueira César, São Paulo, 01246903, Brazil, 55 1130617093, pmenezes@usp.br %K depression %K mHealth %K pilot study %K feasibility study %K PHQ-9 %D 2019 %7 26.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is underdiagnosed and undertreated in primary health care. When associated with chronic physical disorders, it worsens outcomes. There is a clear gap in the treatment of depression in low- and middle-income countries (LMICs), where specialists and funds are scarce. Interventions supported by mobile health (mHealth) technologies may help to reduce this gap. Mobile phones are widely used in LMICs, offering potentially feasible and affordable alternatives for the management of depression among individuals with chronic disorders. Objective: This study aimed to explore the potential effectiveness of an mHealth intervention to help people with depressive symptoms and comorbid hypertension or diabetes and explore the feasibility of conducting large randomized controlled trials (RCTs). Methods: Emotional Control (CONEMO) is a low-intensity psychoeducational 6-week intervention delivered via mobile phones and assisted by a nurse for reducing depressive symptoms among individuals with diabetes or hypertension. CONEMO was tested in 3 pilot studies, 1 in São Paulo, Brazil, and 2 in Lima, Peru. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) at enrollment and at 6-week follow-up. Results: The 3 pilot studies included a total of 66 people. Most participants were females aged between 41 and 60 years. There was a reduction in depressive symptoms as measured by PHQ-9 in all pilot studies. In total, 58% (38/66) of the participants reached treatment success rate (PHQ-9 <10), with 62% (13/21) from São Paulo, 62% (13/21) from the first Lima pilot, and 50% (12/24) from the second Lima pilot study. The intervention, the app, and the support offered by the nurse and nurse assistants were well received by participants in both settings. Conclusions: The intervention was feasible in both settings. Clinical data suggested that CONEMO may help in decreasing participants’ depressive symptoms. The findings also indicated that it was possible to conduct RCTs in these settings. %M 31025949 %R 10.2196/11698 %U http://mental.jmir.org/2019/4/e11698/ %U https://doi.org/10.2196/11698 %U http://www.ncbi.nlm.nih.gov/pubmed/31025949 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11410 %T Improving Moderator Responsiveness in Online Peer Support Through Automated Triage %A Milne,David N %A McCabe,Kathryn L %A Calvo,Rafael A %+ School of Information, Systems and Modelling, Faculty of Engineering and Information Technology, University of Technology, Sydney, PO Box 123, Sydney, NSW 2007, Australia, 61 (02) 9514 3171, david.milne@uts.edu.au %K social support %K triage %K classification %K natural language processing %D 2019 %7 26.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Online peer support forums require oversight to ensure they remain safe and therapeutic. As online communities grow, they place a greater burden on their human moderators, which increases the likelihood that people at risk may be overlooked. This study evaluated the potential for machine learning to assist online peer support by directing moderators’ attention where it is most needed. Objective: This study aimed to evaluate the accuracy of an automated triage system and the extent to which it influences moderator behavior. Methods: A machine learning classifier was trained to prioritize forum messages as green, amber, red, or crisis depending on how urgently they require attention from a moderator. This was then launched as a set of widgets injected into a popular online peer support forum hosted by ReachOut.com, an Australian Web-based youth mental health service that aims to intervene early in the onset of mental health problems in young people. The accuracy of the system was evaluated using a holdout test set of manually prioritized messages. The impact on moderator behavior was measured as response ratio and response latency, that is, the proportion of messages that receive at least one reply from a moderator and how long it took for these replies to be made. These measures were compared across 3 periods: before launch, after an informal launch, and after a formal launch accompanied by training. Results: The algorithm achieved 84% f-measure in identifying content that required a moderator response. Between prelaunch and post-training periods, response ratios increased by 0.9, 4.4, and 10.5 percentage points for messages labelled as crisis, red, and green, respectively, but decreased by 5.0 percentage points for amber messages. Logistic regression indicated that the triage system was a significant contributor to response ratios for green, amber, and red messages, but not for crisis messages. Response latency was significantly reduced (P<.001), between the same periods, by factors of 80%, 80%, 77%, and 12% for crisis, red, amber, and green messages, respectively. Regression analysis indicated that the triage system made a significant and unique contribution to reducing the time taken to respond to green, amber, and red messages, but not to crisis messages, after accounting for moderator and community activity. Conclusions: The triage system was generally accurate, and moderators were largely in agreement with how messages were prioritized. It had a modest effect on response ratios, primarily because moderators were already more likely to respond to high priority content before the introduction of triage. However, it significantly and substantially reduced the time taken for moderators to respond to prioritized content. Further evaluations are needed to assess the impact of mistakes made by the triage algorithm and how changes to moderator responsiveness impact the well-being of forum members. %M 31025945 %R 10.2196/11410 %U https://www.jmir.org/2019/4/e11410/ %U https://doi.org/10.2196/11410 %U http://www.ncbi.nlm.nih.gov/pubmed/31025945 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e11401 %T Evaluating the Feasibility of an Innovative Self-Confidence Webinar Intervention for Depression in the Workplace: A Proof-of-Concept Study %A Wan Mohd Yunus,Wan Mohd Azam %A Musiat,Peter %A Brown,June SL %+ Department of Psychology, School of Human Resource Development and Psychology, Faculty of Social Sciences and Humanities, Universiti Teknologi Malaysia, UTM Johor Bahru, Skudai, Johor, 81310, Malaysia, 60 176136163, azam.yunus@kcl.ac.uk %K online %K videoconferencing %K cognitive behavioral therapy %K depression %K workplace %D 2019 %7 26.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression in the workplace is a very common problem that exacerbates employees’ functioning and consequently influences the productivity of organizations. Despite the commonness of the problem and the currently available interventions, a high proportion of employees do not seek help. A new intervention, a webinar (Web-based seminar), was developed, which integrated the use of technology and the traditional guided therapist support to provide accessible help for the problem of depression in the workplace. Objective: The aim of this study was to explore the feasibility, preliminary outcome, and acceptability of the webinar intervention conducted in organizations. Methods: In total, 2 organizations were invited to participate, and 33 employees participated in this proof-of-concept study. The webinar intervention consisted of 6 1-hour sessions conducted via the Adobe Connect platform, developed by Adobe Inc. The intervention was developed based on a systematic review, focus group studies, and face-to-face self-confidence workshops that utilized cognitive behavior therapy (CBT). The final webinar intervention used CBT and the coping flexibility approach. The structure of the intervention included PowerPoint presentations, animation videos, utilization of chat panels, and whiteboard features. The intervention was conducted live and guided by a consultant psychologist assisted by a moderator. Study outcomes were self-assessed using self-reported Web surveys. The acceptability of the intervention was assessed using self-reported user experience Web surveys and open-ended questions. Results: The findings showed: (1) evidence of feasibility of the intervention: the webinar intervention was successfully conducted in 3 groups, with 6 1-hour sessions for each group, with 82% (23/28) participants completing all 6 sessions; (2) positive improvements in depression: the linear mixed effects modeling analysis recorded a significant overall effect of time primarily for depression (F2, 48.813=31.524; P<.001) with a Hedge g effect size of 0.522 at 1-month follow-up. Individually, 8 subjects showed significant reliable and clinically significant changes, with 3 subjects showing clinically significant change only; and (3) encouraging evidence regarding the acceptability of the webinar intervention among the employees: the user experience score was above average for 4 out of 6 domains measured (perspicuity mean 1.198 [95% CI 0.832-1.564], efficiency mean 1.000 [95% CI 0.571-1.429], dependability mean 1.208 [95% CI 0.899-1.517], and stimulation mean 1.323 [95% CI 0.987-1.659]). The open-ended questions also yielded 52% (47/91) of the responses that reported facilitators, whereas only 12% (11/91) of the responses reported barriers. Conclusions: The self-confidence webinar intervention appears to be a potentially feasible, effective, and acceptable intervention for depression in the workplace that merits further investigation. %M 31025943 %R 10.2196/11401 %U http://mental.jmir.org/2019/4/e11401/ %U https://doi.org/10.2196/11401 %U http://www.ncbi.nlm.nih.gov/pubmed/31025943 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e12974 %T Seasonality Patterns of Internet Searches on Mental Health: Exploratory Infodemiology Study %A Soreni,Noam %A Cameron,Duncan H %A Streiner,David L %A Rowa,Karen %A McCabe,Randi E %+ Anxiety Treatment and Research Clinic, St. Joseph's Healthcare Hamilton, 100 West 5th Street, Office B141, Hamilton, ON, L8P3R2, Canada, 1 9055221155 ext 35373, nsoreni@stjosham.on.ca %K anxiety %K depression %K OCD %K schizophrenia %K autism %K suicide %K seasonality %K Google %K internet %K infodemiology %K infoveillance %K mental health %D 2019 %7 24.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: The study of seasonal patterns of public interest in psychiatric disorders has important theoretical and practical implications for service planning and delivery. The recent explosion of internet searches suggests that mining search databases yields unique information on public interest in mental health disorders, which is a significantly more affordable approach than population health studies. Objective: This study aimed to investigate seasonal patterns of internet mental health queries in Ontario, Canada. Methods: Weekly data on health queries in Ontario from Google Trends were downloaded for a 5-year period (2012-2017) for the terms “schizophrenia,” “autism,” “bipolar,” “depression,” “anxiety,” “OCD” (obsessive-compulsive disorder), and “suicide.” Control terms were overall search results for the terms “health” and “how.” Time-series analyses using a continuous wavelet transform were performed to isolate seasonal components in the search volume for each term. Results: All mental health queries showed significant seasonal patterns with peak periodicity occurring over the winter months and troughs occurring during summer, except for “suicide.” The comparison term “health” also exhibited seasonal periodicity, while the term “how” did not, indicating that general information seeking may not follow a seasonal trend in the way that mental health information seeking does. Conclusions: Seasonal patterns of internet search volume in a wide range of mental health terms were observed, with the exception of “suicide.” Our study demonstrates that monitoring internet search trends is an affordable, instantaneous, and naturalistic method to sample public interest in large populations and inform health policy planners. %M 31017582 %R 10.2196/12974 %U https://mental.jmir.org/2019/4/e12974/ %U https://doi.org/10.2196/12974 %U http://www.ncbi.nlm.nih.gov/pubmed/31017582 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11081 %T How Confidence in Prior Attitudes, Social Tag Popularity, and Source Credibility Shape Confirmation Bias Toward Antidepressants and Psychotherapy in a Representative German Sample: Randomized Controlled Web-Based Study %A Schweiger,Stefan %A Cress,Ulrike %+ Knowledge Construction Lab, Knowledge Media Research Center, Leibniz-Institut für Wissensmedien, Schleichstrasse 6, Tuebingen, 72076, Germany, 49 6702023838, schw.stefan@gmail.com %K attitude %K psychotherapy %K antidepressive agents %K culture %K Germany %K health literacy %K professional competence %K information systems %K consumer health information %K information dissemination %D 2019 %7 23.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: In health-related, Web-based information search, people should select information in line with expert (vs nonexpert) information, independent of their prior attitudes and consequent confirmation bias. Objective: This study aimed to investigate confirmation bias in mental health–related information search, particularly (1) if high confidence worsens confirmation bias, (2) if social tags eliminate the influence of prior attitudes, and (3) if people successfully distinguish high and low source credibility. Methods: In total, 520 participants of a representative sample of the German Web-based population were recruited via a panel company. Among them, 48.1% (250/520) participants completed the fully automated study. Participants provided prior attitudes about antidepressants and psychotherapy. We manipulated (1) confidence in prior attitudes when participants searched for blog posts about the treatment of depression, (2) tag popularity —either psychotherapy or antidepressant tags were more popular, and (3) source credibility with banners indicating high or low expertise of the tagging community. We measured tag and blog post selection, and treatmentefficacy ratings after navigation. Results: Tag popularity predicted the proportion of selected antidepressant tags (beta=.44, SE 0.11; P<.001) and blog posts (beta=.46, SE 0.11; P<.001). When confidence was low (−1 SD), participants selected more blog posts consistent with prior attitudes (beta=−.26, SE 0.05; P<.001). Moreover, when confidence was low (−1 SD) and source credibility was high (+1 SD), the efficacy ratings of attitude-consistent treatments increased (beta=.34, SE 0.13; P=.01). Conclusions: We found correlational support for defense motivation account underlying confirmation bias in the mental health–related search context. That is, participants tended to select information that supported their prior attitudes, which is not in line with the current scientific evidence. Implications for presenting persuasive Web-based information are also discussed. Trial Registration: ClinicalTrials.gov NCT03899168; https://clinicaltrials.gov/ct2/show/NCT03899168 (Archived by WebCite at http://www.webcitation.org/77Nyot3Do) %M 31012865 %R 10.2196/11081 %U http://www.jmir.org/2019/4/e11081/ %U https://doi.org/10.2196/11081 %U http://www.ncbi.nlm.nih.gov/pubmed/31012865 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11706 %T Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis %A Romijn,Geke %A Batelaan,Neeltje %A Kok,Robin %A Koning,Jeroen %A van Balkom,Anton %A Titov,Nickolai %A Riper,Heleen %+ Department of Clinical, Neuro and Developmental Psychology, VU University, Amsterdam Public Health Research Institute, Van der Boechorstraat 7, Amsterdam,, Netherlands, 31 20 59 89009, g.a.romijn@vu.nl %K anxiety disorders %K cognitive behavioral therapy %K internet %K recruitment method %K efficacy %K effectiveness %D 2019 %7 17.04.2019 %9 Review %J J Med Internet Res %G English %X Background: Ample studies have shown the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) for anxiety disorders. These studies recruited their participants mainly from the community and, to a lesser extent, from within routine care services. Little is known about whether different recruitment strategies lead to different treatment effects. Objective: This meta-analysis compared clinical results obtained in trials with recruitment from the community versus results obtained in trials with clinical service recruitment and explored factors that may mediate differences in treatment outcome. Methods: We included randomized controlled trials in which the clinical effects of iCBT for anxiety disorders were compared with a control condition (waitlist controls or face-to-face cognitive behavioral therapy). We classified trials as open recruitment trials (recruitment from the community) or clinical service recruitment trials (recruitment through outpatient clinics). Pooled effect sizes based on measures examining anxiety symptoms, depressive symptoms, and quality of life were computed for each type of trial. Subgroup analyses examined whether clinical results from open recruitment trials differed from those obtained in clinical service recruitment trials. Additional analyses explored which demographic, clinical, and treatment-related factors contributed to differences in effect sizes of open recruitment versus clinical service recruitment trials. Results: We included 42 studies with 53 comparisons (43 open recruitment comparisons and 10 clinical recruitment comparisons). Analyses of anxiety measures revealed, first, that iCBT open recruitment studies with waitlist control comparators showed a significantly higher effect size for decrease in anxiety symptoms than did those with clinical recruitment (Q=10.09; P=.001). This association between recruitment method and effect size was no longer significant in a multivariate metaregression with treatment adherence and exclusion of patients with depressive symptoms entered as additional predictors of effect size. Second, effect size for decrease in anxiety symptoms did not differ significantly between clinical recruitment and open recruitment studies with face-to-face cognitive behavioral therapy comparators. The effects of open recruitment trials and clinical recruitment trials did not differ significantly for the secondary outcomes, compared with face-to-face cognitive behavioral therapy and waitlist controls. Conclusions: iCBT was effective in samples recruited in clinical practice, but effect sizes were smaller than those found in trials with an open recruitment method for studies with waitlist control comparators. Hence, for patients with anxiety disorders in routine care, the impact of iCBT may not be as positive as for study participants recruited from the community. The difference between open recruitment trials and clinical service recruitment trials might be partly explained by patients’ greater therapy adherence in open recruitment trials and the stricter exclusion of patients with severe depressive symptoms in these studies. Since most trials in this meta-analysis applied an open recruitment method, more studies with routine care populations are needed to further validate these findings. %M 30994462 %R 10.2196/11706 %U http://www.jmir.org/2019/4/e11706/ %U https://doi.org/10.2196/11706 %U http://www.ncbi.nlm.nih.gov/pubmed/30994462 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11029 %T Mood Prediction of Patients With Mood Disorders by Machine Learning Using Passive Digital Phenotypes Based on the Circadian Rhythm: Prospective Observational Cohort Study %A Cho,Chul-Hyun %A Lee,Taek %A Kim,Min-Gwan %A In,Hoh Peter %A Kim,Leen %A Lee,Heon-Jeong %+ Korea University College of Medicine, Department of Psychiatry, Anam Hospital, Korea University College of Medicine, Seoul,, Republic of Korea, 82 029205815, leehjeong@korea.ac.kr %K mood disorder %K circadian rhythm %K projections and predictions %K machine learning %K digital phenotype %K wearable device %D 2019 %7 17.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtually, all organisms on Earth have their own circadian rhythm, and humans are no exception. Circadian rhythms are associated with various human states, especially mood disorders, and disturbance of the circadian rhythm is known to be very closely related. Attempts have also been made to derive clinical implications associated with mood disorders using the vast amounts of digital log that is acquired by digital technologies develop and using computational analysis techniques. Objective: This study was conducted to evaluate the mood state or episode, activity, sleep, light exposure, and heart rate during a period of about 2 years by acquiring various digital log data through wearable devices and smartphone apps as well as conventional clinical assessments. We investigated a mood prediction algorithm developed with machine learning using passive data phenotypes based on circadian rhythms. Methods: We performed a prospective observational cohort study on 55 patients with mood disorders (major depressive disorder [MDD] and bipolar disorder type 1 [BD I] and 2 [BD II]) for 2 years. A smartphone app for self-recording daily mood scores and detecting light exposure (using the installed sensor) were provided. From daily worn activity trackers, digital log data of activity, sleep, and heart rate were collected. Passive digital phenotypes were processed into 130 features based on circadian rhythms, and a mood prediction algorithm was developed by random forest. Results: The mood state prediction accuracies for the next 3 days in all patients, MDD patients, BD I patients, and BD II patients were 65%, 65%, 64%, and 65% with 0.7, 0.69, 0.67, and 0.67 area under the curve (AUC) values, respectively. The accuracies of all patients for no episode (NE), depressive episode (DE), manic episode (ME), and hypomanic episode (HME) were 85.3%, 87%, 94%, and 91.2% with 0.87, 0.87, 0.958, and 0.912 AUC values, respectively. The prediction accuracy in BD II patients was distinctively balanced as high showing 82.6%, 74.4%, and 87.5% of accuracy (with generally good sensitivity and specificity) with 0.919, 0.868, and 0.949 AUC values for NE, DE, and HME, respectively. Conclusions: On the basis of the theoretical basis of chronobiology, this study proposed a good model for future research by developing a mood prediction algorithm using machine learning by processing and reclassifying digital log data. In addition to academic value, it is expected that this study will be of practical help to improve the prognosis of patients with mood disorders by making it possible to apply actual clinical application owing to the rapid expansion of digital technology. %M 30994461 %R 10.2196/11029 %U http://www.jmir.org/2019/4/e11029/ %U https://doi.org/10.2196/11029 %U http://www.ncbi.nlm.nih.gov/pubmed/30994461 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e11965 %T User Involvement in Developing the MYPLAN Mobile Phone Safety Plan App for People in Suicidal Crisis: Case Study %A Buus,Niels %A Juel,Anette %A Haskelberg,Hila %A Frandsen,Hanne %A Larsen,Jette Louise Skovgaard %A River,Jo %A Andreasson,Kate %A Nordentoft,Merete %A Davenport,Tracey %A Erlangsen,Annette %+ Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, 88, Mallett St, Camperdown, 2050, Australia, 61 0429835019, niels.buus@sydney.edu.au %K mobile apps %K patient participation %K primary prevention %K self-injurious behavior %K suicide, attempted %D 2019 %7 16.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: The effect of safety planning for people in suicidal crisis is not yet determined, but using safety plans to mitigate acute psychological crisis is regarded as best practice. Between 2016 and 2017, Australian and Danish stakeholders were involved in revising and updating the Danish MYPLAN mobile phone safety plan and translating the app into a culturally appropriate version for Australia. Objective: The objective of this study was to examine the negotiation of stakeholders’ suggestions and contributions to the design, function, and content of the MYPLAN app and to characterize significant developments in the emerging user-involving processes. Methods: We utilized a case study design where 4 focus groups and 5 user-involving workshops in Denmark and Australia were subjected to thematic analysis. Results: The analyses identified 3 consecutive phases in the extensive development of the app: from phase 1, Suggesting core functions, through phase 2, Refining functions, to phase 3, Negotiating the finish. The user-involving processes continued to prevent closure and challenged researchers and software developers to repeatedly reconsider the app’s basic user interface and functionality. It was a limitation that the analysis did not include potentially determinative backstage dimensions of the decision-making process. Conclusions: The extended user involvement prolonged the development process, but it also allowed for an extensive exploration of different user perspectives and needs. %M 30990456 %R 10.2196/11965 %U http://mental.jmir.org/2019/4/e11965/ %U https://doi.org/10.2196/11965 %U http://www.ncbi.nlm.nih.gov/pubmed/30990456 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e13202 %T Transdiagnostic Mobile Health: Smartphone Intervention Reduces Depressive Symptoms in People With Mood and Psychotic Disorders %A Ben-Zeev,Dror %A Buck,Benjamin %A Chu,Phuonguyen Vu %A Razzano,Lisa %A Pashka,Nicole %A Hallgren,Kevin A %+ Behavioral Research In Technology and Engineering Center, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, United States, 1 206 685 9655, dbenzeev@uw.edu %K mHealth %K schizophrenia %K bipolar disorder %K depression %K illness management %K symptoms %K transdiagnostic %D 2019 %7 12.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is the most prevalent mental health problem. The need for effective treatments for depression far outstrips the availability of trained mental health professionals. Smartphones and other widely available technologies are increasingly being leveraged to deliver treatments for depression. Whether there are patient characteristics that affect the potency of smartphone interventions for depression is not well understood. Objective: This study aimed to evaluate whether patient characteristics including clinical diagnosis, depression severity, psychosis status, and current use of antidepressant medications impact the effects of an evidence-based smartphone intervention on depressive symptoms. Methods: Data were collected as part of a 2-arm randomized controlled trial comparing a multimodal smartphone intervention called FOCUS with a clinic-based intervention. Here, we report on 82 participants assigned to 12 weeks of FOCUS treatment. We conducted assessments of depressive symptoms using the Beck Depression Inventory-second edition (BDI-II) at baseline, postintervention (3 months), and follow-up (6 months). We tested for differences in the amount of improvement in BDI-II scores from baseline to posttreatment and 6-month follow-up between each of the following patient subgroups using 2 (group) × 2 (time) mixed effects models: diagnosis (ie, schizophrenia spectrum disorder vs bipolar disorder vs major depressive disorder), depression severity (ie, minimal-mild vs moderate-severe depression), psychosis status (ie, presence vs absence of psychotic symptoms), and antidepressant use (ie, taking antidepressants vs not taking antidepressants). Results: The majority of participants were male (60%, 49/82), African American (65%, 53/82), and middle-aged (mean age 49 years), with a high school education or lower (62%, 51/82). There were no differences in patient demographics across the variables that were used to stratify the analyses. There was a significant group × time interaction for baseline depression severity (F1,76.8=5.26, P=.02 [posttreatment] and F1,77.4=6.56, P=.01 [6-month follow-up]). Participants with moderate or severe depression had significant improvements (t42=3.20, P=.003 [posttreatment] and t42=4.20, P<.001 [6-month follow-up]), but participants with minimal or mild depression did not (t31=0.20, P=.84 [posttreatment] and t30=0.43, P=.67 [6-month follow-up]). There were no significant group × time interactions for diagnosis, psychosis status, or antidepressant medication use. Participants with minimal or mild depression had negligible nonsignificant improvements (<1 point on the BDI-II). Reduction in depression in all other groups was larger (range 1.7-6.5 points on the BDI-II). Conclusions: Our results suggest that FOCUS can be deployed to treat moderate to severe depressive symptoms among people with schizophrenia spectrum disorders, bipolar disorder, and major depressive disorder, in concert with antidepressant medications or without them, in both people with and without active psychotic symptoms. The study results are consistent with research on transdiagnostic models in psychotherapy and extend our knowledge about the potential of transdiagnostic mobile health. Trial Registration: ClinicalTrials.gov NCT02421965; http://clinicaltrials.gov/ct2/show/NCT02421965 (Archived by WebCite at http://www.webcitation.org/76pyDlvAS) %M 30977736 %R 10.2196/13202 %U http://mental.jmir.org/2019/4/e13202/ %U https://doi.org/10.2196/13202 %U http://www.ncbi.nlm.nih.gov/pubmed/30977736 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e12578 %T The Role of Data Type and Recipient in Individuals’ Perspectives on Sharing Passively Collected Smartphone Data for Mental Health: Cross-Sectional Questionnaire Study %A Nicholas,Jennifer %A Shilton,Katie %A Schueller,Stephen M %A Gray,Elizabeth L %A Kwasny,Mary J %A Mohr,David C %+ Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Drive, 10th Floor, CBITs, Chicago, IL, 60611, United States, 1 3125034156, j.nicholas@northwestern.edu %K mHealth %K privacy %K personal sensing %K digital mental health %K depression %K anxiety %K mobile phone %D 2019 %7 05.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The growing field of personal sensing harnesses sensor data collected from individuals’ smartphones to understand their behaviors and experiences. Such data could be a powerful tool within mental health care. However, it is important to note that the nature of these data differs from the information usually available to, or discussed with, health care professionals. To design digital mental health tools that are acceptable to users, understanding how personal sensing data can be used and shared is critical. Objective: This study aimed to investigate individuals’ perspectives about sharing different types of sensor data beyond the research context, specifically with doctors, electronic health record (EHR) systems, and family members. Methods: A questionnaire assessed participants’ comfort with sharing six types of sensed data: physical activity, mood, sleep, communication logs, location, and social activity. Participants were asked about their comfort with sharing these data with three different recipients: doctors, EHR systems, and family members. A series of principal component analyses (one for each data recipient) was performed to identify clusters of sensor data types according to participants’ comfort with sharing them. Relationships between recipients and sensor clusters were then explored using generalized estimating equation logistic regression models. Results: A total of 211 participants completed the questionnaire. The majority were female (171/211, 81.0%), and the mean age was 38 years (SD 10.32). Principal component analyses consistently identified two clusters of sensed data across the three data recipients: “health information,” including sleep, mood, and physical activity, and “personal data,” including communication logs, location, and social activity. Overall, participants were significantly more comfortable sharing any type of sensed data with their doctor than with the EHR system or family members (P<.001) and more comfortable sharing “health information” than “personal data” (P<.001). Participant characteristics such as age or presence of depression or anxiety did not influence participants’ comfort with sharing sensed data. Conclusions: The comfort level in sharing sensed data was dependent on both data type and recipient, but not individual characteristics. Given the identified differences in comfort with sensed data sharing, contextual factors of data type and recipient appear to be critically important as we design systems that harness sensor data for mental health treatment and support. %M 30950799 %R 10.2196/12578 %U http://mhealth.jmir.org/2019/4/e12578/ %U https://doi.org/10.2196/12578 %U http://www.ncbi.nlm.nih.gov/pubmed/30950799 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11387 %T Identification of Anxiety and Depression Symptoms in Patients With Cancer: Comparison Between Short and Long Web-Based Questionnaires %A Mattsson,Susanne %A Olsson,Erik Martin Gustaf %A Carlsson,Maria %A Johansson,Birgitta Beda Kristina %+ Lifestyle and Rehabilitation in long term illness, Public Health and Caring Sciences, Uppsala University, Box 564, Uppsala, 75122, Sweden, 46 184710000 ext 6637, susanne.mattsson@pubcare.uu.se %K screening %K cancer %K depression %K anxiety %K internet %K eHealth %D 2019 %7 05.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Physicians and nurses in cancer care easily fail to detect symptoms of psychological distress because of barriers such as lack of time, training on screening methods, and knowledge about how to diagnose anxiety and depression. National guidelines in several countries recommend routine screening for emotional distress in patients with cancer, but in many clinics, this is not implemented. By inventing screening methods that are time-efficient, such as digitalized and automatized screenings with short instruments, we can alleviate the burden on patients and staff. Objective: The aim of this study was to compare Web-based versions of the ultrashort electronic Visual Analogue Scale (eVAS) anxiety and eVAS depression and the short Hospital Anxiety and Depression Scale (HADS) with Web-based versions of the longer Montgomery Åsberg Depression Rating Scale-Self-report (MADRS-S) and the State Trait Anxiety Inventory- State (STAI-S) with regard to their ability to identify symptoms of anxiety and depression in patients with cancer. Methods: Data were obtained from a consecutive sample of patients with newly diagnosed (<6 months) breast, prostate, or colorectal cancer or with recurrence of colorectal cancer (N=558). The patients were recruited at 4 hospitals in Sweden between April 2013 and September 2015, as part of an intervention study administered via the internet. All questionnaires were completed on the Web at the baseline assessment in the intervention study. Results: The ultrashort and short Web-based-delivered eVAS anxiety, eVAS depression and HADS were found to have an excellent ability to discriminate between persons with and without clinical levels of symptoms of anxiety and depression compared with recommended cutoffs of the longer instruments MADRS-S and STAI-S (area under the curve: 0.88-0.94). Cutoffs of >6 on HADS anxiety and >7 hundredths (hs) on eVAS anxiety identified patients with anxiety symptoms with high accuracy. For HADS depression, at a cutoff of >5 and eVAS depression at a cutoff of >7 hs, the accuracy was very high likewise. Conclusions: The use of the short and ultrashort tools, eVAS and HADS, may be a suitable initial method of Web-based screening in busy clinical settings. However, there are still a proportion of patients who lack access to the internet or the ability to use it. There is a need to find solutions for this group to find all the patients with psychological distress. %M 30950804 %R 10.2196/11387 %U https://www.jmir.org/2019/4/e11387/ %U https://doi.org/10.2196/11387 %U http://www.ncbi.nlm.nih.gov/pubmed/30950804 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 4 %P e13239 %T Effectiveness of a Web- and Mobile-Guided Psychological Intervention for Depressive Symptoms in Turkey: Protocol for a Randomized Controlled Trial %A Ünlü Ince,Burçin %A Gökçay,Didem %A Riper,Heleen %A Cuijpers,Pim %+ Department of Medical Informatics / Informatics Institute, Middle East Technical University, Üniversiteler Mahallesi, Çankaya, Ankara, 06800, Turkey, 90 312 2103741, unlu_burcin@outlook.com %K randomized controlled trial %K depressive symptoms %K mobile app %K psychotherapy %K telemedicine %K depression %D 2019 %7 05.04.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: In Turkey, there are serious deficiencies in mental health care. Although depression is highly prevalent, only a small number of people seek professional help. Innovative solutions are needed to overcome this treatment gap. Web-based problem-solving therapy (PST) is an intervention proven to be effective in the treatment of depression, although little is known about its clinical effects in Turkey. Objective: This study aims to test the clinical effects of a Web and mobile app of an adapted PST for depressive symptoms among the general population in Turkey. Methods: Participants will be recruited through announcements in social media and the Middle East Technical University. Adults (18-55 years) with mild to moderate depressive symptoms (Beck Depression Inventory-II [BDI-II] score between 10-29) will be included in the study. Participants with a medium-to-high suicidal risk (according to the Mini-International Neuropsychiatric Interview) will be excluded. A 3-armed randomized controlled trial with a waiting control group will be utilized. A sample size of 444 participants will be randomized across 3 groups. The first experimental group will receive direct access to the Web version of the intervention; the second experimental group will receive direct access to the mobile app of the intervention as well as automated supportive short message service text messages based on PST. The control group consists of a wait-list and will gain access to the intervention 4 months after the baseline. The intervention is based on an existing PST for the Turkish population, Her Şey Kontrol Altında (HŞKA), consisting of 5 modules each with a duration of 1 week and is guided by a clinical psychologist. The primary outcome is change in depressive symptoms measured by the BDI-II. Secondary outcomes include symptoms of anxiety, stress, worry, self-efficacy, and quality of life. Furthermore, satisfaction with, usability and acceptability of the intervention are important features that will be evaluated. All outcomes will take place online through self-assessment at posttest (6-8 weeks after baseline) and at follow-up (4 months after baseline). Results: We will recruit a total of 444 participants with mild to moderate depressive symptoms from March 2018 to February 2019 or until the recruitment is complete. We expect the final trial results to be available by the end of May 2019. This trial is funded by the Scientific and Technological Research Council of Turkey (National Postdoctoral Research Fellowship Programme 2016/1). Conclusions: Results from this study will reveal more information about the clinical effects of HŞKA as well as its applicability in a Turkish setting through the Web and mobile platforms. On the basis of the results, a guided Web- and mobile-based PST intervention might become an appropriate alternative for treating mild to moderate depressive symptoms. Trial Registration: ClinicalTrials.gov NCT03754829; https://clinicaltrials.gov/ct2/show/NCT03754829 (Archived by WebCite at http://www.webcitation.org/74HugwLo7). International Registered Report Identifier (IRRID): DERR1-10.2196/13239 %M 30950802 %R 10.2196/13239 %U http://www.researchprotocols.org/2019/4/e13239/ %U https://doi.org/10.2196/13239 %U http://www.ncbi.nlm.nih.gov/pubmed/30950802 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e11671 %T Utilization of Patient-Generated Data Collected Through Mobile Devices: Insights From a Survey on Attitudes Toward Mobile Self-Monitoring and Self-Management Apps for Depression %A Hartmann,Ralf %A Sander,Christian %A Lorenz,Noah %A Böttger,Daniel %A Hegerl,Ulrich %+ Research Center of the German Depression Foundation, Semmelweisstraße 10, Leipzig, 04103, Germany, 49 3419724506, ralf.hartmann@medizin.uni-leipzig.de %K mHealth %K depression %K adherence %K mobile applications, self-management %D 2019 %7 03.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is a severe psychiatric disease with high prevalence and an elevated risk for recurrence and chronicity. A substantial proportion of individuals with a diagnosis of unipolar depressive disorder do not receive treatment as advised by national guidelines. Consequently, self-monitoring and self-management become increasingly important. New mobile technologies create unique opportunities to obtain and utilize patient-generated data. As common adherence rates to mobile technologies are scarce, a profound knowledge of user behavior and attitudes and preferences is important throughout any developmental process of mobile technologies and apps. Objective: The aim of this survey was to provide descriptive data upon usage and anticipated usage of self-monitoring and self-management of depression and preferences of potential users in terms of documented parameters and data-sharing options. Methods: A Web-based survey comprising 55 questions was conducted to obtain data on the usage of mobile devices, app usage, and participant’s attitudes and preferences toward mobile health apps for the self-monitoring and self-management of depression. Results: A total of 825 participants provided information. Moreover, two-thirds of the sample self-reported to be affected by depressive symptoms, but only 12.1% (81/668) of those affected by depression have ever used any mobile self-monitoring or self-management app. Analysis showed that people want personally relevant information and feedback but also focus on handling sensitive data. Conclusions: New mobile technologies and smartphone apps, especially in combination with mobile sensor systems, offer unique opportunities to overcome challenges in the treatment of depression by utilizing the potential of patient-generated data. Focus on patient-relevant information, security and safe handling of sensitive personal data, as well as options to share data with self-selected third parties should be considered mandatory throughout any development process. %M 30942693 %R 10.2196/11671 %U https://mental.jmir.org/2019/4/e11671/ %U https://doi.org/10.2196/11671 %U http://www.ncbi.nlm.nih.gov/pubmed/30942693 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e11521 %T Service Use History of Individuals Enrolling in a Web-Based Suicidal Ideation Treatment Trial: Analysis of Baseline Data %A Wong,Quincy JJ %A Werner-Seidler,Aliza %A Torok,Michelle %A van Spijker,Bregje %A Calear,Alison L %A Christensen,Helen %+ School of Social Sciences and Psychology, Western Sydney University, Kingswood Campus, Sydney,, Australia, 61 2 4736 0080, q.wong@westernsydney.edu.au %K internet %K treatment %K service use %K health service %K suicidal ideation %K suicide, attempted %K suicide %K facilities and services utilization %K telehealth %D 2019 %7 02.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: A significant recent innovation is the development of internet-based psychological treatments for suicidal thinking. However, we know very little about individuals experiencing suicidal ideation who seek help through Web-based services and, in particular, their previous health service use patterns. Objective: We aimed to examine service use history and its correlates among adults experiencing suicidal ideation who enrolled in a Web-based suicidal ideation treatment trial. Methods: We used baseline data of 418 individuals seeking Web-based treatment for their suicidal ideation recruited into a randomized controlled trial of a 6-week Web-based self-help program. Participants at preintervention reported demographic information, clinical characteristics, and health service use over the previous 6 months. Results: Participants had a high rate of service use in the 6 months before enrolling in the treatment trial (404/418, 96.7% of participants had contact with services). The two most common contact points were general practitioners (385/418, 92.1% of participants) and mental health professionals (295/418, 70.6% of participants). Notably, those with a previous single suicide attempt had lower odds of contact with any service than those with no attempt (odds ratio [OR] 0.21, 95% CI 0.05-0.86; P=.03). Those living in rural or remote areas had lower odds of contacting general practitioners (OR 0.35, 95% CI 0.13-0.91; P=.03) or mental health professionals (OR 0.44, 95% CI 0.23-0.83; P=.01) than those living in metropolitan areas. Conclusions: Individuals enrolling in an electronic health intervention trial have often received treatment from general practitioners or mental health professionals. These services can therefore play an important role in preventing the escalation of suicidal thinking. Enrollment in our Web-based treatment trial suggested, though, that face-to-face health services may not be enough. Our study also highlighted the need to improve the provision of coordinated and assertive care after a suicide attempt, as well as health service availability and utilization for those living in rural and remote areas. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12613000410752; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364016 (Archived by WebCite at http://www.webcitation.org/6vK5FvQXy); Universal Trial Number U1111-1141-6595 %M 30938686 %R 10.2196/11521 %U https://mental.jmir.org/2019/4/e11521/ %U https://doi.org/10.2196/11521 %U http://www.ncbi.nlm.nih.gov/pubmed/30938686 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e11215 %T Methodological Strategies for Ecological Momentary Assessment to Evaluate Mood and Stress in Adult Patients Using Mobile Phones: Systematic Review %A Yang,Yong Sook %A Ryu,Gi Wook %A Choi,Mona %+ Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2 2228 3341, monachoi@yuhs.ac %K review %K experience sampling method %K ecological momentary assessment %K mobile apps %K mood %K stress %D 2019 %7 01.04.2019 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Ecological momentary assessment (EMA) has utility for measuring psychological properties in daily life. EMA has also allowed researchers to collect data on diverse experiences and symptoms from various subjects. Objective: The aim of this study was to review methodological strategies and useful related information for EMA using mobile phones to capture changes of mood and stress in adult patients seeking health care. Methods: We searched PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, the Cochrane Library, PsycINFO, and Web of Science. This review included studies published in peer-reviewed journals in English between January 2008 and November 2017 that used basic- or advanced-feature mobile phones to measure momentary mood or stress in adult patients seeking health care in outpatient departments. We excluded studies of smoking and substance addictions and studies of mental disorder patients who had been diagnosed by physicians. Results: We reviewed 12 selected articles that used EMA via mobile phones to measure momentary mood and stress and other related variables from various patients with chronic fatigue syndrome, breast cancer, migraine, HIV, tinnitus, temporomandibular disorder, end-stage kidney disease, and traumatic brain injury. Most of the selected studies (11/12, 92%) used signal contingency and in 8 of the 12 studies (67%) alarms were sent at random or semirandom intervals to prompt the momentary measurement. Out of 12 studies, 7 (58%) used specific apps directly installed on mobile phones, 3 (25%) used mobile phones to link to Web-based survey programs, and 2 (17%) used an interactive voice-response system. Conclusions: This study provides researchers with useful information regarding methodological details for utilizing EMA to measure mood and stress in adult patients. This review shows that EMA methods could be effective and reasonable for measuring momentary mood and stress, given that basic- and advanced-feature mobile phones are ubiquitous, familiar, and easy to approach. Therefore, researchers could adopt and utilize EMA methods using mobile phones to measure psychological health outcomes, such as mood and stress, in adult patients. %M 30932866 %R 10.2196/11215 %U https://mhealth.jmir.org/2019/4/e11215/ %U https://doi.org/10.2196/11215 %U http://www.ncbi.nlm.nih.gov/pubmed/30932866 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 3 %P e12392 %T Screening Depression and Related Conditions via Text Messaging Versus Interview Assessment: Protocol for a Randomized Study %A Jin,Haomiao %A Wu,Shinyi %+ Department of Adult Mental Health and Wellness, Suzanne Dworak-Peck School of Social Work, University of Southern California, 1149 South Hill Street, Suite 360, Los Angeles, CA, 90015, United States, 1 213 821 9361, haomiaoj@usc.edu %K depression %K diabetes %K comorbidity %K screening %K primary care %K health information technology %K information and communication technology %K text messaging %K patient-reported outcome measures %D 2019 %7 29.03.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is an often underdiagnosed and, therefore, untreated comorbidity for low-income, racially or ethnically diverse patients with a chronic illness such as diabetes. Recent updates from the US Preventive Services Task Force guidelines in 2016 recommend depression screening for every adult but does not suggest the mode of assessment. Short message service (SMS) text messaging is an inexpensive, private, and scalable approach to provide depression screening and monitoring; it can also alleviate many barriers, such as transportation, childcare, and clinical visit time faced by the low-income population, in receiving a diagnosis of depression. Current evidence is inconsistent in comparing technology-mediated assessment versus interviewer (INTW) assessment in collecting sensitive health information, as some studies suggest that technology encourages self-disclosure while the other studies show the opposite effect. Objective: The proposed study will test the use of SMS text messaging to assess depression and its related conditions, including functional disability, pain, and anxiety, in low-income, culturally diverse, safety-net primary care populations with diabetes. The study will examine the concordance between SMS text message and interviewer assessments and evaluate test-retest reliability. Methods: The proposed study will adopt a randomized design with 200 patients assigned to four study groups: SMS/INTW, INTW/SMS, SMS/SMS, and INTW/INTW. The first two groups will be used to examine the concordance between SMS text message and interviewer assessments. The third and fourth groups will be used to evaluate test-retest reliability. Participants of the study will be recruited from the participants of the prior Diabetes-Depression Care-management Adoption Trial, a large comparative effectiveness research trial in collaboration with the Los Angeles County Department of Health Services. Test-retest reliability and concordance between SMS text message and interviewer assessments will be evaluated by the interclass correlation coefficient and the kappa statistic. Missing data patterns will be explored to understand whether participants are willing to self-disclose information related to depression in SMS text message assessments. Results: Recruitment of participants was conducted from June 2017 to November 2017. A total of 206 participants were enrolled: 52 (25.2%) in SMS/INTW, 53 (25.7%) in SMS/SMS, 49 (23.8%) in INTW/SMS, and 52 (25.2%) in INTW/INTW. The average age of the participants was 57.1 years (SD 9.2). A total of 57.8% (119/206) of participants were female, 93.2% (192/206) were Latino, and 77.7% (160/206) chose Spanish as their preferred language. Analysis of the SMS text message assessment shows the cost of distributing the 16 questions is about US $0.50 per person per assessment. Full results of the study will be reported elsewhere. Conclusions: This study is anticipated to establish the feasibility of using SMS text messaging to assess depression and its related conditions in low-income, culturally diverse, safety-net primary care populations with diabetes. We also expect to generate knowledge about whether patients in the targeted population are willing to reply and self-disclose sensitive information about depression and its related conditions through SMS text message assessments. International Registered Report Identifier (IRRID): DERR1-10.2196/12392 %M 30924787 %R 10.2196/12392 %U http://www.researchprotocols.org/2019/3/e12392/ %U https://doi.org/10.2196/12392 %U http://www.ncbi.nlm.nih.gov/pubmed/30924787 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 3 %P e12613 %T Relationship Between Sleep Quality and Mood: Ecological Momentary Assessment Study %A Triantafillou,Sofia %A Saeb,Sohrab %A Lattie,Emily G %A Mohr,David C %A Kording,Konrad Paul %+ Department of Biomedical Engineering, School of Engineering and Applied Sciences, University of Pennsylvania, , Philadelphia, PA,, United States, 1 412 624 7198, sof.triantafillou@gmail.com %K sleep %K affect %K ecological momentary assessment %K smartphone %K depression %K causality %D 2019 %7 27.03.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Sleep disturbances play an important role in everyday affect and vice versa. However, the causal day-to-day interaction between sleep and mood has not been thoroughly explored, partly because of the lack of daily assessment data. Mobile phones enable us to collect ecological momentary assessment data on a daily basis in a noninvasive manner. Objective: This study aimed to investigate the relationship between self-reported daily mood and sleep quality. Methods: A total of 208 adult participants were recruited to report mood and sleep patterns daily via their mobile phones for 6 consecutive weeks. Participants were recruited in 4 roughly equal groups: depressed and anxious, depressed only, anxious only, and controls. The effect of daily mood on sleep quality and vice versa were assessed using mixed effects models and propensity score matching. Results: All methods showed a significant effect of sleep quality on mood and vice versa. However, within individuals, the effect of sleep quality on next-day mood was much larger than the effect of previous-day mood on sleep quality. We did not find these effects to be confounded by the participants’ past mood and sleep quality or other variables such as stress, physical activity, and weather conditions. Conclusions: We found that daily sleep quality and mood are related, with the effect of sleep quality on mood being significantly larger than the reverse. Correcting for participant fixed effects dramatically affected results. Causal analysis suggests that environmental factors included in the study and sleep and mood history do not mediate the relationship. %M 30916663 %R 10.2196/12613 %U http://mental.jmir.org/2019/3/e12613/ %U https://doi.org/10.2196/12613 %U http://www.ncbi.nlm.nih.gov/pubmed/30916663 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 3 %P e12235 %T Do Search Engine Helpline Notices Aid in Preventing Suicide? Analysis of Archival Data %A Cheng,Qijin %A Yom-Tov,Elad %+ Microsoft Research, 13 Shenkar Street, Herzeliya, 46733, Israel, 972 747111359, eladyt@yahoo.com %K search engines %K suicide %D 2019 %7 26.03.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Search engines display helpline notices when people query for suicide-related information. Objective: In this study, we aimed to examine if these notices and other information displayed in response to suicide-related queries are correlated with subsequent searches for suicide prevention rather than harmful information. Methods: Anonymous suicide-related searches made on Bing and Google in the United States, the United Kingdom, Hong Kong, and Taiwan in a span of 10 months were extracted. Descriptive analyses and regression models were fit to the data to assess the correlation with observed behaviors. Results: Display of helpline notices was not associated with an observed change in the likelihood of or future suicide searches (P=.42). No statistically significant differences were observed in the likelihood of people making future suicide queries (both generally and specific types of suicide queries) when comparing search engines in locations that display helpline notices versus ones that do not. Pages with higher rank, being neutral to suicide, and those shown among more antisuicide pages were more likely to be clicked on. Having more antisuicide Web pages displayed was the only factor associated with further searches for suicide prevention information (hazard=1.18, P=.002). Conclusions: Helpline notices are not associated with harm. If they cause positive change in search behavior, it is small. This is possibly because of the variability in intent of users seeking suicide-related information. Nonetheless, helpline notice should be displayed, but more efforts should be made to improve the visibility and ranking of suicide prevention Web pages. %M 30912753 %R 10.2196/12235 %U http://www.jmir.org/2019/3/e12235/ %U https://doi.org/10.2196/12235 %U http://www.ncbi.nlm.nih.gov/pubmed/30912753 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 2 %N 1 %P e12850 %T Mentalizing Imagery Therapy Mobile App to Enhance the Mood of Family Dementia Caregivers: Feasibility and Limited Efficacy Testing %A Sikder,Abu Taher %A Yang,Francis Cheng %A Schafer,Rhiana %A Dowling,Glenna A %A Traeger,Lara %A Jain,Felipe Ananda %+ Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, One Bowdoin Square, 6th Floor, Boston, MA, 02114, United States, 1 617 643 4682, felipe.jain@post.harvard.edu %K family caregivers %K mindfulness %K depression %K mobile apps %K psychotherapy %D 2019 %7 21.03.2019 %9 Original Paper %J JMIR Aging %G English %X Background: Family caregivers of patients with Alzheimer disease and related dementias (AD and ADRD) often experience high stress and are at high risk for depression. Technologically delivered therapy is attractive for AD and ADRD caregivers because of the time demands associated with in-person participation. Objective: We aimed to study the feasibility and conduct limited efficacy testing of a mobile app intervention delivering mentalizing imagery therapy (MIT) for family caregivers. Methods: A 4-week trial of the MIT app for family AD and ADRD caregivers was conducted to assess the feasibility of use and investigate changes in depression symptoms, mood, and caregiving experience. Semistructured interviews were conducted to characterize participants’ perceived feasibility and benefits. Results: A total of 17 of the 21 (80%) consented participants (mean age 67 years, range 54-79) utilized the app at least once and were further analyzed. Average usage of audio recordings was on 14 (SD 10) days out of 28 possible and comprised 29 (SD 28) individual sessions. There were improvements in depression with a large effect size for those who used the app at least moderately (P=.008), increases in positive mood postintervention (P<.05), and acute increases in mood following daily guided imagery practice (Stretching and Breathing, P<.001; Eye in the Center, P<.001; Nesting Doll, P=.002; Situation Solver, P=.003; and Life Globe, P=.006). Semistructured interviews revealed perceived benefits such as greater ability to remain “centered” despite caregiving challenges and positive reframing of the caregiver experience. Conclusions: App delivery of MIT is feasible for family AD and ADRD caregivers, including aging seniors. Results showed moderate to high usage of the app for a majority of users. Limited efficacy testing provides justification for studying the MIT app for AD and ADRD caregivers to improve mood and reduce depression in larger, controlled trials. %M 31518275 %R 10.2196/12850 %U http://aging.jmir.org/2019/1/e12850/ %U https://doi.org/10.2196/12850 %U http://www.ncbi.nlm.nih.gov/pubmed/31518275 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 3 %P e11572 %T Exploring the Use of Multiple Mental Health Apps Within a Platform: Secondary Analysis of the IntelliCare Field Trial %A Kwasny,Mary J %A Schueller,Stephen M %A Lattie,Emily %A Gray,Elizabeth L %A Mohr,David C %+ Division of Biostatistics, Department of Preventive Medicine, Northwestern University, Suite 1400, 680 N Lake Shore Drive, Chicago, IL, 60611, United States, 1 3125032294, m-kwasny@northwestern.edu %K mobile apps %K depression %K anxiety %K mobile phone %D 2019 %7 21.03.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: IntelliCare is a mental health app platform with 14 apps that are elemental, simple and brief to use, and eclectic. Although a variety of apps may improve engagement, leading to better outcomes, they may require navigation aids such as recommender systems that can quickly direct a person to a useful app. Objective: As the first step toward developing navigation and recommender tools, this study explored app-use patterns across the IntelliCare platform and their relationship with depression and anxiety outcomes. Methods: This is a secondary analysis of the IntelliCare Field Trial, which recruited people with depression or anxiety. Participants of the trial received 8 weeks of coaching, primarily by text, and weekly random recommendations for apps. App-use metrics included frequency and lifetime use. Depression and anxiety, measured using the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7, respectively, were assessed at baseline and end of treatment. Cluster analysis was utilized to determine patterns of app use; ordinal logistic regression models and log-rank tests were used to determine if these use metrics alone, or in combination, predicted improvement or remission in depression or anxiety. Results: The analysis included 96 people who generally followed recommendations to download and try new apps each week. Apps were clustered into 5 groups: Thinking (apps that targeted or relied on thinking), Calming (relaxation and insomnia), Checklists (apps that used checklists), Activity (behavioral activation and activity), and Other. Both overall frequency of use and lifetime use predicted response for depression and anxiety. The Thinking, Calming, and Checklist clusters were associated with improvement in depression and anxiety, and the Activity cluster was associated with improvement in Anxiety only. However, the use of clusters was less strongly associated with improvement than individual app use. Conclusions: Participants in the field trial remained engaged with a suite of apps for the full 8 weeks of the trial. App-use patterns did fall into clusters, suggesting that some knowledge about the use of one app may be useful in selecting another app that the person is more likely to use and may help suggest apps based on baseline symptomology and personal preference. %M 30896433 %R 10.2196/11572 %U http://mental.jmir.org/2019/3/e11572/ %U https://doi.org/10.2196/11572 %U http://www.ncbi.nlm.nih.gov/pubmed/30896433 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 3 %P e11224 %T Health-Related Internet Usage and Design Feature Preference for E-Mental Health Programs Among Men and Women %A Smail-Crevier,Rachel %A Powers,Gabrielle %A Noel,Chelsea %A Wang,JianLi %+ Work & Mental Health Research Unit, The Royal's Institute of Mental Health Research, University of Ottawa, 1145 Carling Ave, Ottawa, ON, K1Z 7K4, Canada, 1 613 722 6521 ext 6057, jianli.wang@theroyal.ca %K occupational health %K workplace %K mental health %K preventive health program %K depression %K internet %D 2019 %7 18.03.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Major depressive episodes (MDEs) are prevalent in the workplace and affect workers’ health and productivity. Therefore, there is a pressing need for innovation in the prevention of MDEs in the workplace. Electronic mental (e-mental) health programs are a cost-effective approach toward the self-management of stress and emotional issues. E-mental health dropout rate, MDE prevalence, and symptoms greatly vary by sex and age. Thus, the development and implementation of e-mental health programs for the prevention of MDEs need to be examined through a sex and age lens to enhance program use and effectiveness. Objective: This study aimed to examine design feature preferences based on sex and age for an e-mental health program targeted toward depression prevention. Methods: Household residents across Canada were contacted using the random digit dialing method. 500 women and 511 men who were 18 years and older and who were at high risk of having MDEs were interviewed. Internet use was assessed using questions from the 2012 Canadian Internet Use Survey conducted by Statistics Canada, and preferred design features of e-mental health program questions were developed by the BroMatters team members. The proportions of likely use of specific features of e-mental health programs in women were estimated and compared with those in men using chi-square tests. The comparisons were made overall and by age groups. Results: Men (181/511, 35.4%) and women (211/500, 42.2%) differed significantly in their likelihood of using an e-mental health program. Compared with men (307/489, 62.8%), women (408/479, 85.2%) were more likely to use the internet for medical or health-related information. Women were more likely to use the following design features: practices and exercises to help reduce symptoms of stress and depression (350/500, 70.7%), a self-help interactive program that provides information about stress and work problems (302/500, 61.8%), the ability to ask questions and receive answers from mental health professionals via email or text message (294/500, 59.9%), and to receive printed materials by mail (215/500, 43.4%). Men preferred to receive information in a video game format (156/511, 30.7%). Younger men (46/73, 63%) and younger women (49/60, 81%) were more likely to access a program through a mobile phone or an app, and younger men preferred having access to information in a video game format. Conclusions: Factors such as sex and age influenced design feature preferences for an e-mental health program. Working women who are at high risk for MDEs preferred interactive programs incorporating practice and exercise for reducing stress, quality information about work stress, and some guidance from professionals. This suggests that sex and age should be taken into account when designing e-mental health programs to meet the needs of individuals seeking help via Web-based mental health programs and to enhance their use. %M 30882361 %R 10.2196/11224 %U http://www.jmir.org/2019/3/e11224/ %U https://doi.org/10.2196/11224 %U http://www.ncbi.nlm.nih.gov/pubmed/30882361 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 3 %P e11255 %T A Game-Based School Program for Mental Health Literacy and Stigma Regarding Depression (Moving Stories): Protocol for a Randomized Controlled Trial %A Tuijnman,Anouk %A Kleinjan,Marloes %A Hoogendoorn,Evert %A Granic,Isabela %A Engels,Rutger CME %+ Behavioural Science Institute, Radboud University, Montessorilaan 3, Nijmegen, 6525 HR, Netherlands, 31 24 3612076, a.tuijnman@pwo.ru.nl %K depression %K help-seeking behavior %K helping behavior %K health literacy %K stigma %K video games %K adolescence %K secondary schools %D 2019 %7 14.03.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: The prevalence of elevated depressive symptoms among youth in most western societies is high. Yet, most adolescents who are experiencing depressive symptoms do not seek help. Low mental health literacy, high stigma, and low social support have been shown to hinder help-seeking. A small number of interventions has been developed to target mental health literacy and stigma, but few focus on actual help-seeking and first aid behavior. We have developed a game-based school program called Moving Stories that targets mental health literacy, including knowledge and behavior, and stigma among adolescents, in regard to depression specifically. Objective: Our aim is to describe the protocol for a study that will test the effectiveness of the program Moving Stories in a Dutch adolescent sample. We hypothesize that adolescents who participate in the program Moving Stories will have better mental health literacy and less stigma regarding depression compared to adolescents in the nonintervention control group at posttest and at 3- and 6-months follow-up. We also expect a positive change in actual help-seeking and first aid behavior at 3- and 6-months follow-up. Methods: Moving Stories has been developed by a professional game design company in collaboration with researchers and relevant stakeholders. The effectiveness of Moving Stories will be tested through a randomized controlled trial with two conditions: Moving Stories versus control. Participants will fill in questionnaires at pretest, posttest, and 3- and 6-months follow-up. Our power analysis showed a required sample size of 180 adolescents. Results: Four high schools have agreed to participate with a total of 10 classes. A total of 185 adolescents filled in the pretest questionnaire. The last of the follow-up data was collected in December 2018. Conclusions: If Moving Stories proves to be effective, it could be implemented as a school-based program to target mental health literacy and stigma regarding depression; this could, in turn, improve early help-seeking in adolescents suffering from depression. Trial Registration: Nederlands Trial Register NTR7033; https://www.trialregister.nl/trial/6855 International Registered Report Identifier (IRRID): DERR1-10.2196/11255 %M 30869652 %R 10.2196/11255 %U https://www.researchprotocols.org/2019/3/e11255/ %U https://doi.org/10.2196/11255 %U http://www.ncbi.nlm.nih.gov/pubmed/30869652 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11711 %T How Do Adolescents Use Electronic Diaries? A Mixed-Methods Study Among Adolescents With Depressive Symptoms %A Metsäranta,Kiki %A Kurki,Marjo %A Valimaki,Maritta %A Anttila,Minna %+ Department of Nursing Science, University of Turku, Hoitotieteen laitos, Joukahaisenkatu 3-5, Turun yliopisto, 20014, Finland, 358 456716156, kianme@utu.fi %K adolescent %K depression %K electronic diary %K mental health %K mobile phone %K outpatient care %D 2019 %7 20.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression in adolescence is common. Less than half of the adolescents with depression receive mental health care; furthermore, treatment tends to be suspended, and its success rates are low. There is a need for these adolescents to have a safe place to share their thoughts. Studies have shown that writing may be a useful treatment method for people with mental health problems. Objective: This study aims to describe the use of an electronic diary (e-diary) among adolescents with depressive symptoms. Methods: This paper describes a substudy of a randomized controlled trial. We used a mixed-methods approach to understand the way in which e-diaries were used by participants in the intervention under the randomized controlled trial. Data were collected during 2008-2010 at 2 university hospitals in Finland. Study participants (N=89) were 15-17-year-old adolescents who had been referred to an adolescent outpatient psychiatric clinic due to depressive symptoms. Participants were instructed to use the e-diary at least once a week to describe their thoughts, feelings, and moods. The content of the e-diary data was analyzed using descriptive statistics and inductive content analysis. Results: Overall, 53% (47/89) of the adolescents used the e-diary. Most of them (39/47, 83%) logged into the program during the first week, and about one-third (19/47, 40%) logged into the e-diary weekly as suggested. The number of words used in the e-diary per each log ranged between 8 and 1442 words. The 3 topics most often written about in the e-diary were related to mental health problems (mental disorder), social interaction (relationship), and one’s own development (identity). Conclusions: An e-diary may be a usable tool to reflect experiences and thoughts, especially among adolescents who have signs of depression. The results of this study can be used to develop user-centered electronic health applications that allow users to express their own thoughts and experiences in ways other than systematic mood monitoring. %M 30785408 %R 10.2196/11711 %U http://www.jmir.org/2019/2/e11711/ %U https://doi.org/10.2196/11711 %U http://www.ncbi.nlm.nih.gov/pubmed/30785408 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12894 %T Resilience@Work Mindfulness Program: Results From a Cluster Randomized Controlled Trial With First Responders %A Joyce,Sadhbh %A Shand,Fiona %A Lal,Tara J %A Mott,Brendan %A Bryant,Richard A %A Harvey,Samuel B %+ School of Psychiatry, Faculty of Medicine, University of New South Wales, The Black Dog Institute, Hospital Road, Randwick, 2031, Australia, 61 401297711, sadhbh.joyce@unsw.edu.au %K resilience training %K workplace mental health %K occupational health %K well-being %K online intervention %K employee resilience %K health and safety %K psychological health %K first responders %D 2019 %7 19.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: A growing body of research suggests that resilience training can play a pivotal role in creating mentally healthy workplaces, particularly with regard to protecting the long-term well-being of workers. Emerging research describes positive outcomes from various types of resilience training programs (RTPs) among different occupational groups. One specific group of workers that may benefit from this form of proactive resilience training is first responders. Given the nature of their work, first responders are frequently exposed to stressful circumstances and potentially traumatic events, which may impact their overall resilience and well-being over time. Objective: This study aimed to examine whether a mindfulness-based RTP (the Resilience@Work [RAW] Mindfulness Program) delivered via the internet can effectively enhance resilience among a group of high-risk workers. Methods: We conducted a cluster randomized controlled trial (RCT) comprising 24 Primary Fire and Rescue and Hazmat stations within New South Wales. Overall, 12 stations were assigned to the 6-session RAW Mindfulness Program and 12 stations were assigned to the control condition. A total of 143 active full-time firefighters enrolled in the study. Questionnaires were administered at baseline, immediately post training, and at 6-month follow-up. Measurements examined change in both adaptive and bounce-back resilience as well as several secondary outcomes examining resilience resources and acceptance and mindfulness skills. Results: Mixed-model repeated measures analysis found that the overall test of group-by-time interaction was significant (P=.008), with the intervention group increasing in adaptive resilience over time. However, no significant differences were found between the intervention group and the control group in terms of change in bounce-back resilience (P=.09). At 6-month follow-up, the group receiving the RAW intervention had an average increase in their resilience score of 1.3, equating to a moderate-to-large effect size compared with the control group of 0.73 (95% CI 0.38-1.06). Per-protocol analysis found that compared with the control group, the greatest improvements in adaptive resilience were observed among those who completed most of the RAW program, that is, 5 to 6 sessions (P=.002). Conclusions: The results of this RCT suggest that mindfulness-based resilience training delivered in an internet format can create improvements in adaptive resilience and related resources among high-risk workers, such as first responders. Despite a number of limitations, the results of this study suggest that the RAW Mindfulness Program is an effective, scalable, and practical means of delivering online resilience training in high-risk workplace settings. To the best of our knowledge, this is the first time a mindfulness-based RTP delivered entirely via the internet has been tested in the workplace. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000574549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368296 (Archived by WebCite at http://www.webcitation.org/75w4xtrpw). %M 30777846 %R 10.2196/12894 %U http://www.jmir.org/2019/2/e12894/ %U https://doi.org/10.2196/12894 %U http://www.ncbi.nlm.nih.gov/pubmed/30777846 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 2 %P e12121 %T Transforming Mental Health Delivery Through Behavioral Economics and Implementation Science: Protocol for Three Exploratory Projects %A Beidas,Rinad S %A Volpp,Kevin G %A Buttenheim,Alison N %A Marcus,Steven C %A Olfson,Mark %A Pellecchia,Melanie %A Stewart,Rebecca E %A Williams,Nathaniel J %A Becker-Haimes,Emily M %A Candon,Molly %A Cidav,Zuleyha %A Fishman,Jessica %A Lieberman,Adina %A Zentgraf,Kelly %A Mandell,David %+ Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market St, Philadelphia, PA, 19104, United States, 1 215 746 1759, rbeidas@upenn.edu %K implementation science %K behavioral economics %K mental health %D 2019 %7 12.02.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Efficacious psychiatric treatments are not consistently deployed in community practice, and clinical outcomes are attenuated compared with those achieved in clinical trials. A major focus for mental health services research is to develop effective and cost-effective strategies that increase the use of evidence-based assessment, prevention, and treatment approaches in community settings. Objective: The goal of this program of research is to apply insights from behavioral economics and participatory design to advance the science and practice of implementing evidence-based practice (EBP) for individuals with psychiatric disorders across the life span. Methods: Project 1 (Assisting Depressed Adults in Primary care Treatment [ADAPT]) is patient-focused and leverages decision-making heuristics to compare ways to incentivize adherence to antidepressant medications in the first 6 weeks of treatment among adults newly diagnosed with depression. Project 2 (App for Strengthening Services In Specialized Therapeutic Support [ASSISTS]) is provider-focused and utilizes normative pressure and social status to increase data collection among community mental health workers treating children with autism. Project 3 (Motivating Outpatient Therapists to Implement: Valuing a Team Effort [MOTIVATE]) explores how participatory design can be used to design organizational-level implementation strategies to increase clinician use of EBPs. The projects are supported by a Methods Core that provides expertise in implementation science, behavioral economics, participatory design, measurement, and associated statistical approaches. Results: Enrollment for project ADAPT started in 2018; results are expected in 2020. Enrollment for project ASSISTS will begin in 2019; results are expected in 2021. Enrollment for project MOTIVATE started in 2018; results are expected in 2019. Data collection had begun for ADAPT and MOTIVATE when this protocol was submitted. Conclusions: This research will advance the science of implementation through efforts to improve implementation strategy design, measurement, and statistical methods. First, we will test and refine approaches to collaboratively design implementation strategies with stakeholders (eg, discrete choice experiments and innovation tournaments). Second, we will refine the measurement of mechanisms related to heuristics used in decision making. Third, we will develop new ways to test mechanisms in multilevel implementation trials. This trifecta, coupled with findings from our 3 exploratory projects, will lead to improvements in our knowledge of what causes successful implementation, what variables moderate and mediate the effects of those causal factors, and how best to leverage this knowledge to increase the quality of care for people with psychiatric disorders. Trial Registration: ClinicalTrials.gov NCT03441399; https://www.clinicaltrials.gov/ct2/show/NCT03441399 (Archived by WebCite at http://www.webcitation.org/74dRbonBD) International Registered Report Identifier (IRRID): DERR1-10.2196/12121 %M 30747719 %R 10.2196/12121 %U http://www.researchprotocols.org/2019/2/e12121/ %U https://doi.org/10.2196/12121 %U http://www.ncbi.nlm.nih.gov/pubmed/30747719 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e11325 %T Barriers to and Facilitators of Engagement With mHealth Technology for Remote Measurement and Management of Depression: Qualitative Analysis %A Simblett,Sara %A Matcham,Faith %A Siddi,Sara %A Bulgari,Viola %A Barattieri di San Pietro,Chiara %A Hortas López,Jorge %A Ferrão,José %A Polhemus,Ashley %A Haro,Josep Maria %A de Girolamo,Giovanni %A Gamble,Peter %A Eriksson,Hans %A Hotopf,Matthew %A Wykes,Til %A , %+ Institute of Psychology, Psychiatry and Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, United Kingdom, 44 207 848 0762, sara.simblett@kcl.ac.uk %K acceptability %K barriers %K depression %K facilitators %K feasibility %K mHealth %K qualitative %D 2019 %7 30.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile technology has the potential to provide accurate, impactful data on the symptoms of depression, which could improve health management or assist in early detection of relapse. However, for this potential to be achieved, it is essential that patients engage with the technology. Although many barriers to and facilitators of the use of this technology are common across therapeutic areas and technology types, many may be specific to cultural and health contexts. Objective: This study aimed to determine the potential barriers to and facilitators of engagement with mobile health (mHealth) technology for remote measurement and management of depression across three Western European countries. Methods: Participants (N=25; 4:1 ratio of women to men; age range, 25-73 years) who experienced depression participated in five focus groups held in three countries (two in the United Kingdom, two in Spain, and one in Italy). The focus groups investigated the potential barriers to and facilitators of the use of mHealth technology. A systematic thematic analysis was used to extract themes and subthemes. Results: Facilitators and barriers were categorized as health-related factors, user-related factors, and technology-related factors. A total of 58 subthemes of specific barriers and facilitators or moderators emerged. A core group of themes including motivation, potential impact on mood and anxiety, aspects of inconvenience, and ease of use was noted across all countries. Conclusions: Similarities in the barriers to and facilitators of the use of mHealth technology have been observed across Spain, Italy, and the United Kingdom. These themes provide guidance on ways to promote the design of feasible and acceptable cross-cultural mHealth tools. %M 30698535 %R 10.2196/11325 %U http://mhealth.jmir.org/2019/1/e11325/ %U https://doi.org/10.2196/11325 %U http://www.ncbi.nlm.nih.gov/pubmed/30698535 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e11041 %T Using Passive Smartphone Sensing for Improved Risk Stratification of Patients With Depression and Diabetes: Cross-Sectional Observational Study %A Sarda,Archana %A Munuswamy,Suresh %A Sarda,Shubhankar %A Subramanian,Vinod %+ Touchkin eServices Private Limited, 1st Floor, Manjusha, No 532, 16th Cross, 2nd Main Road, 2nd Stage, Indira Nagar, Bangalore, 560038, India, 91 9762665119, shubhankar@touchkin.com %K depression %K diabetes %K mental health %K comorbidity %K passive sensing %K smartphone %K classification %K machine learning %K mHealth %K risk assessment %D 2019 %7 29.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Research studies are establishing the use of smartphone sensing to measure mental well-being. Smartphone sensor information captures behavioral patterns, and its analysis helps reveal well-being changes. Depression in diabetes goes highly underdiagnosed and underreported. The comorbidity has been associated with increased mortality and worse clinical outcomes, including poor glycemic control and self-management. Clinical-only intervention has been found to have a very modest effect on diabetes management among people with depression. Smartphone technologies could play a significant role in complementing comorbid care. Objective: This study aimed to analyze the association between smartphone-sensing parameters and symptoms of depression and to explore an approach to risk-stratify people with diabetes. Methods: A cross-sectional observational study (Project SHADO—Analyzing Social and Health Attributes through Daily Digital Observation) was conducted on 47 participants with diabetes. The study’s smartphone-sensing app passively collected data regarding activity, mobility, sleep, and communication from each participant. Self-reported symptoms of depression using a validated Patient Health Questionnaire-9 (PHQ-9) were collected once every 2 weeks from all participants. A descriptive analysis was performed to understand the representation of the participants. A univariate analysis was performed on each derived sensing variable to compare behavioral changes between depression states—those with self-reported major depression (PHQ-9>9) and those with none (PHQ-9≤9). A classification predictive modeling, using supervised machine-learning methods, was explored using derived sensing variables as input to construct and compare classifiers that could risk-stratify people with diabetes based on symptoms of depression. Results: A noticeably high prevalence of self-reported depression (30 out of 47 participants, 63%) was found among the participants. Between depression states, a significant difference was found for average activity rates (daytime) between participant-day instances with symptoms of major depression (mean 16.06 [SD 14.90]) and those with none (mean 18.79 [SD 16.72]), P=.005. For average number of people called (calls made and received), a significant difference was found between participant-day instances with symptoms of major depression (mean 5.08 [SD 3.83]) and those with none (mean 8.59 [SD 7.05]), P<.001. These results suggest that participants with diabetes and symptoms of major depression exhibited lower activity through the day and maintained contact with fewer people. Using all the derived sensing variables, the extreme gradient boosting machine-learning classifier provided the best performance with an average cross-validation accuracy of 79.07% (95% CI 74%-84%) and test accuracy of 81.05% to classify symptoms of depression. Conclusions: Participants with diabetes and self-reported symptoms of major depression were observed to show lower levels of social contact and lower activity levels during the day. Although findings must be reproduced in a broader randomized controlled study, this study shows promise in the use of predictive modeling for early detection of symptoms of depression in people with diabetes using smartphone-sensing information. %M 30694197 %R 10.2196/11041 %U http://mhealth.jmir.org/2019/1/e11041/ %U https://doi.org/10.2196/11041 %U http://www.ncbi.nlm.nih.gov/pubmed/30694197 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 1 %P e11334 %T Adoption of Mobile Apps for Depression and Anxiety: Cross-Sectional Survey Study on Patient Interest and Barriers to Engagement %A Lipschitz,Jessica %A Miller,Christopher J %A Hogan,Timothy P %A Burdick,Katherine E %A Lippin-Foster,Rachel %A Simon,Steven R %A Burgess,James %+ Department of Psychiatry, Brigham and Women's Hospital, 221 Longwood Ave, Boston, MA, 02115, United States, 1 617 732 6548, jlipschitz@bwh.harvard.edu %K mHealth %K depression %K anxiety %K mobile apps %K patient preference %D 2019 %7 25.01.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Emerging research suggests that mobile apps can be used to effectively treat common mental illnesses like depression and anxiety. Despite promising efficacy results and ease of access to these interventions, adoption of mobile health (mHealth; mobile device–delivered) interventions for mental illness has been limited. More insight into patients’ perspectives on mHealth interventions is required to create effective implementation strategies and to adapt existing interventions to facilitate higher rates of adoption. Objective: The aim of this study was to examine, from the patient perspective, current use and factors that may impact the use of mHealth interventions for mental illness. Methods: This was a cross-sectional survey study of veterans who had attended an appointment at a single Veterans Health Administration facility in early 2016 that was associated with one of the following mental health concerns: unipolar depression, any anxiety disorder, or posttraumatic stress disorder. We used the Veteran Affairs Corporate Data Warehouse to create subsets of eligible participants demographically stratified by gender (male or female) and minority status (white or nonwhite). From each subset, 100 participants were selected at random and mailed a paper survey with items addressing the demographics, overall health, mental health, technology ownership or use, interest in mobile app interventions for mental illness, reasons for use or nonuse, and interest in specific features of mobile apps for mental illness. Results: Of the 400 potential participants, 149 (37.3%, 149/400) completed and returned a survey. Most participants (79.9%, 119/149) reported that they owned a smart device and that they use apps in general (71.1%, 106/149). Most participants (73.1%, 87/149) reported interest in using an app for mental illness, but only 10.7% (16/149) had done so. Paired samples t tests indicated that ratings of interest in using an app recommended by a clinician were significantly greater than general interest ratings and even greater when the recommending clinician was a specialty mental health provider. The most frequent concerns related to using an app for mental illness were lacking proof of efficacy (71.8%, 107/149), concerns about data privacy (59.1%, 88/149), and not knowing where to find such an app (51.0%, 76/149). Participants expressed interest in a number of app features with particularly high-interest ratings for context-sensitive apps (85.2%, 127/149), and apps focused on the following areas: increasing exercise (75.8%, 113/149), improving sleep (73.2%, 109/149), changing negative thinking (70.5%, 105/149), and increasing involvement in activities (67.1%, 100/149). Conclusions: Most respondents had access to devices to use mobile apps for mental illness, already used apps for other purposes, and were interested in mobile apps for mental illness. Key factors that may improve adoption include provider endorsement, greater publicity of efficacious apps, and clear messaging about efficacy and privacy of information. Finally, multifaceted apps that address a range of concerns, from sleep to negative thought patterns, may be best received. %M 30681968 %R 10.2196/11334 %U http://mental.jmir.org/2019/1/e11334/ %U https://doi.org/10.2196/11334 %U http://www.ncbi.nlm.nih.gov/pubmed/30681968 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e10948 %T Effectiveness of a Multimodal Digital Psychotherapy Platform for Adult Depression: A Naturalistic Feasibility Study %A Marcelle,Enitan T %A Nolting,Laura %A Hinshaw,Stephen P %A Aguilera,Adrian %+ Department of Psychology, University of California, Berkeley, Tolman Hall, Berkeley, CA,, United States, 1 2164968894, emarcelle@berkeley.edu %K cognitive therapy %K depression %K digital health %K live chat %K mHealth %K mental health %K text messaging %K video %K mobile phone %D 2019 %7 23.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although psychotherapy is one of the most efficacious and effective treatments for depression, limited accessibility to trained providers markedly limits access to care. In an attempt to overcome this obstacle, several platforms seeking to provide these services using digital modalities (eg, video, text, and chat) have been developed. However, the use of these modalities individually poses barriers to intervention access and acceptability. Multimodal platforms, comprising those that allow users to select from a number of available modalities, may be able to provide a solution to these concerns. Objective: We aimed to investigate the preliminary effectiveness of providing psychotherapy through a multimodal digital psychotherapy platform. In addition, we aimed to examine differential responses to intervention by gender, self-reported physical health status, and self-reported financial status, as well as how prior exposure to traditional face-to-face psychotherapy affected the effectiveness of a multimodal digital psychotherapy intervention. Finally, we aimed to examine the dose-response effect. Methods: Data were collected from a total of 318 active users of BetterHelp, a multimodal digital psychotherapy platform. Data on physical health status, financial status, and prior exposure to psychotherapy were obtained using self-report measures. Effectiveness was determined by the extent of symptom severity change, which was measured using the Patient Health Questionnaire at Time 1 (time of enrollment) and Time 2 (3 months after enrollment). Intervention dosage was measured as the sum of individual therapist-user interactions across modalities. Results: Depression symptom severity was significantly reduced after the use of the multimodal digital psychotherapy intervention (P<.001). Individuals without prior traditional psychotherapy experience revealed increased improvement after intervention (P=.006). We found no significant dose-response effect of therapy, nor significant differences in outcomes across gender, self-reported financial status, and self-reported physical health status. Conclusions: Users of BetterHelp experienced significantly reduced depression symptom severity after engaging with the platform. Study findings suggest that this intervention is equally effective across gender, self-reported financial status, and self-reported physical health status and particularly effective for individuals without a history of psychotherapy. Overall, study results suggest that multimodal digital psychotherapy is a potentially effective treatment for adult depression; nevertheless, experimental trials are needed. We discuss directions for future research. %M 30674448 %R 10.2196/10948 %U http://mhealth.jmir.org/2019/1/e10948/ %U https://doi.org/10.2196/10948 %U http://www.ncbi.nlm.nih.gov/pubmed/30674448 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11509 %T Feasibility of a Therapist-Supported, Mobile Phone–Delivered Online Intervention for Depression: Longitudinal Observational Study %A Goldin,Philippe R %A Lindholm,Riku %A Ranta,Kristian %A Hilgert,Outi %A Helteenvuori,Tiia %A Raevuori,Anu %+ Betty Irene Moore School of Nursing, University of California Davis, 4610 X Street, Sacramento, CA, 95817, United States, 1 4156769793, philippegoldin@gmail.com %K cognitive therapy %K depression %K digital health %K digital therapeutics %K mindfulness %K online intervention %D 2019 %7 22.01.2019 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Depression is a very common condition that impairs functioning and is often untreated. More than 60% of the treatments for depressive disorder are administered in primary care settings by care providers who lack the time and expertise to treat depression. To address this issue, we developed Ascend, a therapist-supported, mobile phone–delivered 8-week intervention administered at the Meru Health Online Clinic in Finland. Objective: We conducted two pilot studies to examine the feasibility of the Ascend intervention, specifically, dropout rates, daily practice, weekly group chat use, and changes in depression symptoms. We also explored whether daily practice and weekly group chat use were associated with changes in depression symptoms. Methods: A total of 117 Finnish adults with elevated depressive symptoms enrolled in Ascend, a program that included daily cognitive behavioral and mindfulness meditation exercises delivered through a mobile phone app, anonymous group chat with other users, and chat/phone access to a licensed therapist. Eight weekly themes were delivered in a fixed, sequential format. Depression symptoms were measured at baseline, every second week during the intervention, immediately after the intervention, and 4 weeks after completion of the intervention. Data were analyzed using intent-to-treat repeated-measures analysis of variance and linear regression models. Results: For studies 1 and 2, we observed dropout rates of 27% and 15%, respectively, decreasing daily practice and group chat use, and decreased depression symptoms from baseline to immediately and 4 weeks after the intervention (P<.001). We found that both more daily practice and chat group use predicted the occurrence of fewer depressive symptoms at 4 weeks postintervention (Study 1: ∆R2=.38, P=.004 and ∆R2=.38, P=.002, respectively; Study 2: ∆R2=.16, P<.001 and ∆R2=.08, P=.002, respectively). Conclusions: This therapist-supported, mobile phone–delivered treatment for depression is feasible and associated with reduced depression symptoms. Design features that enhance daily practice and group chat use are areas of future investigation. Validation of these results using a controlled study design is needed to establish the evidence base for the Ascend intervention. %R 10.2196/11509 %U http://formative.jmir.org/2019/1/e11509/ %U https://doi.org/10.2196/11509 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 1 %P e10675 %T Web-Based Measure of Life Events Using Computerized Life Events and Assessment Record (CLEAR): Preliminary Cross-Sectional Study of Reliability, Validity, and Association With Depression %A Bifulco,Antonia %A Spence,Ruth %A Nunn,Stephen %A Kagan,Lisa %A Bailey-Rodriguez,Deborah %A Hosang,Georgina M %A Taylor,Matthew %A Fisher,Helen L %+ Centre for Abuse and Trauma Studies, Department of Psychology, Middlesex University, The Burroughs, London, NW4 4BT, United Kingdom, 44 02084113705, a.bifulco@mdx.ac.uk %K depression %K life change events %K life stress %K health technology %K internet %K psychometrics %K psychological tests %D 2019 %7 08.01.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Given the criticisms of life event checklists and the costs associated with interviews, life event research requires a sophisticated but easy-to-use measure for research and clinical practice. Therefore, the Computerized Life Events and Assessment Record (CLEAR), based on the Life Events and Difficulties Schedule (LEDS), was developed. Objective: The objective of our study was to test CLEAR’s reliability, validity, and association with depression. Methods: CLEAR, the General Health Questionnaire, and the List of Threatening Experiences Questionnaire (LTE-Q) were completed by 328 participants (126 students; 202 matched midlife sample: 127 unaffected controls, 75 recurrent depression cases). Test-retest reliability over 3-4 weeks was examined and validity determined by comparing CLEAR with LEDS and LTE-Q. Both CLEAR and LTE-Q were examined in relation to depression. Results: CLEAR demonstrated good test-retest reliability for the overall number of life events (0.89) and severe life events (.60). Long-term problems showed similar findings. In terms of validity, CLEAR severe life events had moderate sensitivity (59.1%) and specificity (65.4%) when compared with LEDS. CLEAR demonstrated moderate sensitivity (43.1%) and specificity (78.6%) when compared with LTE-Q. CLEAR severe life events and long-term problems were significantly associated with depression (odds ratio, OR 3.50, 95% CI 2.10 to 5.85, P<.001; OR 3.38, 95% CI 2.02 to 5.67, P<.001, respectively), whereas LTE-Q events were not (OR 1.06, 95% CI 0.43 to 2.60, P=.90). Conclusions: CLEAR has acceptable reliability and validity and predicts depression. It, therefore, has great potential for effective use in research and clinical practice identifying stress-related factors for the onset and maintenance of depression and related disorders. %M 30622088 %R 10.2196/10675 %U https://mental.jmir.org/2019/1/e10675/ %U https://doi.org/10.2196/10675 %U http://www.ncbi.nlm.nih.gov/pubmed/30622088 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10179 %T How Search Engine Data Enhance the Understanding of Determinants of Suicide in India and Inform Prevention: Observational Study %A Adler,Natalia %A Cattuto,Ciro %A Kalimeri,Kyriaki %A Paolotti,Daniela %A Tizzoni,Michele %A Verhulst,Stefaan %A Yom-Tov,Elad %A Young,Andrew %+ ISI Foundation, Via Chisola 5, Torino, 10126, Italy, 39 011 660 3090, daniela.paolotti@isi.it %K internet data %K India %K suicide %K mobile phone %D 2019 %7 04.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: India is home to 20% of the world’s suicide deaths. Although statistics regarding suicide in India are distressingly high, data and cultural issues likely contribute to a widespread underreporting of the problem. Social stigma and only recent decriminalization of suicide are among the factors hampering official agencies’ collection and reporting of suicide rates. Objective: As the product of a data collaborative, this paper leverages private-sector search engine data toward gaining a fuller, more accurate picture of the suicide issue among young people in India. By combining official statistics on suicide with data generated through search queries, this paper seeks to: add an additional layer of information to more accurately represent the magnitude of the problem, determine whether search query data can serve as an effective proxy for factors contributing to suicide that are not represented in traditional datasets, and consider how data collaboratives built on search query data could inform future suicide prevention efforts in India and beyond. Methods: We combined official statistics on demographic information with data generated through search queries from Bing to gain insight into suicide rates per state in India as reported by the National Crimes Record Bureau of India. We extracted English language queries on “suicide,” “depression,” “hanging,” “pesticide,” and “poison”. We also collected data on demographic information at the state level in India, including urbanization, growth rate, sex ratio, internet penetration, and population. We modeled the suicide rate per state as a function of the queries on each of the 5 topics considered as linear independent variables. A second model was built by integrating the demographic information as additional linear independent variables. Results: Results of the first model fit (R2) when modeling the suicide rates from the fraction of queries in each of the 5 topics, as well as the fraction of all suicide methods, show a correlation of about 0.5. This increases significantly with the removal of 3 outliers and improves slightly when 5 outliers are removed. Results for the second model fit using both query and demographic data show that for all categories, if no outliers are removed, demographic data can model suicide rates better than query data. However, when 3 outliers are removed, query data about pesticides or poisons improves the model over using demographic data. Conclusions: In this work, we used search data and demographics to model suicide rates. In this way, search data serve as a proxy for unmeasured (hidden) factors corresponding to suicide rates. Moreover, our procedure for outlier rejection serves to single out states where the suicide rates have substantially different correlations with demographic factors and query rates. %M 30609976 %R 10.2196/10179 %U https://www.jmir.org/2019/1/e10179/ %U https://doi.org/10.2196/10179 %U http://www.ncbi.nlm.nih.gov/pubmed/30609976 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11683 %T Use of In-Game Rewards to Motivate Daily Self-Report Compliance: Randomized Controlled Trial %A Taylor,Sara %A Ferguson,Craig %A Peng,Fengjiao %A Schoeneich,Magdalena %A Picard,Rosalind W %+ Affective Computing Group, Department of Media Arts and Sciences, Massachusetts Institute of Technology, 77 Massachusetts Avenue, E14-348V, Cambridge, MA, 02142, United States, 1 6128608622, sataylor@mit.edu %K self-reports %K protocol compliance %K recreational games %D 2019 %7 03.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Encouraging individuals to report daily information such as unpleasant disease symptoms, daily activities and behaviors, or aspects of their physical and emotional state is difficult but necessary for many studies and clinical trials that rely on patient-reported data as primary outcomes. Use of paper diaries is the traditional method of completing daily diaries, but digital surveys are becoming the new standard because of their increased compliance; however, they still fall short of desired compliance levels. Objective: Mobile games using in-game rewards offer the opportunity to increase compliance above the rates of digital diaries and paper diaries. We conducted a 5-week randomized control trial to compare the completion rates of a daily diary across 3 conditions: a paper-based participant-reported outcome diary (Paper PRO), an electronic-based participant-reported outcome diary (ePRO), and a novel ePRO diary with in-game rewards (Game-Motivated ePRO). Methods: We developed a novel mobile game that is a combination of the idle and pet collection genres to reward individuals who complete a daily diary with an in-game reward. Overall, 197 individuals aged 6 to 24 years (male: 100 and female: 97) were enrolled in a 5-week study after being randomized into 1 of the 3 methods of daily diary completion. Moreover, 157 participants (male: 84 and female: 69) completed at least one diary and were subsequently included in analysis of compliance rates. Results: We observed a significant difference (F2,124=6.341; P=.002) in compliance to filling out daily diaries, with the Game-Motivated ePRO group having the highest compliance (mean completion 86.4%, SD 19.6%), followed by the ePRO group (mean completion 77.7%, SD 24.1%), and finally, the Paper PRO group (mean completion 70.6%, SD 23.4%). The Game-Motivated ePRO (P=.002) significantly improved compliance rates above the Paper PRO. In addition, the Game-Motivated ePRO resulted in higher compliance rates than the rates of ePRO alone (P=.09). Equally important, even though we observed significant differences in completion of daily diaries between groups, we did not observe any statistically significant differences in association between the responses to a daily mood question and study group, the average diary completion time (P=.52), or the System Usability Scale score (P=.88). Conclusions: The Game-Motivated ePRO system encouraged individuals to complete the daily diaries above the compliance rates of the Paper PRO and ePRO without altering the participants’ responses. Trial Registration: ClinicalTrials.gov NCT03738254; http://clinicaltrials.gov/ct2/show/NCT03738254 (Archived by WebCite at http://www.webcitation.org/74T1p8u52) %M 30609986 %R 10.2196/11683 %U https://www.jmir.org/2019/1/e11683/ %U https://doi.org/10.2196/11683 %U http://www.ncbi.nlm.nih.gov/pubmed/30609986 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e11249 %T How LGBT+ Young People Use the Internet in Relation to Their Mental Health and Envisage the Use of e-Therapy: Exploratory Study %A Lucassen,Mathijs %A Samra,Rajvinder %A Iacovides,Ioanna %A Fleming,Theresa %A Shepherd,Matthew %A Stasiak,Karolina %A Wallace,Louise %+ School of Health, Wellbeing and Social Care, The Open University, Walton Hall, Milton Keynes, MK7 6AA, United Kingdom, 44 1908652987, mathijs.lucassen@open.ac.uk %K sexuality %K LGBT %K transgender %K depression %K adolescent %K psychotherapy %K mental health %K computer games %K computerized CBT %K e-therapy %D 2018 %7 21.12.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Lesbian, gay, bisexual, and transgender (LGBT) youth and other young people diverse in terms of their sexuality and gender (LGBT+) are at an elevated risk of mental health problems such as depression. Factors such as isolation and stigma mean that accessing mental health services can be particularly challenging for LGBT+ young people, and previous studies have highlighted that many prefer to access psychological support on the Web. Research from New Zealand has demonstrated promising effectiveness and acceptability for an LGBT+ focused, serious game–based, computerized cognitive behavioral therapy program, Rainbow Smart, Positive, Active, Realistic, X-factor thoughts (SPARX). However, there has been limited research conducted in the area of electronic therapy (e-therapy) for LGBT+ people. Objective: This study aimed to explore how and why LGBT+ young people use the internet to support their mental health. This study also sought to explore LGBT+ young people’s and professionals’ views about e-therapies, drawing on the example of Rainbow SPARX. Methods: A total of 3 focus groups and 5 semistructured interviews were conducted with 21 LGBT+ young people (aged 15-22 years) and 6 professionals (4 health and social care practitioners and 2 National Health Service commissioners) in England and Wales. A general inductive approach was used to analyze data. Results: LGBT+ youth participants considered that the use of the internet was ubiquitous, and it was valuable for support and information. However, they also thought that internet use could be problematic, and they highlighted certain internet safety and personal security considerations. They drew on a range of gaming experiences and expectations to inform their feedback about Rainbow SPARX. Their responses focused on the need for this e-therapy program to be updated and refined. LGBT+ young people experienced challenges related to stigma and mistreatment, and they suggested that strategies addressing their common challenges should be included in e-therapy content. Professional study participants also emphasized the need to update and refine Rainbow SPARX. Moreover, professionals highlighted some of the issues associated with e-therapies needing to demonstrate effectiveness and challenges associated with health service commissioning processes. Conclusions: LGBT+ young people use the internet to obtain support and access information, including information related to their mental health. They are interested in LGBT-specific e-therapies; however, these must be in a contemporary format, engaging, and adequately acknowledge the experiences of LGBT+ young people. %M 30578194 %R 10.2196/11249 %U http://games.jmir.org/2018/4/e11249/ %U https://doi.org/10.2196/11249 %U http://www.ncbi.nlm.nih.gov/pubmed/30578194 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11467 %T Supported Internet-Delivered Cognitive Behavioral Therapy Programs for Depression, Anxiety, and Stress in University Students: Open, Non-Randomised Trial of Acceptability, Effectiveness, and Satisfaction %A Palacios,Jorge E %A Richards,Derek %A Palmer,Riley %A Coudray,Carissa %A Hofmann,Stefan G %A Palmieri,Patrick A %A Frazier,Patricia %+ E-mental Health Research Group, School of Psychology, University of Dublin, Trinity College Dublin, College Green, Dublin,, Ireland, 353 18961000, jorge.palacios@tcd.ie %K depression %K anxiety %K cognitive therapy %K students %D 2018 %7 14.12.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Many university campuses have limited mental health services that cannot cope with the high demand. One alternative is to use internet-delivered cognitive behavioral therapy (iCBT) as a way of tackling barriers such as lack of availability and scheduling issues. Objective: This study aimed to assess feasibility, acceptability, effectiveness, and satisfaction of a supported iCBT intervention offering 3 programs on depression, anxiety, and stress to university students. The design was an open or nonrandomized feasibility trial. Methods: Participants were recruited from 3 counseling centers at a large midwestern University in the United States. Those agreeing to take part chose 1 of 3 iCBT programs—Space from Depression, Space from Anxiety, or Space from Stress —all comprised 8 modules of media-rich interactive content. Participants were supported throughout the trial by a trained professional. The Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7) questionnaire, and stress subscale of the Depression Anxiety and Stress Scale (DASS-21) were completed at baseline, 8 weeks, and 3-month follow-up. A Satisfaction With Treatment (SAT) questionnaire was completed at 8 weeks, and qualitative interviews were completed by a subsample of participants at 3 months. Results: A total of 102 participants were recruited, with 52 choosing Space from Anxiety, 31 choosing Space from Depression, and 19 choosing Space from Stress. Mixed-effects models showed a significant decrease in symptoms of depression (F4=6.36, P<.001), anxiety (F4=7.97, P<.001), and stress (F4=8.50, P<.001) over time across all 3 programs. The largest decreases in PHQ-9 scores at 8 weeks were among participants who chose the Space from Depression program (d=0.84); at 3 months, the largest decreases in PHQ-9 scores were among those who chose the Space from Stress program (d=0.74). The largest decreases in GAD-7 scores were among those who chose the Space from Anxiety program (d=0.74 at 8 weeks and d=0.94 at 3 months). The largest decrease in DASS-21 stress subscale scores was among those who chose the Space from Stress program (d=0.49 at 8 weeks and d=1.16 at 3 months). The mean time spent using the platform per session was 27.4 min (SD 33.8), and participants completed 53% (SD 37.6) of the total program content on average. Most (37/53, 69%) participants found the programs helpful or very helpful and liked the convenience and flexibility of the intervention. Qualitative interviews (n=14) indicated the intervention met students’ expectations, and they saw it as a valuable complement to face-to-face treatment. Conclusions: The iCBT programs tested in our study appear to be feasible, acceptable, and effective in a university environment. Participants described the benefits of having a flexible, supported Web-based intervention available on campus. Larger trials should be conducted to further test the effectiveness of supported Web-based interventions that give students a choice of program depending on their symptom profile. %M 30552076 %R 10.2196/11467 %U http://mental.jmir.org/2018/4/e11467/ %U https://doi.org/10.2196/11467 %U http://www.ncbi.nlm.nih.gov/pubmed/30552076 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11483 %T Monitoring Online Discussions About Suicide Among Twitter Users With Schizophrenia: Exploratory Study %A Hswen,Yulin %A Naslund,John A %A Brownstein,John S %A Hawkins,Jared B %+ Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Harvard University, 677 Huntington Avenue, Boston, MA, 02115, United States, 1 6177751889, yhswen@gmail.com %K schizophrenia %K social media %K suicide %K Twitter %K digital technology %K mental health %D 2018 %7 13.12.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: People with schizophrenia experience elevated risk of suicide. Mental health symptoms, including depression and anxiety, contribute to increased risk of suicide. Digital technology could support efforts to detect suicide risk and inform suicide prevention efforts. Objective: This exploratory study examined the feasibility of monitoring online discussions about suicide among Twitter users who self-identify as having schizophrenia. Methods: Posts containing the terms suicide or suicidal were collected from a sample of Twitter users who self-identify as having schizophrenia (N=203) and a random sample of control users (N=173) over a 200-day period. Frequency and timing of posts about suicide were compared between groups. The associations between posting about suicide and common mental health symptoms were examined. Results: Twitter users who self-identify as having schizophrenia posted more tweets about suicide (mean 7.10, SD 15.98) compared to control users (mean 1.89, SD 4.79; t374=-4.13, P<.001). Twitter users who self-identify as having schizophrenia showed greater odds of tweeting about suicide compared to control users (odds ratio 2.15, 95% CI 1.42-3.28). Among all users, tweets about suicide were associated with tweets about depression (r=0.62, P<.001) and anxiety (r=0.45, P<.001). Conclusions: Twitter users who self-identify as having schizophrenia appear to commonly discuss suicide on social media, which is associated with greater discussion about other mental health symptoms. These findings should be interpreted cautiously, as it is not possible to determine whether online discussions about suicide correlate with suicide risk. However, these patterns of online discussion may be indicative of elevated risk of suicide observed in this patient group. There may be opportunities to leverage social media for supporting suicide prevention among individuals with schizophrenia. %M 30545811 %R 10.2196/11483 %U http://mental.jmir.org/2018/4/e11483/ %U https://doi.org/10.2196/11483 %U http://www.ncbi.nlm.nih.gov/pubmed/30545811 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e64 %T Using Psychological Artificial Intelligence (Tess) to Relieve Symptoms of Depression and Anxiety: Randomized Controlled Trial %A Fulmer,Russell %A Joerin,Angela %A Gentile,Breanna %A Lakerink,Lysanne %A Rauws,Michiel %+ Northwestern University, 633 Clark Street, Evanston, IL, United States, 1 312 609 5300 ext 699, russell.fulmer@northwestern.edu %K artificial intelligence %K mental health services %K depression %K anxiety %K students %D 2018 %7 13.12.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Students in need of mental health care face many barriers including cost, location, availability, and stigma. Studies show that computer-assisted therapy and 1 conversational chatbot delivering cognitive behavioral therapy (CBT) offer a less-intensive and more cost-effective alternative for treating depression and anxiety. Although CBT is one of the most effective treatment methods, applying an integrative approach has been linked to equally effective posttreatment improvement. Integrative psychological artificial intelligence (AI) offers a scalable solution as the demand for affordable, convenient, lasting, and secure support grows. Objective: This study aimed to assess the feasibility and efficacy of using an integrative psychological AI, Tess, to reduce self-identified symptoms of depression and anxiety in college students. Methods: In this randomized controlled trial, 75 participants were recruited from 15 universities across the United States. All participants completed Web-based surveys, including the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), and Positive and Negative Affect Scale (PANAS) at baseline and 2 to 4 weeks later (T2). The 2 test groups consisted of 50 participants in total and were randomized to receive unlimited access to Tess for either 2 weeks (n=24) or 4 weeks (n=26). The information-only control group participants (n=24) received an electronic link to the National Institute of Mental Health’s (NIMH) eBook on depression among college students and were only granted access to Tess after completion of the study. Results: A sample of 74 participants completed this study with 0% attrition from the test group and less than 1% attrition from the control group (1/24). The average age of participants was 22.9 years, with 70% of participants being female (52/74), mostly Asian (37/74, 51%), and white (32/74, 41%). Group 1 received unlimited access to Tess, with daily check-ins for 2 weeks. Group 2 received unlimited access to Tess with biweekly check-ins for 4 weeks. The information-only control group was provided with an electronic link to the NIMH’s eBook. Multivariate analysis of covariance was conducted. We used an alpha level of .05 for all statistical tests. Results revealed a statistically significant difference between the control group and group 1, such that group 1 reported a significant reduction in symptoms of depression as measured by the PHQ-9 (P=.03), whereas those in the control group did not. A statistically significant difference was found between the control group and both test groups 1 and 2 for symptoms of anxiety as measured by the GAD-7. Group 1 (P=.045) and group 2 (P=.02) reported a significant reduction in symptoms of anxiety, whereas the control group did not. A statistically significant difference was found on the PANAS between the control group and group 1 (P=.03) and suggests that Tess did impact scores. Conclusions: This study offers evidence that AI can serve as a cost-effective and accessible therapeutic agent. Although not designed to appropriate the role of a trained therapist, integrative psychological AI emerges as a feasible option for delivering support. Trial Registration: International Standard Randomized Controlled Trial Number: ISRCTN61214172; https://doi.org/10.1186/ISRCTN61214172. %M 30545815 %R 10.2196/mental.9782 %U http://mental.jmir.org/2018/4/e64/ %U https://doi.org/10.2196/mental.9782 %U http://www.ncbi.nlm.nih.gov/pubmed/30545815 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11513 %T Video-Delivered Family Therapy for Home Visited Young Mothers With Perinatal Depressive Symptoms: Quasi-Experimental Implementation-Effectiveness Hybrid Trial %A Cluxton-Keller,Fallon %A Williams,Melony %A Buteau,Jennifer %A Donnelly,Craig L %A Stolte,Patricia %A Monroe-Cassel,Maggie %A Bruce,Martha L %+ Department of Psychiatry, Geisel School of Medicine at Dartmouth College, 1 Medical Center Drive, Lebanon, NH, 03756, United States, 1 603 650 4724, Fallon.P.Cluxton-Keller@dartmouth.edu %K videoconferencing %K family therapy, depression %D 2018 %7 10.12.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: The Federal Maternal, Infant, and Early Childhood Home Visiting Program is a national child abuse prevention strategy that serves families at risk for child maltreatment throughout the United States. Significant portions of the clients are young mothers who screen positive for clinically significant perinatal depressive symptoms and experience relational discord that worsens their symptoms. Although home visitors refer those who screen positive for depression to community-based treatment, they infrequently obtain treatment because of multiple barriers. These barriers are compounded for home visited families in rural areas. Objective: This pilot study aimed to explore the feasibility, acceptability, and effectiveness of a video-delivered family therapy intervention on reducing maternal depressive symptoms and improving family functioning and emotion regulation. Methods: A total of 13 home visited families received the video-delivered family therapy intervention. This study included a historical comparison group of mothers (N=13) who were previously enrolled in home visiting and screened positive for clinically significant perinatal depressive symptoms but refused treatment. A licensed marriage and family therapist delivered the family therapy intervention using Health Insurance Portability and Accountability Act–compliant videoconferencing technology on a computer from an office. Families participated in sessions in their homes using cell phones, tablets, and computers equipped with microphones and video cameras. Outcomes were measured following the final therapy session (post intervention) and 2 months later (follow-up). Depressive symptom scores of mothers who received the video-delivered family therapy intervention were compared with those of mothers in the historical comparison group over a 6-month period. Univariate statistics and correlations were calculated to assess measures of feasibility. Percentages and qualitative thematic analysis were used to assess acceptability. Wilcoxon signed-rank tests were used to assess changes in maternal and family outcomes. Results: No families dropped out of the study. All families reported that the technology was convenient and easy to use. All families reported high satisfaction with the video-delivered intervention. Nearly all families reported that they preferred video-delivered family therapy instead of clinic-based therapy. Therapeutic alliance was strong. Mothers demonstrated a statistically significant reduction in depressive symptoms (P=.001). When compared with mothers in the historical comparison group, those in the family therapy intervention showed a significant reduction in depressive symptoms (P=.001). Families demonstrated statistically significant improvements in family functioning (P=.02) and cognitive reappraisal (P=.004). Conclusions: This pilot study yielded preliminary findings that support the feasibility, acceptability, and effectiveness of the video-delivered family therapy intervention for underserved home visited families in rural areas. Our findings are very promising, but more research is needed to ultimately influence mental health practices and policies that pertain to video-delivered mental health interventions in unsupervised settings (eg, homes). %M 30530456 %R 10.2196/11513 %U http://mental.jmir.org/2018/4/e11513/ %U https://doi.org/10.2196/11513 %U http://www.ncbi.nlm.nih.gov/pubmed/30530456 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11290 %T Online Positive Affect Journaling in the Improvement of Mental Distress and Well-Being in General Medical Patients With Elevated Anxiety Symptoms: A Preliminary Randomized Controlled Trial %A Smyth,Joshua M %A Johnson,Jillian A %A Auer,Brandon J %A Lehman,Erik %A Talamo,Giampaolo %A Sciamanna,Christopher N %+ Department of Biobehavioral Health, The Pennsylvania State University, 231 Biobehavioral Health Building, The Pennsylvania State University, University Park, PA, 16802, United States, 1 8148638402, jms1187@psu.edu %K adult %K anxiety %K depression %K emotions %K expressed emotion %K internet %K stress, psychological/physiopathology %K surveys and questionnaires %K treatment outcome %K writing %D 2018 %7 10.12.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Positive affect journaling (PAJ), an emotion-focused self-regulation intervention, has been associated with positive outcomes among medical populations. It may be adapted for Web-based dissemination to address a need for scalable, evidence-based psychosocial interventions among distressed patients with medical conditions. Objective: This study aimed to examine the impact of a 12-week Web-based PAJ intervention on psychological distress and quality of life in general medical patients. Methods: A total of 70 adults with various medical conditions and elevated anxiety symptoms were recruited from local clinics and randomly assigned to a Web-based PAJ intervention (n=35) or usual care (n=35). The intervention group completed 15-min Web-based PAJ sessions on 3 days each week for 12 weeks. At baseline and the end of months 1 through 3, surveys of psychological, interpersonal, and physical well-being were completed. Results: Patients evidenced moderate sustained adherence to Web-based intervention. PAJ was associated with decreased mental distress and increased well-being relative to baseline. PAJ was also associated with less depressive symptoms and anxiety after 1 month and greater resilience after the first and second month, relative to usual care. Conclusions: Web-based PAJ may serve as an effective intervention for mitigating mental distress, increasing well-being, and enhancing physical functioning among medical populations. PAJ may be integrated into routine medical care to improve quality of life. Trial Registration: ClinicalTrials.gov NCT01873599; https://clinicaltrials.gov/ct2/show/NCT01873599 (Archived by WebCite at http://www.webcitation.org/73ZGFzD2Z) %M 30530460 %R 10.2196/11290 %U http://mental.jmir.org/2018/4/e11290/ %U https://doi.org/10.2196/11290 %U http://www.ncbi.nlm.nih.gov/pubmed/30530460 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 12 %P e11135 %T An Electronic Clinical Decision Support System for the Assessment and Management of Suicidality in Primary Care: Protocol for a Mixed-Methods Study %A Horrocks,Matthew %A Michail,Maria %A Aubeeluck,Aimee %A Wright,Nicola %A Morriss,Richard %+ Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Wollaton Road, Nottingham, NG7 2TU, United Kingdom, 44 (0) 115 8231427, matthew.horrocks@nottingham.ac.uk %K suicide %K primary care %K general practitioner %K clinical decision support system %D 2018 %7 07.12.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Suicide is a global public health concern, but it is preventable. Increased contact with primary care before the suicide or attempted suicide raises opportunities for intervention and prevention. However, suicide assessment and management are areas that many general practitioners (GPs) find particularly challenging. Previous research has indicated significant variability in how GPs understand, operationalize, and assess suicide risk, which subsequently has an impact on clinical decision making. Clinical decision support systems (CDSS) have been widely implemented across different health care settings, including primary care to support practitioners in clinical decision making. A CDSS may reduce inconsistencies in the identification, assessment, and management of suicide risk by GPs by guiding them through the consultation and generating a risk assessment plan that can be shared with a service user or with specialized mental health services. Objective: Our aim is to co-develop and test with end users (eg, GPs, primary care attendees, mental health professionals) an electronic clinical decision support system (e-CDSS) to support GPs in the identification, assessment, and management of suicidality in primary care. Methods: Ours is an ongoing embedded mixed-methods study with four phases: (1) qualitative interviews with GPs to explore their views on the content, format, and use of the e-CDSS, as well as consultation with two service-user advisory groups (people aged ≤25 and people aged ≥25) to inform the content of the e-CDSS including phrasing of items and clarity; (2) participatory co-production workshops with GPs, service users, and clinical experts in suicidality to determine the content and format of the e-CDDS; gain consensus of the relevance of items; establish content validity and identify pathways to implementation, using the Consolidated Framework for Implementation Research; (3) building the e-CDSS so that it guides the GP through a consultation; and (4) usability testing of the e-CDSS with GPs and service users in one primary care practice involving a nonlive and a live stage. Results: The study was funded for four years, to take place between 2015 and 2019, and is currently completing phase 4 data collection. The first results are expected to be submitted for publication in June 2019. The findings will enable us to evaluate the feasibility, acceptability, and usability of a suicide-specific, electronic, guided decision support system in primary care. Conclusions: This study will be the first to explore the feasibility, acceptability, and usability of an electronic, guided decision support system for use in primary care consultations for the improved assessment and management of suicidality. International Registered Report Identifier (IRRID): RR1-10.2196/11135 %M 30530459 %R 10.2196/11135 %U http://www.researchprotocols.org/2018/12/e11135/ %U https://doi.org/10.2196/11135 %U http://www.ncbi.nlm.nih.gov/pubmed/30530459 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 12 %P e11817 %T Exploring the Utility of Community-Generated Social Media Content for Detecting Depression: An Analytical Study on Instagram %A Ricard,Benjamin J %A Marsch,Lisa A %A Crosier,Benjamin %A Hassanpour,Saeed %+ Department of Biomedical Data Science, Dartmouth College, One Medical Center Drive, HB 7261, Lebanon, NH, 03756, United States, 1 603 650 1983, Saeed.Hassanpour@dartmouth.edu %K machine learning %K depression %K social media %K mental health %D 2018 %7 06.12.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: The content produced by individuals on various social media platforms has been successfully used to identify mental illness, including depression. However, most of the previous work in this area has focused on user-generated content, that is, content created by the individual, such as an individual’s posts and pictures. In this study, we explored the predictive capability of community-generated content, that is, the data generated by a community of friends or followers, rather than by a sole individual, to identify depression among social media users. Objective: The objective of this research was to evaluate the utility of community-generated content on social media, such as comments on an individual’s posts, to predict depression as defined by the clinically validated Patient Health Questionnaire-8 (PHQ-8) assessment questionnaire. We hypothesized that the results of this research may provide new insights into next generation of population-level mental illness risk assessment and intervention delivery. Methods: We created a Web-based survey on a crowdsourcing platform through which participants granted access to their Instagram profiles as well as provided their responses to PHQ-8 as a reference standard for depression status. After data quality assurance and postprocessing, the study analyzed the data of 749 participants. To build our predictive model, linguistic features were extracted from Instagram post captions and comments, including multiple sentiment scores, emoji sentiment analysis results, and meta-variables such as the number of likes and average comment length. In this study, 10.4% (78/749) of the data were held out as a test set. The remaining 89.6% (671/749) of the data were used to train an elastic-net regularized linear regression model to predict PHQ-8 scores. We compared different versions of this model (ie, a model trained on only user-generated data, a model trained on only community-generated data, and a model trained on the combination of both types of data) on a test set to explore the utility of community-generated data in our predictive analysis. Results: The 2 models, the first trained on only community-generated data (area under curve [AUC]=0.71) and the second trained on a combination of user-generated and community-generated data (AUC=0.72), had statistically significant performances for predicting depression based on the Mann-Whitney U test (P=.03 and P=.02, respectively). The model trained on only user-generated data (AUC=0.63; P=.11) did not achieve statistically significant results. The coefficients of the models revealed that our combined data classifier effectively amalgamated both user-generated and community-generated data and that the 2 feature sets were complementary and contained nonoverlapping information in our predictive analysis. Conclusions: The results presented in this study indicate that leveraging community-generated data from social media, in addition to user-generated data, can be informative for predicting depression among social media users. %M 30522991 %R 10.2196/11817 %U http://www.jmir.org/2018/12/e11817/ %U https://doi.org/10.2196/11817 %U http://www.ncbi.nlm.nih.gov/pubmed/30522991 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 12 %P e11661 %T Preliminary Effectiveness of a Smartphone App to Reduce Depressive Symptoms in the Workplace: Feasibility and Acceptability Study %A Deady,Mark %A Johnston,David %A Milne,David %A Glozier,Nick %A Peters,Dorian %A Calvo,Rafael %A Harvey,Samuel %+ Black Dog Institute, Faculty of Medicine, University of New South Wales, Hospital Road, Randwick, Sydney,, Australia, 61 293824517, m.deady@unsw.edu.au %K depression %K workplace %K mHealth %K smartphone %K eHealth %K pilot %D 2018 %7 04.12.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The workplace represents a unique setting for mental health interventions. Due to range of job-related factors, employees in male-dominated industries are at an elevated risk. However, these at-risk groups are often overlooked. HeadGear is a smartphone app–based intervention designed to reduce depressive symptoms and increase well-being in these populations. Objective: This paper presents the development and pilot testing of the app’s usability, acceptability, feasibility, and preliminary effectiveness. Methods: The development process took place from January 2016 to August 2017. Participants for prototype testing (n=21; stage 1) were recruited from industry partner organizations to assess acceptability and utility. A 5-week effectiveness and feasibility pilot study (n=84; stage 2) was then undertaken, utilizing social media recruitment. Demographic data, acceptability and utility questionnaires, depression (Patient Health Questionnaire-9), and other mental health measures were collected. Results: The majority of respondents felt HeadGear was easy to use (92%), easily understood (92%), were satisfied with the app (67%), and would recommend it to a friend (75%; stage 1). Stage 2 found that compared with baseline, depression and anxiety symptoms were significantly lower at follow-up (t30=2.53; P=.02 and t30=2.18; P=.04, respectively), days of sick leave in past month (t28=2.38; P=.02), and higher self-reported job performance (t28=−2.09; P=.046; stage 2). Over 90% of respondents claimed it helped improve their mental fitness, and user feedback was again positive. Attrition was high across the stages. Conclusions: Overall, HeadGear was well received, and preliminary findings indicate it may provide an innovative new platform for improving mental health outcomes. Unfortunately, attrition was a significant issue, and findings should be interpreted with caution. The next stage of evaluation will be a randomized controlled trial. If found to be efficacious, the app has the potential to reduce disease burden and improve health in this at-risk group. %M 30514694 %R 10.2196/11661 %U https://mhealth.jmir.org/2018/12/e11661/ %U https://doi.org/10.2196/11661 %U http://www.ncbi.nlm.nih.gov/pubmed/30514694 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 12 %P e291 %T Accessibility and Applicability of Currently Available e-Mental Health Programs for Depression for People With Poststroke Aphasia: Scoping Review %A Clunne,Stephanie Jane %A Ryan,Brooke Jade %A Hill,Annie Jane %A Brandenburg,Caitlin %A Kneebone,Ian %+ School of Health and Rehabilitation Sciences, The University of Queensland, 84A Services Road, St Lucia, Brisbane, QLD 4067, Australia, 61 336 51380, brooke.ryan@uq.edu.au %K aphasia %K stroke %K depression %K mental health %K internet %K technology %K access to health care %D 2018 %7 04.12.2018 %9 Review %J J Med Internet Res %G English %X Background: Depression affects approximately 60% of people with aphasia 1 year post stroke and is associated with disability, lower quality of life, and mortality. Web-delivered mental health (e-mental health) programs are effective, convenient, and cost-effective for the general population and thus are increasingly used in the management of depression. However, it is unknown if such services are applicable and communicatively accessible to people with poststroke aphasia. Objective: The aim of this study was to identify freely available e-mental health programs for depression and determine their applicability and accessibility for people with poststroke aphasia. Methods: A Web-based search was conducted to identify and review freely available e-mental health programs for depression. These programs were then evaluated in terms of their (1) general features via a general evaluation tool, (2) communicative accessibility for people with aphasia via an aphasia-specific communicative accessibility evaluation tool, and (3) empirical evidence for the general population and stroke survivors with and without aphasia. The program that met the most general evaluation criteria and aphasia-specific communicative accessibility evaluation criteria was then trialed by a small subgroup of people with poststroke aphasia. Results: A total of 8 programs were identified. Of these, 4 had published evidence in support of their efficacy for use within the general population. However, no empirical evidence was identified that specifically supported any programs’ use for stroke survivors with or without aphasia. One evidence-based program scored at least 80% (16/19 and 16/20, respectively) on both the general and aphasia-specific communicative accessibility evaluation tools and was subject to a preliminary trial by 3 people with poststroke aphasia. During this trial, participants were either unable to independently use the program or gave it low usability scores on a post-trial satisfaction survey. On this basis, further evaluation was considered unwarranted. Conclusions: Despite fulfilling majority of the general evaluation and aphasia-specific evaluation criteria, the highest rated program was still found to be unsuitable for people with poststroke aphasia. Thus, e-mental health programs require substantial redevelopment if they are likely to be useful to people with poststroke aphasia. %M 30514696 %R 10.2196/jmir.9864 %U https://www.jmir.org/2018/12/e291/ %U https://doi.org/10.2196/jmir.9864 %U http://www.ncbi.nlm.nih.gov/pubmed/30514696 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 11 %P e11508 %T The Association Between the Use of Antenatal Care Smartphone Apps in Pregnant Women and Antenatal Depression: Cross-Sectional Study %A Mo,Yushi %A Gong,Wenjie %A Wang,Joyce %A Sheng,Xiaoqi %A Xu,Dong R %+ XiangYa School of Public Health, Central South University, 238 Shangmayuanling Lane, Xiangya Road, KaiFu District, Changsha,, China, 86 13607445252, gongwenjie@csu.edu.cn %K antenatal care %K antenatal depression %K app %K mobile phone %D 2018 %7 29.11.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Antenatal care smartphone apps are increasingly used by pregnant women, but studies on their use and impact are scarce. Objective: This study investigates the use of antenatal care apps in pregnant women and explores the association between the use of these apps and antenatal depression. Methods: This study used a convenient sample of pregnant women recruited from Hunan Provincial Maternal and Child Health Hospital in November 2015. The participants were surveyed for their demographic characteristics, use of antenatal care apps, and antenatal depression. Factors that influenced antenatal pregnancy were analyzed using logistic regression. Results: Of the 1304 pregnant women, 71.31% (930/1304) used antenatal care apps. Higher usage of apps was associated with urban residency, nonmigrant status, first pregnancy, planned pregnancy, having no previous children, and opportunity to communicate with peer pregnant women. The cutoff score of the Edinburgh Postnatal Depression Scale was 10, and 46.11% (601/1304) of the pregnant women had depression. Logistic regression showed that depression was associated with the availability of disease-screening functions in the apps (odds ratio (OR) 1.78, 95% CI 1.03-3.06) and spending 30 minutes or more using the app (OR 2.05, 95% CI 1.19-3.52). Using apps with social media features was a protective factor for antenatal depression (OR 0.33, 95% CI 0.12-0.89). Conclusions: The prevalence of the use of prenatal care apps in pregnant women is high. The functions and time spent on these apps are associated with the incidence of antenatal depression. %M 30497996 %R 10.2196/11508 %U http://mhealth.jmir.org/2018/11/e11508/ %U https://doi.org/10.2196/11508 %U http://www.ncbi.nlm.nih.gov/pubmed/30497996 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 11 %P e10927 %T Guided Internet-Based Cognitive Behavioral Therapy for Adult Depression and Anxiety in Routine Secondary Care: Observational Study %A Mathiasen,Kim %A Riper,Heleen %A Andersen,Tonny E %A Roessler,Kirsten K %+ Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, Odense, 5230, Denmark, 45 61677747, kim.mathiasen@rsyd.dk %K anxiety %K cognitive therapy %K cohort studies %K depression %K Internet %K secondary care %D 2018 %7 28.11.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet-based cognitive behavioral therapy (iCBT) is a promising new treatment method for depression and anxiety. However, it is important to determine whether its results can be replicated in routine care before its implementation on a large scale. Although many studies have demonstrated the efficacy of iCBT under controlled conditions, only a few studies have investigated its effectiveness in routine care. Furthermore, several effects of iCBT such as treatment effects in routine care are unclear. Objective: This study aimed to evaluate the clinical effectiveness of iCBT for depression and anxiety in routine secondary care. Methods: n a retrospective cohort study, we analysed patients treated for depression or anxiety in a dedicated iCBT clinic in secondary care in Denmark. Patients were examined before treatment and weekly thereafter by using the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 scales for the diagnoses of depression and anxiety, respectively. Primary analyses were conducted using a linear mixed-effects model with random slope and intercept. Secondary analyses were conducted using baseline characteristics as predictors (gender, age, highest level of education, occupational status, marital status, psychotropic medication use, consumption of alcohol, and leisure drugs). Additionally, logistic regression analyses were used to predict noncompletion of treatment. Results: A total of 203 (depression, N=60; anxiety, N=143) patients were included. Participants were mainly female (78.3% with depression and 65.7% with anxiety), with a mean age of 36.03 (SD 10.97) years (range, 19-67 years) for patients with depression and 36.80 (SD 13.55) years (range, 19-69 years) for patients with anxiety. The completion rates were 62% (37) and 40% (57) for depression and anxiety treatments, respectively. The primary analyses revealed large and significant reductions in the symptom levels of depression (beta=-6.27, SE 0.83, P<.001, d=1.0) and anxiety (beta=-3.78, SE 0.43, P<.001, d=1.1). High baseline severity of the primary disorder was associated with high treatment gains (r=-0.31 for depression; r=-0.41 for anxiety). In patients with anxiety, high baseline severity also predicted a high risk of noncompletion (odds ratio=1.08, CI=1.01-1.16, P=.03). An increase in the baseline severity of the comorbid disorder slightly increased the risk of noncompletion for both disorders (depression: odds ratio=1.03, CI=1.01-1.06, P=.02; anxiety: odds ratio=1.08, CI=1.01-1.16, P=.03). Conclusions: iCBT can be clinically effective in routine care. Since depression and anxiety are costly and debilitating disorders that are vastly undertreated, this finding is important. Additionally, iCBT may help bridge the gap between the need for treatment and its provision. Our results are comparable to the within-group results of efficacy and effectiveness studies. Our noncompletion rates are similar to those observed in psychotherapy but are higher than those reported in similar clinics. Multiple factors predicted outcome and noncompletion. However, all predictor effects were statistically weak. %M 30487118 %R 10.2196/10927 %U http://www.jmir.org/2018/11/e10927/ %U https://doi.org/10.2196/10927 %U http://www.ncbi.nlm.nih.gov/pubmed/30487118 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 11 %P e10437 %T Economic Evaluation of an Internet-Based Preventive Cognitive Therapy With Minimal Therapist Support for Recurrent Depression: Randomized Controlled Trial %A Klein,Nicola S %A Bockting,Claudi LH %A Wijnen,Ben %A Kok,Gemma D %A van Valen,Evelien %A Riper,Heleen %A Cuijpers,Pim %A Dekker,Jack %A van der Heiden,Colin %A Burger,Huibert %A Smit,Filip %+ Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam,, Netherlands, 31 20 891 3610, c.l.bockting@amc.uva.nl %K major depressive disorders %K recurrence %K cognitive therapy %K internet %K prevention %K cost effectiveness %D 2018 %7 26.11.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Major depressive disorder (MDD) is highly recurrent and has a significant disease burden. Although the effectiveness of internet-based interventions has been established for the treatment of acute MDD, little is known about their cost effectiveness, especially in recurrent MDD. Objectives: Our aim was to evaluate the cost effectiveness and cost utility of an internet-based relapse prevention program (mobile cognitive therapy, M-CT). Methods: The economic evaluation was performed alongside a single-blind parallel group randomized controlled trial. Participants were recruited via media, general practitioners, and mental health care institutions. In total, 288 remitted individuals with a history of recurrent depression were eligible, of whom 264 were randomly allocated to M-CT with minimal therapist support added to treatment as usual (TAU) or TAU alone. M-CT comprised 8 online lessons, and participants were advised to complete 1 lesson per week. The economic evaluation was performed from a societal perspective with a 24-month time horizon. The health outcomes were number of depression-free days according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) criteria assessed with the Structured Clinical Interview for DSM-IV axis I disorders by blinded interviewers after 3, 12, and 24 months. Quality-adjusted life years (QALYs) were self-assessed with the three level version of the EuroQol Five Dimensional Questionnaire (EQ-5D-3L). Costs were assessed with the Trimbos and Institute for Medical Technology Assessment Questionnaire on Costs Associated with Psychiatric Illness (TiC-P). Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were displayed to assess the probability that M-CT is cost effective compared to TAU. Results: Mean total costs over 24 months were €8298 (US $9415) for M-CT and €7296 (US $8278) for TAU. No statistically significant differences were found between M-CT and TAU regarding depression-free days and QALYs (P=.37 and P=.92, respectively). The incremental costs were €179 (US $203) per depression-free day and €230,816 (US $261,875) per QALY. The cost-effectiveness acceptability curves suggested that for depression-free days, high investments have to be made to reach an acceptable probability that M-CT is cost effective compared to TAU. Regarding QALYs, considerable investments have to be made but the probability that M-CT is cost effective compared to TAU does not rise above 40%. Conclusions: The results suggest that adding M-CT to TAU is not effective and cost effective compared to TAU alone. Adherence rates were similar to other studies and therefore do not explain this finding. The participants scarcely booked additional therapist support, resulting in 17.3 minutes of mean total therapist support. More studies are needed to examine the cost effectiveness of internet-based interventions with respect to long-term outcomes and the role and optimal dosage of therapist support. Overall, more research is needed on scalable and cost-effective interventions that can reduce the burden of recurrent MDD. Trial registration: Netherlands Trial Register NTR2503; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2503 (Archived by WebCite at http://www.webcitation.org/73aBn41r3) %M 30478021 %R 10.2196/10437 %U http://www.jmir.org/2018/11/e10437/ %U https://doi.org/10.2196/10437 %U http://www.ncbi.nlm.nih.gov/pubmed/30478021 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 11 %P e12106 %T An Empathy-Driven, Conversational Artificial Intelligence Agent (Wysa) for Digital Mental Well-Being: Real-World Data Evaluation Mixed-Methods Study %A Inkster,Becky %A Sarda,Shubhankar %A Subramanian,Vinod %+ School of Clinical Medicine, Department of Psychiatry, University of Cambridge, Box 189, Cambridge Biomedical Campus, Cambridge, CB2 2QQ, United Kingdom, 44 773 847 8045, becky.inkster@gmail.com %K mental health %K conversational agents %K artificial intelligence %K chatbots %K coping skills %K resilience, psychological %K depression %K mHealth %K emotions %K empathy %D 2018 %7 23.11.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: A World Health Organization 2017 report stated that major depression affects almost 5% of the human population. Major depression is associated with impaired psychosocial functioning and reduced quality of life. Challenges such as shortage of mental health personnel, long waiting times, perceived stigma, and lower government spends pose barriers to the alleviation of mental health problems. Face-to-face psychotherapy alone provides only point-in-time support and cannot scale quickly enough to address this growing global public health challenge. Artificial intelligence (AI)-enabled, empathetic, and evidence-driven conversational mobile app technologies could play an active role in filling this gap by increasing adoption and enabling reach. Although such a technology can help manage these barriers, they should never replace time with a health care professional for more severe mental health problems. However, app technologies could act as a supplementary or intermediate support system. Mobile mental well-being apps need to uphold privacy and foster both short- and long-term positive outcomes. Objective: This study aimed to present a preliminary real-world data evaluation of the effectiveness and engagement levels of an AI-enabled, empathetic, text-based conversational mobile mental well-being app, Wysa, on users with self-reported symptoms of depression. Methods: In the study, a group of anonymous global users were observed who voluntarily installed the Wysa app, engaged in text-based messaging, and self-reported symptoms of depression using the Patient Health Questionnaire-9. On the basis of the extent of app usage on and between 2 consecutive screening time points, 2 distinct groups of users (high users and low users) emerged. The study used mixed-methods approach to evaluate the impact and engagement levels among these users. The quantitative analysis measured the app impact by comparing the average improvement in symptoms of depression between high and low users. The qualitative analysis measured the app engagement and experience by analyzing in-app user feedback and evaluated the performance of a machine learning classifier to detect user objections during conversations. Results: The average mood improvement (ie, difference in pre- and post-self-reported depression scores) between the groups (ie, high vs low users; n=108 and n=21, respectively) revealed that the high users group had significantly higher average improvement (mean 5.84 [SD 6.66]) compared with the low users group (mean 3.52 [SD 6.15]); Mann-Whitney P=.03 and with a moderate effect size of 0.63. Moreover, 67.7% of user-provided feedback responses found the app experience helpful and encouraging. Conclusions: The real-world data evaluation findings on the effectiveness and engagement levels of Wysa app on users with self-reported symptoms of depression show promise. However, further work is required to validate these initial findings in much larger samples and across longer periods. %M 30470676 %R 10.2196/12106 %U http://mhealth.jmir.org/2018/11/e12106/ %U https://doi.org/10.2196/12106 %U http://www.ncbi.nlm.nih.gov/pubmed/30470676 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e63 %T Lamotrigine Therapy for Bipolar Depression: Analysis of Self-Reported Patient Data %A Nzeyimana,Antoine %A Saunders,Kate EA %A Geddes,John R %A McSharry,Patrick E %+ Department of Geography, University of Oregon, 1251 University of Oregon, Eugene, OR, 97403-1251, United States, 1 541 346 0785, anzeyima@uoregon.edu %K bipolar disorder %K CEQUEL study %K data analysis %K depressive symptoms %K lamotrigine %K time series %D 2018 %7 22.11.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression in people with bipolar disorder is a major cause of long-term disability, possibly leading to early mortality and currently, limited safe and effective therapies exist. Although existing monotherapies such as quetiapine have limited proven efficacy and practical tolerability, treatment combinations may lead to improved outcomes. Lamotrigine is an anticonvulsant currently licensed for the prevention of depressive relapses in individuals with bipolar disorder. A double-blinded randomized placebo-controlled trial (comparative evaluation of Quetiapine-Lamotrigine [CEQUEL] study) was conducted to evaluate the efficacy of lamotrigine plus quetiapine versus quetiapine monotherapy in patients with bipolar type I or type II disorders. Objective: Because the original CEQUEL study found significant depressive symptom improvements, the objective of this study was to reanalyze CEQUEL data and determine an unbiased classification accuracy for active lamotrigine versus placebo. We also wanted to establish the time it took for the drug to provide statistically significant outcomes. Methods: Between October 21, 2008 and April 27, 2012, 202 participants from 27 sites in United Kingdom were randomly assigned to two treatments; 101: lamotrigine, 101: placebo. The primary variable used for estimating depressive symptoms was based on the Quick Inventory of Depressive Symptomatology—self report version 16 (QIDS-SR16). The original CEQUEL study findings were confirmed by performing t test and linear regression. Multiple features were computed from the QIDS-SR16 time series; different linear and nonlinear binary classifiers were trained to distinguish between the two groups. Various feature-selection techniques were used to select a feature set with the greatest explanatory power; a 10-fold cross-validation was used. Results: From weeks 10 to 14, the mean difference in QIDS-SR16 ratings between the groups was −1.6317 (P=.09; sample size=81, 77; 95% CI −0.2403 to 3.5036). From weeks 48 to 52, the mean difference was −2.0032 (P=.09; sample size=54, 48; 95% CI −0.3433 to 4.3497). The coefficient of variation (σ/μ) and detrended fluctuation analysis (DFA) exponent alpha had the greatest explanatory power. The out-of-sample classification accuracy for the 138 participants who reported more than 10 times after week 12 was 62%. A consistent classification accuracy higher than the no-information benchmark was obtained in week 44. Conclusions: Adding lamotrigine to quetiapine treatment decreased depressive symptoms in patients with bipolar disorder. Our classification model suggested that lamotrigine increased the coefficient of variation in the QIDS-SR16 scores. The lamotrigine group also tended to have a lower DFA exponent, implying a substantial temporal instability in the time series. The performance of the model over time suggested that a trial of at least 44 weeks was required to achieve consistent results. The selected model confirmed the original CEQUEL study findings and helped in understanding the temporal dynamics of bipolar depression during treatment. Trial Registration: EudraCT Number 2007-004513-33; https://www.clinicaltrialsregister.eu/ctr-search/trial/2007-004513-33/GB (Archived by WebCite at http://www.webcitation.org/73sNaI29O). %M 30467104 %R 10.2196/mental.9026 %U http://mental.jmir.org/2018/4/e63/ %U https://doi.org/10.2196/mental.9026 %U http://www.ncbi.nlm.nih.gov/pubmed/30467104 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11124 %T The Mediating Role of Perceived Social Support Between Physical Activity Habit Strength and Depressive Symptoms in People Seeking to Decrease Their Cardiovascular Risk: Cross-Sectional Study %A Storm,Vera %A Reinwand,Dominique Alexandra %A Wienert,Julian %A Tan,Shu-Ling %A Lippke,Sonia %+ Institute of Sport and Exercise Sciences, Department of Sport and Exercise Psychology, University of Münster, Horstmarer Landweg 62b, Münster, 48149, Germany, 49 251 83 31805, vera.storm@uni-muenster.de %K physical activity %K habit %K social support %K depressive symptoms %K cardiac diseases %D 2018 %7 14.11.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Regular physical activity treatment has been advocated for the prevention and rehabilitation of patients at risk of cardiovascular diseases and depressive symptoms. How physical activity is related to depressive symptoms is widely discussed. Objective: The aim of this internet-based study was to investigate the role of perceived social support in the relationship between physical activity habit strength and depressive symptoms. Methods: In total, 790 participants (mean 50.9 years, SD 12.2, range 20-84 years) who were interested in reducing their cardiovascular risk were recruited in Germany and the Netherlands. Data collection was conducted via an internet-based questionnaire addressing physical activity habit strength, depressive symptoms, and perceived social support. Cross-sectional data analysis was done with SPSS version 24 using the Macro PROCESS version 2 16.3 by Hayes with bootstrapping (10,000 samples), providing 95% CIs. Results: Physical activity habit strength was negatively related to depressive symptoms (r=–.13, P=.006), but this interrelation disappeared when controlling for perceived social support (beta=–.14, SE 0.09, P=.11). However, there was an indirect relationship between physical activity habit strength and depressive symptoms, which was mediated via perceived social support (beta=–.13; SE 0.04, 95% CI –0.21 to 0.06). The negative relationship between physical activity habit strength and depressive symptoms was fully mediated by perceived social support. Conclusions: We suggest that physical activity treatment in people interested in reducing their cardiovascular risk should also embed social support to target depressive symptoms. Internet-based interventions and electronic health may provide a good option for doing so. Trial Registration: ClinicalTrials.gov NCT01909349; https://clinicaltrials.gov/ct2/show/NCT01909349 (Archived by WebCite at http://www.webcitation.org/73Y9RfdiY) %M 30429112 %R 10.2196/11124 %U http://mental.jmir.org/2018/4/e11124/ %U https://doi.org/10.2196/11124 %U http://www.ncbi.nlm.nih.gov/pubmed/30429112 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 11 %P e10113 %T The Generalizability of Randomized Controlled Trials of Self-Guided Internet-Based Cognitive Behavioral Therapy for Depressive Symptoms: Systematic Review and Meta-Regression Analysis %A Lorenzo-Luaces,Lorenzo %A Johns,Emily %A Keefe,John R %+ Department of Psychological and Brain Sciences, Indiana University Bloomington, 1101 East 10th Street, Room 158, Bloomington, IN, 47401, United States, 1 787 222 2493, lolorenz@indiana.edu %K depression %K psychotherapy %K CBT %K internet-based therapy %K pharmacotherapy %K generalizability %K exclusion criteria %K cognitive therapy %K telemedicine %K drug therapy %K patient selection %D 2018 %7 09.11.2018 %9 Review %J J Med Internet Res %G English %X Background: Self-guided internet-based cognitive behavioral therapies (iCBTs) for depressive symptoms may substantially increase accessibility to mental health treatment. Despite this, questions remain as to the generalizability of the research on self-guided iCBT. Objective: We sought to describe the clinical entry criteria used in studies of self-guided iCBT, explore the criteria’s effects on study outcomes, and compare the frequency of use of these criteria with their use in studies of face-to-face psychotherapy and antidepressant medications. We hypothesized that self-guided iCBT studies would use more stringent criteria that would bias the sample toward those with a less complex clinical profile, thus inflating treatment outcomes. Methods: We updated a recently published meta-analysis by conducting a systematic literature search in PubMed, MEDLINE, PsycINFO, and EMBASE. We conducted a meta-regression analysis to test the effect of the different commonly used psychiatric entry criteria on the treatment-control differences. We also compared the frequency with which exclusion criteria were used in the self-guided iCBT studies versus studies of face-to-face psychotherapy and antidepressants from a recently published review. Results: Our search yielded 5 additional studies, which we added to the 16 studies identified by Karyotaki and colleagues in 2017. Few self-guided iCBT studies excluded patients with severe depressive symptoms (6/21, 29%), but self-guided iCBT studies were more likely than antidepressant (14/170, 8.2%) studies to use this criterion. However, self-guided iCBT studies did not use this criterion more frequently than face-to-face psychotherapy studies (6/16, 38%). Beyond this, we found no evidence that self-guided iCBTs used more stringent entry criteria. Strong evidence suggested that they were actually less likely to use most entry criteria, especially exclusions on the basis of substance use or personality pathology. None of the entry criteria used had an effect on outcomes. Conclusions: A conservative interpretation of our findings is that the patient population sampled in the literature on self-guided iCBT is relatively comparable with that of studies of antidepressants or face-to-face psychotherapy. Alternatively, studies of unguided cognitive behavioral therapy may sample from a more heterogeneous and representative patient population. Until evidence emerges to suggest otherwise, the patient population sampled in self-guided iCBT studies cannot be considered as less complex than the patient population from face-to-face psychotherapy or antidepressant studies. %M 30413400 %R 10.2196/10113 %U http://www.jmir.org/2018/11/e10113/ %U https://doi.org/10.2196/10113 %U http://www.ncbi.nlm.nih.gov/pubmed/30413400 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 11 %P e10114 %T Using Mobile Phones to Examine and Enhance Perceptions of Control in Mildly Depressed and Nondepressed Volunteers: Intervention Study %A Msetfi,Rachel %A O'Sullivan,Donal %A Walsh,Amy %A Nelson,John %A Van de Ven,Pepijn %+ Department of Psychology, Health Research Institute, University of Limerick, Castletroy, Limerick,, Ireland, 353 61202709, rachel.msetfi@ul.ie %K perception of control %K illusory control %K well-being %K depression %K health %K intervention %K causal learning %D 2018 %7 09.11.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Perceived control is strongly linked to healthy outcomes, mental healthiness, and psychological well-being. This is particularly important when people have little control over things that are happening to them. Perceived control studies have been performed extensively in laboratory settings and show that perceived control can be increased by experimental manipulations. Although these studies suggest that it may be possible to improve people’s mental health by increasing their perceived control, there is very little evidence to date to suggest that perceived control can also be influenced in the real world. Objective: The first aim of this study was to test for evidence of a link between noncontrol situations and psychological well-being in the real world using a mobile phone app. The second and arguably more important aim of the study was to test whether a simple instructional intervention on the nature of alternative causes would enhance people’s perceptions of their own control in these noncontrol situations. Methods: We implemented a behavioral action-outcome contingency judgment task using a mobile phone app. An opportunity sample of 106 healthy volunteers scoring low (n=56, no depression) or high (n=50, mild depression) on a depression scale participated. They were given no control over the occurrence of a low- or high-frequency stimulus that was embedded in everyday phone interactions during a typical day lasting 8 hours. The intervention involved instructions that either described a consistent alternative cause against which to assess their own control, or dynamic alternative causes of the outcome. Throughout the day, participants rated their own control over the stimulus using a quantitative judgment scale. Results: Participants with no evidence of depression overestimated their control, whereas those who were most depressed were more accurate in their control ratings. Instructions given to all participants about the nature of alternative causes significantly affected the pattern of perceived control ratings. Instructions describing discrete alternative causes enhanced perceived control for all participants, whereas dynamic alternative causes were linked to less perceived control. Conclusions: Perceptions of external causes are important to perceived control and can be used to enhance people’s perceptions. Theoretically motivated interventions can be used to enhance perceived control using mobile phone apps. This is the first study to do so in a real-world setting. %M 30413398 %R 10.2196/10114 %U http://mhealth.jmir.org/2018/11/e10114/ %U https://doi.org/10.2196/10114 %U http://www.ncbi.nlm.nih.gov/pubmed/30413398 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e61 %T Identifying and Understanding Communities Using Twitter to Connect About Depression: Cross-Sectional Study %A DeJohn,Amber D %A Schulz,Emily English %A Pearson,Amber L %A Lachmar,E Megan %A Wittenborn,Andrea K %+ Department of Geography, Environment, and Spatial Sciences, Michigan State University, Geography Building, 673 Auditorium Road, East Lansing, MI, 48824, United States, 1 5173554649, apearson@msu.edu %K depression %K Web-based %K social connection %K Twitter %K tweet %K online communities %D 2018 %7 05.11.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is the leading cause of diseases globally and is often characterized by a lack of social connection. With the rise of social media, it is seen that Twitter users are seeking Web-based connections for depression. Objective: This study aimed to identify communities where Twitter users tweeted using the hashtag #MyDepressionLooksLike to connect about depression. Once identified, we wanted to understand which community characteristics correlated to Twitter users turning to a Web-based community to connect about depression. Methods: Tweets were collected using NCapture software from May 25 to June 1, 2016 during the Mental Health Month (n=104) in the northeastern United States and Washington DC. After mapping tweets, we used a Poisson multilevel regression model to predict tweets per community (county) offset by the population and adjusted for percent female, percent population aged 15-44 years, percent white, percent below poverty, and percent single-person households. We then compared predicted versus observed counts and calculated tweeting index values (TIVs) to represent undertweeting and overtweeting. Last, we examined trends in community characteristics by TIV using Pearson correlation. Results: We found significant associations between tweet counts and area-level proportions of females, single-person households, and population aged 15-44 years. TIVs were lower than expected (TIV 1) in eastern, seaboard areas of the study region. There were communities tweeting as expected in the western, inland areas (TIV 2). Counties tweeting more than expected were generally scattered throughout the study region with a small cluster at the base of Maine. When examining community characteristics and overtweeting and undertweeting by county, we observed a clear upward gradient in several types of nonprofits and TIV values. However, we also observed U-shaped relationships for many community factors, suggesting that the same characteristics were correlated with both overtweeting and undertweeting. Conclusions: Our findings suggest that Web-based communities, rather than replacing physical connection, may complement or serve as proxies for offline social communities, as seen through the consistent correlations between higher levels of tweeting and abundant nonprofits. Future research could expand the spatiotemporal scope to confirm these findings. %M 30401662 %R 10.2196/mental.9533 %U http://mental.jmir.org/2018/4/e61/ %U https://doi.org/10.2196/mental.9533 %U http://www.ncbi.nlm.nih.gov/pubmed/30401662 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 1 %N 2 %P e10973 %T Feasibility and Conceptualization of an e-Mental Health Treatment for Depression in Older Adults: Mixed-Methods Study %A Eichenberg,Christiane %A Schott,Markus %A Sawyer,Adam %A Aumayr,Georg %A Plößnig,Manuela %+ Sigmund Freud Privat Universität Wien, Freudpl. 1, Vienna, 1020, Austria, 43 15124049991, markus.s.c.schott@gmail.com %K depression %K online therapy %K e-mental health %D 2018 %7 23.10.2018 %9 Original Paper %J JMIR Aging %G English %X Background: Depression is one of the most common mental disorders in older adults. Unfortunately, it often goes unrecognized in the older population. Objective: The aim of this study was to identify how Web-based apps can recognize and help treat depression in older adults. Methods: Focus groups were conducted with mental health care experts. A Web-based survey of 56 older adults suffering from depression was conducted. Qualitative interviews were conducted with 2 individuals. Results: Results of the focus groups highlighted that there is a need for a collaborative care platform for depression in old age. Findings from the Web-based study showed that younger participants (aged 50 to 64 years) used electronic media more often than older participants (aged 65 years and older). The interviews pointed in a comparable direction. Conclusions: Overall, an e-mental (electronic mental) health treatment for depression in older adults would be well accepted. Web-based care platforms should be developed, evaluated, and in case of evidence for their effectiveness, integrated into the everyday clinic. %M 31518235 %R 10.2196/10973 %U http://aging.jmir.org/2018/2/e10973/ %U https://doi.org/10.2196/10973 %U http://www.ncbi.nlm.nih.gov/pubmed/31518235 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e10698 %T Individualized Web-Based Exercise for the Treatment of Depression: Randomized Controlled Trial %A Haller,Nils %A Lorenz,Sonja %A Pfirrmann,Daniel %A Koch,Cora %A Lieb,Klaus %A Dettweiler,Ulrich %A Simon,Perikles %A Jung,Patrick %+ Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Strasse 8, Mainz, 55131, Germany, 49 69633909719, patrick.jung@unimedizin-mainz.de %K depression %K exercise %K Web-based intervention %K eHealth %D 2018 %7 12.10.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Due to the high prevalence of depressive disorders, it is mandatory to develop therapeutic strategies that provide universal access and require limited financial and human resources. Web-based therapeutic approaches fulfill these conditions. Objective: The objective of our study was to assess the feasibility, acceptability, and efficacy of a supervised, individualized 8-week Web-based exercise intervention conducted for patients with moderate to severe depression. Methods: We recruited 20 patients with unipolar depression and randomly assigned them into 2 groups (intervention, exercise program group, n=14, and control, treatment-as-usual group, n=6). At baseline, depressive symptoms were rated via the Quick Inventory of Depressive Symptomatology (QIDS) by patients themselves (QIDS–self-report, QIDS-SR) and by a blinded psychiatrist (QIDS–clinician rating, QIDS-C). In addition, performance diagnostics (lactate analysis, spiroergometry during a treadmill walking test) were conducted. Quality of life was assessed via the Short Form-36 questionnaire (SF-36) and self-efficacy via the General Self-Efficacy scale (GSE). In addition, habitual physical activity (HPA) was determined via the Baecke questionnaire. Participants of the intervention group received exercise schedules once weekly with endurance and strength training instructions. Rating of depressive symptoms was repeated after 6-12 days and 8 weeks; performance diagnostics and the completion of all the questionnaires were repeated after 8 weeks only. Results: The severity of depression subsided significantly in the intervention group after 8 weeks (median change in QIDS-SR: −5; interquartile range, IQR: −2 to −10), although it was already evident within the first 6-12 days (median change in QIDS-SR: −6; IQR: −2 to −8). During the intervention, participants undertook a median of 75 (IQR: 63 to 98) minutes of endurance training per week or 84% (16 [IQR: 9 to 19] of 19 [IQR: 15 to 21]) recommended endurance units in total. In addition, 9 (IQR: 4 to 12) of 10 (IQR: 8 to 13) recommended strength training exercise units were conducted during the 8 weeks. Performance diagnostics revealed a substantial increase in the maximum output in Watt for the intervention group after 8 weeks. Moreover, the intervention showed a favorable effect on SF-36 items “emotional well-being” and “social functioning” as well as on GSE and HPA scores. Conclusions: Our individualized Web-based exercise intervention for moderate to severe depression was highly accepted by the patients and led to a significant and clinically relevant improvement of depressive symptoms. Trial Registration: ClinicalTrials.gov NCT02874833; https://clinicaltrials.gov/ct2/show/NCT02874833 (Archived by WebCite at http://www.webcitation.org/72ZUUR4tE) %M 30314962 %R 10.2196/10698 %U http://mental.jmir.org/2018/4/e10698/ %U https://doi.org/10.2196/10698 %U http://www.ncbi.nlm.nih.gov/pubmed/30314962 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 10 %P e10754 %T Predicting Adherence to Internet-Delivered Psychotherapy for Symptoms of Depression and Anxiety After Myocardial Infarction: Machine Learning Insights From the U-CARE Heart Randomized Controlled Trial %A Wallert,John %A Gustafson,Emelie %A Held,Claes %A Madison,Guy %A Norlund,Fredrika %A von Essen,Louise %A Olsson,Erik Martin Gustaf %+ Clinical Psychology in Healthcare, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, SE-75185, Uppsala,, Sweden, 46 729999217, john.wallert@kbh.uu.se %K applied predictive modeling %K cardiac rehabilitation %K linguistics %K supervised machine learning %K recursive feature elimination %K treatment adherence and compliance %K Web-based interventions %D 2018 %7 10.10.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Low adherence to recommended treatments is a multifactorial problem for patients in rehabilitation after myocardial infarction (MI). In a nationwide trial of internet-delivered cognitive behavior therapy (iCBT) for the high-risk subgroup of patients with MI also reporting symptoms of anxiety, depression, or both (MI-ANXDEP), adherence was low. Since low adherence to psychotherapy leads to a waste of therapeutic resources and risky treatment abortion in MI-ANXDEP patients, identifying early predictors for adherence is potentially valuable for effective targeted care. Objectives: The goal of the research was to use supervised machine learning to investigate both established and novel predictors for iCBT adherence in MI-ANXDEP patients. Methods: Data were from 90 MI-ANXDEP patients recruited from 25 hospitals in Sweden and randomized to treatment in the iCBT trial Uppsala University Psychosocial Care Programme (U-CARE) Heart study. Time point of prediction was at completion of the first homework assignment. Adherence was defined as having completed more than 2 homework assignments within the 14-week treatment period. A supervised machine learning procedure was applied to identify the most potent predictors for adherence available at the first treatment session from a range of demographic, clinical, psychometric, and linguistic predictors. The internal binary classifier was a random forest model within a 3×10–fold cross-validated recursive feature elimination (RFE) resampling which selected the final predictor subset that best differentiated adherers versus nonadherers. Results: Patient mean age was 58.4 years (SD 9.4), 62% (56/90) were men, and 48% (43/90) were adherent. Out of the 34 potential predictors for adherence, RFE selected an optimal subset of 56% (19/34; Accuracy 0.64, 95% CI 0.61-0.68, P<.001). The strongest predictors for adherence were, in order of importance, (1) self-assessed cardiac-related fear, (2) sex, and (3) the number of words the patient used to answer the first homework assignment. Conclusions: For developing and testing effective iCBT interventions, investigating factors that predict adherence is important. Adherence to iCBT for MI-ANXDEP patients in the U-CARE Heart trial was best predicted by cardiac-related fear and sex, consistent with previous research, but also by novel linguistic predictors from written patient behavior which conceivably indicate verbal ability or therapeutic alliance. Future research should investigate potential causal mechanisms and seek to determine what underlying constructs the linguistic predictors tap into. Whether these findings replicate for other interventions outside of Sweden, in larger samples, and for patients with other conditions who are offered iCBT should also be investigated. Trial registration: ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191 (Archived at Webcite at http://www.webcitation.org/6xWWSEQ22) %M 30305255 %R 10.2196/10754 %U http://www.jmir.org/2018/10/e10754/ %U https://doi.org/10.2196/10754 %U http://www.ncbi.nlm.nih.gov/pubmed/30305255 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e10726 %T Identifying the Underlying Factors Associated With Patients’ Attitudes Toward Antidepressants: Qualitative and Quantitative Analysis of Patient Drug Reviews %A Zolnoori,Maryam %A Fung,Kin Wah %A Fontelo,Paul %A Kharrazi,Hadi %A Faiola,Anthony %A Wu,Yi Shuan Shirley %A Stoffel,Virginia %A Patrick,Timothy %+ Section of Medical Informatics, Department of Health Science Research, Mayo Clinic, 200 First Street SW, Rochester, MN,, United States, 1 3175151950, Zolnoori.Maryam@mayo.edu %K medication adherence %K attitude %K perception %K antidepressive agents %K patient-centered care %K chronic disease %K depression %K community networks %K internet %K social media %K data mining %K framework method %D 2018 %7 30.9.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Nonadherence to antidepressants is a major obstacle to deriving antidepressants’ therapeutic benefits, resulting in significant burdens on the individuals and the health care system. Several studies have shown that nonadherence is weakly associated with personal and clinical variables but strongly associated with patients’ beliefs and attitudes toward medications. Patients’ drug review posts in online health care communities might provide a significant insight into patients’ attitude toward antidepressants and could be used to address the challenges of self-report methods such as patients’ recruitment. Objective: The aim of this study was to use patient-generated data to identify factors affecting the patient’s attitude toward 4 antidepressants drugs (sertraline [Zoloft], escitalopram [Lexapro], duloxetine [Cymbalta], and venlafaxine [Effexor XR]), which in turn, is a strong determinant of treatment nonadherence. We hypothesized that clinical variables (drug effectiveness; adverse drug reactions, ADRs; perceived distress from ADRs, ADR-PD; and duration of treatment) and personal variables (age, gender, and patients’ knowledge about medications) are associated with patients’ attitude toward antidepressants, and experience of ADRs and drug ineffectiveness are strongly associated with negative attitude. Methods: We used both qualitative and quantitative methods to analyze the dataset. Patients’ drug reviews were randomly selected from a health care forum called askapatient. The Framework method was used to build the analytical framework containing the themes for developing structured data from the qualitative drug reviews. Then, 4 annotators coded the drug reviews at the sentence level using the analytical framework. After managing missing values, we used chi-square and ordinal logistic regression to test and model the association between variables and attitude. Results: A total of 892 reviews posted between February 2001 and September 2016 were analyzed. Most of the patients were females (680/892, 76.2%) and aged less than 40 years (540/892, 60.5%). Patient attitude was significantly (P<.001) associated with experience of ADRs, ADR-PD, drug effectiveness, perceived lack of knowledge, experience of withdrawal, and duration of usage, whereas oth age (F4,874=0.72, P=.58) and gender (χ24=2.7, P=.21) were not found to be associated with patient attitudes. Moreover, modeling the relationship between variables and attitudes showed that drug effectiveness and perceived distress from adverse drug reactions were the 2 most significant factors affecting patients’ attitude toward antidepressants. Conclusions: Patients’ self-report experiences of medications in online health care communities can provide a direct insight into the underlying factors associated with patients’ perceptions and attitudes toward antidepressants. However, it cannot be used as a replacement for self-report methods because of the lack of information for some of the variables, colloquial language, and the unstructured format of the reports. %M 30287417 %R 10.2196/10726 %U http://mental.jmir.org/2018/4/e10726/ %U https://doi.org/10.2196/10726 %U http://www.ncbi.nlm.nih.gov/pubmed/30287417 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e10204 %T Supported Internet-Delivered Cognitive Behavior Treatment for Adults with Severe Depressive Symptoms: A Secondary Analysis %A Richards,Derek %A Duffy,Daniel %A Burke,John %A Anderson,Melissa %A Connell,Sarah %A Timulak,Ladislav %+ Clinical Research & Innovation, SilverCloud Health, One Stephen Street, Stephen Street Upper, Dublin, D08 DR9P, Ireland, 353 15549771, derek.richards@silvercloudhealth.com %K severe depression %K internet-delivered interventions %K iCBT %D 2018 %7 02.10.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is a highly prevalent mental health issue that exacts significant economic, societal, personal, and interpersonal costs. Innovative internet-delivered interventions have been designed to increase accessibility to and cost-effectiveness of treatments. These treatments have mainly targeted mild to moderate levels of depression. The increased risk associated with severe depression, particularly of suicidal ideation often results in this population being excluded from research studies. As a result, the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) in more severely depressed cohorts is less researched. Objective: The aim of this study is to examine the effect of iCBT on symptoms of severe depression, comorbid symptoms of anxiety, and levels of work and social functioning. Methods: Retrospective consent was provided by participants with elevated scores (>28 severe depression symptoms) on the Beck Depression Inventory (BDI-II) who accessed an iCBT intervention (Space from Depression) with support for up to 8 weeks. Data were collected at baseline, posttreatment, and 3-month follow-up on the primary outcome (BDI-II), and secondary outcomes (the Generalized Anxiety Disorder-7 and the Work and Social Adjustment Scale). Results: A significant change was observed on all measures between pre- and postmeasurement and maintained at 3-month follow-up. Clinical improvement was observed for participants on the BDI-II from pre- to postmeasurement, and suicidal ideation also reduced from pre- to postmeasurement. Conclusions: Users of Space from Depression with symptoms of severe depression were found to have decreased symptoms of depression and anxiety and increased levels of work and social functioning. The intervention also demonstrated its potential to decrease suicidal ideation. Further investigation is required to determine why some individuals improve, and others do not. iCBT may have the potential to be used as an adjunct treatment for severe depression symptoms, but participants may require further treatment if they receive iCBT as a standalone intervention. Although promising, further research incorporating control groups is needed to support the utility of Space from Depression for use in or as an adjunct to treatment for severe depression. %M 30279154 %R 10.2196/10204 %U https://mental.jmir.org/2018/4/e10204/ %U https://doi.org/10.2196/10204 %U http://www.ncbi.nlm.nih.gov/pubmed/30279154 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 10 %P e10455 %T Complaint-Directed Mini-Interventions for Depressive Symptoms: A Health Economic Evaluation of Unguided Web-Based Self-Help Interventions Based on a Randomized Controlled Trial %A Wijnen,Ben FM %A Lokman,Suzanne %A Leone,Stephanie %A Evers,Silvia MAA %A Smit,Filip %+ Centre for Economic Evaluation, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Da Costakade 45, Utrecht, 3521 VS, Netherlands, 31 030 297 1100, b.wijnen@maastrichtuniversity.nl %K prevention %K depression %K internet-based intervention %K economic evaluation %K quality of life %K cost-effectiveness analysis %K cost-utility analysis %K early medical intervention %K cost-benefit analysis %D 2018 %7 01.10.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression prevention and early intervention have become a top priority in the Netherlands, but with considerable room for improvement. To address this, Web-based complaint-directed mini-interventions (CDMIs) were developed. These brief and low-threshold interventions focus on psychological stress, sleep problems, and worry, because these complaints are highly prevalent, are demonstrably associated with depression, and have substantial economic impact. Objective: The objective of this economic evaluation was to examine the added value of Web-based, unguided, self-help CDMIs compared with a wait-listed control group with unrestricted access to usual care from both a societal and a health care perspective. Methods: This health economic evaluation was embedded in a randomized controlled trial. The study entailed 2 arms, in which 3 Web-based CDMIs were compared with a no-intervention waiting-list control group (which received the intervention after 3 months). We conducted measurements at baseline, and at 3 and 6 months. The primary outcome was the rate of responders to treatment on depressive symptoms as measured by the Inventory of Depressive Symptomatology Self-Report (IDS-SR). We estimated change in quality of life by calculating effect sizes (Cohen d) for individual pre- and posttreatment IDS-SR scores using a conversion factor to map a change in standardized effect size onto a corresponding change in utility. We calculated incremental cost-effectiveness ratios using bootstraps (5000 times) of seemingly unrelated regression equations and constructed cost-effectiveness acceptability curves for the costs per quality-adjusted life-year (QALY) gained. Results: Of 329 study participants, we randomly assigned 165 to the CDMI group. At 3 months, the rate of responders to treatment was 13.9% (23/165) in the CDMI group and 7.3% (12/164) in the control group. At 3 months, participants in the CDMI group gained 0.15 QALYs compared with baseline, whereas participants in the control group gained 0.03 QALYs. Average total costs per patient at 3 months were €2094 for the CDMI group and €2230 for the control group (excluding baseline costs). Bootstrapped seemingly unrelated regression equations models resulted in a dominant incremental cost-effectiveness ratio (ie, lower costs and a higher rate of responders to treatment) for the CDMI group compared with the control group at 3 months, with the same result for the costs per QALY gained. Various sensitivity analyses attested to the robustness of the findings of the main analysis. Conclusions: Brief and low-threshold Web-based, unguided, self-help CDMIs have the potential to be a cost-effective addition to usual care for adults with mild to moderate depressive symptoms. The CDMIs improved health status, while reducing participant health care costs, and hence dominated the care-as-usual control condition. As intervention costs were relatively low, and the internet is readily available in the Western world, we believe CDMIs can be easily implemented on a large scale. Trial Registration: Netherlands Trial Register NTR4612; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4612 (Archived by WebCite at http://www.webcitation.org/6n4PVYddM) %M 30274958 %R 10.2196/10455 %U https://www.jmir.org/2018/10/e10455/ %U https://doi.org/10.2196/10455 %U http://www.ncbi.nlm.nih.gov/pubmed/30274958 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 9 %P e10035 %T Mobile App Use by Primary Care Patients to Manage Their Depressive Symptoms: Qualitative Study %A Pung,Alison %A Fletcher,Susan Louise %A Gunn,Jane Maree %+ Department of General Practice, The University of Melbourne, 200 Berkeley Street, Victoria, 3053, Australia, 61 3 9035 4872, susanlf@unimelb.edu.au %K mobile apps %K depression %K health care %K general practice %D 2018 %7 27.09.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile apps are emerging as tools with the potential to revolutionize the treatment of mental health conditions such as depression. At the forefront of the community health sector, general practitioners are in a unique position to guide the integration of technology and depression management; however, little is currently known about how primary care patients with depressive symptoms are currently using apps. Objective: The objective of our study was to explore the natural patterns of mobile app use among patients with depressive symptoms to facilitate the understanding of the potential role for mobile apps in managing depressive symptoms in the community. Methods: Semistructured phone interviews were conducted with primary care patients in Victoria, Australia, who reported symptoms of depression and were enrolled in a larger randomized controlled trial of depression care. Interviews explored current depression management strategies and the use of mobile apps (if any). Interviews were audio-recorded and transcribed verbatim. Inductive thematic analysis was iteratively conducted using QSR NVivo 11 Pro to identify emergent themes. Results: A total of 16 participants, aged between 20 to 58 years, took part in the interviews with 11 reporting the use of at least one mobile app to manage depressive symptoms and 5 reporting no app use. A variety of apps were described including relaxation, mindfulness, cognitive, exercise, gaming, social media, and well-being apps to aid with depressive symptoms. Among users, there were the following 4 main patterns of app use: skill acquisition, social connectedness, inquisitive trial, and safety netting. Factors that influenced app use included accessibility, perceptions of technology, and personal compatibility. Health care providers also had a role in initiating app use. Conclusions: Mobile apps are being utilized for self-management of depressive symptoms by primary care patients. This study provided insight into the natural patterns and perspectives of app use, which enhanced the understanding of how this technology may be integrated into the toolbox for the management of depression. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000537459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367152 (Archived at WebCite at http://www.webcitation.org/71Vf06X2T) %M 30262449 %R 10.2196/10035 %U http://www.jmir.org/2018/9/e10035/ %U https://doi.org/10.2196/10035 %U http://www.ncbi.nlm.nih.gov/pubmed/30262449 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10278 %T Web-Based Mindfulness Interventions for Mental Health Treatment: Systematic Review and Meta-Analysis %A Sevilla-Llewellyn-Jones,Julia %A Santesteban-Echarri,Olga %A Pryor,Ingrid %A McGorry,Patrick %A Alvarez-Jimenez,Mario %+ Institute of Psychiatry and Mental Health, Health Research Institute (IdISSC). Hospital Clínico San Carlos, Av/ Prof Martin Lago s/n, Madrid, 28040, Spain, 34 651563055, juliasevill@gmail.com %K mindfulness %K anxiety disorder %K depressive disorder %K internetinternet-based %K treatment %K meta-analysis %K mental health. %K systematic review %D 2018 %7 25.9.2018 %9 Review %J JMIR Ment Health %G English %X Background: Web-based mindfulness interventions are increasingly delivered through the internet to treat mental health conditions. Objective: The objective of this study was to determine the effectiveness of web-based mindfulness interventions in clinical mental health populations. Secondary aims were to explore the impact of study variables on the effectiveness of web-based mindfulness interventions. Methods: We performed a systematic review and meta-analysis of studies investigating the effects of web-based mindfulness interventions on clinical populations. Results: The search strategy yielded 12 eligible studies. Web-based mindfulness interventions were effective in reducing depression in the total clinical sample (n=656 g=−0.609, P=.004) and in the anxiety disorder subgroup (n=313, g=−0.651, P<.001), but not in the depression disorder subgroup (n=251, P=.18). Similarly, web-based mindfulness interventions significantly reduced anxiety in the total clinical sample (n=756, g=−0.433, P=.004) and the anxiety disorder subgroup (n=413, g=−0.719, P<.001), but not in the depression disorder group (n=251, g=−0.213, P=.28). Finally, web-based mindfulness interventions improved quality of life and functioning in the total sample (n=591, g=0.362, P=.02) in the anxiety disorder subgroup (n=370, g=0.550, P=.02) and mindfulness skills in the total clinical sample (n=251, g=0.724, P<.001). Conclusions: Results support the effectiveness of web-based mindfulness interventions in reducing depression and anxiety and in enhancing quality of life and mindfulness skills, particularly in those with clinical anxiety. Results should be interpreted with caution given the high heterogeneity of web-based mindfulness interventions and the low number of studies included. %M 30274963 %R 10.2196/10278 %U http://mental.jmir.org/2018/3/e10278/ %U https://doi.org/10.2196/10278 %U http://www.ncbi.nlm.nih.gov/pubmed/30274963 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 9 %P e10743 %T Web-Based Cognitive Behavioral Therapy Blended With Face-to-Face Sessions for Major Depression: Randomized Controlled Trial %A Nakao,Shigetsugu %A Nakagawa,Atsuo %A Oguchi,Yoshiyo %A Mitsuda,Dai %A Kato,Noriko %A Nakagawa,Yuko %A Tamura,Noriko %A Kudo,Yuka %A Abe,Takayuki %A Hiyama,Mitsunori %A Iwashita,Satoru %A Ono,Yutaka %A Mimura,Masaru %+ Clinical and Translational Research Center, Keio University Hospital, 35, Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan, 81 3 3353 1211, anakagawa@keio.jp %K blended cognitive behavioral therapy %K cognitive behavioral therapy %K major depressive disorder %K major depression %K randomized controlled trial %D 2018 %7 21.9.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Meta-analyses of several randomized controlled trials have shown that cognitive behavioral therapy (CBT) has comparable efficacy to antidepressant medication, but therapist availability and cost-effectiveness is a problem. Objective: This study aimed to evaluate the effectiveness of Web-based CBT blended with face-to-face sessions that reduce therapist time in patients with major depression who were unresponsive to antidepressant medications. Methods: A 12-week, assessor-masked, parallel-group, waiting- list controlled, randomized trial was conducted at 3 medical institutions in Tokyo. Outpatients aged 20-65 years with a primary diagnosis of major depression who were taking ≥1 antidepressant medications at an adequate dose for ≥6 weeks and had a 17-item GRID-Hamilton Depression Rating Scale (HAMD) score of ≥14 were randomly assigned (1:1) to blended CBT or waiting-list groups using a computer allocation system, stratified by the study site with the minimization method, to balance age and baseline GRID-HAMD score. The CBT intervention was given in a combined format, comprising a Web-based program and 12 45-minute face-to-face sessions. Thus, across 12 weeks, a participant could receive up to 540 minutes of contact with a therapist, which is approximately two-thirds of the therapist contact time provided in the conventional CBT protocol, which typically provides 16 50-minute sessions. The primary outcome was the alleviation of depressive symptoms, as measured by a change in the total GRID-HAMD score from baseline (at randomization) to posttreatment (at 12 weeks). Moreover, in an exploratory analysis, we investigated whether the expected positive effects of the intervention were sustained during follow-up, 3 months after the posttreatment assessment. Analyses were performed on an intention-to-treat basis, and the primary outcome was analyzed using a mixed-effects model for repeated measures. Results: We randomized 40 participants to either blended CBT (n=20) or waiting-list (n=20) groups. All patients completed the 12-week treatment protocol and were included in the intention-to-treat analyses. Participants in the blended CBT group had significantly alleviated depressive symptoms at week 12, as shown by greater least squares mean changes in the GRID-HAMD score, than those in the waiting list group (−8.9 points vs −3.0 points; mean between-group difference=−5.95; 95% CI −9.53 to −2.37; P<.001). The follow-up effects within the blended CBT group, as measured by the GRID-HAMD score, were sustained at the 3-month follow-up (week 24) and posttreatment (week 12): posttreatment, 9.4 (SD 5.2), versus follow-up, 7.2 (SD 5.7); P=.009. Conclusions: Although our findings warrant confirmation in larger and longer term studies with active controls, these suggest that a combined form of CBT is effective in reducing depressive symptoms in patients with major depression who are unresponsive to antidepressant medications. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry: UMIN000009242; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000010852 (Archived by WebCite at http://www.webcitation. org/729VkpyYL) %M 30249583 %R 10.2196/10743 %U http://www.jmir.org/2018/9/e10743/ %U https://doi.org/10.2196/10743 %U http://www.ncbi.nlm.nih.gov/pubmed/30249583 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 3 %N 3 %P e13 %T Web-Based Interventions for Depression in Individuals with Diabetes: Review and Discussion %A Franco,Pamela %A Gallardo,Ana María %A Urtubey,Xavier %+ Psychology Department, Universidad del Desarrollo, Av Plaza 680, Santiago, 7610658, Chile, 56 223279110, p.franco@udd.cl %K Web-based intervention %K internet %K depression %K diabetes %K cognitive behavioral therapy %D 2018 %7 14.09.2018 %9 Review %J JMIR Diabetes %G English %X Background: Depression is twice as common in people with diabetes, and this comorbidity worsens the course of both pathologies. In clinical practice guidelines, screening and treatment of depression in patients with diabetes are highly recommended. However, depression is still both underrecognized and undertreated. To find ways to enhance their reach, psychological treatments have taken advantage of benefits of internet and technological devices as delivery formats, providing interventions that require considerably less (or even no) interaction time with therapists. Web-based treatments hold promise for effective interventions at low cost with positive results. Objective: The objectives of this review were to describe Web-based interventions for depression in individuals with diabetes and to discuss these studies’ procedures and findings in light of evidence from a wider range of interventions for depression and diabetes. Methods: A comprehensive literature search was conducted in PsycINFO and MEDLINE electronic databases. Studies were included when they met the following selection criteria: the study was available in a peer-reviewed journal mainly publishing studies written in either English or Spanish; the studied sample comprised individuals with diabetes; the intervention targeted depression symptomatology; the intervention was accessible via the internet; and the intervention was accessible via the internet with little or no clinician support. Results: Overall, 5 research studies were identified in the review. All studies were randomized controlled trials, and most used a wait list as a control; 4 studies reported treatment dropout, rates of which varied from 13% to 42%. Studies supported the notion that the Web-based format is a suitable psychology service delivery option for diabetic individuals with depression (effect size range for completers 0.7-0.89). Interventions varied in their characteristics but most were clinical-assisted, had a cognitive behavioral therapy approach, used diabetes-specific topics, had a weekly modular display, used homework assignments, and had some adherence management strategy. These characteristics are consistent with the intervention features associated with positive results in the literature. Conclusions: The analyzed studies’ findings and procedures are discussed in light of evidence drawn from a wider range of reviews on Web-based interventions for depression and diabetes. Consistent with previous research on depression treatment, Web-based interventions for depression among individuals with diabetes have shown positive results. Future research should contribute new evidence as to why these interventions are effective, for whom, and which particular aspects can increase patients’ adherence. %M 30291082 %R 10.2196/diabetes.9694 %U http://diabetes.jmir.org/2018/3/e13/ %U https://doi.org/10.2196/diabetes.9694 %U http://www.ncbi.nlm.nih.gov/pubmed/30291082 %0 Journal Article %@ 2152-7202 %I JMIR Publications %V 10 %N 3 %P e10655 %T Phase I of the Detecting and Evaluating Childhood Anxiety and Depression Effectively in Subspecialties (DECADES) Study: Development of an Integrated Mental Health Care Model for Pediatric Gastroenterology %A Hullmann,Stephanie E %A Keller,Stacy A %A Lynch,Dustin O %A Jenkins,Kelli %A Moore,Courtney %A Cockrum,Brandon %A Wiehe,Sarah E %A Carroll,Aaron E %A Bennett Jr,William E %+ Center for Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, 410 W 10th Street, HITS Building, Indianapolis, IN, 46202, United States, 1 3172786928, webjr@iu.edu %K qualitative research %K patient-reported outcomes %K depression %K anxiety %D 2018 %7 10.09.2018 %9 Original Paper %J J Participat Med %G English %X Background: Children with gastrointestinal symptoms have a very high rate of anxiety and depression. Rapid identification of comorbid anxiety and depression is essential for effective treatment of a wide variety of functional gastrointestinal disorders. Objective: The objective of our study was to determine patient and parent attitudes toward depression, anxiety, and mental health screening during gastroenterology (GI) visits and to determine patient and parent preferences for communication of results and referral to mental health providers after a positive screen. Methods: We augmented standard qualitative group session methods with patient-centered design methods to assess patient and parent preferences. We used a variety of specific design methods in these sessions, including card sorting, projective methods, experience mapping, and constructive methods. Results: Overall, 11 families (11 patients and 14 parents) participated in 2 group sessions. Overall, patients and their parents found integrated mental health care to be acceptable in the subspecialty setting. Patients’ primary concerns were for the privacy and confidentiality of their screening results. Patients and their parents emphasized the importance of mental health services not interfering with the GI visit and collaboration between the GI physician, psychologist, and primary care provider. Conclusions: Patients and their families are open to integrated mental health care in the pediatric subspecialty clinic. The next phase of the DECADES study will translate patient and parent preferences into an integrated mental health care system and test its efficacy in the pediatric GI office. %R 10.2196/10655 %U http://jopm.jmir.org/2018/3/e10655/ %U https://doi.org/10.2196/10655 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 9 %P e10302 %T Patient Experiences of Web-Based Cognitive Behavioral Therapy for Heart Failure and Depression: Qualitative Study %A Lundgren,Johan %A Johansson,Peter %A Jaarsma,Tiny %A Andersson,Gerhard %A Kärner Köhler,Anita %+ Division of Nursing Science, Department of Social and Welfare Studies, Linköping University, Campus Norrköping, Kåkenhus, Norrköping, SE-601 74, Sweden, 46 01136 ext 3592, johan.lundgren@liu.se %K cognitive therapy %K content analysis %K depression %K heart failure %K internet %K patient experience %K telehealth %D 2018 %7 05.09.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based cognitive behavioral therapy (wCBT) has been proposed as a possible treatment for patients with heart failure and depressive symptoms. Depressive symptoms are common in patients with heart failure and such symptoms are known to significantly worsen their health. Although there are promising results on the effect of wCBT, there is a knowledge gap regarding how persons with chronic heart failure and depressive symptoms experience wCBT. Objective: The aim of this study was to explore and describe the experiences of participating and receiving health care through a wCBT intervention among persons with heart failure and depressive symptoms. Methods: In this qualitative, inductive, exploratory, and descriptive study, participants with experiences of a wCBT program were interviewed. The participants were included through purposeful sampling among participants previously included in a quantitative study on wCBT. Overall, 13 participants consented to take part in this study and were interviewed via telephone using an interview guide. Verbatim transcripts from the interviews were qualitatively analyzed following the recommendations discussed by Patton in Qualitative Research & Evaluation Methods: Integrating Theory and Practice. After coding each interview, codes were formed into categories. Results: Overall, six categories were identified during the analysis process. They were as follows: “Something other than usual health care,” “Relevance and recognition,” “Flexible, understandable, and safe,” “Technical problems,” “Improvements by real-time contact,” and “Managing my life better.” One central and common pattern in the findings was that participants experienced the wCBT program as something they did themselves and many participants described the program as a form of self-care. Conclusions: Persons with heart failure and depressive symptoms described wCBT as challenging. This was due to participants balancing the urge for real-time contact with perceived anonymity and not postponing the work with the program. wCBT appears to be a valuable tool for managing depressive symptoms. %M 30185405 %R 10.2196/10302 %U http://www.jmir.org/2018/9/e10302/ %U https://doi.org/10.2196/10302 %U http://www.ncbi.nlm.nih.gov/pubmed/30185405 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10334 %T The Effortless Assessment of Risk States (EARS) Tool: An Interpersonal Approach to Mobile Sensing %A Lind,Monika N %A Byrne,Michelle L %A Wicks,Geordie %A Smidt,Alec M %A Allen,Nicholas B %+ Center for Digital Mental Health, Department of Psychology, University of Oregon, 1227 University Street, Eugene, OR, 97403, United States, 1 541 346 4075, nallen3@uoregon.edu %K passive mobile sensing %K personal sensing %K mobile sensing %K mental health %K risk assessment %K crisis prevention %K individual big data %K telemedicine %K mobile apps %K cell phone %K depression %D 2018 %7 28.08.2018 %9 Viewpoint %J JMIR Ment Health %G English %X Background: To predict and prevent mental health crises, we must develop new approaches that can provide a dramatic advance in the effectiveness, timeliness, and scalability of our interventions. However, current methods of predicting mental health crises (eg, clinical monitoring, screening) usually fail on most, if not all, of these criteria. Luckily for us, 77% of Americans carry with them an unprecedented opportunity to detect risk states and provide precise life-saving interventions. Smartphones present an opportunity to empower individuals to leverage the data they generate through their normal phone use to predict and prevent mental health crises. Objective: To facilitate the collection of high-quality, passive mobile sensing data, we built the Effortless Assessment of Risk States (EARS) tool to enable the generation of predictive machine learning algorithms to solve previously intractable problems and identify risk states before they become crises. Methods: The EARS tool captures multiple indices of a person’s social and affective behavior via their naturalistic use of a smartphone. Although other mobile data collection tools exist, the EARS tool places a unique emphasis on capturing the content as well as the form of social communication on the phone. Signals collected include facial expressions, acoustic vocal quality, natural language use, physical activity, music choice, and geographical location. Critically, the EARS tool collects these data passively, with almost no burden on the user. We programmed the EARS tool in Java for the Android mobile platform. In building the EARS tool, we concentrated on two main considerations: (1) privacy and encryption and (2) phone use impact. Results: In a pilot study (N=24), participants tolerated the EARS tool well, reporting minimal burden. None of the participants who completed the study reported needing to use the provided battery packs. Current testing on a range of phones indicated that the tool consumed approximately 15% of the battery over a 16-hour period. Installation of the EARS tool caused minimal change in the user interface and user experience. Once installation is completed, the only difference the user notices is the custom keyboard. Conclusions: The EARS tool offers an innovative approach to passive mobile sensing by emphasizing the centrality of a person’s social life to their well-being. We built the EARS tool to power cutting-edge research, with the ultimate goal of leveraging individual big data to empower people and enhance mental health. %M 30154072 %R 10.2196/10334 %U http://mental.jmir.org/2018/3/e10334/ %U https://doi.org/10.2196/10334 %U http://www.ncbi.nlm.nih.gov/pubmed/30154072 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e54 %T A Mobile App–Based Intervention for Depression: End-User and Expert Usability Testing Study %A Fuller-Tyszkiewicz,Matthew %A Richardson,Ben %A Klein,Britt %A Skouteris,Helen %A Christensen,Helen %A Austin,David %A Castle,David %A Mihalopoulos,Cathrine %A O'Donnell,Renee %A Arulkadacham,Lilani %A Shatte,Adrian %A Ware,Anna %+ School of Psychology, Deakin University, 1 Gheringhap Street, Geelong, 3220, Australia, 61 392517344, matthewf@deakin.edu.au %K depression %K eHealth %K mHealth %K young adult %D 2018 %7 23.08.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Despite the growing number of mental health apps available for smartphones, the perceived usability of these apps from the perspectives of end users or health care experts has rarely been reported. This information is vital, particularly for self-guided mHealth interventions, as perceptions of navigability and quality of content are likely to impact participant engagement and treatment compliance. Objective: The aim of this study was to conduct a usability evaluation of a personalized, self-guided, app-based intervention for depression. Methods: Participants were administered the System Usability Scale and open-ended questions as part of a semistructured interview. There were 15 participants equally divided into 3 groups: (1) individuals with clinical depression who were the target audience for the app, (2) mental health professionals, and (3) researchers who specialize in the area of eHealth interventions and/or depression research. Results: The end-user group rated the app highly, both in quantitative and qualitative assessments. The 2 expert groups highlighted the self-monitoring features and range of established psychological treatment options (such as behavioral activation and cognitive restructuring) but had concerns that the amount and layout of content may be difficult for end users to navigate in a self-directed fashion. The end-user data did not confirm these concerns. Conclusions: Encouraging participant engagement via self-monitoring and feedback, as well as personalized messaging, may be a viable way to maintain participation in self-guided interventions. Further evaluation is necessary to determine whether levels of engagement with these features enhance treatment effects. %M 30139722 %R 10.2196/mental.9445 %U http://mental.jmir.org/2018/3/e54/ %U https://doi.org/10.2196/mental.9445 %U http://www.ncbi.nlm.nih.gov/pubmed/30139722 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 8 %P e10748 %T Veterans’ Attitudes Toward Smartphone App Use for Mental Health Care: Qualitative Study of Rurality and Age Differences %A Connolly,Samantha L %A Miller,Christopher J %A Koenig,Christopher J %A Zamora,Kara A %A Wright,Patricia B %A Stanley,Regina L %A Pyne,Jeffrey M %+ Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S Huntington Avenue, Building 9 Room 208F, Boston, MA, 02130, United States, 1 857 364 5987, Samantha.connolly@va.gov %K smartphone apps %K mobile phone %K mhealth %K mental health %K qualitative analysis %K rurality %K age %K veterans %K depression %K anxiety disorders %K posttraumatic stress disorder %K PTSD %K alcohol abuse %D 2018 %7 22.08.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental health smartphone apps provide support, skills, and symptom tracking on demand and come at minimal to no additional cost to patients. Although the Department of Veterans Affairs has established itself as a national leader in the creation of mental health apps, veterans’ attitudes regarding the use of these innovations are largely unknown, particularly among rural and aging populations who may benefit from increased access to care. Objective: The objective of our study was to examine veterans’ attitudes toward smartphone apps and to assess whether openness toward this technology varies by age or rurality. Methods: We conducted semistructured qualitative interviews with 66 veterans from rural and urban areas in Maine, Arkansas, and California. Eligible veterans aged 18 to 70 years had screened positive for postraumatic stress disorder (PTSD), alcohol use disorder, or major depressive disorder, but a history of mental health service utilization was not required. Interviews were digitally recorded, professionally transcribed, and coded by a research team using an established codebook. We then conducted a thematic analysis of segments pertaining to smartphone use, informed by existing theories of technology adoption. Results: Interviews revealed a marked division regarding openness to mental health smartphone apps, such that veterans either expressed strongly positive or negative views about their usage, with few participants sharing ambivalent or neutral opinions. Differences emerged between rural and urban veterans’ attitudes, with rural veterans tending to oppose app usage, describe smartphones as hard to navigate, and cite barriers such as financial limitations and connectivity issues, more so than urban populations. Moreover, rural veterans more often described smartphones as being opposed to their values. Differences did not emerge between younger and older (≥50) veterans regarding beliefs that apps could be effective or compatible with their culture and identity. However, compared with younger veterans, older veterans more often reported not owning a smartphone and described this technology as being difficult to use. Conclusions: Openness toward the use of smartphone apps in mental health treatment may vary based on rurality, and further exploration of the barriers cited by rural veterans is needed to improve access to care. In addition, findings indicate that older patients may be more open to integrating technology into their mental health care than providers might assume, although such patients may have more trouble navigating these devices and may benefit from simplified app designs or smartphone training. Given the strong opinions expressed either for or against smartphone apps, our findings suggest that apps may not be an ideal adjunctive treatment for all patients, but it is important to identify those who are open to and may greatly benefit from this technology. %M 30135050 %R 10.2196/10748 %U http://mhealth.jmir.org/2018/8/e10748/ %U https://doi.org/10.2196/10748 %U http://www.ncbi.nlm.nih.gov/pubmed/30135050 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10277 %T Adapting Coordinated Anxiety Learning and Management for Veterans Affairs Community-Based Outpatient Clinics: Iterative Approach %A Abraham,Traci H %A Marchant-Miros,Kathy %A McCarther,Michael B %A Craske,Michelle G %A Curran,Geoffrey M %A Kearney,Lisa K %A Greene,Carolyn %A Lindsay,Jan A %A Cucciare,Michael A %+ Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, 72114, United States, 1 501 257 1744, Traci.Abraham@va.gov %K therapy %K veterans %K depression %K anxiety disorders %K posttraumatic stress disorder %K PTSD %D 2018 %7 22.08.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: A national priority at the US Department of Veterans Affairs (VA) is to increase the availability and accessibility of evidence-based psychotherapies (EBPs) across all VA medical facilities. Yet many veterans, particularly those who use remote outpatient VA clinics, still do not receive much needed evidence-based treatment. Strategies are needed for supporting mental health providers at rural VA community-based outpatient clinics (CBOCs) as they translate their clinical training to routine practice. The Coordinated Anxiety Learning Management (CALM) program is a computer-delivered program that supports the delivery of cognitive behavioral therapy (CBT) by providers in outpatient settings to patients with depression and anxiety, including posttraumatic stress disorder. Objective: The objectives of our study were to (1) adapt an existing computer-based program to rural VA CBOCs through feedback from key stakeholder focus groups; (2) develop a prototype of the adapted program; and (3) determine the adapted program’s acceptability and feasibility. Mental health stakeholders included VA leaders (n=4) in the implementation of EBPs, VA experts (n=4) in CBT, VA CBOC mental health providers (n=8), and veterans (n=8) diagnosed with a mental health condition treated using the CALM program and receiving treatment in a VA CBOC. Methods: An iterative approach comprising 3 waves of focus group discussions was used to develop a modified prototype of CALM. Following each wave of focus group discussions, template analysis was used to rapidly communicate stakeholder recommendations and feedback to the design team. The original program was first adapted through a process of data collection, design modification, and product development. Next, a prototype was developed. Finally, the redesigned program was tested for acceptability and feasibility through a live demonstration. Results: Key stakeholders suggested modifications to the original CALM program that altered its modules’ appearance by incorporating veteran-centric content. These modifications likely have no impact on the integrity of the original CALM program, but have altered its content to reflect better the demographic characteristics and experiences of rural veterans. Feedback from stakeholder groups indicates that changes will help VA patients identify with the program content, potentially enhancing their treatment engagement. Conclusions: The development model was effective for economically gathering actionable recommendations from stakeholders to adapt a computer-based program, and it can result in the development of an acceptable and feasible computer-delivered intervention. Results have implications for developing computer-based programs targeting behavior change more broadly and enhancing engagement in EBP. %M 30135051 %R 10.2196/10277 %U http://mental.jmir.org/2018/3/e10277/ %U https://doi.org/10.2196/10277 %U http://www.ncbi.nlm.nih.gov/pubmed/30135051 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 8 %P e165 %T Correlations Between Objective Behavioral Features Collected From Mobile and Wearable Devices and Depressive Mood Symptoms in Patients With Affective Disorders: Systematic Review %A Rohani,Darius A %A Faurholt-Jepsen,Maria %A Kessing,Lars Vedel %A Bardram,Jakob E %+ Embedded Systems Engineering, Department of Applied Mathematics and Computer Science, Technical University of Denmark, Richard Petersens Plads, Bldg 324, 1st Floor, Room 160, Kongens Lyngby, 2800, Denmark, 45 61452393, daroh@dtu.dk %K mood disorder %K affective disorder %K depression %K depressive mood symptoms %K bipolar disorder %K objective features %K correlation %K behavior %K sensor data %K mobile phone %K wearable devices %K systematic review %D 2018 %7 13.08.2018 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Several studies have recently reported on the correlation between objective behavioral features collected via mobile and wearable devices and depressive mood symptoms in patients with affective disorders (unipolar and bipolar disorders). However, individual studies have reported on different and sometimes contradicting results, and no quantitative systematic review of the correlation between objective behavioral features and depressive mood symptoms has been published. Objective: The objectives of this systematic review were to (1) provide an overview of the correlations between objective behavioral features and depressive mood symptoms reported in the literature and (2) investigate the strength and statistical significance of these correlations across studies. The answers to these questions could potentially help identify which objective features have shown most promising results across studies. Methods: We conducted a systematic review of the scientific literature, reported according to the preferred reporting items for systematic reviews and meta-analyses guidelines. IEEE Xplore, ACM Digital Library, Web of Sciences, PsychINFO, PubMed, DBLP computer science bibliography, HTA, DARE, Scopus, and Science Direct were searched and supplemented by hand examination of reference lists. The search ended on April 27, 2017, and was limited to studies published between 2007 and 2017. Results: A total of 46 studies were eligible for the review. These studies identified and investigated 85 unique objective behavioral features, covering 17 various sensor data inputs. These features were divided into 7 categories. Several features were found to have statistically significant and consistent correlation directionality with mood assessment (eg, the amount of home stay, sleep duration, and vigorous activity), while others showed directionality discrepancies across the studies (eg, amount of text messages [short message service] sent, time spent between locations, and frequency of mobile phone screen activity). Conclusions: Several studies showed consistent and statistically significant correlations between objective behavioral features collected via mobile and wearable devices and depressive mood symptoms. Hence, continuous and everyday monitoring of behavioral aspects in affective disorders could be a promising supplementary objective measure for estimating depressive mood symptoms. However, the evidence is limited by methodological issues in individual studies and by a lack of standardization of (1) the collected objective features, (2) the mood assessment methodology, and (3) the statistical methods applied. Therefore, consistency in data collection and analysis in future studies is needed, making replication studies as well as meta-analyses possible. %M 30104184 %R 10.2196/mhealth.9691 %U http://mhealth.jmir.org/2018/8/e165/ %U https://doi.org/10.2196/mhealth.9691 %U http://www.ncbi.nlm.nih.gov/pubmed/30104184 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 8 %P e10231 %T Differences in the Effect of Internet-Based Cognitive Behavioral Therapy for Improving Nonclinical Depressive Symptoms Among Workers by Time Preference: Randomized Controlled Trial %A Imamura,Kotaro %A Furukawa,Toshi A %A Matsuyama,Yutaka %A Shimazu,Akihito %A Kuribayashi,Kazuto %A Kasai,Kiyoto %A Kawakami,Norito %+ Department of Mental Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan, 81 3 5841 3522, nkawakami@m.u-tokyo.ac.jp %K internet-based computerized cognitive behavioral therapy %K time preference %K nonclinical depressive symptoms %K workers %D 2018 %7 10.08.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Previous randomized controlled trials (RCTs) have shown a significant intervention effect of internet-based computerized cognitive behavioral therapy (iCBT) on improving nonclinical depressive symptoms among healthy workers and community residents in a primary prevention setting. Time preference is one’s relative valuation for having a reward (eg, money) at present than at a later date. Time preference may affect the effectiveness of cognitive behavioral therapy. Objective: This RCT aimed to test the difference of intervention effect of an iCBT program on improving nonclinical depressive symptoms between two subgroups classified post-hoc on the basis of time preference among workers in Japan. Methods: All workers in one corporate group (approximate n=20,000) were recruited. Participants who fulfilled the inclusion criteria were randomly allocated to either intervention or control groups. Participants in the intervention group completed 6 weekly lessons and homework assignments within the iCBT program. The Beck Depression Inventory-II (BDI-II) and Kessler’s Psychological Distress Scale (K6) measures were obtained at baseline and 3-, 6-, and 12-month follow-ups. Two subgroups were defined by the median of time preference score at baseline. Results: Only few (835/20,000, 4.2%) workers completed the baseline survey. Of the 835 participants, 706 who fulfilled the inclusion criteria were randomly allocated to the intervention or control group. Participants who selected irrational time preference options were excluded (21 and 18 participants in the intervention and control groups, respectively). A three-way interaction (group [intervention/control] × time [baseline/follow-up] × time preference [higher/lower]) effect of iCBT was significant for BDI-II (t1147.42=2.33, P=.02) and K6 (t1254.04=2.51, P=.01) at the 3-month follow-up, with a greater effect of the iCBT in the group with higher time preference. No significant three-way interaction was found at the 6- and 12-month follow-ups. Conclusions: The effects of the iCBT were greater for the group with higher time preference at the shorter follow-up, but it was leveled off later. Workers with higher time preference may change their cognition or behavior more quickly, but these changes may not persist. Trial Registration: UMIN Clinical Trials Registry UMIN000014146; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi? recptno=R000016466 (Archived by WebCite at http://www.webcitation.org/70o2rNk2V) %M 30097419 %R 10.2196/10231 %U http://www.jmir.org/2018/8/e10231/ %U https://doi.org/10.2196/10231 %U http://www.ncbi.nlm.nih.gov/pubmed/30097419 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 8 %P e10130 %T Using Mobile Apps to Assess and Treat Depression in Hispanic and Latino Populations: Fully Remote Randomized Clinical Trial %A Pratap,Abhishek %A Renn,Brenna N %A Volponi,Joshua %A Mooney,Sean D %A Gazzaley,Adam %A Arean,Patricia A %A Anguera,Joaquin A %+ Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, UW Medicine South Lake Union, Building C, Box 358047, 850 Republican Street, Seattle, WA, 98109, United States, 1 206 928 8263, apratap@uw.edu %K mobile apps %K smartphone %K depression %K Hispanics %K Latinos %K clinical trial %K cognition %K problem solving %K mHealth %K minority groups %D 2018 %7 09.08.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Most people with mental health disorders fail to receive timely access to adequate care. US Hispanic/Latino individuals are particularly underrepresented in mental health care and are historically a very difficult population to recruit into clinical trials; however, they have increasing access to mobile technology, with over 75% owning a smartphone. This technology has the potential to overcome known barriers to accessing and utilizing traditional assessment and treatment approaches. Objective: This study aimed to compare recruitment and engagement in a fully remote trial of individuals with depression who either self-identify as Hispanic/Latino or not. A secondary aim was to assess treatment outcomes in these individuals using three different self-guided mobile apps: iPST (based on evidence-based therapeutic principles from problem-solving therapy, PST), Project Evolution (EVO; a cognitive training app based on cognitive neuroscience principles), and health tips (a health information app that served as an information control). Methods: We recruited Spanish and English speaking participants through social media platforms, internet-based advertisements, and traditional fliers in select locations in each state across the United States. Assessment and self-guided treatment was conducted on each participant's smartphone or tablet. We enrolled 389 Hispanic/Latino and 637 non-Hispanic/Latino adults with mild to moderate depression as determined by Patient Health Questionnaire-9 (PHQ-9) score≥5 or related functional impairment. Participants were first asked about their preferences among the three apps and then randomized to their top two choices. Outcomes were depressive symptom severity (measured using PHQ-9) and functional impairment (assessed with Sheehan Disability Scale), collected over 3 months. Engagement in the study was assessed based on the number of times participants completed active surveys. Results: We screened 4502 participants and enrolled 1040 participants from throughout the United States over 6 months, yielding a sample of 348 active users. Long-term engagement surfaced as a key issue among Hispanic/Latino participants, who dropped from the study 2 weeks earlier than their non-Hispanic/Latino counterparts (P<.02). No significant differences were observed for treatment outcomes between those identifying as Hispanic/Latino or not. Although depressive symptoms improved (beta=–2.66, P=.006) over the treatment course, outcomes did not vary by treatment app. Conclusions: Fully remote mobile-based studies can attract a diverse participant pool including people from traditionally underserved communities in mental health care and research (here, Hispanic/Latino individuals). However, keeping participants engaged in this type of “low-touch” research study remains challenging. Hispanic/Latino populations may be less willing to use mobile apps for assessing and managing depression. Future research endeavors should use a user-centered design to determine the role of mobile apps in the assessment and treatment of depression for this population, app features they would be interested in using, and strategies for long-term engagement. Trial Registration: Clinicaltrials.gov NCT01808976; https://clinicaltrials.gov/ct2/show/NCT01808976 (Archived by WebCite at http://www.webcitation.org/70xI3ILkz) %M 30093372 %R 10.2196/10130 %U http://www.jmir.org/2018/8/e10130/ %U https://doi.org/10.2196/10130 %U http://www.ncbi.nlm.nih.gov/pubmed/30093372 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10153 %T Emotion Recognition Using Smart Watch Sensor Data: Mixed-Design Study %A Quiroz,Juan Carlos %A Geangu,Elena %A Yong,Min Hooi %+ Department of Psychology, Sunway University, 5 Jalan Universiti, Bandar Sunway, 47500, Malaysia, 60 374918622, mhyong@sunway.edu.my %K emotion recognition %K accelerometer %K supervised learning %K psychology %D 2018 %7 08.08.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Research in psychology has shown that the way a person walks reflects that person’s current mood (or emotional state). Recent studies have used mobile phones to detect emotional states from movement data. Objective: The objective of our study was to investigate the use of movement sensor data from a smart watch to infer an individual’s emotional state. We present our findings of a user study with 50 participants. Methods: The experimental design is a mixed-design study: within-subjects (emotions: happy, sad, and neutral) and between-subjects (stimulus type: audiovisual “movie clips” and audio “music clips”). Each participant experienced both emotions in a single stimulus type. All participants walked 250 m while wearing a smart watch on one wrist and a heart rate monitor strap on the chest. They also had to answer a short questionnaire (20 items; Positive Affect and Negative Affect Schedule, PANAS) before and after experiencing each emotion. The data obtained from the heart rate monitor served as supplementary information to our data. We performed time series analysis on data from the smart watch and a t test on questionnaire items to measure the change in emotional state. Heart rate data was analyzed using one-way analysis of variance. We extracted features from the time series using sliding windows and used features to train and validate classifiers that determined an individual’s emotion. Results: Overall, 50 young adults participated in our study; of them, 49 were included for the affective PANAS questionnaire and 44 for the feature extraction and building of personal models. Participants reported feeling less negative affect after watching sad videos or after listening to sad music, P<.006. For the task of emotion recognition using classifiers, our results showed that personal models outperformed personal baselines and achieved median accuracies higher than 78% for all conditions of the design study for binary classification of happiness versus sadness. Conclusions: Our findings show that we are able to detect changes in the emotional state as well as in behavioral responses with data obtained from the smartwatch. Together with high accuracies achieved across all users for classification of happy versus sad emotional states, this is further evidence for the hypothesis that movement sensor data can be used for emotion recognition. %M 30089610 %R 10.2196/10153 %U http://mental.jmir.org/2018/3/e10153/ %U https://doi.org/10.2196/10153 %U http://www.ncbi.nlm.nih.gov/pubmed/30089610 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e10131 %T Using Mobile Phone Sensor Technology for Mental Health Research: Integrated Analysis to Identify Hidden Challenges and Potential Solutions %A Boonstra,Tjeerd W %A Nicholas,Jennifer %A Wong,Quincy JJ %A Shaw,Frances %A Townsend,Samuel %A Christensen,Helen %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney,, Australia, 61 2 9382 9285, t.boonstra@unsw.edu.au %K passive sensing %K mental health %K ubiquitous computing %K ethics %K depression %K mobile health %K smartphone %K wearable sensors %D 2018 %7 30.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile phone sensor technology has great potential in providing behavioral markers of mental health. However, this promise has not yet been brought to fruition. Objective: The objective of our study was to examine challenges involved in developing an app to extract behavioral markers of mental health from passive sensor data. Methods: Both technical challenges and acceptability of passive data collection for mental health research were assessed based on literature review and results obtained from a feasibility study. Socialise, a mobile phone app developed at the Black Dog Institute, was used to collect sensor data (Bluetooth, location, and battery status) and investigate views and experiences of a group of people with lived experience of mental health challenges (N=32). Results: On average, sensor data were obtained for 55% (Android) and 45% (iOS) of scheduled scans. Battery life was reduced from 21.3 hours to 18.8 hours when scanning every 5 minutes with a reduction of 2.5 hours or 12%. Despite this relatively small reduction, most participants reported that the app had a noticeable effect on their battery life. In addition to battery life, the purpose of data collection, trust in the organization that collects data, and perceived impact on privacy were identified as main factors for acceptability. Conclusions: Based on the findings of the feasibility study and literature review, we recommend a commitment to open science and transparent reporting and stronger partnerships and communication with users. Sensing technology has the potential to greatly enhance the delivery and impact of mental health care. Realizing this requires all aspects of mobile phone sensor technology to be rigorously assessed. %M 30061092 %R 10.2196/10131 %U http://www.jmir.org/2018/7/e10131/ %U https://doi.org/10.2196/10131 %U http://www.ncbi.nlm.nih.gov/pubmed/30061092 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e15 %T Video Games as a Potential Modality for Behavioral Health Services for Young Adult Veterans: Exploratory Analysis %A Grant,Sean %A Spears,Asya %A Pedersen,Eric R %+ RAND Corporation, 1776 Main Street, Santa Monica, CA,, United States, 1 310 393 0411 ext 6438, sgrant@rand.org %K behavioral health %K replication %K veterans %K video games %D 2018 %7 26.07.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Improving the reach of behavioral health services to young adult veterans is a policy priority. Objective: The objective of our study was to explore differences in video game playing by behavioral health need for young adult veterans to identify potential conditions for which video games could be used as a modality for behavioral health services. Methods: We replicated analyses from two cross-sectional, community-based surveys of young adult veterans in the United States and examined the differences in time spent playing video games by whether participants screened positive for behavioral health issues and received the required behavioral health services. Results: Pooling data across studies, participants with a positive mental health screen for depression or posttraumatic stress disorder (PTSD) spent 4.74 more hours per week (95% CI 2.54-6.94) playing video games. Among participants with a positive screen for a substance use disorder, those who had received substance use services since discharge spent 0.75 more days per week (95% CI 0.28-1.21) playing video games than participants who had not received any substance use services since discharge. Conclusions: We identified the strongest evidence that participants with a positive PTSD or depression screen and participants with a positive screen for a substance use disorder who also received substance use services since their discharge from active duty spent more time playing video games. Future development and evaluation of video games as modalities for enhancing and increasing access to behavioral health services should be explored for this population. %M 30049668 %R 10.2196/games.9327 %U http://games.jmir.org/2018/3/e15/ %U https://doi.org/10.2196/games.9327 %U http://www.ncbi.nlm.nih.gov/pubmed/30049668 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10496 %T For Better or for Worse? A Systematic Review of the Evidence on Social Media Use and Depression Among Lesbian, Gay, and Bisexual Minorities %A Escobar-Viera,César G %A Whitfield,Darren L %A Wessel,Charles B %A Shensa,Ariel %A Sidani,Jaime E %A Brown,Andre L %A Chandler,Cristian J %A Hoffman,Beth L %A Marshal,Michael P %A Primack,Brian A %+ Center for Research on Media, Technology, and Health, School of Medicine, University of Pittburgh, 230 McKee Place, Suite 600.11, Pittsburgh, PA, 15213, United States, 1 412 692 4297, escobar-viera@pitt.edu %K social media %K social networking sites %K sexual minorities %K lesbian %K gay %K bisexual %K depression %K systematic review %D 2018 %7 23.07.2018 %9 Review %J JMIR Ment Health %G English %X Background: Over 90% of adults in the United States have at least one social media account, and lesbian, gay, and bisexual (LGB) persons are more socially active on social media than heterosexuals. Rates of depression among LGB persons are between 1.5- and 2-fold higher than those among their heterosexual counterparts. Social media allows users to connect, interact, and express ideas, emotions, feelings, and thoughts. Thus, social media use might represent both a protective and a risk factor for depression among LGB persons. Studying the nature of the relationship between social media use and depression among LGB individuals is a necessary step to inform public health interventions for this population. Objective: The objective of this systematic review was to synthesize and critique the evidence on social media use and depression among LGB populations. Methods: We conducted a literature search for quantitative and qualitative studies published between January 2003 and June 2017 using 3 electronic databases. Articles were included if they were peer-reviewed, were in English, assessed social media use either quantitatively or qualitatively, measured depression, and focused on LGB populations. A minimum of two authors independently extracted data from each study using an a priori developed abstraction form. We assessed appropriate reporting of studies using the Strengthening the Reporting of Observational Studies in Epidemiology and the Consolidated Criteria for Reporting Qualitative Research for quantitative and qualitative studies, respectively. Results: We included 11 articles in the review; 9 studies were quantitative and cross-sectional and 2 were qualitative. Appropriate reporting of results varied greatly. Across quantitative studies, we found heterogeneity in how social media use was defined and measured. Cyberbullying was the most studied social media experience and was associated with depression and suicidality. Qualitative studies found that while social media provides a space to disclose minority experiences and share ways to cope and get support, constant surveillance of one’s social media profile can become a stressor, potentially leading to depression. In most studies, sexual minority participants were identified inconsistently. Conclusions: This review supports the need for research on the role of social media use on depression outcomes among LBG persons. Using social media may be both a protective and a risk factor for depression among LGB individuals. Support gained via social media may buffer the impact of geographic isolation and loneliness. Negative experiences such as cyberbullying and other patterns of use may be associated with depression. Future research would benefit from more consistent definitions of both social media use and study populations. Moreover, use of larger samples and accounting for patterns of use and individuals’ experiences on social media may help better understand the factors that impact LGB mental health disparities. %M 30037786 %R 10.2196/10496 %U http://mental.jmir.org/2018/3/e10496/ %U https://doi.org/10.2196/10496 %U http://www.ncbi.nlm.nih.gov/pubmed/30037786 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e241 %T Predicting Mood Disturbance Severity with Mobile Phone Keystroke Metadata: A BiAffect Digital Phenotyping Study %A Zulueta,John %A Piscitello,Andrea %A Rasic,Mladen %A Easter,Rebecca %A Babu,Pallavi %A Langenecker,Scott A %A McInnis,Melvin %A Ajilore,Olusola %A Nelson,Peter C %A Ryan,Kelly %A Leow,Alex %+ University of Illinois at Chicago, 1601 W Taylor St, Chicago, IL, 60612, United States, 1 312 996 7383, aleow@psych.uic.edu %K digital phenotype %K mHealth %K ecological momentary assessment %K keystroke dynamics %K bipolar disorder %K depression %K mania %K mobile phone %D 2018 %7 20.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Mood disorders are common and associated with significant morbidity and mortality. Better tools are needed for their diagnosis and treatment. Deeper phenotypic understanding of these disorders is integral to the development of such tools. This study is the first effort to use passively collected mobile phone keyboard activity to build deep digital phenotypes of depression and mania. Objective: The objective of our study was to investigate the relationship between mobile phone keyboard activity and mood disturbance in subjects with bipolar disorders and to demonstrate the feasibility of using passively collected mobile phone keyboard metadata features to predict manic and depressive signs and symptoms as measured via clinician-administered rating scales. Methods: Using a within-subject design of 8 weeks, subjects were provided a mobile phone loaded with a customized keyboard that passively collected keystroke metadata. Subjects were administered the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) weekly. Linear mixed-effects models were created to predict HDRS and YMRS scores. The total number of keystrokes was 626,641, with a weekly average of 9791 (7861), and that of accelerometer readings was 6,660,890, with a weekly average 104,076 (68,912). Results: A statistically significant mixed-effects regression model for the prediction of HDRS-17 item scores was created: conditional R2=.63, P=.01. A mixed-effects regression model for YMRS scores showed the variance accounted for by random effect was zero, and so an ordinary least squares linear regression model was created: R2=.34, P=.001. Multiple significant variables were demonstrated for each measure. Conclusions: Mood states in bipolar disorder appear to correlate with specific changes in mobile phone usage. The creation of these models provides evidence for the feasibility of using passively collected keyboard metadata to detect and monitor mood disturbances. %M 30030209 %R 10.2196/jmir.9775 %U http://www.jmir.org/2018/7/e241/ %U https://doi.org/10.2196/jmir.9775 %U http://www.ncbi.nlm.nih.gov/pubmed/30030209 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e10402 %T The Association Between Increased Levels of Patient Engagement With an Internet Support Group and Improved Mental Health Outcomes at 6-Month Follow-Up: Post-Hoc Analyses From a Randomized Controlled Trial %A Geramita,Emily M %A Herbeck Belnap,Bea %A Abebe,Kaleab Z %A Rothenberger,Scott D %A Rotondi,Armando J %A Rollman,Bruce L %+ Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, United States, 1 412 692 2659, rollmanbl@upmc.edu %K internet support group %K patient engagement %K anxiety %K depression %D 2018 %7 17.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: We recently reported that depressed and anxious primary care patients randomized to a moderated internet support group (ISG) plus computerized cognitive behavioral therapy (cCBT) did not experience improvements in depression and anxiety over cCBT alone at 6-month follow-up. Objective: The 1% rule posits that 1% of participants in online communities generate approximately 90% of new user-created content. The aims of this study were to apply the 1% rule to categorize patient engagement with the ISG and identify whether any patient subgroups benefitted from ISG use. Methods: We categorized the 302 patients randomized to the ISG as: superusers (3/302, 1.0%), top contributors (30/302, 9.9%), contributors (108/302, 35.8%), observers (87/302, 28.8%) and those who never logged in (74/302, 24.5%). We then applied linear mixed models to examine associations between engagement and 6-month changes in health-related quality of life (HRQoL; Short Form Health Survey Mental Health Component, SF-12 MCS) and depression and anxiety symptoms (Patient-Reported Outcomes Measurement Information System, PROMIS). Results: At baseline, participant mean age was 42.6 years, 81.1% (245/302) were female, and mean Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder scale (GAD-7), and SF-12 MCS scores were 13.4, 12.6, and 31.7, respectively. Of the 75.5% (228/302) who logged in, 61.8 % (141/228) created ≥1 post (median 1, interquartile range, IQR 0-5); superusers created 42.3 % (630/1488) of posts (median 246, IQR 78-306), top contributors created 34.6% (515/1488; median 11, IQR 10-18), and contributors created 23.1 % (343/1488; median 3, IQR 1-5). Compared to participants who never logged in, the combined superuser + top contributor subgroup (n=33) reported 6-month improvements in anxiety (PROMIS: –11.6 vs –7.8; P=.04) and HRQoL (SF-12 MCS: 16.1 vs 10.1; P=.01) but not in depression. No other subgroup reported significant symptom improvements. Conclusions: Patient engagement with the ISG was more broadly distributed than predicted by the 1% rule. The 11% of participants with the highest engagement levels reported significant improvements in anxiety and HRQoL. Trial Registration: ClinicalTrials.gov NCT01482806; https://clinicaltrials.gov/ct2/show/NCT01482806 (Archived by WebCite at http://www.webcitation.org/708Bjlge9). %M 30021711 %R 10.2196/10402 %U http://www.jmir.org/2018/7/e10402/ %U https://doi.org/10.2196/10402 %U http://www.ncbi.nlm.nih.gov/pubmed/30021711 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e10139 %T Exploring User Needs for a Mobile Behavioral-Sensing Technology for Depression Management: Qualitative Study %A Meng,Jingbo %A Hussain,Syed Ali %A Mohr,David C %A Czerwinski,Mary %A Zhang,Mi %+ Department of Communication, Michigan State University, , East Lansing, MI,, United States, 1 5173553480, jingbome@msu.edu %K mobile sensing %K mental health %K depression %K counseling %K user-centered design %D 2018 %7 17.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Today, college students are dealing with depression at some of the highest rates in decades. As the primary mental health service provider, university counseling centers are limited in their capacity and efficiency to provide mental health care due to time constraints and reliance on students’ self-reports. A mobile behavioral-sensing platform may serve as a solution to enhance the efficiency and accessibility of university counseling services. Objective: The main objectives of this study are to (1) understand the usefulness of a mobile sensing platform (ie, iSee) in improving counseling services and assisting students’ self-management of their depression conditions, and (2) explore what types of behavioral targets (ie, meaningful information extracted from raw sensor data) and feedback to deliver from both clinician and students’ perspectives. Methods: We conducted semistructured interviews with 9 clinicians and 12 students with depression recruited from a counseling center at a large Midwestern university. The interviews were 40-50 minutes long and were audio recorded and transcribed. The interview data were analyzed using thematic analysis with an inductive approach. Clinician and student interviews were analyzed separately for comparison. The process of extracting themes involved iterative coding, memo writing, theme revisits, and refinement. Results: From the clinician perspective, the mobile sensing platform helps to improve counseling service by providing objective evidence for clinicians and filling gaps in clinician-patient communication. Clinicians suggested providing students with their sensed behavioral targets organized around personalized goals. Clinicians also recommended delivering therapeutic feedback to students based on their sensed behavioral targets, including positive reinforcement, reflection reminders, and challenging negative thoughts. From the student perspective, the mobile sensing platform helps to ease continued self-tracking practices. Students expressed their need for integrated behavioral targets to understand correlations between behaviors and depression. They also pointed out that they would prefer to avoid seeing negative feedback. Conclusions: Although clinician and student participants shared views on the advantages of iSee in supporting university counseling, they had divergent opinions on the types of behavioral targets and feedback to be provided via iSee. This exploratory work gained initial insights into the design of a mobile sensing platform for depression management and informed a more conclusive research project for the future. %M 30021710 %R 10.2196/10139 %U http://www.jmir.org/2018/7/e10139/ %U https://doi.org/10.2196/10139 %U http://www.ncbi.nlm.nih.gov/pubmed/30021710 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e10112 %T Web-Based Intervention Using Behavioral Activation and Physical Activity for Adults With Depression (The eMotion Study): Pilot Randomized Controlled Trial %A Lambert,Jeffrey D %A Greaves,Colin J %A Farrand,Paul %A Price,Lisa %A Haase,Anne M %A Taylor,Adrian H %+ Institute for Health Research, Primary Care, University of Exeter Medical School, Smeall Building, Heavitree Roadd, University of Exeter, Exeter, EX1 2LU, United Kingdom, 44 1392725705, j.d.lambert@exeter.ac.uk %K psychological therapy %K mood %K anxiety %K exercise %K eHealth %K feasibility %K acceptability %D 2018 %7 16.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Physical activity is a potentially effective treatment for depression and depressive relapse. However, promoting physical activity in people with depression is challenging. Interventions informed by theory and evidence are therefore needed to support people with depression to become more physically active. eMotion is a Web-based intervention combining behavioral activation and physical activity promotion for people in the community with symptoms of depression. Objective: The objectives were to assess the feasibility and acceptability of delivering eMotion to people in the community with symptoms of depression and to explore outcomes. Methods: Participants with elevated depressive symptoms were recruited from the community through various methods (eg, social media) and randomized to eMotion or a waiting list control group for 8 weeks. eMotion is an administratively supported weekly modular program that helps people use key behavior change techniques (eg, graded tasks, action planning, and self-monitoring) to re-engage in routine, pleasurable, and necessary activities, with a focus on physical activities. Feasibility data were collected that included the following: recruitment and trial retention rates; fidelity of intervention delivery, receipt, and enactment; and acceptability of the intervention and data collection procedures. Data were collected for the primary (depression) and secondary outcomes (eg, anxiety, physical activity, fidelity, and client satisfaction) at baseline and 2 months postrandomization using self-reported Web-based questionnaires and accelerometers. Delivery fidelity (logins, modules accessed, time spent) was tracked using Web usage statistics. Exploratory analyses were conducted on the primary and secondary outcomes. Results: Of the 183 people who contacted the research team, 62 were recruited and randomized. The mean baseline score was 14.6 (SD 3.2) on the 8-item Patient Health Questionnaire depression scale (PHQ-8). Of those randomized, 52 participants provided accelerometer-recorded physical activity data at baseline that showed a median of 35.8 (interquartile range [IQR] 0.0-98.6) minutes of moderate-to-vigorous physical activity (MVPA) recorded in at least 10-minute bouts per week, with only 13% (7/52) people achieving guideline levels (150 minutes of MVPA per week). In total, 81% (50/62) of participants provided follow-up data for the primary outcome (PHQ-8), but only 39% (24/62) provided follow-up accelerometer data. Within the intervention group, the median number of logins, modules accessed, and total minutes spent on eMotion was 3 (IQR 2.0-8.0), 3 (IQR 2.0-5.0), and 41.3 (IQR 18.9-90.4), respectively. Acceptability was mixed. Exploratory data analysis showed that PHQ-8 levels were lower for the intervention group than for the control group at 2 months postrandomization (adjusted mean difference −3.6, 95% CI −6.1 to −1.1). Conclusions: It was feasible to deliver eMotion in UK communities to inactive populations. eMotion has the potential to be effective and is ready for testing in a full-scale trial. Further work is needed to improve engagement with both the intervention and data collection procedures. Trial Registration: ClinicalTrials.gov NCT03084055; https://clinicaltrials.gov/ct2/show/NCT03084055 (Archived by WebCite at http://www.webcitation.org/6zoyM8UXa) %M 30012547 %R 10.2196/10112 %U http://www.jmir.org/2018/7/e10112/ %U https://doi.org/10.2196/10112 %U http://www.ncbi.nlm.nih.gov/pubmed/30012547 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10200 %T Measurement of Symptom Change Following Web-Based Psychotherapy: Statistical Characteristics and Analytical Methods for Measuring and Interpreting Change %A Karin,Eyal %A Dear,Blake F %A Heller,Gillian Z %A Gandy,Milena %A Titov,Nickolai %+ eCentreClinic, Department of Psychology, Macquarie University, Building C3A, First Walk Macquarie University NSW, Sydney, 2109, Australia, 61 298508657, eyal.karin@mq.edu.au %K clinical measurement %K treatment evaluation %K symptom change %K symptom scales %K psychotherapeutic change %D 2018 %7 12.07.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Accurate measurement of treatment-related change is a key part of psychotherapy research and the investigation of treatment efficacy. For this reason, the ability to measure change with accurate and valid methods is critical for psychotherapy. Objective: The aims of this study were to (1) explore the underlying characteristics of depressive symptom change, measured with the nine-item Patient Health Questionnaire (PHQ-9), following psychotherapy, and (2) compare the suitability of different ways to measure and interpret symptom change. A treatment sample of Web-based psychotherapy participants (n=1098) and a waitlist sample (n=96) were used to (1) explore the statistical characteristics of depressive symptom change, and (2) compare the suitability of two common types of change functions: linear and proportional change. Methods: These objectives were explored using hypotheses that tested (1) the relationship between baseline symptoms and the rate of change, (2) the shape of symptom score distribution following treatment, and (3) measurement error associated with linear and proportional measurement models. Results: Findings demonstrated that (1) individuals with severe depressive baseline symptoms had greater reductions in symptom scores than individuals with mild baseline symptoms (11.4 vs 3.7); however, as a percentage measurement, change remained similar across individuals with mild, moderate, or severe baseline symptoms (50%-55%); (2) positive skewness was observed in PHQ-9 score distributions following treatment; and (3) models that measured symptom change as a proportional function resulted in greater model fit and reduced measurement error (<30%). Conclusions: This study suggests that symptom scales, sharing an implicit feature of score bounding, are associated with a proportional function of change. Selecting statistics that overlook this proportional change (eg, Cohen d) is problematic and leads to (1) artificially increased estimates of change with higher baseline symptoms, (2) increased measurement error, and (3) confounded estimates of treatment efficacy and clinical change. Implications, limitations, and idiosyncrasies from these results are discussed. %M 30001999 %R 10.2196/10200 %U http://mental.jmir.org/2018/3/e10200/ %U https://doi.org/10.2196/10200 %U http://www.ncbi.nlm.nih.gov/pubmed/30001999 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e49 %T Patients’ Experiences of Web- and Mobile-Assisted Group Therapy for Depression and Implications of the Group Setting: Qualitative Follow-Up Study %A Schuster,Raphael %A Sigl,Sophia %A Berger,Thomas %A Laireiter,Anton-Rupert %+ Center for Clinical Psychology, Psychotherapy and Health Psychology, Department of Psychology, University of Salzburg, Hellbrunnerstraße 34, Salzburg, 5020, Austria, 43 6628044 ext 5102, raphael.schuster@sbg.ac.at %K internet %K computer-assisted therapy %K smartphone-assisted therapy %K blended therapy %K cognitive behavioral therapy %K depression %K therapeutic process %K working alliance %D 2018 %7 11.07.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Blended group therapy combines group sessions with Web- and mobile-based treatment modules. Consequently, blended group therapy widens the choice within blended interventions at reasonable costs. This is the first qualitative study on blended group therapy. Objective: The objective of this study was to investigate the patient-centered feasibility of blended group therapy for major depression, with special emphasis on the fit and dynamic interplay between face-to-face and internet-based elements. Methods: A total of 22 patients who had a variety of experiences through participating in one of the two blended group therapy interventions were interviewed following a semistructured interview guide. In-depth interviews were analyzed by three trained psychologists, using thematic analysis and a rule-guided internet-based program (QCAmap). The transcript of the interviews (113,555 words) was reduced to 1081 coded units, with subsequent extraction of 16 themes. Results: Web- and mobile-based elements were described as a treatment facilitator and motivator, increasing the salience and consolidation of cognitive behavioral therapy materials, resulting in in- and inter-session alignment to the treatment. Additionally, patients valued the option of intimate Web-based self-disclosure (by lateral patient-therapist communication), and therapists were provided with tools for between-session monitoring and reinforcement of exercising. In this context, group phenomena seemed to back up therapists’ efforts to increase treatment engagement. The dissonance because of noncompliance with Web-based tasks and the constriction of in-session group interaction were considered as possible negative effects. Finally, issues of tailoring and structure seemed to fulfill different preconditions compared with individual therapy. Conclusions: Blended group therapy constitutes a structured and proactive approach to work with depression, and the integration of both modalities initiates a beneficial interplay. Results support the patient-centered value of blended group therapy and provide the first insight into blended group therapy’s role in fostering therapeutic treatment factors. However, potential negative effects should be considered carefully. %M 29997106 %R 10.2196/mental.9613 %U http://mental.jmir.org/2018/3/e49/ %U https://doi.org/10.2196/mental.9613 %U http://www.ncbi.nlm.nih.gov/pubmed/29997106 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e10078 %T Reaching Those At Risk for Psychiatric Disorders and Suicidal Ideation: Facebook Advertisements to Recruit Military Veterans %A Teo,Alan R %A Liebow,Samuel BL %A Chan,Benjamin %A Dobscha,Steven K %A Graham,Amanda L %+ HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Road (R&D 66), Portland, OR, 97239-2964, United States, 1 503 220 8262 ext 52461, teoa@ohsu.edu %K Facebook %K social media %K methodology %K Veterans Affairs %K veterans %D 2018 %7 05.07.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Younger military veterans are at high risk for psychiatric disorders and suicide. Reaching and engaging veterans in mental health care and research is challenging. Social media platforms may be an effective channel to connect with veterans. Objective: This study tested the effectiveness of Facebook advertisements in reaching and recruiting Iraq and Afghanistan-era military veterans in a research study focused on mental health. Methods: Facebook ads requesting participation in an online health survey ran for six weeks in 2017. Ads varied imagery and headlines. Validated instruments were used to screen for psychiatric disorders and suicidality. Outcomes included impressions, click-through rate, survey completion, and cost per survey completed. Results: Advertisements produced 827,918 impressions, 9,527 clicks, and 587 survey completions. Lack of enrollment in Veterans Affairs health care (193/587, 33%) and positive screens for current mental health problems were common, including posttraumatic stress disorder (266/585, 45%), problematic drinking (243/584, 42%), major depression (164/586, 28%), and suicidality (132/585, 23%). Approximately half of the survey participants (285/587, 49%) were recruited with just 2 of the 15 ads, which showed soldiers marching tied to an “incentive” or “sharing” headline. These 2 ads were also the most cost-effective, at US $4.88 and US $5.90 per participant, respectively. Among veterans with current suicidal ideation, the survey-taking image resulted in higher survey completion than the soldiers marching image (P=.007). Conclusions: Facebook advertisements are effective in rapidly and inexpensively reaching military veterans, including those at risk for mental health problems and suicidality, and those not receiving Veterans Affairs health care. Advertisement image and headlines may help optimize the effectiveness of advertisements for specific subgroups. %M 29980498 %R 10.2196/10078 %U http://mental.jmir.org/2018/3/e10078/ %U https://doi.org/10.2196/10078 %U http://www.ncbi.nlm.nih.gov/pubmed/29980498 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e13 %T Indigenous Adolescents’ Perception of an eMental Health Program (SPARX): Exploratory Qualitative Assessment %A Shepherd,Matthew %A Merry,Sally %A Lambie,Ian %A Thompson,Andrew %+ School of Counselling, Human Services and Social Work, Faculty of Education, The University of Auckland, Gate 4, 60 Epsom Ave, Epsom, Auckland,, New Zealand, 64 9 623 8899 ext 46368, m.shepherd@auckland.ac.nz %K Māori youth %K indigenous %K depression %K computerized CBT %K consumer views %K serious games %K virtual worlds %D 2018 %7 05.07.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a major health issue for indigenous adolescents, yet there is little research conducted about the efficacy and development of psychological interventions for these populations. In New Zealand there is little known about taitamariki (Māori adolescent) opinions regarding the development and effectiveness of psychological interventions, let alone computerized cognitive behavioral therapy. SPARX (Smart, Positive, Active, Realistic, X-factor thoughts) is a computerized intervention developed in New Zealand to treat mild-to-moderate depression in young people. Users are engaged in a virtual 3D environment where they must complete missions to progress to the next level. In each level there are challenges and puzzles to completeIt was designed to appeal to all young people in New Zealand and incorporates several images and concepts that are specifically Māori. Objective: The aim was to conduct an exploratory qualitative study of Māori adolescents’ opinions about the SPARX program. This is a follow-up to an earlier study where taitamariki opinions were gathered to inform the design of a computerized cognitive behavior therapy program. Methods: Taitamariki were interviewed using a semistructured interview once they had completed work with the SPARX resource. Six participants agreed to complete the interview; the interviews ranged from 10 to 30 minutes. Results: Taitamariki participating in the interviews found SPARX to be helpful. The Māori designs from the SPARX game were appropriate and useful, and the ability to customize the SPARX characters with Māori designs was beneficial and appeared to enhance cultural identity. These helped young people to feel engaged with SPARX which, in turn, assisted with the acquisition of relaxation and cognitive restructuring skills. Overall, using SPARX led to improved mood and increased levels of hope for the participants. In some instances, SPARX was used by wider whānau (Māori word for family) members with reported beneficial effect. Conclusions: Overall, this small group of Māori adolescents reported that cultural designs made it easier for them to engage with SPARX, which, in turn, led to an improvement in their mood and gave them hope. Further research is needed about how SPARX could be best used to support the families of these young people. %M 29980495 %R 10.2196/games.8752 %U http://games.jmir.org/2018/3/e13/ %U https://doi.org/10.2196/games.8752 %U http://www.ncbi.nlm.nih.gov/pubmed/29980495 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e10122 %T Data-Driven Learning in High-Resolution Activity Sampling From Patients With Bipolar Depression: Mixed-Methods Study %A Rohani,Darius Adam %A Tuxen,Nanna %A Quemada Lopategui,Andrea %A Kessing,Lars Vedel %A Bardram,Jakob Eyvind %+ Embedded Systems Engineering, Department of Applied Mathematics and Computer Science, Technical University of Denmark, Richard Petersens Plads Bygning 324, Kgs. Lyngby, 2800, Denmark, 45 61452393 ext 45, daroh@dtu.dk %K activities %K behavior %K behavioral activation %K bipolar disorder %K circadian rhythm %K depression %K hourly planning %K psychotherapy %K statistics %D 2018 %7 28.06.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Behavioral activation is a pen and paper-based therapy form for treating depression. The patient registers their activity hourly, and together with the therapist, they agree on a plan to change behavior. However, with the limited clinical personnel, and a growing patient population, new methods are needed to advance behavioral activation. Objective: The objectives of this paper were to (1) automatically identify behavioral patterns through statistical analysis of the paper-based activity diaries, and (2) determine whether it is feasible to move the behavioral activation therapy format to a digital solution. Methods: We collected activity diaries from seven patients with bipolar depression, covering in total 2,480 hours of self-reported activities. A pleasure score, on a 1-10 rating scale, was reported for each activity. The activities were digitalized into 6 activity categories, and statistical analyses were conducted. Results: Across all patients, movement-related activities were associated with the highest pleasure score followed by social activities. On an individual level, through a nonparametric Wilcoxon Signed-Rank test, one patient had a statistically significant larger amount of spare time activities when feeling bad (z=–2.045, P=.041). Through a within-subject analysis of covariance, the patients were found to have a better day than the previous, if that previous day followed their diurnal rhythm (ρ=.265, P=.029). Furthermore, a second-order trend indicated that two hours of daily social activity was optimal for the patients (β2=–0.08, t (63)=–1.22, P=.23). Conclusions: The data-driven statistical approach was able to find patterns within the behavioral traits that could assist the therapist in as well as help design future technologies for behavioral activation. %M 29954726 %R 10.2196/10122 %U http://mental.jmir.org/2018/2/e10122/ %U https://doi.org/10.2196/10122 %U http://www.ncbi.nlm.nih.gov/pubmed/29954726 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e48 %T eMental Healthcare Technologies for Anxiety and Depression in Childhood and Adolescence: Systematic Review of Studies Reporting Implementation Outcomes %A Wozney,Lori %A McGrath,Patrick J %A Gehring,Nicole D %A Bennett,Kathryn %A Huguet,Anna %A Hartling,Lisa %A Dyson,Michele P %A Soleimani,Amir %A Newton,Amanda S %+ Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 3-526 Edmonton Clinic Health Academy, 11405 - 87 Avenue, Edmonton, AB, T6G 1C9, Canada, 1 780 248 5581, mandi.newton@ualberta.ca %K eHealth %K mental health %K implementation science %K healthcare planning %K organizational innovation %K decision-making %K healthcare organizations %D 2018 %7 26.06.2018 %9 Review %J JMIR Ment Health %G English %X Background: Anxiety disorders and depression are frequent conditions in childhood and adolescence. eMental healthcare technologies may improve access to services, but their uptake within health systems is limited. Objective: The objective of this review was to examine and describe how the implementation of eMental healthcare technologies for anxiety disorders and depression in children and adolescents has been studied. Methods: We conducted a search of 5 electronic databases and gray literature. Eligible studies were those that assessed an eMental healthcare technology for treating or preventing anxiety or depression, included children or adolescents (<18 years), or their parents or healthcare providers and reported findings on technology implementation. The methodological quality of studies was evaluated using the Mixed Methods Appraisal Tool. Outcomes of interest were based on 8 implementation outcomes: acceptability (satisfaction with a technology), adoption (technology uptake and utilization), appropriateness (“fitness for purpose”), cost (financial impact of technology implementation), feasibility (extent to which a technology was successfully used), fidelity (implementation as intended), penetration (“spread” or “reach” of the technology), and sustainability (maintenance or integration of a technology within a healthcare service). For extracted implementation outcome data, we coded favorable ratings on measurement scales as “positive results” and unfavorable ratings on measurement scales as “negative results.” Those studies that reported both positive and negative findings were coded as having “mixed results.” Results: A total of 46 studies met the inclusion criteria, the majority of which were rated as very good to excellent in methodological quality. These studies investigated eMental healthcare technologies for anxiety (n=23), depression (n=18), or both anxiety and depression (n=5). Studies of technologies for anxiety evaluated the following: (1) acceptability (78%) reported high levels of satisfaction, (2) adoption (43%) commonly reported positive results, and (3) feasibility (43%) reported mixed results. Studies of technologies for depression evaluated the following: (1) appropriateness (56%) reported moderate helpfulness and (2) acceptability (50%) described a mix of both positive and negative findings. Studies of technologies designed to aid anxiety and depression commonly reported mixed experiences with acceptability and adoption and positive findings for appropriateness of the technologies for treatment. Across all studies, cost, fidelity, and penetration and sustainability were the least measured implementation outcomes. Conclusions: Acceptability of eMental healthcare technology is high among users and is the most commonly investigated implementation outcome. Perceptions of the appropriateness and adoption of eMental healthcare technology were varied. Implementation research that identifies, evaluates, and reports on costs, sustainability, and fidelity to clinical guidelines is crucial for making high-quality eMental healthcare available to children and adolescents. %M 29945858 %R 10.2196/mental.9655 %U http://mental.jmir.org/2018/2/e48/ %U https://doi.org/10.2196/mental.9655 %U http://www.ncbi.nlm.nih.gov/pubmed/29945858 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e10732 %T Efficacy of Acceptance and Commitment Therapy in Reducing Suicidal Ideation and Deliberate Self-Harm: Systematic Review %A Tighe,Joseph %A Nicholas,Jennifer %A Shand,Fiona %A Christensen,Helen %+ Black Dog Institute, School of Psychiatry, University of New South Wales, Hospital Road, Randwick, Sydney, 2031, Australia, 61 416747998, j.tighe@blackdog.org.au %K suicidal ideation %K suicide %K deliberate self-harm %K depression %K mental health %K acceptance and commitment therapy %K cognitive behavioral therapy %K mHealth %K psychology %K ACT %D 2018 %7 25.06.2018 %9 Review %J JMIR Ment Health %G English %X Background: Since its emergence in the 1980s, acceptance and commitment therapy (ACT) has become a reputable evidence-based psychological therapy for certain disorders. Trials examining the efficacy of ACT are spread across a broad spectrum of presentations, such as chronic pain, anxiety, and depression. Nevertheless, ACT has very rarely been trialed as an intervention for suicidal ideation (SI) or deliberate self-harm (DSH). Objective: The objective of this review is to assess the efficacy of ACT in reducing SI and DSH and to examine the suitability of reported SI, DSH, and other measures in determining the efficacy of ACT. Methods: We systematically reviewed studies on ACT as intervention for SI and self-harm. Electronic databases, including MEDLINE, PubMed, EMBASE, PsycINFO, SCOPUS, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, were searched. The reference lists of included studies and relevant systematic reviews were examined to identify additional publications. Search terms were identified with reference to the terminology used in previous review papers on ACT and suicide prevention. The study design was not restricted to randomized controlled trials. Screening was completed by 2 reviewers, and all duplicates were removed. Publications were excluded if they were not published in English, were multicomponent therapy or were not based on ACT, or lacked a validated measure or structured reporting of SI/DSH outcomes. Results: After removing the duplicates, 554 articles were screened for relevance. Following the screening, 5 studies that used ACT as an intervention for suicidal or self-harming individuals were identified. The studies used diverse methodologies and included 2 case studies, 2 pre–post studies, and 1 mHealth randomized controlled trial. Conclusions: The review found that ACT is effective in reducing SI in the 2 pre–post studies but not in other studies. However, given the small number and lack of methodological rigor of the studies included in this review, insufficient evidence exists for the recommendation of ACT as an intervention for SI or DSH. %M 29941419 %R 10.2196/10732 %U http://mental.jmir.org/2018/2/e10732/ %U https://doi.org/10.2196/10732 %U http://www.ncbi.nlm.nih.gov/pubmed/29941419 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 6 %P e161 %T Prospective Epidemiological Research on Functioning Outcomes Related to Major Depressive Disorder in Japan (PERFORM-J): Protocol for a Prospective Cohort Study %A Sumiyoshi,Tomiki %A Watanabe,Koichiro %A Noto,Shinichi %A Sakamoto,Shigeru %A Moriguchi,Yoshiya %A Okamoto,Shuichi %+ Department of Preventive Intervention for Psychiatric Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi, Kodaira, Tokyo, 187-8551, Japan, 81 42 341 2711, sumiyot@ncnp.go.jp %K antidepressants %K depression %K major depressive disorder %K cognitive dysfunction %K observational study %D 2018 %7 25.06.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Patients with major depressive disorder may exhibit cognitive dysfunction that can affect functional outcomes. However, the prevalence and burden of cognitive dysfunction in Japanese patients with MDD have not been thoroughly examined. Objective: To investigate the time course (over 6 months) of several functional outcomes during treatment with antidepressants in Japanese patients with major depressive disorder. The primary objective is to assess longitudinal changes in cognitive function and depressive symptoms, using both clinician-rated and patient-rated scales. The study incorporates assessments of cognitive function and other functional outcomes (functional capacity, disability, work productivity and impairments of activity, and quality of life), as well as depressive symptoms. Methods: PERFORM-J (Prospective Epidemiological Research on Functioning Outcomes Related to Major Depressive Disorder in Japan) is a 6-month, prospective, multi-center, epidemiological cohort study. Participants are Japanese outpatients aged 18-65 years with a recurrent or new diagnosis of a major depressive episode (according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision [DSM-IV-TR]), who are initiating a new antidepressant as monotherapy (either as first-line therapy or after switching from a previous antidepressant). Eligible patients are evaluated objectively during four visits (at baseline and at Months 1, 2, and 6) using physician-rated assessments of severity of depressive symptoms, cognitive function, and functional capacity. Subjective, patient-reported, outcomes are also assessed as indicators of depressive symptoms, disability, work productivity or impairments of activity, and perceived cognitive dysfunction. Results: The study began in September 2016. Patient enrollment was completed on June 30, 2017, with 523 patients having been enrolled from 48 study sites. As of October, 2017, 279 patients had completed the study. Conclusions: PERFORM-J is expected to provide valuable information on the longitudinal relationship between cognitive dysfunction, depressive symptoms, and other functional outcomes in Japanese patients with major depressive disorder who initiate monotherapy with antidepressants. Trial Registration: UMIN Clinical Trials Registry UMIN000024320; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi? recptno=R000028011 (Archived by WebCite at http://www.webcitation.org/70K7W9PgC). Registered Report Identifier: RR1-10.2196/9682 %M 29941418 %R 10.2196/resprot.9682 %U http://www.researchprotocols.org/2018/6/e161/ %U https://doi.org/10.2196/resprot.9682 %U http://www.ncbi.nlm.nih.gov/pubmed/29941418 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e10144 %T Using Neural Networks with Routine Health Records to Identify Suicide Risk: Feasibility Study %A DelPozo-Banos,Marcos %A John,Ann %A Petkov,Nicolai %A Berridge,Damon Mark %A Southern,Kate %A LLoyd,Keith %A Jones,Caroline %A Spencer,Sarah %A Travieso,Carlos Manuel %+ Swansea University, Swansea University Medical School, Institute of Life Science 2, 3rd Floor, Swansa University Singleton Park Campus, Swansea, SA2 8PP, United Kingdom, 44 1792604094, M.DelPozoBanos@swansea.ac.uk %K suicide prevention %K risk assessment %K electronic health records %K routine data %K machine learning %K artificial neural networks %D 2018 %7 22.06.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Each year, approximately 800,000 people die by suicide worldwide, accounting for 1–2 in every 100 deaths. It is always a tragic event with a huge impact on family, friends, the community and health professionals. Unfortunately, suicide prevention and the development of risk assessment tools have been hindered by the complexity of the underlying mechanisms and the dynamic nature of a person’s motivation and intent. Many of those who die by suicide had contact with health services in the preceding year but identifying those most at risk remains a challenge. Objective: To explore the feasibility of using artificial neural networks with routinely collected electronic health records to support the identification of those at high risk of suicide when in contact with health services. Methods: Using the Secure Anonymised Information Linkage Databank UK, we extracted the data of those who died by suicide between 2001 and 2015 and paired controls. Looking at primary (general practice) and secondary (hospital admissions) electronic health records, we built a binary feature vector coding the presence of risk factors at different times prior to death. Risk factors included: general practice contact and hospital admission; diagnosis of mental health issues; injury and poisoning; substance misuse; maltreatment; sleep disorders; and the prescription of opiates and psychotropics. Basic artificial neural networks were trained to differentiate between the suicide cases and paired controls. We interpreted the output score as the estimated suicide risk. System performance was assessed with 10x10-fold repeated cross-validation, and its behavior was studied by representing the distribution of estimated risk across the cases and controls, and the distribution of factors across estimated risks. Results: We extracted a total of 2604 suicide cases and 20 paired controls per case. Our best system attained a mean error rate of 26.78% (SD 1.46; 64.57% of sensitivity and 81.86% of specificity). While the distribution of controls was concentrated around estimated risks < 0.5, cases were almost uniformly distributed between 0 and 1. Prescription of psychotropics, depression and anxiety, and self-harm increased the estimated risk by ~0.4. At least 95% of those presenting these factors were identified as suicide cases. Conclusions: Despite the simplicity of the implemented system, the proposed methodology obtained an accuracy like other published methods based on specialized questionnaire generated data. Most of the errors came from the heterogeneity of patterns shown by suicide cases, some of which were identical to those of the paired controls. Prescription of psychotropics, depression and anxiety, and self-harm were strongly linked with higher estimated risk scores, followed by hospital admission and long-term drug and alcohol misuse. Other risk factors like sleep disorders and maltreatment had more complex effects. %M 29934287 %R 10.2196/10144 %U http://mental.jmir.org/2018/2/e10144/ %U https://doi.org/10.2196/10144 %U http://www.ncbi.nlm.nih.gov/pubmed/29934287 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 6 %P e215 %T Detecting Suicidal Ideation on Forums: Proof-of-Concept Study %A Aladağ,Ahmet Emre %A Muderrisoglu,Serra %A Akbas,Naz Berfu %A Zahmacioglu,Oguzhan %A Bingol,Haluk O %+ Department of Computer Engineering, Bogazici University, Bebek, Istanbul, 34342, Turkey, 90 2123594523, emre.aladag@boun.edu.tr %K suicide %K suicidal ideation %K suicidality %K detection %K prevention %K classification model %K text mining %K machine learning %K artificial intelligence %K suicidal surveillance %D 2018 %7 21.06.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: In 2016, 44,965 people in the United States died by suicide. It is common to see people with suicidal ideation seek help or leave suicide notes on social media before attempting suicide. Many prefer to express their feelings with longer passages on forums such as Reddit and blogs. Because these expressive posts follow regular language patterns, potential suicide attempts can be prevented by detecting suicidal posts as they are written. Objective: This study aims to build a classifier that differentiates suicidal and nonsuicidal forum posts via text mining methods applied on post titles and bodies. Methods: A total of 508,398 Reddit posts longer than 100 characters and posted between 2008 and 2016 on SuicideWatch, Depression, Anxiety, and ShowerThoughts subreddits were downloaded from the publicly available Reddit dataset. Of these, 10,785 posts were randomly selected and 785 were manually annotated as suicidal or nonsuicidal. Features were extracted using term frequency-inverse document frequency, linguistic inquiry and word count, and sentiment analysis on post titles and bodies. Logistic regression, random forest, and support vector machine (SVM) classification algorithms were applied on resulting corpus and prediction performance is evaluated. Results: The logistic regression and SVM classifiers correctly identified suicidality of posts with 80% to 92% accuracy and F1 score, respectively, depending on different data compositions closely followed by random forest, compared to baseline ZeroR algorithm achieving 50% accuracy and 66% F1 score. Conclusions: This study demonstrated that it is possible to detect people with suicidal ideation on online forums with high accuracy. The logistic regression classifier in this study can potentially be embedded on blogs and forums to make the decision to offer real-time online counseling in case a suicidal post is being written. %M 29929945 %R 10.2196/jmir.9840 %U http://www.jmir.org/2018/6/e215/ %U https://doi.org/10.2196/jmir.9840 %U http://www.ncbi.nlm.nih.gov/pubmed/29929945 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 6 %P e10001 %T Comparing Approaches to Mobile Depression Assessment for Measurement-Based Care: Prospective Study %A Bauer,Amy M %A Baldwin,Scott A %A Anguera,Joaquin A %A Areán,Patricia A %A Atkins,David C %+ Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Box 356560, Seattle, WA, 98195 6560, United States, 1 2062218385, abauer1@uw.edu %K Patient Health Questionnaire %K depression %K mobile health %K symptom assessment %D 2018 %7 19.06.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: To inform measurement-based care, practice guidelines suggest routine symptom monitoring, often on a weekly or monthly basis. Increasingly, patient-provider contacts occur remotely (eg, by telephone and Web-based portals), and mobile health tools can now monitor depressed mood daily or more frequently. However, the reliability and utility of daily ratings are unclear. Objective: This study aimed to examine the association between a daily depressive symptom measure and the Patient Health Questionnaire-9 (PHQ-9), the most widely adopted depression self-report measure, and compare how well these 2 assessment methods predict patient outcomes. Methods: A total of 547 individuals completed smartphone-based measures, including the Patient Health Questionnaire-2 (PHQ-2) modified for daily administration, the PHQ-9, and the Sheehan Disability Scale. Multilevel factor analyses evaluated the reliability of latent depression based on the PHQ-2 (for repeated measures) between weeks 2 and 4 and its correlation with the PHQ-9 at week 4. Regression models predicted week 8 depressive symptoms and disability ratings with daily PHQ-2 and PHQ-9. Results: The daily PHQ-2 and PHQ-9 are highly reliable (range: 0.80-0.88) and highly correlated (r=.80). Findings were robust across demographic groups (age, gender, and ethnic minority status). Daily PHQ-2 and PHQ-9 were comparable in predicting week 8 disability and were independent predictors of week 8 depressive symptoms and disability, though the unique contribution of the PHQ-2 was small in magnitude. Conclusions: Daily completion of the PHQ-2 is a reasonable proxy for the PHQ-9 and is comparable to the PHQ-9 in predicting future outcomes. Mobile assessment methods offer researchers and clinicians reliable and valid new methods for depression assessment that may be leveraged for measurement-based depression care. %M 29921564 %R 10.2196/10001 %U http://www.jmir.org/2018/6/e10001/ %U https://doi.org/10.2196/10001 %U http://www.ncbi.nlm.nih.gov/pubmed/29921564 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e12 %T Investigating Associations Between Changes in Mobile Phone Use and Emotions Using the Experience Sampling Method: Pilot Study %A Roggeveen,Suzanne %A van Os,Jim %A Bemelmans,Kelly %A van Poll,Mikal %A Lousberg,Richel %+ Department of Psychiatry and Psychology, Maastricht University, Vijverdalseweg 1, Maastricht,, Netherlands, 31 43 3884111, s.roggeveen@maastrichtuniversity.nl %K mobile phone %K experience sampling method %K emotions %K affect %K concentration %D 2018 %7 18.06.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The use of mobile phones has become, especially for young people, an integrated part of everyday life. Using the experience sampling method (ESM) may provide further insight on the association between mobile phone use and mental health. Objective: The objective of this study was to examine associations between mobile phone use and subtle changes in mental state. Methods: The ESM-based PsyMate app was installed on the mobile phones of 2 healthy 20-year-old participants. Over a period of 3 months, participants rated their mental states at 10 semirandom moments in the flow of daily life. Each assessment included present state emotions, environmental circumstances, and phone use. Results: Multilevel regression analyses indicated that an increase in mobile phone use was associated with a small increase in negative affect (particularly feeling bored and feeling lonely; P<.001) and small decreases in positive affect (P=.002) and concentration (P=.001). Treating the data as 2 separate N=1 studies revealed that the association with negative affect was present in both participants, whereas the associations with positive affect and concentration were evident in only 1 of the 2 participants. Conclusions: This pilot study suggests that mobile phone use may be associated with person-specific and group-level changes in emotional state. A larger study is required to study these associations, possible causality, and factors driving underlying heterogeneity in the pattern of associations. Trial registration: ClinicalTrials.gov NCT03221985; https://clinicaltrials.gov/ct2/show/NCT03221985 (archived by WebCite at http://www.webcitation.org/6zJnp61Wj) %M 30684428 %R 10.2196/formative.8499 %U http://formative.jmir.org/2018/1/e12/ %U https://doi.org/10.2196/formative.8499 %U http://www.ncbi.nlm.nih.gov/pubmed/30684428 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 6 %P e139 %T Smartphone Apps for Mindfulness Interventions for Suicidality in Asian Youths: Literature Review %A Choo,Carol C %A Burton,André AD %+ James Cook University, 149 Sims Drive, Singapore,, Singapore, 65 67093760, carol.choo@jcu.edu.au %K suicidality %K Asian youths %K smartphone applications %K mindfulness %D 2018 %7 07.06.2018 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: The advent of mobile technology has ushered in an era in which smartphone apps can be used as interventions for suicidality. Objective: We aimed to review recent research that is relevant to smartphone apps that can be used for mindfulness interventions for suicidality in Asian youths. Methods: The inclusion criteria for this review were: papers published in peer-reviewed journals from 2007 to 2017 with usage of search terms (namely “smartphone application” and “mindfulness”) and screened by an experienced Asian clinician to be of clinical utility for mindfulness interventions for suicidality with Asian youths. Results: The initial search of databases yielded 375 results. Fourteen full text papers that fit the inclusion criteria were assessed for eligibility and 10 papers were included in the current review. Conclusions: This review highlighted the paucity of evidence-based and empirically validated research into effective smartphone apps that can be used for mindfulness interventions for suicidality with Asian youths. %R 10.2196/mhealth.8304 %U http://mhealth.jmir.org/2018/6/e139/ %U https://doi.org/10.2196/mhealth.8304 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 6 %P e10120 %T User Experience of Cognitive Behavioral Therapy Apps for Depression: An Analysis of App Functionality and User Reviews %A Stawarz,Katarzyna %A Preist,Chris %A Tallon,Debbie %A Wiles,Nicola %A Coyle,David %+ Bristol Interaction Group, Faculty of Engineering, University of Bristol, Merchant Venturers Building, Woodland Road, Bristol, BS8 1UB, United Kingdom, 44 1179545289, k.stawarz@bristol.ac.uk %K mental health %K mobile apps %K cognitive behavioral therapy %K depression %K user experience %K mHealth %D 2018 %7 06.06.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Hundreds of mental health apps are available to the general public. With increasing pressures on health care systems, they offer a potential way for people to support their mental health and well-being. However, although many are highly rated by users, few are evidence-based. Equally, our understanding of what makes apps engaging and valuable to users is limited. Objective: The aim of this paper was to analyze functionality and user opinions of mobile apps purporting to support cognitive behavioral therapy for depression and to explore key factors that have an impact on user experience and support engagement. Methods: We systematically identified apps described as being based on cognitive behavioral therapy for depression. We then conducted 2 studies. In the first, we analyzed the therapeutic functionality of apps. This corroborated existing work on apps’ fidelity to cognitive behavioral therapy theory, but we also extended prior work by examining features designed to support user engagement. Engagement features found in cognitive behavioral therapy apps for depression were compared with those found in a larger group of apps that support mental well-being in a more general sense. Our second study involved a more detailed examination of user experience, through a thematic analysis of publicly available user reviews of cognitive behavioral therapy apps for depression. Results: We identified 31 apps that purport to be based on cognitive behavioral therapy for depression. Functionality analysis (study 1) showed that they offered an eclectic mix of features, including many not based on cognitive behavioral therapy practice. Cognitive behavioral therapy apps used less varied engagement features compared with 253 other mental well-being apps. The analysis of 1287 user reviews of cognitive behavioral therapy apps for depression (study 2) showed that apps are used in a wide range of contexts, both replacing and augmenting therapy, and allowing users to play an active role in supporting their mental health and well-being. Users, including health professionals, valued and used apps that incorporated both core cognitive behavioral therapy and non-cognitive behavioral therapy elements, but concerns were also expressed regarding the unsupervised use of apps. Positivity was seen as important to engagement, for example, in the context of automatic thoughts, users expressed a preference to capture not just negative but also positive ones. Privacy, security, and trust were crucial to the user experience. Conclusions: Cognitive behavioral therapy apps for depression need to improve with respect to incorporating evidence-based cognitive behavioral therapy elements. Equally, a positive user experience is dependent on other design factors, including consideration of varying contexts of use. App designers should be able to clearly identify the therapeutic basis of their apps, but they should also draw on evidence-based strategies to support a positive and engaging user experience. The most effective apps are likely to strike a balance between evidence-based cognitive behavioral therapy strategies and evidence-based design strategies, including the possibility of eclectic therapeutic techniques. %R 10.2196/10120 %U http://www.jmir.org/2018/6/e10120/ %U https://doi.org/10.2196/10120 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 6 %P e199 %T Beyond the Trial: Systematic Review of Real-World Uptake and Engagement With Digital Self-Help Interventions for Depression, Low Mood, or Anxiety %A Fleming,Theresa %A Bavin,Lynda %A Lucassen,Mathijs %A Stasiak,Karolina %A Hopkins,Sarah %A Merry,Sally %+ Faculty of Health, Victoria University of Wellington, Kelburn Parade, Wellington,, New Zealand, 64 800 842 8888, terry.fleming@vuw.ac.nz %K e-therapy %K mobile applications %K eHealth %K depression %K anxiety %D 2018 %7 06.06.2018 %9 Review %J J Med Internet Res %G English %X Background: Digital self-help interventions (including online or computerized programs and apps) for common mental health issues have been shown to be appealing, engaging, and efficacious in randomized controlled trials. They show potential for improving access to therapy and improving population mental health. However, their use in the real world, ie, as implemented (disseminated) outside of research settings, may differ from that reported in trials, and implementation data are seldom reported. Objective: This study aimed to review peer-reviewed articles reporting user uptake and/or ongoing use, retention, or completion data (hereafter usage data or, for brevity, engagement) from implemented pure self-help (unguided) digital interventions for depression, anxiety, or the enhancement of mood. Methods: We conducted a systematic search of the Scopus, Embase, MEDLINE, and PsychINFO databases for studies reporting user uptake and/or usage data from implemented digital self-help interventions for the treatment or prevention of depression or anxiety, or the enhancement of mood, from 2002 to 2017. Additionally, we screened the reference lists of included articles, citations of these articles, and the titles of articles published in Internet Interventions, Journal of Medical Internet Research (JMIR), and JMIR Mental Health since their inception. We extracted data indicating the number of registrations or downloads and usage of interventions. Results: After the removal of duplicates, 970 papers were identified, of which 10 met the inclusion criteria. Hand searching identified 1 additional article. The included articles reported on 7 publicly available interventions. There was little consistency in the measures reported. The number of registrants or downloads ranged widely, from 8 to over 40,000 per month. From 21% to 88% of users engaged in at least minimal use (eg, used the intervention at least once or completed one module or assessment), whereas 7-42% engaged in moderate use (completing between 40% and 60% of modular fixed-length programs or continuing to use apps after 4 weeks). Indications of completion or sustained use (completion of all modules or the last assessment or continuing to use apps after six weeks or more) varied from 0.5% to 28.6%. Conclusions: Available data suggest that uptake and engagement vary widely among the handful of implemented digital self-help apps and programs that have reported this, and that usage may vary from that reported in trials. Implementation data should be routinely gathered and reported to facilitate improved uptake and engagement, arguably among the major challenges in digital health. %R 10.2196/jmir.9275 %U http://www.jmir.org/2018/6/e199/ %U https://doi.org/10.2196/jmir.9275 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 6 %P e10494 %T A Self-Paced, Web-Based, Positive Emotion Skills Intervention for Reducing Symptoms of Depression: Protocol for Development and Pilot Testing of MARIGOLD %A Cheung,Elaine O %A Addington,Elizabeth L %A Bassett,Sarah M %A Schuette,Stephanie A %A Shiu,Eva W %A Cohn,Michael A %A Leykin,Yan %A Saslow,Laura R %A Moskowitz,Judith T %+ Department of Medical Social Sciences, Osher Center for Integrative Medicine, Northwestern University Feinberg School of Medicine, 625 N Michigan, Suite #2700, Chicago, IL, 60611, United States, 1 3125034388, elaine-cheung@northwestern.edu %K emotions %K depression %K telemedicine %K happiness %K mobile apps %D 2018 %7 05.06.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Living with elevated symptoms of depression can have debilitating consequences for an individual’s psychosocial and physical functioning, quality of life, and health care utilization. A growing body of evidence demonstrates that skills for increasing positive emotion can be helpful to individuals with depression. Although Web-based interventions to reduce negative emotion in individuals with depression are available, these interventions frequently suffer from poor retention and adherence and do not capitalize on the potential benefits of increasing positive emotion. Objective: The aim of this study was to develop and test a Web-based positive emotion skills intervention tailored for individuals living with elevated depressive symptoms, as well as to develop and test enhancement strategies for increasing retention and adherence to that intervention. Methods: This study protocol describes the development and testing for Mobile Affect Regulation Intervention with the Goal of Lowering Depression (MARIGOLD), a Web-based positive emotion skills intervention, adapted for individuals with elevated depressive symptomatology. The intervention development is taking place in three phases. In phase 1, we are tailoring an existing positive emotion skills intervention for individuals with elevated symptoms of depression and are pilot testing the tailored version of the intervention in a randomized controlled trial with two control conditions (N=60). In phase 2, we are developing and testing three enhancements aimed at boosting retention and adherence to the Web-based intervention (N=75): facilitator contact, an online discussion board, and virtual badges. In phase 3, we are conducting a multifactorial, nine-arm pilot trial (N=600) to systematically test these enhancement strategies, individually and in combination. The primary outcome is depressive symptom severity. Secondary outcomes include positive and negative emotion, psychological well-being, and coping resources. Results: The project was funded in August 2014, and data collection was completed in May 2018. Data analysis is currently under way, and the first results are expected to be submitted for publication in 2018. Conclusions: Findings from this investigation will enable us to develop an optimal package of intervention content and enhancement strategies for individuals with elevated symptoms of depression. If this intervention proves to be effective, it will provide a cost-effective, anonymous, appealing, and flexible approach for reducing symptoms of depression and improving psychological adjustment through increasing positive emotion. Trial Registration: ClinicalTrials.gov NCT01964820 (Phase 1); https://clinicaltrials.gov/ct2/show/NCT01964820 (Archived by WebCite at http://www.webcitation.org/6zpmKBcyX). ClinicalTrials.gov NCT02861755 (Phase 2); https://clinicaltrials.gov/ct2/show/NCT02861755 (Archived by WebCite at http://www.webcitation.org/6zpmLmy8k). Registered Report Identifier: RR1-10.2196/10494 %R 10.2196/10494 %U http://www.researchprotocols.org/2018/6/e10494/ %U https://doi.org/10.2196/10494 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e10425 %T Mobile Phone Intervention to Reduce Youth Suicide in Rural Communities: Field Test %A Pisani,Anthony R %A Wyman,Peter A %A Gurditta,Kunali %A Schmeelk-Cone,Karen %A Anderson,Carolyn L %A Judd,Emily %+ Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Box PSYC, 300 Crittenden Boulevard, Rochester, NY, 14642, United States, 1 (585) 275 3644, anthony_pisani@urmc.rochester.edu %K suicide prevention %K school-based program %K text messaging %K school health services %D 2018 %7 31.05.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide is a leading cause of death among 10- to 19-year-olds in the United States, with 5% to 8% attempting suicide each year. Suicide risk rises significantly during early adolescence and is higher in rural and underserved communities. School-based universal prevention programs offer a promising way of reducing suicide by providing strategies for emotion regulation and encouraging help-seeking behaviors and youth-adult connectedness. However, such programs frequently run into difficulties in trying to engage a broad range of students. Text messaging is a dominant medium of communication among youths, and studies show both efficacy and uptake in text messaging interventions aimed at adolescents. Text-based interventions may, thus, offer a means for school-based universal prevention programs to engage adolescents who would otherwise be difficult to reach. Objective: We field tested Text4Strength, an automated, interactive text messaging intervention that seeks to reach a broad range of early adolescents in rural communities. Text4Strength extends Sources of Strength, a peer-led school suicide prevention program, by encouraging emotion regulation, help-seeking behaviors, and youth-adult connectedness in adolescents. The study tested the appeal and feasibility of Text4Strength and its potential to extend universal school-based suicide prevention. Methods: We field tested Text4Strength with 42 ninth-grade students. Over 9 weeks, students received 28 interactive message sequences across 9 categories (Sources of Strength introduction, positive friend, mentors, family support, healthy activities, generosity, spirituality, medical access, and emotion regulation strategies). The message sequences included games, requests for advice, questions about students’ own experiences, and peer testimonial videos. We measured baseline mental health characteristics, frequency of replies, completion of sequences and video viewing, appeal to students, and their perception of having benefited from the program. Results: Of the 42 participating students, 38 (91%) responded to at least one sequence and 22 (52%) responded to more than a third of the sequences. The proportion of students who completed multistep sequences they had started ranged from 35% (6/17) to 100% (3/3 to 28/28), with responses dropping off when more than 4 replies were needed. With the exception of spirituality and generosity, each of the content areas generated at least a moderate number of student replies from both boys and girls. Students with higher and lower levels of risk and distress interacted with the sequences at similar rates. Contrary to expectations, few students watched videos. Students viewed the intervention as useful—even those who rarely responded to messages. More than 70% found the texts useful (3 items, n range 29-34) and 90% (36) agreed the program should be repeated. Conclusions: Text4Strength offers a potentially engaging way to extend school-based interventions that promote protective factors for suicide. Text4Strength is ready to be revised, based on findings and student feedback from this field test, and rigorously tested for efficacy. %R 10.2196/10425 %U http://mental.jmir.org/2018/2/e10425/ %U https://doi.org/10.2196/10425 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e36 %T A Web-Based Transdiagnostic Intervention for Affective and Mood Disorders: Randomized Controlled Trial %A Tulbure,Bogdan Tudor %A Rusu,Andrei %A Sava,Florin Alin %A Sălăgean,Nastasia %A Farchione,Todd J %+ Psychology Department, West University of Timisoara, Blvd. V. Parvan 4, Timisoara, 300134, Romania, 40 0 745753061, bogdan.tulbure@e-uvt.ro %K transdiagnostic %K anxiety disorders %K depressive disorder %K cognitive therapy %D 2018 %7 24.05.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Research increasingly supports a transdiagnostic conceptualization of emotional disorders (ie applying the same underlying treatment principles across mental disorders, without tailoring the protocol to specific diagnoses), and many international researchers are currently investigating this issue. Objective: The aim of this study was to evaluate the efficacy and acceptability of a Web-based transdiagnostic program using a sample of Romanian adults diagnosed with anxiety and/or depression. Methods: Volunteer participants registered for the study and completed a series of online self-report measures. Participants who fulfilled basic inclusion criteria on these measures were contacted for a telephone diagnostic interview using the Structural Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Axis I Disorders (SCID-I). Enrolled participants were randomized to either the active treatment group (N=69) or the wait-list control group (N=36) using a 2:1 ratio. The transdiagnostic treatment was based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP; Barlow et al, 2011) that addresses common underlying mechanisms of anxiety and depression. Participants randomized to the active treatment condition received 10 weeks of Web-based treatment based on the UP. Throughout treatment, graduate students in clinical psychology provided guidance that consisted of asynchronous written communication on a secure Web platform. After the intervention, participants in both study conditions were invited to complete a set of self-report measures and a postintervention SCID-I interview conducted by a different team of graduate students blinded to participants’ group and diagnostic status. Six months later, participants in the active treatment group were invited to complete an online follow-up assessment. Results: During the intervention, active treatment participants completed on average 19 homework assignments (SD 12.10), and we collected data from 79.0% (83/105) at postintervention and 51% (35/69) at follow-up for self-report measures. Postintervention SCID-I interviews were collected from 77.1% (81/105) participants. Relative to the wait-list control group, the transdiagnostic intervention yielded overall medium to large effect sizes for the primary outcome measures (within-group Hedges g=0.52-1.34 and between-group g=0.39-0.86), and also for anxiety sensitivity (g=0.80), symptom interference (g=0.48), and quality of life (g=0.38). Significant within-groups effects only were reported for the active treatment group on Panic Disorder Severity Scale-Self Report (PDSS-SR, g=0.58-0.65) and Yale-Brown Obsessive Compulsive Scale (Y-BOCS, g=0.52-0.58). Conclusions: Insignificant between-group differences for the Y-BOCS and PDSS-SR could be explained by the small number of participants with the associated primary diagnostic (eg, only 3 participants with obsessive compulsive disorder) by the choice of outcome measure (PDSS-SR was not rated among the evidence-based measures) and by the fact that these disorders may be more difficult to treat. However, the overall results suggest that the transdiagnostic intervention tested in this study represents an effective treatment option that may prove easier to disseminate through the use of Web-based delivery systems. Trial Registration: ClinicalTrials.gov CT02739607; https://clinicaltrials.gov/ct2/show/study/NCT02739607 (Archived by WebCite at http://www.webcitation.org/6yY1VeYIZ) %M 29798831 %R 10.2196/mental.8901 %U http://mental.jmir.org/2018/2/e36/ %U https://doi.org/10.2196/mental.8901 %U http://www.ncbi.nlm.nih.gov/pubmed/29798831 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e43 %T Diurnal Variations of Depression-Related Health Information Seeking: Case Study in Finland Using Google Trends Data %A Tana,Jonas Christoffer %A Kettunen,Jyrki %A Eirola,Emil %A Paakkonen,Heikki %+ Department of Health and Welfare, Arcada University of Applied Sciences, Jan-Magnus Janssons plats 1, Helsinki, 00560, Finland, 358 400500090, jonas.tana@arcada.fi %K depression %K consumer health information %K information seeking behavior %K infoveillance %K infodemiology %K mental health %K search engine %D 2018 %7 23.05.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Some of the temporal variations and clock-like rhythms that govern several different health-related behaviors can be traced in near real-time with the help of search engine data. This is especially useful when studying phenomena where little or no traditional data exist. One specific area where traditional data are incomplete is the study of diurnal mood variations, or daily changes in individuals’ overall mood state in relation to depression-like symptoms. Objective: The objective of this exploratory study was to analyze diurnal variations for interest in depression on the Web to discover hourly patterns of depression interest and help seeking. Methods: Hourly query volume data for 6 depression-related queries in Finland were downloaded from Google Trends in March 2017. A continuous wavelet transform (CWT) was applied to the hourly data to focus on the diurnal variation. Longer term trends and noise were also eliminated from the data to extract the diurnal variation for each query term. An analysis of variance was conducted to determine the statistical differences between the distributions of each hour. Data were also trichotomized and analyzed in 3 time blocks to make comparisons between different time periods during the day. Results: Search volumes for all depression-related query terms showed a unimodal regular pattern during the 24 hours of the day. All queries feature clear peaks during the nighttime hours around 11 PM to 4 AM and troughs between 5 AM and 10 PM. In the means of the CWT-reconstructed data, the differences in nighttime and daytime interest are evident, with a difference of 37.3 percentage points (pp) for the term “Depression,” 33.5 pp for “Masennustesti,” 30.6 pp for “Masennus,” 12.8 pp for “Depression test,” 12.0 pp for “Masennus testi,” and 11.8 pp for “Masennus oireet.” The trichotomization showed peaks in the first time block (00.00 AM-7.59 AM) for all 6 terms. The search volumes then decreased significantly during the second time block (8.00 AM-3.59 PM) for the terms “Masennus oireet” (P<.001), “Masennus” (P=.001), “Depression” (P=.005), and “Depression test” (P=.004). Higher search volumes for the terms “Masennus” (P=.14), “Masennustesti” (P=.07), and “Depression test” (P=.10) were present between the second and third time blocks. Conclusions: Help seeking for depression has clear diurnal patterns, with significant rise in depression-related query volumes toward the evening and night. Thus, search engine query data support the notion of the evening-worse pattern in diurnal mood variation. Information on the timely nature of depression-related interest on an hourly level could improve the chances for early intervention, which is beneficial for positive health outcomes. %M 29792291 %R 10.2196/mental.9152 %U http://mental.jmir.org/2018/2/e43/ %U https://doi.org/10.2196/mental.9152 %U http://www.ncbi.nlm.nih.gov/pubmed/29792291 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e44 %T Internet Use, Depression, and Anxiety in a Healthy Adolescent Population: Prospective Cohort Study %A Thom,Robyn Pauline %A Bickham,David S %A Rich,Michael %+ Harvard Longwood Psychiatry Residency Training Program, Brigham and Women's Hospital & Beth Israel Deaconess Medical Center, 60 Fenwood Road, Department of Psychiatry, Boston, MA, 02115, United States, 1 857 307 5521, rthom@bidmc.harvard.edu %K mental health %K psychiatric disorders %K internet use %K social networking sites %D 2018 %7 22.05.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Psychiatric disorders, including conduct disturbances, substance abuse, and affective disorders, emerge in approximately 20% of adolescents. In parallel with the rise in internet use, the prevalence of depression among adolescents has increased. It remains unclear whether and how internet use impacts mental health in adolescents. Objective: We assess the association between patterns of internet use and two mental health outcomes (depression and anxiety) in a healthy adolescent population. Methods: A total of 126 adolescents between the ages of 12 and 15 years were recruited. Participants reported their typical computer and internet usage patterns. At baseline and one-year follow-up, they completed the Beck Depression Index for primary care (BDI-PC) and the Beck Anxiety Inventory for Primary Care (BAI-PC). Individual linear regressions were completed to determine the association between markers of internet use at baseline and mental health outcomes at one-year follow-up. All models controlled for age, gender, and ethnicity. Results: There was an inverse correlation between minutes spent on a favorite website per visit and BAI-PC score. No association was found between internet use and BDI-PC score. Conclusions: There is no relationship between internet use patterns and depression in adolescents, whereas internet use may mitigate anxiety in adolescents with higher levels of baseline anxiety. %R 10.2196/mental.8471 %U http://mental.jmir.org/2018/2/e44/ %U https://doi.org/10.2196/mental.8471 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e38 %T Temporal Associations Between Social Activity and Mood, Fatigue, and Pain in Older Adults With HIV: An Ecological Momentary Assessment Study %A Paolillo,Emily W %A Tang,Bin %A Depp,Colin A %A Rooney,Alexandra S %A Vaida,Florin %A Kaufmann,Christopher N %A Mausbach,Brent T %A Moore,David J %A Moore,Raeanne C %+ Department of Psychiatry, University of California, San Diego, 220 Dickinson Street, Suite B, San Diego, CA, 92103, United States, 1 619 543 5378, r6moore@ucsd.edu %K AIDS %K ecological momentary assessment %K social isolation %K happiness %K quality of life %D 2018 %7 14.05.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Social isolation is associated with an increased risk for mental and physical health problems, especially among older persons living with HIV (PLWH). Thus, there is a need to better understand real-time temporal associations between social activity and mood- and health-related factors in this population to inform possible future interventions. Objective: This study aims to examine real-time relationships between social activity and mood, fatigue, and pain in a sample of older PLWH. Methods: A total of 20 older PLWH, recruited from the University of California, San Diego HIV Neurobehavioral Research Program in 2016, completed smartphone-based ecological momentary assessment (EMA) surveys 5 times per day for 1 week. Participants reported their current social activity (alone vs not alone and number of social interactions) and levels of mood (sadness, happiness, and stress), fatigue, and pain. Mixed-effects regression models were used to analyze concurrent and lagged associations among social activity, mood, fatigue, and pain. Results: Participants (mean age 58.8, SD 4.3 years) reported being alone 63% of the time, on average, (SD 31.5%) during waking hours. Being alone was related to lower concurrent happiness (beta=−.300; 95% CI −.525 to −.079; P=.008). In lagged analyses, social activity predicted higher levels of fatigue later in the day (beta=−1.089; 95% CI −1.780 to −0.396; P=.002), and higher pain levels predicted being alone in the morning with a reduced likelihood of being alone as the day progressed (odds ratio 0.945, 95% CI 0.901-0.992; P=.02). Conclusions: The use of EMA elucidated a high rate of time spent alone among older PLWH. Promoting social activity despite the presence of pain or fatigue may improve happiness and psychological well-being in this population. %M 29759960 %R 10.2196/mental.9802 %U http://mental.jmir.org/2018/2/e38/ %U https://doi.org/10.2196/mental.9802 %U http://www.ncbi.nlm.nih.gov/pubmed/29759960 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 5 %P e168 %T Predicting Depression From Language-Based Emotion Dynamics: Longitudinal Analysis of Facebook and Twitter Status Updates %A Seabrook,Elizabeth M %A Kern,Margaret L %A Fulcher,Ben D %A Rickard,Nikki S %+ Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Melbourne, 3800, Australia, 61 0413170668, elizabeth.seabrook@monash.edu %K automated text analysis %K depression %K Facebook %K Twitter %K emotions %K variability %K instability %D 2018 %7 08.05.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Frequent expression of negative emotion words on social media has been linked to depression. However, metrics have relied on average values, not dynamic measures of emotional volatility. Objective: The aim of this study was to report on the associations between depression severity and the variability (time-unstructured) and instability (time-structured) in emotion word expression on Facebook and Twitter across status updates. Methods: Status updates and depression severity ratings of 29 Facebook users and 49 Twitter users were collected through the app MoodPrism. The average proportion of positive and negative emotion words used, within-person variability, and instability were computed. Results: Negative emotion word instability was a significant predictor of greater depression severity on Facebook (rs(29)=.44, P=.02, 95% CI 0.09-0.69), even after controlling for the average proportion of negative emotion words used (partial rs(26)=.51, P=.006) and within-person variability (partial rs(26)=.49, P=.009). A different pattern emerged on Twitter where greater negative emotion word variability indicated lower depression severity (rs(49)=−.34, P=.01, 95% CI −0.58 to 0.09). Differences between Facebook and Twitter users in their emotion word patterns and psychological characteristics were also explored. Conclusions: The findings suggest that negative emotion word instability may be a simple yet sensitive measure of time-structured variability, useful when screening for depression through social media, though its usefulness may depend on the social media platform. %M 29739736 %R 10.2196/jmir.9267 %U http://www.jmir.org/2018/5/e168/ %U https://doi.org/10.2196/jmir.9267 %U http://www.ncbi.nlm.nih.gov/pubmed/29739736 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e33 %T Ethical Issues in Addressing Social Media Posts About Suicidal Intentions During an Online Study Among Youth: Case Study %A Young,Sean D %A Garett,Renee %+ University of California Institute for Prediction Technology, Department of Family Medicine, University of California, Los Angeles, Suite 1800, 10880 Wilshire Blvd, Los Angeles, CA,, United States, 1 310 794 8530, sdyoung@mednet.ucla.edu %K suicide %K social media %K undergraduates %D 2018 %7 03.05.2018 %9 Case Study %J JMIR Ment Health %G English %X Due to the popularity of social media, researchers are increasingly conducting studies that monitor and analyze people’s health-related social media conversations. Because social media users can post about any topic at any time, no known best ethical practices exist as to whether and how to monitor participants’ posts for safety-related issues that might be unrelated to the study, such as expressions of suicidal intentions. This is a case study during a social media-based study on sleep and activity among freshman undergraduate students, where we by chance noticed that a student was using social media to express suicidal intentions. Although we connected the student to student psychological services in order to receive treatment, we encountered a number of barriers that initially prevented this from occurring, such as institutional review board and regulatory practices related to lack of experience with these newer types of studies. We discuss the implications of this experience for future research. %M 29724707 %R 10.2196/mental.8971 %U http://mental.jmir.org/2018/2/e33/ %U https://doi.org/10.2196/mental.8971 %U http://www.ncbi.nlm.nih.gov/pubmed/29724707 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 5 %P e174 %T Behind the Scenes of Online Therapeutic Feedback in Blended Therapy for Depression: Mixed-Methods Observational Study %A Mol,Mayke %A Dozeman,Els %A Provoost,Simon %A van Schaik,Anneke %A Riper,Heleen %A Smit,Johannes H %+ Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Van der Boechorststraat 7, Amsterdam, 1081 BT, Netherlands, 31 204448180, m.mol@ggzingeest.nl %K cognitive behavioral therapy %K eHealth %K depressive disorder %D 2018 %7 03.05.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: In Internet-delivered cognitive behavioral therapies (iCBT), written feedback by therapists is a substantial part of therapy. However, it is not yet known how this feedback should be given best and which specific therapist behaviors and content are most beneficial for patients. General instructions for written feedback are available, but the uptake and effectiveness of these instructions in iCBT have not been studied yet. Objective: This study aimed to identify therapist behaviors in written online communication with patients in blended CBT for adult depression in routine secondary mental health care, to identify the extent to which the therapists adhere to feedback instructions, and to explore whether therapist behaviors and adherence to feedback instructions are associated with patient outcome. Methods: Adults receiving blended CBT (10 online sessions in combination with 5 face-to-face sessions) for depression in routine mental health care were recruited in the context of the European implementation project MasterMind. A qualitative content analysis was used to identify therapist behaviors in online written feedback messages, and a checklist for the feedback instruction adherence of the therapists was developed. Correlations were explored between the therapist behaviors, therapist instruction adherence, and patient outcomes (number of completed online sessions and symptom change scores). Results: A total of 45 patients (73%, 33/45 female, mean age 35.9 years) received 219 feedback messages given by 19 therapists (84%, 16/19 female). The most frequently used therapist behaviors were informing, encouraging, and affirming. However, these were not related to patient outcomes. Although infrequently used, confronting was positively correlated with session completion (ρ=.342, P=.02). Therapists adhered to most of the feedback instructions. Only 2 feedback aspects were correlated with session completion: the more therapists adhere to instructions containing structure (limiting to 2 subjects and sending feedback within 3 working days) and readability (short sentences and short paragraphs), the less online sessions were completed (ρ=−.340, P=.02 and ρ=−.361, P=.02, respectively). No associations were found with depression symptom change scores. Conclusions: The therapist behaviors found in this study are comparable to previous research. The findings suggest that online feedback instructions for therapists provide sufficient guidance to communicate in a supportive and positive manner with patients. However, the instructions might be improved by adding more therapeutic techniques besides the focus on style and form. %M 29724708 %R 10.2196/jmir.9890 %U http://www.jmir.org/2018/5/e174/ %U https://doi.org/10.2196/jmir.9890 %U http://www.ncbi.nlm.nih.gov/pubmed/29724708 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 5 %P e10028 %T A Mental Health Storytelling Intervention Using Transmedia to Engage Latinas: Grounded Theory Analysis of Participants’ Perceptions of the Story’s Main Character %A Heilemann,MarySue V %A Martinez,Adrienne %A Soderlund,Patricia D %+ School of Nursing, University of California, Los Angeles, Factor Building, Room 5252, Box 956919, Los Angeles, CA, 90095 6919, United States, 1 310 206 4735, mheilema@sonnet.ucla.edu %K depression %K anxiety %K transmedia storytelling %K Internet %K cell phone %K mental health %K eHealth %K mood disorders %K smartphone %D 2018 %7 02.05.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Transmedia storytelling was used to attract English-speaking Latina women with elevated symptoms of depression and anxiety to engage in an intervention that included videos and a webpage with links to symptom management resources. However, a main character for the storyline who was considered dynamic, compelling, and relatable by the target group was needed. Objective: We conducted interviews with 28 English-speaking Latinas (target group) with elevated symptoms of depression or anxiety who participated in an Internet-accessible transmedia storytelling intervention. The objective of this study was to examine participants’ perceptions of the lead character of the story. Development of this character was informed by deidentified data from previous studies with members of the target group. Critique of the character from a panel of therapists informed editing, as did input from women of the target group. Methods: All interviews were conducted via telephone, audio-recorded, and transcribed. Data analysis was guided by grounded theory methodology. Results: Participants embraced the main character, Catalina, related to her as a person with an emotional life and a temporal reality, reported that they learned from her and wanted more episodes that featured her and her life. Grounded theory analysis led to the development of one category (She “just felt so real”: relating to Catalina as a real person with a past, present, and future) with 4 properties. Properties included (1) relating emotionally to Catalina’s vulnerability, (2) recognizing shared experiences, (3) needing to support others while simultaneously lacking self-support, and (4) using Catalina as a springboard for imagining alternative futures. Participants found Catalina’s efforts to pursue mental health treatment to be meaningful and led them to compare themselves to her and consider how they might pursue treatment themselves. Conclusions: When creating a story-based mental health intervention to be delivered through an app, regardless of type, careful development of the main character is valuable. Theoretical guidance, previous deidentified data from the target group, critique from key stakeholders and members of the target group, and preliminary testing are likely to enhance the main character’s relatability and appropriateness, which can increase sustained engagement. %M 29720357 %R 10.2196/10028 %U http://www.jmir.org/2018/5/e10028/ %U https://doi.org/10.2196/10028 %U http://www.ncbi.nlm.nih.gov/pubmed/29720357 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e158 %T A Remote Collaborative Care Program for Patients with Depression Living in Rural Areas: Open-Label Trial %A Rojas,Graciela %A Guajardo,Viviana %A Martínez,Pablo %A Castro,Ariel %A Fritsch,Rosemarie %A Moessner,Markus %A Bauer,Stephanie %+ Escuela de Psicología, Facultad de Humanidades, Universidad de Santiago de Chile, Tercer Piso, Av Ecuador 3650, Santiago, 9170197, Chile, 56 227182953, pablo.martinezd@usach.cl %K primary health care %K depression %K telemedicine %K rural health care %K medically underserved area %D 2018 %7 30.04.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: In the treatment of depression, primary care teams have an essential role, but they are most effective when inserted into a collaborative care model for disease management. In rural areas, the shortage of specialized mental health resources may hamper management of depressed patients. Objective: The aim was to test the feasibility, acceptability, and effectiveness of a remote collaborative care program for patients with depression living in rural areas. Methods: In a nonrandomized, open-label (blinded outcome assessor), two-arm clinical trial, physicians from 15 rural community hospitals recruited 250 patients aged 18 to 70 years with a major depressive episode (DSM-IV criteria). Patients were assigned to the remote collaborative care program (n=111) or to usual care (n=139). The remote collaborative care program used Web-based shared clinical records between rural primary care teams and a specialized/centralized mental health team, telephone monitoring of patients, and remote supervision by psychiatrists through the Web-based shared clinical records and/or telephone. Depressive symptoms, health-related quality of life, service use, and patient satisfaction were measured 3 and 6 months after baseline assessment. Results: Six-month follow-up assessments were completed by 84.4% (221/250) of patients. The remote collaborative care program achieved higher user satisfaction (odds ratio [OR] 1.94, 95% CI 1.25-3.00) and better treatment adherence rates (OR 1.81, 95% CI 1.02-3.19) at 6 months compared to usual care. There were no statically significant differences in depressive symptoms between the remote collaborative care program and usual care. Significant differences between groups in favor of remote collaborative care program were observed at 3 months for mental health-related quality of life (beta 3.11, 95% CI 0.19-6.02). Conclusions: Higher rates of treatment adherence in the remote collaborative care program suggest that technology-assisted interventions may help rural primary care teams in the management of depressive patients. Future cost-effectiveness studies are needed. Trial Registration: Clinicaltrials.gov NCT02200367; https://clinicaltrials.gov/ct2/show/NCT02200367 (Archived by WebCite at http://www.webcitation.org/6xtZ7OijZ) %M 29712627 %R 10.2196/jmir.8803 %U http://www.jmir.org/2018/4/e158/ %U https://doi.org/10.2196/jmir.8803 %U http://www.ncbi.nlm.nih.gov/pubmed/29712627 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e148 %T A Single-Session, Web-Based Parenting Intervention to Prevent Adolescent Depression and Anxiety Disorders: Randomized Controlled Trial %A Cardamone-Breen,Mairead C %A Jorm,Anthony F %A Lawrence,Katherine A %A Rapee,Ronald M %A Mackinnon,Andrew J %A Yap,Marie Bee Hui %+ Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton, Melbourne, 3800, Australia, 61 399050723, marie.yap@monash.edu %K adolescent %K mental health %K depression, anxiety, parenting %K family %K preventive health services %K Internet %D 2018 %7 26.04.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression and anxiety disorders are significant contributors to burden of disease in young people, highlighting the need to focus preventive efforts early in life. Despite substantial evidence for the role of parents in the prevention of adolescent depression and anxiety disorders, there remains a need for translation of this evidence into preventive parenting interventions. To address this gap, we developed a single-session, Web-based, tailored psychoeducation intervention that aims to improve parenting practices known to influence the development of adolescent depression and anxiety disorders. Objective: The aim of this study was to evaluate the short-term effects of the intervention on parenting risk and protective factors and symptoms of depression and anxiety in adolescent participants. Methods: We conducted a single-blind, parallel group, superiority randomized controlled trial comparing the intervention with a 3-month waitlist control. The intervention is fully automated and consists of two components: (1) completion of an online self-assessment of current parenting practices against evidence-based parenting recommendations for the prevention of adolescent depression and anxiety disorders and (2) an individually tailored feedback report highlighting each parent’s strengths and areas for improvement based on responses to the self-assessment. A community sample of 349 parents, together with 327 adolescents (aged 12-15 years), were randomized to either the intervention or waitlist control condition. Parents and adolescents completed online self-reported assessments of parenting and adolescent symptoms of depression and anxiety at baseline, 1-month (parent-report of parenting only), and 3-month follow-up. Results: Compared with controls, intervention group parents showed significantly greater improvement in parenting risk and protective factors from baseline to 1-month and 3-month follow-up (F2,331.22=16.36, P<.001), with a small to medium effect size at 3-month follow-up (d=0.33). There were no significant effects of the intervention on adolescent-report of parenting or symptoms of depression or anxiety in the adolescents (all P>.05). Conclusions: Findings suggest that a single-session, individually tailored, Web-based parenting intervention can improve parenting factors that are known to influence the development of depression and anxiety in adolescents. However, our results do not support the effectiveness of the intervention in improving adolescent depression or anxiety symptoms in the short-term. Long-term studies are required to adequately assess the relationship between improving parenting factors and adolescent depression and anxiety outcomes. Nonetheless, this is a promising avenue for the translation of research into a low-cost, sustainable, universal prevention approach. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12615000247572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12615000247572 (Archived by WebCite at http://www.webcitation.org/6v1ha19XG) %M 29699964 %R 10.2196/jmir.9499 %U http://www.jmir.org/2018/4/e148/ %U https://doi.org/10.2196/jmir.9499 %U http://www.ncbi.nlm.nih.gov/pubmed/29699964 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e30 %T Worker Preferences for a Mental Health App Within Male-Dominated Industries: Participatory Study %A Peters,Dorian %A Deady,Mark %A Glozier,Nick %A Harvey,Samuel %A Calvo,Rafael A %+ Wellbeing Technology Lab, Faculty of Engineering and IT, University of Sydney, Bldg J03, Electrical Engineering, Sydney, 2006, Australia, 61 0289015604, dorian.peters@sydney.edu.au %K mental health %K mhealth %K mobile apps %K workplace %K men %K participatory design %D 2018 %7 25.04.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Men are less likely to seek help for mental health problems, possibly because of stigma imposed by cultural masculine norms. These tendencies may be amplified within male-dominated workplaces such as the emergency services or transport industries. Mobile apps present a promising way to provide access to mental health support. However, little is known about the kinds of mental health technologies men would be willing to engage with, and no app can be effective if the intended users do not engage with it. Objective: The goal of this participatory user research study was to explore the perceptions, preferences, and ideas of workers in male-dominated workplaces to define requirements for a mental health app that would be engaging and effective at improving psychological well-being. Methods: Workers from male-dominated workplaces in rural, suburban, and urban locations took part in an exploratory qualitative study involving participatory workshops designed to elicit their perspectives and preferences for mental health support and the design of an app for mental health. Participants generated a number of artifacts (including draft screen designs and promotional material) designed to reify their perceptions, tacit knowledge, and ideas. Results: A total of 60 workers aged between 26 and 65 years, 92% (55/60) male, from male-dominated workplaces in rural (16/60, 27%), suburban (14/60, 23%), and urban (30/60, 50%) locations participated in one of the 6 workshops, resulting in 49 unique feature ideas and 81 participant-generated artifacts. Thematic analysis resulted in a set of feature, language, and style preferences, as well as characteristics considered important by participants for a mental health app. The term “mental health” was highly stigmatized and disliked by participants. Tools including a mood tracker, self-assessment, and mood-fix tool were highly valued, and app characteristics such as brevity of interactions, minimal on-screen text, and a solutions-oriented approach were considered essential by participants. Some implementation strategies based on these findings are included in the discussion. Conclusions: Future mental health mobile phone apps targeting workers in male-dominated workplaces need to consider language use and preferred features, as well as balance the preferences of users with the demands of evidence-based intervention. In addition to informing the development of mental health apps for workers in male-dominated industries, these findings may also provide insights for mental health technologies, for men in general, and for others in high-stigma environments. %M 29695371 %R 10.2196/mental.8999 %U http://mental.jmir.org/2018/2/e30/ %U https://doi.org/10.2196/mental.8999 %U http://www.ncbi.nlm.nih.gov/pubmed/29695371 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 4 %P e95 %T Development of a Mobile Clinical Prediction Tool to Estimate Future Depression Severity and Guide Treatment in Primary Care: User-Centered Design %A Wachtler,Caroline %A Coe,Amy %A Davidson,Sandra %A Fletcher,Susan %A Mendoza,Antonette %A Sterling,Leon %A Gunn,Jane %+ Department of General Practice, The University of Melbourne, 200 Berkeley St, Carlton, 3053, Australia, 61 83444530, j.gunn@unimelb.edu.au %K user-centered design %K depression %K ehealth %K primary health care %K decision support techniques %K risk %K mental health %D 2018 %7 23.04.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Around the world, depression is both under- and overtreated. The diamond clinical prediction tool was developed to assist with appropriate treatment allocation by estimating the 3-month prognosis among people with current depressive symptoms. Delivering clinical prediction tools in a way that will enhance their uptake in routine clinical practice remains challenging; however, mobile apps show promise in this respect. To increase the likelihood that an app-delivered clinical prediction tool can be successfully incorporated into clinical practice, it is important to involve end users in the app design process. Objective: The aim of the study was to maximize patient engagement in an app designed to improve treatment allocation for depression. Methods: An iterative, user-centered design process was employed. Qualitative data were collected via 2 focus groups with a community sample (n=17) and 7 semistructured interviews with people with depressive symptoms. The results of the focus groups and interviews were used by the computer engineering team to modify subsequent protoypes of the app. Results: Iterative development resulted in 3 prototypes and a final app. The areas requiring the most substantial changes following end-user input were related to the iconography used and the way that feedback was provided. In particular, communicating risk of future depressive symptoms proved difficult; these messages were consistently misinterpreted and negatively viewed and were ultimately removed. All participants felt positively about seeing their results summarized after completion of the clinical prediction tool, but there was a need for a personalized treatment recommendation made in conjunction with a consultation with a health professional. Conclusions: User-centered design led to valuable improvements in the content and design of an app designed to improve allocation of and engagement in depression treatment. Iterative design allowed us to develop a tool that allows users to feel hope, engage in self-reflection, and motivate them to treatment. The tool is currently being evaluated in a randomized controlled trial. %M 29685864 %R 10.2196/mhealth.9502 %U http://mhealth.jmir.org/2018/4/e95/ %U https://doi.org/10.2196/mhealth.9502 %U http://www.ncbi.nlm.nih.gov/pubmed/29685864 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e147 %T Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial %A Wu,Shinyi %A Ell,Kathleen %A Jin,Haomiao %A Vidyanti,Irene %A Chou,Chih-Ping %A Lee,Pey-Jiuan %A Gross-Schulman,Sandra %A Sklaroff,Laura Myerchin %A Belson,David %A Nezu,Arthur M %A Hay,Joel %A Wang,Chien-Ju %A Scheib,Geoffrey %A Di Capua,Paul %A Hawkins,Caitlin %A Liu,Pai %A Ramirez,Magaly %A Wu,Brian W %A Richman,Mark %A Myers,Caitlin %A Agustines,Davin %A Dasher,Robert %A Kopelowicz,Alex %A Allevato,Joseph %A Roybal,Mike %A Ipp,Eli %A Haider,Uzma %A Graham,Sharon %A Mahabadi,Vahid %A Guterman,Jeffrey %+ Suzanne Dworak-Peck School of Social Work, University of Southern California, 1150 S Olive Street, Suite 1400, Los Angeles, CA, 90015, United States, 1 2138216442, shinyiwu@usc.edu %K primary care %K disease management %K depression %K diabetes mellitus %K health information technology %K telemedicine %K comparative effectiveness research %K propensity score %K population health %K patient reported outcome measures %D 2018 %7 23.04.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. Objective: The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. Methods: DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. Results: DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001). Conclusions: Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality. %M 29685872 %R 10.2196/jmir.7692 %U http://www.jmir.org/2018/4/e147/ %U https://doi.org/10.2196/jmir.7692 %U http://www.ncbi.nlm.nih.gov/pubmed/29685872 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e129 %T Self-Harm, Suicidal Behaviours, and Cyberbullying in Children and Young People: Systematic Review %A John,Ann %A Glendenning,Alexander Charles %A Marchant,Amanda %A Montgomery,Paul %A Stewart,Anne %A Wood,Sophie %A Lloyd,Keith %A Hawton,Keith %+ Population Psychiatry, Suicide and Informatics, Medical School, Swansea University, Institute of Life Science 2, Swansea, SA2 8PP, United Kingdom, 44 01792602568 ext 2568, A.John@swansea.ac.uk %K cyberbullying %K bullying %K self-injurious behavior %K suicide %K suicide, attempted %K suicidal ideation %D 2018 %7 19.04.2018 %9 Review %J J Med Internet Res %G English %X Background: Given the concerns about bullying via electronic communication in children and young people and its possible contribution to self-harm, we have reviewed the evidence for associations between cyberbullying involvement and self-harm or suicidal behaviors (such as suicidal ideation, suicide plans, and suicide attempts) in children and young people. Objective: The aim of this study was to systematically review the current evidence examining the association between cyberbullying involvement as victim or perpetrator and self-harm and suicidal behaviors in children and young people (younger than 25 years), and where possible, to meta-analyze data on the associations. Methods: An electronic literature search was conducted for all studies published between January 1, 1996, and February 3, 2017, across sources, including MEDLINE, Cochrane, and PsycINFO. Articles were included if the study examined any association between cyberbullying involvement and self-harm or suicidal behaviors and reported empirical data in a sample aged under 25 years. Quality of included papers was assessed and data were extracted. Meta-analyses of data were conducted. Results: A total of 33 eligible articles from 26 independent studies were included, covering a population of 156,384 children and young people. A total of 25 articles (20 independent studies, n=115,056) identified associations (negative influences) between cybervictimization and self-harm or suicidal behaviors or between perpetrating cyberbullying and suicidal behaviors. Three additional studies, in which the cyberbullying, self-harm, or suicidal behaviors measures had been combined with other measures (such as traditional bullying and mental health problems), also showed negative influences (n=44,526). A total of 5 studies showed no significant associations (n=5646). Meta-analyses, producing odds ratios (ORs) as a summary measure of effect size (eg, ratio of the odds of cyber victims who have experienced SH vs nonvictims who have experienced SH), showed that, compared with nonvictims, those who have experienced cybervictimization were OR 2.35 (95% CI 1.65-3.34) times as likely to self-harm, OR 2.10 (95% CI 1.73-2.55) times as likely to exhibit suicidal behaviors, OR 2.57 (95% CI 1.69-3.90) times more likely to attempt suicide, and OR 2.15 (95% CI 1.70-2.71) times more likely to have suicidal thoughts. Cyberbullying perpetrators were OR 1.21 (95% CI 1.02-1.44) times more likely to exhibit suicidal behaviors and OR 1.23 (95% CI 1.10-1.37) times more likely to experience suicidal ideation than nonperpetrators. Conclusions: Victims of cyberbullying are at a greater risk than nonvictims of both self-harm and suicidal behaviors. To a lesser extent, perpetrators of cyberbullying are at risk of suicidal behaviors and suicidal ideation when compared with nonperpetrators. Policy makers and schools should prioritize the inclusion of cyberbullying involvement in programs to prevent traditional bullying. Type of cyberbullying involvement, frequency, and gender should be assessed in future studies. %M 29674305 %R 10.2196/jmir.9044 %U http://www.jmir.org/2018/4/e129/ %U https://doi.org/10.2196/jmir.9044 %U http://www.ncbi.nlm.nih.gov/pubmed/29674305 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e22 %T “Wish You Were Here”: Examining Characteristics, Outcomes, and Statistical Solutions for Missing Cases in Web-Based Psychotherapeutic Trials %A Karin,Eyal %A Dear,Blake F %A Heller,Gillian Z %A Crane,Monique F %A Titov,Nickolai %+ eCentreClinic, Department of Psychology, Macquarie University, 4 First Walk, Sydney, 2109, Australia, 61 298508657, eyal.karin@mq.edu.au %K psychotherapy %K treatment adherence and compliance %K missing data %K treatment efficacy %K statistical bias %D 2018 %7 19.04.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Missing cases following treatment are common in Web-based psychotherapy trials. Without the ability to directly measure and evaluate the outcomes for missing cases, the ability to measure and evaluate the effects of treatment is challenging. Although common, little is known about the characteristics of Web-based psychotherapy participants who present as missing cases, their likely clinical outcomes, or the suitability of different statistical assumptions that can characterize missing cases. Objective: Using a large sample of individuals who underwent Web-based psychotherapy for depressive symptoms (n=820), the aim of this study was to explore the characteristics of cases who present as missing cases at posttreatment (n=138), their likely treatment outcomes, and compare between statistical methods for replacing their missing data. Methods: First, common participant and treatment features were tested through binary logistic regression models, evaluating the ability to predict missing cases. Second, the same variables were screened for their ability to increase or impede the rate symptom change that was observed following treatment. Third, using recontacted cases at 3-month follow-up to proximally represent missing cases outcomes following treatment, various simulated replacement scores were compared and evaluated against observed clinical follow-up scores. Results: Missing cases were dominantly predicted by lower treatment adherence and increased symptoms at pretreatment. Statistical methods that ignored these characteristics can overlook an important clinical phenomenon and consequently produce inaccurate replacement outcomes, with symptoms estimates that can swing from −32% to 70% from the observed outcomes of recontacted cases. In contrast, longitudinal statistical methods that adjusted their estimates for missing cases outcomes by treatment adherence rates and baseline symptoms scores resulted in minimal measurement bias (<8%). Conclusions: Certain variables can characterize and predict missing cases likelihood and jointly predict lesser clinical improvement. Under such circumstances, individuals with potentially worst off treatment outcomes can become concealed, and failure to adjust for this can lead to substantial clinical measurement bias. Together, this preliminary research suggests that missing cases in Web-based psychotherapeutic interventions may not occur as random events and can be systematically predicted. Critically, at the same time, missing cases may experience outcomes that are distinct and important for a complete understanding of the treatment effect. %M 29674311 %R 10.2196/mental.8363 %U http://mental.jmir.org/2018/2/e22/ %U https://doi.org/10.2196/mental.8363 %U http://www.ncbi.nlm.nih.gov/pubmed/29674311 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 4 %P e95 %T Recruitment of Participants and Delivery of Online Mental Health Resources for Depressed Individuals Using Tumblr: Pilot Randomized Control Trial %A Kelleher,Erin %A Moreno,Megan %A Wilt,Megan Pumper %+ Seattle Children's Research Institute, Center for Child Health, Behavior and Development, 2001 8th Ave, Seattle, WA, 98121, United States, 1 8479329259, erin.kelleher6@gmail.com %K adolescents %K depression %K intervention %K social media %K tumblr %D 2018 %7 12.04.2018 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Adolescents and young adults frequently post depression symptom references on social media; previous studies show positive associations between depression posts and self-reported depression symptoms. Depression is common among young people and this population often experiences many barriers to mental health care. Thus, social media may be a new resource to identify, recruit, and intervene with young people at risk for depression. Objective: The purpose of this pilot study was to test a social media intervention on Tumblr. We used social media to identify and recruit participants and to deliver the intervention of online depression resources. Methods: This randomized pilot intervention identified Tumblr users age 15-23 who posted about depression using the search term “#depress”. Eligible participants were recruited via Tumblr messages; consented participants completed depression surveys and were then randomized to an intervention of online mental health resources delivered via a Tumblr message, while control participants did not receive resources. Postintervention online surveys assessed resource access and usefulness and control groups were asked whether they would have liked to receive resources. Analyses included t tests. Results: A total of 25 participants met eligibility criteria. The mean age of the participants was 17.5 (SD 1.9) and 65% were female with average score on the Patient Health Questionnaire-9 of 17.5 (SD 5.9). Among the 11 intervention participants, 36% (4/11) reported accessing intervention resources and 64% (7/11) felt the intervention was acceptable. Among the 14 control participants, only 29% (4/14) of reported that receiving resources online would be acceptable (P=.02). Participants suggested anonymity and ease of use as important characteristics in an online depression resource. Conclusions: The intervention was appropriately targeted to young people at risk for depression, and recruitment via Tumblr was feasible. Most participants in the intervention group felt the social media approach was acceptable, and about a third utilized the online resources. Participants who had not experienced the intervention were less likely to find it acceptable. Future studies should explore this approach in larger samples. Social media may be an appropriate platform for online depression interventions for young people. %M 29650507 %R 10.2196/resprot.9421 %U http://www.researchprotocols.org/2018/4/e95/ %U https://doi.org/10.2196/resprot.9421 %U http://www.ncbi.nlm.nih.gov/pubmed/29650507 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e26 %T Impact of Mental Health Screening on Promoting Immediate Online Help-Seeking: Randomized Trial Comparing Normative Versus Humor-Driven Feedback %A Choi,Isabella %A Milne,David N %A Deady,Mark %A Calvo,Rafael A %A Harvey,Samuel B %A Glozier,Nick %+ Brain and Mind Centre, Central Clinical School, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, 2050, Australia, 61 029515 ext 1593, isabella.choi@sydney.edu.au %K online help-seeking %K screening %K feedback %K randomized trial %K mental health %K resilience %K depression %D 2018 %7 05.04.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Given the widespread availability of mental health screening apps, providing personalized feedback may encourage people at high risk to seek help to manage their symptoms. While apps typically provide personal score feedback only, feedback types that are user-friendly and increase personal relevance may encourage further help-seeking. Objective: The aim of this study was to compare the effects of providing normative and humor-driven feedback on immediate online help-seeking, defined as clicking on a link to an external resource, and to explore demographic predictors that encourage help-seeking. Methods: An online sample of 549 adults were recruited using social media advertisements. Participants downloaded a smartphone app known as “Mindgauge” which allowed them to screen their mental wellbeing by completing standardized measures on Symptoms (Kessler 6-item Scale), Wellbeing (World Health Organization [Five] Wellbeing Index), and Resilience (Brief Resilience Scale). Participants were randomized to receive normative feedback that compared their scores to a reference group or humor-driven feedback that presented their scores in a relaxed manner. Those who scored in the moderate or poor ranges in any measure were encouraged to seek help by clicking on a link to an external online resource. Results: A total of 318 participants scored poorly on one or more measures and were provided with an external link after being randomized to receive normative or humor-driven feedback. There was no significant difference of feedback type on clicking on the external link across all measures. A larger proportion of participants from the Wellbeing measure (170/274, 62.0%) clicked on the links than the Resilience (47/179, 26.3%) or Symptoms (26/75, 34.7%) measures (χ2=60.35, P<.001). There were no significant demographic factors associated with help-seeking for the Resilience or Wellbeing measures. Participants with a previous episode of poor mental health were less likely than those without such history to click on the external link in the Symptoms measure (P=.003, odds ratio [OR] 0.83, 95% CI 0.02-0.44), and younger adults were less likely to click on the link compared to older adults across all measures (P=.005, OR 0.44, 95% CI 0.25-0.78). Conclusions: This pilot study found that there was no difference between normative and humor-driven feedback on promoting immediate clicks to an external resource, suggesting no impact on online help-seeking. Limitations included: lack of personal score control group, limited measures of predictors and potential confounders, and the fact that other forms of professional help-seeking were not assessed. Further investigation into other predictors and factors that impact on help-seeking is needed. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000707460; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=370187 (Archived by WebCite at http://www.webcitation.org/6y8m8sVxr) %M 29622528 %R 10.2196/mental.9480 %U http://mental.jmir.org/2018/2/e26/ %U https://doi.org/10.2196/mental.9480 %U http://www.ncbi.nlm.nih.gov/pubmed/29622528 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e6 %T Gamified Cognitive Control Training for Remitted Depressed Individuals: User Requirements Analysis %A Vervaeke,Jasmien %A Van Looy,Jan %A Hoorelbeke,Kristof %A Baeken,Chris %A Koster,Ernst HW %+ Psychopathology and Affective Neuroscience Lab, Department of Experimental Clinical and Health Psychology, Ghent University, Henri Dunantlaan 2, Ghent, 9000, Belgium, 32 92649446, jasmien.vervaeke@ugent.be %K depression %K cognitive dysfunction %K cognitive remediation %K relapse prevention %K qualitative research %K secondary prevention %D 2018 %7 05.04.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: The high incidence and relapse rates of major depressive disorder demand novel treatment options. Standard treatments (psychotherapy, medication) usually do not target cognitive control impairments, although these seem to play a crucial role in achieving stable remission. The urgent need for treatment combined with poor availability of adequate psychological interventions has instigated a shift toward internet interventions. Numerous computerized programs have been developed that can be presented online and offline. However, their uptake and adherence are oftentimes low. Objective: The aim of this study was to perform a user requirements analysis for an internet-based training targeting cognitive control. This training focuses on ameliorating cognitive control impairments, as these are still present during remission and can be a risk factor for relapse. To facilitate uptake of and adherence to this intervention, a qualitative user requirements analysis was conducted to map mandatory and desirable requirements. Methods: We conducted a user requirements analysis through a focus group with 5 remitted depressed individuals and individual interviews with 6 mental health care professionals. All qualitative data were transcribed and examined using a thematic analytic approach. Results: Results showed mandatory requirements for the remitted sample in terms of training configuration, technological and personal factors, and desirable requirements regarding knowledge and enjoyment. Furthermore, knowledge and therapeutic benefits were key requirements for therapists. Conclusions: The identified requirements provide useful information to be integrated in interventions targeting cognitive control in depression. %M 29622525 %R 10.2196/games.8609 %U http://games.jmir.org/2018/2/e6/ %U https://doi.org/10.2196/games.8609 %U http://www.ncbi.nlm.nih.gov/pubmed/29622525 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e20 %T Improving Implementation of eMental Health for Mood Disorders in Routine Practice: Systematic Review of Barriers and Facilitating Factors %A Vis,Christiaan %A Mol,Mayke %A Kleiboer,Annet %A Bührmann,Leah %A Finch,Tracy %A Smit,Jan %A Riper,Heleen %+ Department of Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, van der Boechorststraat 1, Amsterdam, 1081 BT, Netherlands, 31 646098094, p.d.c.vis@vu.nl %K eMental health %K implementation %K routine practice %K determinants of practices %K RE-AIM %K barriers and facilitators %K mood disorders %K review %D 2018 %7 16.03.2018 %9 Review %J JMIR Ment Health %G English %X Background: Electronic mental health interventions (eMental health or eMH) can be used to increase accessibility of mental health services for mood disorders, with indications of comparable clinical outcomes as face-to-face psychotherapy. However, the actual use of eMH in routine mental health care lags behind expectations. Identifying the factors that might promote or inhibit implementation of eMH in routine care may help to overcome this gap between effectiveness studies and routine care. Objective: This paper reports the results of a systematic review of the scientific literature identifying those determinants of practices relevant to implementing eMH for mood disorders in routine practice. Methods: A broad search strategy was developed with high sensitivity to four key terms: implementation, mental health care practice, mood disorder, and eMH. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was applied to guide the review and structure the results. Thematic analysis was applied to identify the most important determinants that facilitate or hinder implementation of eMH in routine practice. Results: A total of 13,147 articles were screened, of which 48 studies were included in the review. Most studies addressed aspects of the reach (n=33) of eMH, followed by intervention adoption (n=19), implementation of eMH (n=6), and maintenance (n=4) of eMH in routine care. More than half of the studies investigated the provision of mental health services through videoconferencing technologies (n=26), followed by Internet-based interventions (n=20). The majority (n=44) of the studies were of a descriptive nature. Across all RE-AIM domains, we identified 37 determinants clustered in six main themes: acceptance, appropriateness, engagement, resources, work processes, and leadership. The determinants of practices are expressed at different levels, including patients, mental health staff, organizations, and health care system level. Depending on the context, these determinants hinder or facilitate successful implementation of eMH. Conclusions: Of the 37 determinants, three were reported most frequently: (1) the acceptance of eMH concerning expectations and preferences of patients and professionals about receiving and providing eMH in routine care, (2) the appropriateness of eMH in addressing patients’ mental health disorders, and (3) the availability, reliability, and interoperability with other existing technologies such as the electronic health records are important factors for mental health care professionals to remain engaged in providing eMH to their patients in routine care. On the basis of the taxonomy of determinants of practices developed in this review, implementation-enhancing interventions can be designed and applied to achieve better implementation outcomes. Suggestions for future research and implementation practice are provided. %M 29549072 %R 10.2196/mental.9769 %U http://mental.jmir.org/2018/1/e20/ %U https://doi.org/10.2196/mental.9769 %U http://www.ncbi.nlm.nih.gov/pubmed/29549072 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 3 %P e87 %T Treatment Activity, User Satisfaction, and Experienced Usability of Internet-Based Cognitive Behavioral Therapy for Adults With Depression and Anxiety After a Myocardial Infarction: Mixed-Methods Study %A Wallin,Emma %A Norlund,Fredrika %A Olsson,Erik Martin Gustaf %A Burell,Gunilla %A Held,Claes %A Carlsson,Tommy %+ Department of Psychology, Uppsala University, Box 1225, Uppsala, 75142, Sweden, 46 0706606118, emma.wallin@psyk.uu.se %K mental health %K internet %K cognitive behavioral therapy %K computer-assisted therapy %K myocardial infarction %K attrition %K adherence %D 2018 %7 16.03.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Knowledge about user experiences may lead to insights about how to improve treatment activity in Internet-based cognitive behavioral therapy (iCBT) to reduce symptoms of depression and anxiety among people with a somatic disease. There is a need for studies conducted alongside randomized trials, to explore treatment activity and user experiences related to such interventions, especially among people with older age who are recruited in routine care. Objective: The aim of the study was to explore treatment activity, user satisfaction, and usability experiences among patients allocated to treatment in the U-CARE Heart study, a randomized clinical trial of an iCBT intervention for treatment of depression and anxiety following a recent myocardial infarction. Methods: This was a mixed methods study where quantitative and qualitative approaches were used. Patients were recruited consecutively from 25 cardiac clinics in Sweden. The study included 117 patients allocated to 14 weeks of an iCBT intervention in the U-CARE Heart study. Quantitative data about treatment activity and therapist communication were collected through logged user patterns, which were analyzed with descriptive statistics. Qualitative data with regard to positive and negative experiences, and suggestions for improvements concerning the intervention, were collected through semistructured interviews with 21 patients in the treatment arm after follow-up. The interviews were analyzed with qualitative manifest content analysis. Results: Treatment activity was low with regard to number of completed modules (mean 0.76, SD 0.93, range 0-5) and completed assignments (mean 3.09, SD 4.05, range 0-29). Most of the participants initiated the introduction module (113/117, 96.6%), and about half (63/117, 53.9%) of all participants completed the introductory module, but only 18 (15.4%, 18/117) continued to work with any of the remaining 10 modules, and each of the remaining modules was completed by 7 or less of the participants. On average, patients sent less than 2 internal messages to their therapist during the intervention (mean 1.42, SD 2.56, range 0-16). Interviews revealed different preferences with regard to the internet-based portal, the content of the treatment program, and the therapist communication. Aspects related to the personal situation and required skills included unpleasant emotions evoked by the intervention, lack of time, and technical difficulties. Conclusions: Patients with a recent myocardial infarction and symptoms of depression and anxiety showed low treatment activity in this guided iCBT intervention with regard to completed modules, completed assignments, and internal messages sent to their therapist. The findings call attention to the need for researchers to carefully consider the preferences, personal situation, and technical skills of the end users during the development of these interventions. The study indicates several challenges that need to be addressed to improve treatment activity, user satisfaction, and usability in internet-based interventions in this population. %M 29549067 %R 10.2196/jmir.9690 %U http://www.jmir.org/2018/3/e87/ %U https://doi.org/10.2196/jmir.9690 %U http://www.ncbi.nlm.nih.gov/pubmed/29549067 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 3 %P e64 %T Self-Directed Engagement with a Mobile App (Sinasprite) and Its Effects on Confidence in Coping Skills, Depression, and Anxiety: Retrospective Longitudinal Study %A Silva Almodovar,Armando %A Surve,Swatee %A Axon,David Rhys %A Cooper,David %A Nahata,Milap C %+ Institute of Therapeutic Innovations and Outcomes, The College of Pharmacy, The Ohio State University, 500 West 12 Ave, Columbus, OH, 43210, United States, 1 6142922472, nahata.1@osu.edu %K mental health %K retrospective studies %K longitudinal studies %K mobile apps %K anxiety %K depression %D 2018 %7 16.03.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Inadequacies in mental health care coverage remain an enormous problem in the United States. Barriers include scarcity of accessible mental health care professionals. Use of a mental health mobile app incorporating social cognitive theory may help improve confidence in coping skills and improve anxiety and depression. Sinasprite is a mobile app that recruited users via self-referral and clinician referral. Users completed questionnaires to obtain demographic and medical histories. At baseline and 6-week follow-up, users completed the Patient Health Questionnaire 8 (PHQ-8), General Anxiety Disorder 7-Item (GAD-7), and the Coping Self-Efficacy Scale (CSE). It is unknown how self-directed use of a mobile app improves confidence in coping skills and its effects on self-reported depression and anxiety. Objective: The objective of this study was to evaluate the Sinasprite database to assess self-directed engagement and how use of this mobile app impacted self-reported confidence in coping skills and severity of depression and anxiety. Methods: This retrospective longitudinal study involved users recruited via clinician referral and self-referral through social media and news media. Questionnaires were used to record demographic, medical, and prescription medication histories. Mental health status was assessed via PHQ-8, GAD-7, and CSE questionnaires. A deidentified dataset reporting mobile app use data was provided to investigators. Individuals with verifiable usage data and at least one completed questionnaire at 6 weeks of use were included. Mann–Whitney U and Kruskal-Wallis tests were used to assess whether demographic data and psychotherapy were related to baseline questionnaire scores and usage. A Spearman rho (ρ) test was used to assess the relationship between improvement in the CSE and GAD-7 and PHQ-8 questionnaires. Changes in mental health status were assessed using Wilcoxon signed-rank test. A mixed-effects repeated-measures linear regression model assessed the main effects of time, concomitant counseling, and psychotropic prescription medication use on mental health status. Results: Thirty-four users were eligible for inclusion in the analysis. Users were predominantly female, white, married, and college educated. At baseline, 35% (12/34) of respondents reported the use of individual/group counseling, and 38% (19/34) reported using prescription medications for their mental health. The median user completed 5.7 (interquartile range 2.7-14.1) trackable activities per week. Statistically significant improvements using a Wilcoxon signed-ranked test were observed in the PHQ-8 (P<.001), GAD-7 (P=.002), and CSE (P<.001) questionnaire scores. A strong positive correlation between improvement in the GAD-7 and CSE questionnaire scores (ρ=.572, P=.001, n=28) was observed. The mixed-effects repeated-measures regression model revealed a statistically significant effect of time on improvements in the PHQ-8 (P<.001), GAD-7 (P=.007), and CSE (P=.001). Conclusions: This 6-week retrospective study showed that self-directed use of the mobile app, Sinasprite, resulted in significant improvements in self-reported questionnaire scores reflecting depression, anxiety, and confidence in coping skills. %M 29549066 %R 10.2196/mhealth.9612 %U http://mhealth.jmir.org/2018/3/e64/ %U https://doi.org/10.2196/mhealth.9612 %U http://www.ncbi.nlm.nih.gov/pubmed/29549066 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 3 %P e81 %T Evaluation of Technology-Based Peer Support Intervention Program for Preventing Postnatal Depression: Protocol for a Randomized Controlled Trial %A Shorey,Shefaly %A Chee,Cornelia %A Chong,Yap-Seng %A Ng,Esperanza Debby %A Lau,Ying %A Dennis,Cindy-Lee %+ National University of Singapore, Level 2, Clinical Research Centre, 10 Medical Drive, Singapore, Singapore, 117597, Singapore, 65 66011294, nurssh@nus.edu.sg %K anxiety %K loneliness %K peer group %K postpartum depression %K social support %K technology %D 2018 %7 14.03.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Multiple international agencies, including the World Health Organization and the International Monetary Fund, have emphasized the importance of maternal mental health for optimal child health and development. Adequate social support is vital for the most vulnerable to postpartum mood disorders. Hence, an urgent need for sustainable social support programs to aid mothers ease into their new parenting role exists. Objective: This study protocol aims to examine the effectiveness of a technology-based peer support intervention program among mothers at risk for postnatal depression in the early postpartum period. Methods: A randomized controlled 2-group pretest and repeated posttest experimental design will be used. The study will recruit 118 mothers from the postnatal wards of a tertiary public hospital in Singapore. Eligible mothers will be randomly allocated to receive either the peer support intervention program or routine perinatal care from the hospital. Peer volunteers will be mothers who have experienced self-reported depression and will be receiving face-to-face training to support new mothers at risk of depression. Outcome measures include postnatal depression, anxiety, loneliness, and social support. Data will be collected at immediate postnatal period (day of discharge from the hospital), at fourth week and twelfth week post childbirth. Results: The recruitment and training of peer support volunteers (N=20) ended in June 2017, whereas recruitment of study participants commenced in July 2017 and is still ongoing. The current recruitment for new mothers stands at 73, with 36 in the control group and 37 in the intervention group. Data collection is projected to be completed by May 2018. Conclusions: This study will identify a potentially effective and clinically useful method to prevent postnatal depression in new mothers, which is the top cause of maternal morbidity. Receiving social support from others who share similar experiences may enhance the positive parenting experiences of mothers, which in turn can improve the psychosocial well-being of the mothers, tighten mother-child bond, and enhance overall family dynamics for mothers and infants. Trial Registration: International Standard Randomized Controlled Trial Number ISRCTN14864807; http://www.isrctn.com/ISRCTN14864807 (Archived by WebCite at http://www.webcitation.org/6xtBNvBTX) %M 29540338 %R 10.2196/resprot.9416 %U http://www.researchprotocols.org/2018/3/e81/ %U https://doi.org/10.2196/resprot.9416 %U http://www.ncbi.nlm.nih.gov/pubmed/29540338 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 3 %P e88 %T Internet-Based Cognitive Behavioral Therapy for Symptoms of Depression and Anxiety Among Patients With a Recent Myocardial Infarction: The U-CARE Heart Randomized Controlled Trial %A Norlund,Fredrika %A Wallin,Emma %A Olsson,Erik Martin Gustaf %A Wallert,John %A Burell,Gunilla %A von Essen,Louise %A Held,Claes %+ Clinical Psychology in Healthcare, Department of Women's and Children's Health, Uppsala University, Akademiska sjukhuset, Uppsala, 75185, Sweden, 46 737441304, fredrika.norlund@kbh.uu.se %K eHealth %K treatment adherence and compliance %K patient acceptance of health care %K patient selection %K cardiac rehabilitation %D 2018 %7 08.03.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Symptoms of depression and anxiety are common after a myocardial infarction (MI). Internet-based cognitive behavioral therapy (iCBT) has shown good results in other patient groups. Objective: The aim of this study was to evaluate the effectiveness of an iCBT treatment to reduce self-reported symptoms of depression and anxiety among patients with a recent MI. Methods: In total, 3928 patients were screened for eligibility in 25 Swedish hospitals. Of these, 239 patients (33.5%, 80/239 women, mean age 60 years) with a recent MI and symptoms of depression or anxiety were randomly allocated to a therapist-guided, 14-week iCBT treatment (n=117), or treatment as usual (TAU; n=122). The iCBT treatment was designed for post-MI patients. The primary outcome was the total score of the Hospital Anxiety and Depression Scale (HADS) 14 weeks post baseline, assessed over the internet. Treatment effect was evaluated according to the intention-to-treat principle, with multiple imputations. For the main analysis, a pooled treatment effect was estimated, controlling for age, sex, and baseline HADS. Results: There was a reduction in HADS scores over time in the total study sample (mean delta=−5.1, P<.001) but no difference between the study groups at follow-up (beta=−0.47, 95% CI −1.95 to 1.00, P=.53). Treatment adherence was low. A total of 46.2% (54/117) of the iCBT group did not complete the introductory module. Conclusions: iCBT treatment for an MI population did not result in lower levels of symptoms of depression or anxiety compared with TAU. Low treatment adherence might have influenced the result. Trial Registration: ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191 (Archived at Webcite at http://www.webcitation.org/6xWWSEQ22) %M 29519777 %R 10.2196/jmir.9710 %U http://www.jmir.org/2018/3/e88/ %U https://doi.org/10.2196/jmir.9710 %U http://www.ncbi.nlm.nih.gov/pubmed/29519777 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 2 %P e62 %T Help-Seeking on Facebook Versus More Traditional Sources of Help: Cross-Sectional Survey of Military Veterans %A Teo,Alan R %A Marsh,Heather E %A Liebow,Samuel B L %A Chen,Jason I %A Forsberg,Christopher W %A Nicolaidis,Christina %A Saha,Somnath %A Dobscha,Steven K %+ Health Services Research and Development Center to Improve Veteran Involvement in Care, Department of Veterans Affairs Portland Health Care System, 3710 SW US Veterans Hospital Rd (R&D 66), Portland, OR,, United States, 1 503 220 8262 ext 52461, teoa@ohsu.edu %K social media %K social networking sites %K internet %K Facebook %K service use %K utilization %K treatment-seeking %D 2018 %7 26.02.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: The media has devoted significant attention to anecdotes of individuals who post messages on Facebook prior to suicide. However, it is unclear to what extent social media is perceived as a source of help or how it compares to other sources of potential support for mental health problems. Objective: This study aimed to evaluate the degree to which military veterans with depression use social media for help-seeking in comparison to other more traditional sources of help. Methods: Cross-sectional self-report survey of 270 adult military veterans with probable major depression. Help-seeking intentions were measured with a modified General Help-Seeking Questionnaire. Facebook users and nonusers were compared via t tests, Chi-square, and mixed effects regression models. Associations between types of help-seeking were examined using mixed effects models. Results: The majority of participants were users of social media, primarily Facebook (n=162). Mean overall help-seeking intentions were similar between Facebook users and nonusers, even after adjustment for potential confounders. Facebook users were very unlikely to turn to Facebook as a venue for support when experiencing either emotional problems or suicidal thoughts. Compared to help-seeking intentions for Facebook, help-seeking intentions for formal (eg, psychologists), informal (eg, friends), or phone helpline sources of support were significantly higher. Results did not substantially change when examining users of other social media, women, or younger adults. Conclusions: In its current form, the social media platform Facebook is not seen as a venue to seek help for emotional problems or suicidality among veterans with major depression in the United States. %M 29483064 %R 10.2196/jmir.9007 %U http://www.jmir.org/2018/2/e62/ %U https://doi.org/10.2196/jmir.9007 %U http://www.ncbi.nlm.nih.gov/pubmed/29483064 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e17 %T Supporting Our Valued Adolescents (SOVA), a Social Media Website for Adolescents with Depression and/or Anxiety: Technological Feasibility, Usability, and Acceptability Study %A Radovic,Ana %A Gmelin,Theresa %A Hua,Jing %A Long,Cassandra %A Stein,Bradley D %A Miller,Elizabeth %+ Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 3420 Fifth Avenue, Pittsburgh, PA, 15213, United States, 1 412 692 7227, ana.radovic@chp.edu %K adolescent %K adolescent health services %K technology %K depression %K anxiety %D 2018 %7 26.02.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Supporting Our Valued Adolescents (SOVA), a social media website for adolescents, was designed to increase mental health literacy and address negative health beliefs toward depression and/or anxiety diagnosis and treatment. This stakeholder-informed site underwent iterative user testing to evolve into its current version with daily blog posts, round-the-clock site moderation, and Web-based peer interaction to create an online support community. Objective: The aim of this study was to evaluate the technological feasibility (at least 100 users on the site, logging in 12 to 18 times in the first 6 weeks) and acceptability of the SOVA site determined by the System Usability Scale (SUS). Methods: Adolescents and young adults (aged 14-26 years) with a self-reported history of depressive and/or anxiety symptoms were recruited to access the research website (sova.pitt.edu). Participants were screened out if they reported active suicidality or a prior suicide attempt. Baseline survey measures included demographics, symptomatology using the Patient Health Questionnaire-9 modified for adolescents (PHQ-9A) and Screen for Child Anxiety Related Disorders (SCARED-C), and mental health treatment history. The 6-week follow-up measures taken in addition to the symptomatology, included feasibility (total number of log-ins), usability, and acceptability of SOVA using SUS. Results: Most of the 96 participants identified as female (75% [72/96]) and white (67% [64/96]). Most participants (73% [70/96]) reported having taken prior professional psychological help. The average PHQ-9A score was 11.8 (SD 5.5), and for SCARED-C, 85% (80/94) of the participants reported a score consistent with being susceptible to a diagnosed anxiety disorder. There were 46% (41/90) of eligible users who ever logged in. Out of the total users who ever logged in, the mean of total log-ins over the entire study was 4.1 (SD 6.9). Median number of users rated the user-friendliness of the site as “good.” The average SUS score was 71.2% (SD 18.7), or a “C-grade,” which correlated to an acceptable range. The participants reported to have liked the “easy-to-understand format” and “positive, helpful atmosphere,” but they also reported a desire for greater social interaction. Iterative recruitment resulted in incremental improvements to the site. Conclusions: The SOVA site met feasibility goals of recruiting almost 100 users and establishing acceptable usability. Subsequent interventions are planned to increase site engagement and to evaluate efficacy in increasing uptake of primary care–recommended depression and/or anxiety treatment. %M 29483067 %R 10.2196/mental.9441 %U http://mental.jmir.org/2018/1/e17/ %U https://doi.org/10.2196/mental.9441 %U http://www.ncbi.nlm.nih.gov/pubmed/29483067 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e14 %T Influencing the Conversation About Masculinity and Suicide: Evaluation of the Man Up Multimedia Campaign Using Twitter Data %A Schlichthorst,Marisa %A King,Kylie %A Turnure,Jackie %A Sukunesan,Suku %A Phelps,Andrea %A Pirkis,Jane %+ Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Parkville, 3010, Australia, 61 390353508, marisa.schlichthorst@unimelb.edu.au %K mental health %K suicide %K masculinity %K men’s health %D 2018 %7 15.02.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: It has been suggested that some dominant aspects of traditional masculinity are contributing to the high suicide rates among Australian men. We developed a three-episode documentary called Man Up, which explores the complex relationship between masculinity and suicide and encourages men to question socially imposed rules about what it means to be a man and asks them to open up, express difficult emotions, and seek help if and when needed. We ran a three-phase social media campaign alongside the documentary using 5 channels (Twitter, Facebook, Instagram, YouTube, and Tumblr). Objective: This study aimed to examine the extent to which the Man Up Twitter campaign influenced the social media conversation about masculinity and suicide. Methods: We used Twitter insights data to assess the reach of and engagement with the campaign (using metrics on followers, likes, retweets, and impressions) and to determine the highest and lowest performing tweets in the campaign (using an aggregated performance measure of reactions). We used original content tweets to determine whether the campaign increased the volume of relevant Twitter conversations (aggregating the number of tweets for selected campaign hashtags over time), and we used a subset of these data to gain insight into the main content themes with respect to audience engagement. Results: The campaign generated a strong following that was engaged with the content of the campaign; over its whole duration, the campaign earned approximately 5000 likes and 2500 retweets and gained around 1,022,000 impressions. The highest performing tweets posted by the host included video footage and occurred during the most active period of the campaign (around the screening of the documentary). The volume of conversations in relation to commonly used hashtags (#MANUP, #ABCMANUP, #LISTENUP, and #SPEAKUP) grew in direct relation to the campaign activities, achieving strongest growth during the 3 weeks when the documentary was aired. Strongest engagement was found with content related to help-seeking, masculinity, and expressing emotions. A number of followers tweeted personal stories that revealed overwhelmingly positive perceptions of the content of the documentary and strongly endorsed its messages. Conclusions: The Man Up Twitter campaign triggered conversations about masculinity and suicide that otherwise may not have happened. For some, this may have been game-changing in terms of shifting attitudes toward expressing emotions and reaching out to others for help. The campaign was particularly effective in disseminating information and promoting conversations in real time, an advantage that it had over more traditional health promotion campaigns. This sort of approach could well be adapted to other areas of mental (and physical) health promotion campaigns to increase their reach and effectiveness. %M 29449203 %R 10.2196/mental.9120 %U http://mental.jmir.org/2018/1/e14/ %U https://doi.org/10.2196/mental.9120 %U http://www.ncbi.nlm.nih.gov/pubmed/29449203 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e13 %T A Web-Based Psychoeducational Intervention for Adolescent Depression: Design and Development of MoodHwb %A Bevan Jones,Rhys %A Thapar,Anita %A Rice,Frances %A Beeching,Harriet %A Cichosz,Rachel %A Mars,Becky %A Smith,Daniel J %A Merry,Sally %A Stallard,Paul %A Jones,Ian %A Thapar,Ajay K %A Simpson,Sharon A %+ Division of Psychological Medicine and Clinical Neurosciences, Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Hadyn Ellis Building, Maindy Rd, Cardiff, Wales, CF24 4HQ, United Kingdom, 44 02920688451, bevanjonesr1@cardiff.ac.uk %K adolescent %K depression %K internet %K education %K preventive psychiatry %K early medical intervention %D 2018 %7 15.02.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is common in adolescence and leads to distress and impairment in individuals, families and carers. Treatment and prevention guidelines highlight the key role of information and evidence-based psychosocial interventions not only for individuals but also for their families and carers. Engaging young people in prevention and early intervention programs is a challenge, and early treatment and prevention of adolescent depression is a major public health concern. There has been growing interest in psychoeducational interventions to provide accurate information about health issues and to enhance and develop self-management skills. However, for adolescents with, or at high risk of depression, there is a lack of engaging Web-based psychoeducation programs that have been developed with user input and in line with research guidelines and targeted at both the individual and their family or carer. There are also few studies published on the process of development of Web-based psychoeducational interventions. Objective: The aim of this study was to describe the process underlying the design and development of MoodHwb (HwbHwyliau in Welsh): a Web-based psychoeducation multimedia program for young people with, or at high risk of, depression and their families, carers, friends, and professionals. Methods: The initial prototype was informed by (1) a systematic review of psychoeducational interventions for adolescent depression; (2) findings from semistructured interviews and focus groups conducted with adolescents (with depressive symptoms or at high risk), parents or carers, and professionals working with young people; and (3) workshops and discussions with a multimedia company and experts (in clinical, research, and multimedia work). Twelve interviews were completed (four each with young people, parents or carers, and professionals) and six focus groups (three with young people, one with parents and carers, one with professionals, and one with academics). Results: Key themes from the interviews and focus groups were: aims of the program, design and content issues, and integration and context of the program. The prototype was designed to be person-centered, multiplatform, engaging, interactive, and bilingual. It included mood-monitoring and goal-setting components and was available as a Web-based program and an app for mobile technologies. Conclusions: MoodHwb is a Web-based psychoeducational intervention developed for young people with, or at high risk of, depression and their families and carers. It was developed with user input using qualitative methods as well as user-centered design and educational and psychological theory. Further research is needed to evaluate the effectiveness of the program in a randomized controlled trial. If found to be effective, it could be implemented in health, education, youth and social services, and charities, to not only help young people but also families, carers, friends, and professionals involved in their care. %M 29449202 %R 10.2196/mental.8894 %U http://mental.jmir.org/2018/1/e13/ %U https://doi.org/10.2196/mental.8894 %U http://www.ncbi.nlm.nih.gov/pubmed/29449202 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 2 %P e15 %T Effectiveness of a Web-Based Self-Help Program for Suicidal Thinking in an Australian Community Sample: Randomized Controlled Trial %A van Spijker,Bregje AJ %A Werner-Seidler,Aliza %A Batterham,Philip J %A Mackinnon,Andrew %A Calear,Alison L %A Gosling,John A %A Reynolds,Julia %A Kerkhof,Ad JFM %A Solomon,Daniela %A Shand,Fiona %A Christensen,Helen %+ Black Dog Institute, Department of Medicine, University of New South Wales, Hospital Road, Randwick,, Australia, 61 293 823 717, h.christensen@blackdog.org.au %K psychosocial interventions %K randomized controlled trial %K suicide %D 2018 %7 14.02.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Treatment for suicidality can be delivered online, but evidence for its effectiveness is needed. Objective: The goal of our study was to examine the effectiveness of an online self-help intervention for suicidal thinking compared to an attention-matched control program. Methods: A 2-arm randomized controlled trial was conducted with assessment at postintervention, 6, and, 12 months. Through media and community advertizing, 418 suicidal adults were recruited to an online portal and were delivered the intervention program (Living with Deadly Thoughts) or a control program (Living Well). The primary outcome was severity of suicidal thinking, assessed using the Columbia Suicide Severity Rating Scale. Results: Intention-to-treat analyses showed significant reductions in the severity of suicidal thinking at postintervention, 6, and 12 months. However, no overall group differences were found. Conclusions: Living with Deadly Thoughts was of no greater effectiveness than the control group. Further investigation into the conditions under which this program may be beneficial is now needed. Limitations of this trial include it being underpowered given the effect size ultimately observed, a high attrition rate, and the inability of determining suicide deaths or of verifying self-reported suicide attempts. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12613000410752; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=364016 (Archived by WebCite at http://www.webcitation.org/6vK5FvQXy); Universal Trial Number U1111-1141-6595 %M 29444769 %R 10.2196/jmir.8595 %U https://www.jmir.org/2018/2/e15/ %U https://doi.org/10.2196/jmir.8595 %U http://www.ncbi.nlm.nih.gov/pubmed/29444769 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 2 %P e38 %T Digital Peer-Support Platform (7Cups) as an Adjunct Treatment for Women With Postpartum Depression: Feasibility, Acceptability, and Preliminary Efficacy Study %A Baumel,Amit %A Tinkelman,Amanda %A Mathur,Nandita %A Kane,John M %+ Department of Community Mental Health, University of Haifa, Abba Khoushy Ave 199, Haifa,, Israel, 972 482 4011, abaumel@univ.haifa.ac.il %K mhealth %K postpartum depression %K perinatal mood disorder %K peer support %K online %K self-help %D 2018 %7 13.02.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Peer support is considered to be an important framework of support for mothers experiencing postpartum depression (PPD); however, some barriers exist that may limit its use including peer availability and mothers’ lack of time due to child care. Objective: This non-randomized study was designed to examine the feasibility, acceptance, and preliminary clinical outcomes of using 7 Cups of Tea (7Cups), a digital platform that delivers self-help tools and 24/7 emotional support delivered by trained volunteers, as an adjunct treatment for mothers diagnosed with PPD. Methods: Mothers with PPD were referred during intake to the study coach who provided guidance about 7Cups. 7Cups features included self-help tools and chats with trained volunteers who had experienced a perinatal mood disorder in their past. Acceptability was measured by examining self-reports and user engagement with the program. The primary outcome was the Edinburgh Postnatal Depression Scale (EPDS) change score between pre- and postintervention at 2 months, as collected in usual care by clinicians blinded to the study questions. Using a propensity score matching to control for potential confounders, we compared women receiving 7Cups to women receiving treatment as usual (TAU). Results: Participants (n=19) proactively logged into 7Cups for a median of 12 times and 175 minutes. Program use was mostly through the mobile app (median of mobile use 94%) and between 18:00 and 08:00 when clinicians are unavailable (68% of total program use time). Participants chatted with volunteers for a total of 3064 minutes and have indicated in their responses 0 instances in which they felt unsafe. Intent-to-treat analysis revealed that 7Cups recipients experienced significant decreases in EPDS scores (P<.001, Cohen d=1.17). No significant difference in EPDS decrease over time was found between 7Cups and TAU, yet the effect size was medium favoring 7Cups (P=.05, Cohen d=0.58). Conclusions: This study supports using a computerized method to train lay people, without any in-person guidance or screening, and engage them with patients diagnosed with mental illness as part of usual care. The medium effect size (d=0.58) favoring the 7Cups group relative to TAU suggests that 7Cups might enhance treatment outcomes. A fully powered trial has to be conducted to examine this effect. %M 29439944 %R 10.2196/mhealth.9482 %U http://mhealth.jmir.org/2018/2/e38/ %U https://doi.org/10.2196/mhealth.9482 %U http://www.ncbi.nlm.nih.gov/pubmed/29439944 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 2 %P e37 %T Text-Based Program Addressing the Mental Health of Soon-to-be and New Fathers (SMS4dads): Protocol for a Randomized Controlled Trial %A Fletcher,Richard %A May,Chris %A Attia,John %A Garfield,Craig Franklin %A Skinner,Geoff %+ Family Action Centre, Faculty of Health and Medicine, University of Newcastle, Academic Office Block, University Drive, Callaghan, 2308, Australia, 61 0429152405, richard.fletcher@newcastle.edu.au %K perinatal %K fathers %K online intervention %K randomized controlled trial %K mental health %D 2018 %7 06.02.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Recent estimates indicating that approximately 10% of fathers experience Paternal Perinatal Depression (PPND) and the increasing evidence of the impact of PPND on child development suggest that identifying and assisting distressed fathers is justified on public health grounds. However, addressing new fathers’ mental health needs requires overcoming men’s infrequent contact with perinatal health services and their reluctance to seek help. Text-based interventions delivering information and support have the potential to reach such groups in order to reduce the impact of paternal perinatal distress and to improve the wellbeing of their children. While programs utilising mobile phone technology have been developed for mothers, fathers have not been targeted. Since text messages can be delivered to individual mobile phones to be accessed at a time that is convenient, it may provide a novel channel for engaging with “hard-to-reach” fathers in a critical period of their parenting. Objective: The study will test the efficacy of SMS4dads, a text messaging program designed specifically for fathers including embedded links to online information and regular invitations (Mood Tracker) to monitor their mood, in order to reduce self-reported depression, anxiety and stress over the perinatal period. Methods: A total of 800 fathers-to-be or new fathers from within Australia will be recruited via the SMS4dads website and randomized to the intervention or control arm. The intervention arm will receive 14 texts per month addressing fathers’ physical and mental health, their relationship with their child, and coparenting with their partner. The control, SMS4health, delivers generic health promotion messages twice per month. Messages are timed according to the babies’ expected or actual date of birth and fathers can enroll from 16 weeks into the pregnancy until their infant is 12 weeks of age. Participants complete questionnaires assessing depression, anxiety, stress, and alcohol at baseline and 24 weeks postenrolment. Measures of coparenting and parenting confidence are also completed at baseline and 24 weeks for postbirth enrolments. Results: Participant were recruited between October 2016 and September 2017. Follow-up data collection has commenced and will be completed in March 2018 with results expected in June 2018. Conclusions: This study’s findings will assess the efficacy of a novel text-based program specifically targeting fathers in the perinatal period to improve their depression, anxiety and distress symptoms, coparenting quality, and parenting self-confidence. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000261415; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=370085 (Archived by WebCite at http://www.webcitation.org/6wav55wII). %M 29410387 %R 10.2196/resprot.8368 %U http://www.researchprotocols.org/2018/2/e37/ %U https://doi.org/10.2196/resprot.8368 %U http://www.ncbi.nlm.nih.gov/pubmed/29410387 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 1 %P e35 %T The Effectiveness and Cost-Effectiveness of Web-Based and Home-Based Postnatal Psychoeducational Interventions for First-Time Mothers: Randomized Controlled Trial Protocol %A He,Honggu %A Zhu,Lixia %A Chan,Sally Wai Chi %A Chong,Yap-Seng %A Jiao,Nana %A Chan,Yiong Huak %A Luo,Nan %A Shorey,Shefaly %+ Alice Lee Centre for Nursing Studies, National University of Singapore, Level 2 Clinical Research Centre, Block MD 11, 10 Medical Drive, Singapore, 117597, Singapore, 65 66011294 ext 1294, nurssh@nus.edu.sg %K mothers %K education %K postpartum period %K Internet %D 2018 %7 31.01.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: In addition to recuperating from the physical and emotional demands of childbirth, first-time mothers are met with demands of adapting to their social roles while picking up new skills to take care of their newborn. Mothers may not feel adequately prepared for parenthood if they are situated in an unsupported environment. Postnatal psychoeducational interventions have been shown to be useful and can offer a cost-effective solution for improving maternal outcomes. Objective: The objective of this study was to examine the effectiveness and cost-effectiveness of Web-based and home-based postnatal psychoeducational programs for first-time mothers on maternal outcomes. Methods: A randomized controlled three-group pre- and posttests experimental design is proposed. This study plans to recruit 204 first-time mothers on their day of discharge from a public tertiary hospital in Singapore. Eligible first-time mothers will be randomly allocated to either a Web-based psychoeducation group, a home-based psychoeducation group, or a control group receiving standard care. The outcomes include maternal parental self-efficacy, social support, psychological well-being (anxiety and postnatal depression), and cost evaluation. Data will be collected at baseline, 1 month, 3 months, and 6 months post-delivery. Results: The recruitment (n=204) commenced in October 2016 and was completed in February 2017, with 68 mothers in each group. The 6-month follow-up data collection was completed in August 2017. Conclusions: This study may identify an effective and cost-effective Web-based postnatal psychoeducational program to improve first-time mothers’ health outcomes. The provision of a widely-accessed Web-based postnatal psychoeducational program will eventually lead to more positive postnatal experiences for first-time mothers and positively influence their future birth plans. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 45202278; http://www.isrctn.com/ISRCTN45202278 (Archived by WebCite at http://www.webcitation.org/6whx0pQ2F). %M 29386175 %R 10.2196/resprot.9042 %U http://www.researchprotocols.org/2018/1/e35/ %U https://doi.org/10.2196/resprot.9042 %U http://www.ncbi.nlm.nih.gov/pubmed/29386175 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 1 %P e38 %T Remote Collaborative Depression Care Program for Adolescents in Araucanía Region, Chile: Randomized Controlled Trial %A Martínez,Vania %A Rojas,Graciela %A Martínez,Pablo %A Zitko,Pedro %A Irarrázaval,Matías %A Luttges,Carolina %A Araya,Ricardo %+ Departamento de Psiquiatría y Salud Mental, Hospital Clínico Universidad de Chile, Av. La Paz 1003, Recoleta, Santiago,, Chile, 56 229788601, graciela.rojas.castillo@gmail.com %K primary health care %K depression %K adolescents %K Internet %K telemedicine %K medically underserved area %D 2018 %7 31.01.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite evidence on efficacious interventions, a great proportion of depressed adolescents do not receive evidence-based treatment and have no access to specialized mental health care. Remote collaborative depression care (RCDC) may help to reduce the gap between needs and specialized mental health services. Objective: The objective of this study was to assess the feasibility, acceptability, and effectiveness of an RCDC intervention for adolescents with major depressive disorder (MDD) living in the Araucanía Region, Chile. Methods: A cluster randomized, assessor-blind trial was carried out at 16 primary care centers in the Araucanía Region, Chile. Before randomization, all participating primary care teams were trained in clinical guidelines for the treatment of adolescent depression. Adolescents (N=143; 13-19 years) with MDD were recruited. The intervention group (RCDC, N=65) received a 3-month RCDC treatment that included continuous remote supervision by psychiatrists located in Santiago, Chile’s capital city, through shared electronic health records (SEHR) and phone patient monitoring. The control group (enhanced usual care or EUC; N=78) received EUC by clinicians who were encouraged to follow clinical guidelines. Recruitment and response rates and the use of the SEHR system were registered; patient adherence and satisfaction with the treatment and clinician satisfaction with RCDC were assessed at 12-week follow-up; and depressive symptoms and health-related quality of life (HRQoL) were evaluated at baseline and 12-weeks follow-up. Results: More than 60.3% (143/237) of the original estimated sample size was recruited, and a response rate of 90.9% (130/143) was achieved at 12-week follow-up. A mean (SD) of 3.5 (4.0) messages per patient were written on the SEHR system by primary care teams. A third of the patients showed an optimal adherence to psychopharmacological treatment, and adolescents in the RCDC intervention group were more satisfied with psychological assistance than those in EUC group. Primary care clinicians were satisfied with the RCDC intervention, valuing its usefulness. There were no significant differences in depressive symptoms or HRQoL between groups. Satisfaction with psychological care, in both groups, was related to a significant change in depressive symptomatology at 12-weeks follow-up (beta=−4.3, 95% CI −7.2 to −1.3). Conclusions: This is the first trial of its kind in Latin America that includes adolescents from vulnerable backgrounds, with an intervention that proved to be feasible and well accepted by both patients and primary care clinicians. Design and implementation issues may explain similar effectiveness across arms. The effectiveness of the intervention seems to be comparable with an already nationwide established treatment program that proved to be highly efficacious under controlled conditions. Trial Registration: ClinicalTrials.gov: NCT01860443; https://clinicaltrials.gov/ct2/show/NCT01860443 (Archived by WebCite at http://www.webcitation.org/6wafMKlTY) %M 29386172 %R 10.2196/jmir.8021 %U https://www.jmir.org/2018/1/e38/ %U https://doi.org/10.2196/jmir.8021 %U http://www.ncbi.nlm.nih.gov/pubmed/29386172 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 1 %P e28 %T Mobile Health Technology Interventions for Suicide Prevention: Protocol for a Systematic Review and Meta-Analysis %A Melia,Ruth %A Francis,Kady %A Duggan,Jim %A Bogue,John %A O'Sullivan,Mary %A Chambers,Derek %A Young,Karen %+ Psychology Department, Health Service Executive Mid-West, Child and Adolescent Mental Health Service, Quin Road, Ennis, V95HV18, Ireland, 353 656706601, ruth.melia@hse.ie %K mHealth %K suicide prevention %K systematic review %K meta-analysis %D 2018 %7 26.01.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Previous research has reported that two of the major barriers to help-seeking for individuals at risk of suicide are stigma and geographical isolation. Mobile technology offers a potential means of delivering evidence-based interventions with greater specificity to the individual, and at the time that it is needed. Despite documented motivation by at-risk individuals to use mobile technology to track mental health and to support psychological interventions, there is a shortfall of outcomes data on the efficacy of mobile health (mHealth) technology on suicide-specific outcomes. Objective: The objective of this study is to develop a protocol for a systematic review and meta-analysis that aims to evaluate the effectiveness of mobile technology-based interventions for suicide prevention. Methods: The search includes the Cochrane Central Register of Controlled Trials (CENTRAL: The Cochrane Library), MEDLINE, Embase, PsycINFO, CRESP and relevant sources of gray literature. Studies that have evaluated psychological or nonpsychological interventions delivered via mobile computing and communication technology, and have suicidality as an outcome measure will be included. Two authors will independently extract data and assess the study suitability in accordance with the Cochrane Collaboration Risk of Bias Tool. Studies will be included if they measure at least one suicide outcome variable (ie, suicidal ideation, suicidal intent, nonsuicidal self-injurious behavior, suicidal behavior). Secondary outcomes will be measures of symptoms of depression. Where studies are sufficiently homogenous and reported outcomes are amenable for pooled synthesis, meta-analysis will be performed. A narrative synthesis will be conducted if the data is unsuitable for a meta-analysis. Results: The review is in progress, with findings expected by summer 2018. Conclusions: To date, evaluations of mobile technology-based interventions in suicide prevention have focused on evaluating content as opposed to efficacy. Indeed, previous research has identified mobile applications that appear to present harmful content. The current review will address a gap in the literature by evaluating the efficacy of stand-alone mobile technology tools in suicide prevention. It is imperative that research identifies the evidence base for such tools in suicide prevention in order to inform policy, guide clinical practice, inform users and focus future research. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42017072899; https:// www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42017072899  (Archived by WebCite at http://www.webcitation.org/ 6tZAj0yqJ) %M 29374003 %R 10.2196/resprot.8635 %U http://www.researchprotocols.org/2018/1/e28/ %U https://doi.org/10.2196/resprot.8635 %U http://www.ncbi.nlm.nih.gov/pubmed/29374003 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e7 %T Facilitating Factors and Barriers to the Use of Emerging Technologies for Suicide Prevention in Europe: Multicountry Exploratory Study %A Muñoz-Sánchez,Juan-Luis %A Delgado,Carmen %A Sánchez-Prada,Andrés %A Parra-Vidales,Esther %A de Leo,Diego %A Franco-Martín,Manuel %+ Department of Psychiatry, Zamora Hospital, Av Hernán Cortes, 44, Zamora, 49021, Spain, 34 980521816, jlmusa@icloud.com %K suicide %K prevention %K technology %D 2018 %7 24.1.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: This study provides an analysis on the use of emerging technologies for the prevention of suicide in 8 different European countries. Objective: The objective of this study was to analyze the potentiality of using emerging technologies in the area of suicide prevention based on the opinion of different professionals involved in suicide prevention. Methods: Opinions of 3 groups of stakeholders (ie, relevant professionals in suicide field) were gathered using a specifically designed questionnaire to explore dimensions underlying perceptions of facilitating factors and barriers in relation to the use of emerging technologies for suicide prevention. Results: Goal 1 involved facilitating factors for the use of emerging technologies in suicide prevention. Northern European countries, except for Belgium, attach greater relevance to those that optimize implementation and benefits. On the other hand, Southern European countries attach greater importance to professionally oriented and user-centered facilitating factors. According to different stakeholders, the analysis of these facilitating factors suggest that professionals in the field of social work attach greater relevance to those that optimize implementation and benefits. However, professionals involved in the area of mental health, policy makers, and political decision makers give greater importance to professionally oriented and user-centered facilitating factors. Goal 2 was related to barriers to the usability of emerging technologies for suicide prevention. Both countries and stakeholders attach greater importance to barriers associated with resource constraints than to those centered on personal limitations. There are no differences between countries or between stakeholders. Nevertheless, there is a certain stakeholders-countries interaction that indicates that the opinions on resource constraints expressed by different stakeholders do not follow a uniform pattern in different countries, but they differ depending on the country. Conclusions: Although all countries and stakeholders agree in identifying resource constraints as the main barrier to the use of emerging technologies, factors facilitating their use in suicide prevention differ among countries and among stakeholders. %R 10.2196/mental.7784 %U http://mental.jmir.org/2018/1/e7/ %U https://doi.org/10.2196/mental.7784 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e9 %T Youth Codesign of a Mobile Phone App to Facilitate Self-Monitoring and Management of Mood Symptoms in Young People With Major Depression, Suicidal Ideation, and Self-Harm %A Hetrick,Sarah Elisabeth %A Robinson,Jo %A Burge,Eloise %A Blandon,Ryan %A Mobilio,Bianca %A Rice,Simon M %A Simmons,Magenta B %A Alvarez-Jimenez,Mario %A Goodrich,Simon %A Davey,Christopher G %+ Centre for Youth Mental Health, University of Melbourne, Locked Bag 10, Parkville, Victoria, Melbourne, 3052, Australia, 61 3 9342 2880, shetrick@unimelb.edu.au %K depression %K suicidal ideation %K suicide, attempted %K self-injurious behavior %K adolescent %K young adult %K cell phone %D 2018 %7 23.01.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Effective treatment of depression in young people is critical, given its prevalence, impacts, and link to suicide. Clinical practice guidelines point to the need for regular monitoring of depression symptom severity and the emergence of suicidal ideation to track treatment progress and guide intervention delivery. Yet, this is seldom integrated in clinical practice. Objective: The objective of this study was to address the gap between guidelines about monitoring and real-world practice by codesigning an app with young people that allows for self-monitoring of mood and communication of this monitoring with a clinician. Methods: We engaged young people aged 18 to 25 years who had experienced depression, suicidal ideation including those who self-harm, as well as clinicians in a codesign process. We used a human-centered codesign design studio methodology where young people designed the features of the app first individually and then as a group. This resulted in a minimal viable product design, represented through low-fidelity hand-drawn wireframes. Clinicians were engaged throughout the process via focus groups. Results: The app incorporated a mood monitoring feature with innovative design aspects that allowed customization, and was named a “well-being tracker” in response to the need for a positive approach to this function. Brief personalized interventions designed to support young people in the intervals between face-to-face appointments were embedded in the app and were immediately available via pop-ups generated by a back-end algorithm within the well-being tracker. Issues regarding the safe incorporation of alerts generated by the app into face-to-face clinical services were raised by clinicians (ie, responding in a timely manner) and will need to be addressed during the full implementation of the app into clinical services. Conclusions: The potential to improve outcomes for young people via technology-based enhancement to interventions is enormous. Enhancing communication between young people and their clinicians about symptoms and treatment progress and increasing access to timely and evidence-based interventions are desirable outcomes. To achieve positive outcomes for young people using technology- (app) based interventions, it is critical to understand and incorporate, in a meaningful way, the expectations and motivations of both young people and clinicians. %M 29362208 %R 10.2196/mental.9041 %U http://mental.jmir.org/2018/1/e9/ %U https://doi.org/10.2196/mental.9041 %U http://www.ncbi.nlm.nih.gov/pubmed/29362208 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e5 %T Web-based Therapy Plus Support by a Coach in Depressed Patients Referred to Secondary Mental Health Care: Randomized Controlled Trial %A Hatcher,Simon %A Whittaker,Robyn %A Patton,Murray %A Miles,Wayne Sylvester %A Ralph,Nicola %A Kercher,Katharina %A Sharon,Cynthia %+ Brain and Mind Research Institute, Department of Psychiatry, The University of Ottawa, Room 4418, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada, 1 (613) 798 5555, shatcher@uottawa.ca %K Internet %K major depressive disorder %K secondary care %K randomized controlled trial %K New Zealand %D 2018 %7 23.01.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: The evidence for the effectiveness of Web-based therapies comes mainly from nonclinical populations, with a few studies in primary care. There is little evidence from patients referred to secondary mental health care with depression. Adherence to Web-based therapies is often poor. One way to increase this is to create a new health service role of a coach to guide people through the therapy. Objective: This study aimed to test in people referred to secondary care with depression if a Web-based therapy (The Journal) supported by a coach plus usual care would be more effective in reducing depression compared with usual care plus an information leaflet about Web-based resources after 12 weeks. Methods: We conducted a randomized controlled trial with two parallel arms and a process evaluation that included structured qualitative interviews analyzed using thematic analysis. The coach had a background in occupational therapy. Participants were recruited face-to-face at community mental health centers. Results: We recruited 63 people into the trial (intervention 35, control 28). There were no statistically significant differences in the change from baseline in Patient Health Questionnaire-9 (PHQ-9) scores at 12 weeks comparing The Journal with usual care (mean change in PHQ-9 score 9.4 in the intervention group and 7.1 in the control group, t41=1.05, P=.30; mean difference=2.3, 95% CI −2.1 to 6.7). People who were offered The Journal attended on average about one less outpatient appointment compared with usual care, although this difference was not statistically significant (intervention mean number of visits 2.8 (SD 5.5) compared with 4.1 (SD 6.7) in the control group, t45=−0.80, P=.43; mean difference=1.3, 95% CI −4.5 to 2.0). The process evaluation found that the mean number of lessons completed in the intervention group was 2.5 (SD=1.9; range=0-6) and the number of contacts with the coach was a mean of 8.1 (SD=4.4; range=0-17). The qualitative interviews highlighted the problem of engaging clinicians in research and their resistance to recruitment: technical difficulties with The Journal, which prevented people logging in easily; difficulty accessing The Journal as it was not available on mobile devices; participants finding some lessons difficult; and participants saying they were too busy to complete the sessions. Conclusions: The study demonstrated that it is feasible to use a coach in this setting, that people found it helpful, and that it did not conflict with other care that participants were receiving. Future trials need to engage clinicians at an early stage to articulate where Web-based therapies fit into existing clinical pathways; Web-based therapies should be available on mobile devices, and logging in should be easy. The role of the coach should be explored in larger trials. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN): 12613000015741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363351&isReview=true (Archived by WebCite at http://www.webcitation.org/6wEyCc6Ss). %M 29362207 %R 10.2196/mental.8510 %U http://mental.jmir.org/2018/1/e5/ %U https://doi.org/10.2196/mental.8510 %U http://www.ncbi.nlm.nih.gov/pubmed/29362207 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e8 %T Employees’ Perspectives on the Facilitators and Barriers to Engaging With Digital Mental Health Interventions in the Workplace: Qualitative Study %A Carolan,Stephany %A de Visser,Richard O %+ School of Psychology, University of Sussex, Falmer, Brighton, BN1 9QH, United Kingdom, 44 1273876638, sc587@sussex.ac.uk %K anxiety %K depression %K eHealth %K Internet %K mental health %K mHealth %K occupational %K online %K stress %K workplace %D 2018 %7 19.01.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Prevalence rates of work-related stress, depression, and anxiety are high, resulting in reduced productivity and increased absenteeism. There is evidence that these conditions can be successfully treated in the workplace, but take-up of psychological treatments among workers is low. Digital mental health interventions delivered in the workplace may be one way to address this imbalance, but although there is evidence that digital mental health is effective at treating stress, depression, and anxiety in the workplace, uptake of and engagement with these interventions remains a concern. Additionally, there is little research on the appropriateness of the workplace for delivering these interventions or on what the facilitators and barriers to engagement with digital mental health interventions in an occupational setting might be. Objective: The aim of this research was to get a better understanding of the facilitators and barriers to engaging with digital mental health interventions in the workplace. Methods: Semistructured interviews were held with 18 participants who had access to an occupational digital mental health intervention as part of a randomized controlled trial. The interviews were transcribed, and thematic analysis was used to develop an understanding of the data. Results: Digital mental health interventions were described by interviewees as convenient, flexible, and anonymous; these attributes were seen as being both facilitators and barriers to engagement in a workplace setting. Convenience and flexibility could increase the opportunities to engage with digital mental health, but in a workplace setting they could also result in difficulty in prioritizing time and ensuring a temporal and spatial separation between work and therapy. The anonymity of the Internet could encourage use, but that benefit may be lost for people who work in open-plan offices. Other facilitators to engagement included interactive and interesting content and design features such as progress trackers and reminders to log in. The main barrier to engagement was the lack of time. The perfect digital mental health intervention was described as a website that combined a short interactive course that was accessed alongside time-unlimited information and advice that was regularly updated and could be dipped in and out of. Participants also wanted access to e-coaching support. Conclusions: Occupational digital mental health interventions may have an important role in delivering health care support to employees. Although the advantages of digital mental health interventions are clear, they do not always fully translate to interventions delivered in an occupational setting and further work is required to identify ways of minimizing potential barriers to access and engagement. Trial Registration: ClinicalTrials.gov: NCT02729987; https://clinicaltrials.gov/ct2/show/NCT02729987?term=NCT02729987& rank=1 (Archived at WebCite at http://www.webcitation.org/6wZJge9rt) %M 29351900 %R 10.2196/mental.9146 %U http://mental.jmir.org/2018/1/e8/ %U https://doi.org/10.2196/mental.9146 %U http://www.ncbi.nlm.nih.gov/pubmed/29351900 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 1 %P e17 %T A Tailored Web-Based Intervention to Improve Parenting Risk and Protective Factors for Adolescent Depression and Anxiety Problems: Postintervention Findings From a Randomized Controlled Trial %A Yap,Marie Bee Hui %A Mahtani,Shireen %A Rapee,Ronald M %A Nicolas,Claire %A Lawrence,Katherine A %A Mackinnon,Andrew %A Jorm,Anthony F %+ Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton, 3800, Australia, 61 399050723, marie.yap@monash.edu %K family %K anxiety %K parenting %K depression %K adolescent %K Internet %K mental health %K preventive health services %D 2018 %7 19.01.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression and anxiety disorders in young people are a global health concern. Parents have an important role in reducing the risk of these disorders, but cost-effective, evidence-based interventions for parents that can be widely disseminated are lacking. Objective: This study aimed to examine the postintervention effects of the Partners in Parenting (PiP) program on parenting risk and protective factors for adolescent depression and anxiety, and on adolescent depression and anxiety symptoms. Methods: A two-arm randomized controlled trial was conducted with 359 parent-adolescent dyads, recruited primarily through schools across Australia. Parents and adolescents were assessed at baseline and 3 months later (postintervention). Parents in the intervention condition received PiP, a tailored Web-based parenting intervention designed following Persuasive Systems Design (PSD) principles to target parenting factors associated with adolescents’ risk for depression and anxiety problems. PiP comprises a tailored feedback report highlighting each parent’s strengths and areas for improvement, followed by a set of interactive modules (up to nine) that is specifically recommended for the parent based on individually identified areas for improvement. Parents in the active-control condition received a standardized package of five Web-based factsheets about adolescent development and well-being. Parents in both conditions received a 5-min weekly call to encourage progress through their allocated program to completion. Both programs were delivered weekly via the trial website. The primary outcome measure at postintervention was parent-reported changes in parenting risk and protective factors, which were measured using the Parenting to Reduce Adolescent Depression and Anxiety Scale (PRADAS). Secondary outcome measures were the adolescent-report PRADAS, the parent- and child-report Short Mood and Feelings Questionnaire (depressive symptoms), and parent- and child-report Spence Children’s Anxiety Scale (anxiety symptoms). Results: Parents in the intervention condition completed a mean of 73.7% of their intended personalized PiP program. A total of 318 parents (88.6%, 318/359) and 308 adolescents (92.8%, 308/332) completed the postintervention assessment. Attrition was handled using mixed model of repeated measures analysis of variance. As hypothesized, we found a significant condition-by-time interaction on the PRADAS, with a medium effect size, Cohen d=0.57, 95% CI 0.34-0.79. No significant differences between conditions were found at postintervention on any of the secondary outcome measures, with adolescent depressive (parent-report only) and anxiety (both parent- and adolescent-report) symptoms decreasing significantly from baseline to postintervention in both conditions. Conclusions: The fully automated PiP intervention showed promising short-term effects on parenting behaviors that are associated with adolescents’ risk for depression and anxiety. Long-term follow-up is required to ascertain whether these effects translate into reduced adolescent depression and anxiety problems. The intervention may be useful as a low-cost universal public health program to increase parenting practices believed to benefit adolescents’ mental health. Trial Registration: Australia New Zealand Clinical Trials Registry: ACTRN12615000328572; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx? id=368274 (Archived by WebCite at http://www.webcitation.org/6qgsZ3Aqj) %M 29351895 %R 10.2196/jmir.9139 %U http://www.jmir.org/2018/1/e17/ %U https://doi.org/10.2196/jmir.9139 %U http://www.ncbi.nlm.nih.gov/pubmed/29351895 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 1 %P e9 %T Turning Good Intentions Into Actions by Using the Health Action Process Approach to Predict Adherence to Internet-Based Depression Prevention: Secondary Analysis of a Randomized Controlled Trial %A Zarski,Anna-Carlotta %A Berking,Matthias %A Reis,Dorota %A Lehr,Dirk %A Buntrock,Claudia %A Schwarzer,Ralf %A Ebert,David Daniel %+ Friedrich-Alexander-University Erlangen-Nürnberg, Nägelsbachstraße 25a, Erlangen,, Germany, 49 9131 85 67570, Anna-Carlotta.Zarski@fau.de %K health action process approach %K adherence %K Internet intervention %K depression prevention %D 2018 %7 11.01.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Many individuals engaging in Internet-based interventions fail to complete these treatments as intended. The processes responsible for treatment adherence in Internet-based interventions are still poorly understood. Objective: The aim of this study was to investigate to what extent adherence in an Internet-based intervention can be predicted by motivational and volitional factors outlined in the health action process approach (HAPA). Methods: This study investigated motivational and volitional factors included in HAPA in a randomized controlled trial to predict treatment adherence of N=101 individuals with subclinical depression in the intervention group of a depression prevention intervention (GET.ON Mood Enhancer). Adherence was operationalized as the number of completed treatment modules. Using longitudinal structural equation modeling, HAPA variables (motivational, maintenance, and recovery self-efficacy, outcome expectancies, intention, and planning) were assessed at baseline and their associations with adherence 7 weeks later. Results: Planning predicted adherence. Better planning was, in turn, associated with higher levels of maintenance self-efficacy, and the latter significantly affected treatment adherence via planning. The other hypothesized direct associations were not significant. In total, the HAPA variables accounted for 14% of variance in treatment adherence. Conclusions: Planning emerged as the strongest predictor of treatment adherence in highly motivated participants in an Internet-based intervention out of all HAPA variables investigated. Findings are in line with the hypothesis that planning facilitates the translation of good intentions into actions. The findings imply that systematically fostering planning skills and maintenance self-efficacy prior to or during Internet-based interventions would help participants to successfully complete these treatments. Trial Registration: German Clinical Trials Register DRKS00005973; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00005973 (Archived by WebCite at http://www.webcitation.org/6uxCy64sy). %M 29326097 %R 10.2196/jmir.8814 %U https://www.jmir.org/2018/1/e9/ %U https://doi.org/10.2196/jmir.8814 %U http://www.ncbi.nlm.nih.gov/pubmed/29326097 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e4 %T Cognitive and Behavioral Skills Exercises Completed by Patients with Major Depression During Smartphone Cognitive Behavioral Therapy: Secondary Analysis of a Randomized Controlled Trial %A Furukawa,Toshi A %A Horikoshi,Masaru %A Fujita,Hirokazu %A Tsujino,Naohisa %A Jinnin,Ran %A Kako,Yuki %A Ogawa,Sei %A Sato,Hirotoshi %A Kitagawa,Nobuki %A Shinagawa,Yoshihiro %A Ikeda,Yoshio %A Imai,Hissei %A Tajika,Aran %A Ogawa,Yusuke %A Akechi,Tatsuo %A Yamada,Mitsuhiko %A Shimodera,Shinji %A Watanabe,Norio %A Inagaki,Masatoshi %A Hasegawa,Akio %+ Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku,, Nagoya, 467-8601, Japan, 81 52 753 9491, furukawa@kuhp.kyoto-u.ac.jp %K major depressive disorder %K smartphone %K cognitive therapy %K telemedicine %D 2018 %7 11.01.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: A strong and growing body of evidence has demonstrated the effectiveness of cognitive behavioral therapy (CBT), either face-to-face, in person, or as self-help via the Internet, for depression. However, CBT is a complex intervention consisting of several putatively effective components, and how each component may or may not contribute to the overall effectiveness of CBT is poorly understood. Objective: The aim of this study was to investigate how the users of smartphone CBT use and benefit from various components of the program. Methods: This is a secondary analysis from a 9-week, single-blind, randomized controlled trial that has demonstrated the effectiveness of adjunctive use of smartphone CBT (Kokoro-App) over antidepressant pharmacotherapy alone among patients with drug-resistant major depressive disorder (total n=164, standardized mean difference in depression severity at week 9=0.40, J Med Internet Res). Kokoro-App consists of three cognitive behavioral skills of self-monitoring, behavioral activation, and cognitive restructuring, with corresponding worksheets to fill in. All activities of the participants learning each session of the program and completing each worksheet were uploaded onto Kokoro-Web, which each patient could use for self-check. We examined what use characteristics differentiated the more successful users of the CBT app from the less successful ones, split at the median of change in depression severity. Results: A total of 81 patients with major depression were allocated to the smartphone CBT. On average, they completed 7.0 (standard deviation [SD] 1.4) out of 8 sessions of the program; it took them 10.8 (SD 4.2) days to complete one session, during which they spent 62 min (SD 96) on the app. There were no statistically significant differences in the number of sessions completed, time spent for the program, or the number of completed self-monitoring worksheets between the beneficiaries and the nonbeneficiaries. However, the former completed more behavioral activation tasks, engaged in different types of activities, and also filled in more cognitive restructuring worksheets than the latter. Activities such as “test-drive a new car,” “go to a coffee shop after lunch,” or “call up an old friend” were found to be particularly rewarding. All cognitive restructuring strategies were found to significantly decrease the distress level, with “What would be your advice to a friend who has a similar problem?” found more helpful than some other strategies. Conclusions: The CBT program offered via smartphone and connected to the remote server is not only effective in alleviating depression but also opens a new avenue in gathering information of what and how each participant may utilize the program. The activities and strategies found useful in this analysis will provide valuable information in brush-ups of the program itself and of mobile health (mHealth) in general. Trial Registration: Japanese Clinical Trials Registry UMIN CTR 000013693; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ ctr_view.cgi?recptno=R000015984 (Archived by WebCite at http://www.webcitation.org/6u6pxVwik) %M 29326098 %R 10.2196/mental.9092 %U http://mental.jmir.org/2018/1/e4/ %U https://doi.org/10.2196/mental.9092 %U http://www.ncbi.nlm.nih.gov/pubmed/29326098 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 1 %P e8 %T Toward mHealth Brief Contact Interventions in Suicide Prevention: Case Series From the Suicide Intervention Assisted by Messages (SIAM) Randomized Controlled Trial %A Berrouiguet,Sofian %A Larsen,Mark Erik %A Mesmeur,Catherine %A Gravey,Michel %A Billot,Romain %A Walter,Michel %A , %A Lemey,Christophe %A Lenca,Philippe %+ IMT Atlantique, Lab-STICC, Université Bretagne Loire F-29238 Brest, Brest Medical University Hospital at Bohars, Adult Psychiatry, Route de Ploudalmezeau, Brest, 29820, France, 33 668204178, sofian.berrouiguet@gmail.com %K Suicide %K Text Messaging %K Electronic Health Records %K Cell Phone %K Secondary Prevention %K Tertiary Prevention %D 2018 %7 10.01.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Research indicates that maintaining contact either via letter or postcard with at-risk adults following discharge from care services after a suicide attempt (SA) can reduce reattempt risk. Pilot studies have demonstrated that interventions using mobile health (mHealth) technologies are feasible in a suicide prevention setting. Objective: The aim of this study was to report three cases of patients recruited in the Suicide Intervention Assisted by Messages (SIAM) study to describe how a mobile intervention may influence follow-up. Methods: SIAM is a 2-year, multicenter randomized controlled trial conducted by the Brest University Hospital, France. Participants in the intervention group receive SIAM text messages 48 hours after discharge, then at day 8 and day 15, and months 1, 2, 3, 4, 5, and 6. The study includes participants aged 18 years or older, who have attended a participating hospital for an SA, and have been discharged from the emergency department (ED) or a psychiatric unit (PU) for a stay of less than 7 days. Eligible participants are randomized between the SIAM intervention messages and a control group. In this study, we present three cases from the ongoing SIAM study that demonstrate the capability of a mobile-based brief contact intervention for triggering patient-initiated contact with a crisis support team at various time points throughout the mobile-based follow-up period. Results: Out of the 244 patients recruited in the SIAM randomized controlled trial, three cases were selected to illustrate the impact of mHealth on suicide risk management. Participants initiated contact with the emergency crisis support service after receiving text messages up to 6 months following discharge from the hospital. Contact was initiated immediately following receipt of a text message or up to 6 days following a message. Conclusions: This text message–based brief contact intervention has demonstrated the potential to reconnect suicidal individuals with crisis support services while they are experiencing suicidal ideation as well as in a period after receiving messages. As follow-up phone calls over an extended period of time may not be feasible, this intervention has the potential to offer simple technological support for individuals following discharge from the ED. Trial Registration: ClinicalTrials.gov NCT02106949; https://clinicaltrials.gov/ct2/show/NCT02106949 (Archived by WebCite at http://www.webcitation.org/6wMtAFL49) %M 29321126 %R 10.2196/mhealth.7780 %U http://mhealth.jmir.org/2018/1/e8/ %U https://doi.org/10.2196/mhealth.7780 %U http://www.ncbi.nlm.nih.gov/pubmed/29321126 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e1 %T Effect of a Gender-Tailored eHealth Weight Loss Program on the Depressive Symptoms of Overweight and Obese Men: Pre-Post Study %A Young,Myles D %A Morgan,Philip J %+ Priority Research Centre in Physical Activity and Nutrition, University of Newcastle, ATC301, University Drive, Callaghan, 2308, Australia, 61 249216096, myles.young@newcastle.edu.au %K male %K weight loss %K depression %K behavior change %K obesity %K gender-sensitive %D 2018 %7 09.01.2018 %9 Short Paper %J JMIR Ment Health %G English %X Background: Obesity and depression are of two of the largest contributors to the global burden of disease in men. Although lifestyle behavior change programs can improve participants’ weight and depressive symptoms, the evidence is limited by a lack of male participants and a reliance on face-to-face treatment approaches, which are not accessible or appealing for many men. Objective: This study examined the effect of a gender-tailored electronic health (eHealth) program on the depressive symptoms of a community sample of overweight and obese men with or without depression. A secondary aim was to determine whether the eHealth, self-directed format of the program was a feasible and acceptable treatment approach for the subgroup of men with depression at baseline. Methods: In total, 209 overweight/obese men from the Hunter Region of Australia were assessed before and after completing a self-administered eHealth weight loss program over 3 months. To increase engagement, most program elements were socio-culturally targeted to appeal specifically to men and included printed materials, a DVD, motivational text messages, online- or app-based self-monitoring, and other weight loss tools (eg, pedometer). Depressive symptoms were measured with the validated 8-item Patient Health Questionnaire (PHQ-8). Program feasibility and acceptability were assessed with a process questionnaire plus recruitment and retention rates. Changes in depressive symptoms and weight were examined using intention-to-treat linear mixed models, adjusted for the centered baseline score and other covariates. Effect sizes were estimated with Cohen’s d. Results: At baseline, the mean weight and age of the sample was 105.7 kg (standard deviation [SD] 14.0) and 46.6 years (SD 11.3), respectively. Overall, 36 men (36/209, 17.2%) were experiencing depression (PHQ-8 score ≥10). Retention rates were comparable between men with and without depression (32/36, 88.9% vs 145/173, 83.8%; P=.44). At posttest, depressive symptoms had reduced by 1.8 units (95% CI 1.3 to 2.3; P<.001; d=0.5) for the whole sample. These improvements were particularly notable in the subgroup of men with depression (-5.5 units; P<.001; d=1.0) and 72.2% (26/36) of this subgroup no longer met the criterion for depression at posttest. A corresponding, albeit smaller, intervention effect on depressive symptoms was also observed in men without depression (-1.0 units; P<.001; d=0.4). The overall intervention effect on weight was -4.7 kg (d=1.3), which did not vary significantly by depression status. Program acceptability, feasibility, and online engagement metrics were also comparable between men with and without depression. Conclusions: A gender-tailored eHealth lifestyle program generated short-term improvements in the mental health of overweight and obese men, particularly for men with depression at baseline. Despite receiving no personalized support, men with depression reported high levels of satisfaction and engagement with the program. As such, a longer-term controlled trial testing an adapted version of the program for this subgroup is warranted. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12612000749808; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=362575 (Archived by WebCite at http://www.webcitation.org/6wJvbRsNW) %M 29317379 %R 10.2196/mental.8920 %U http://mental.jmir.org/2018/1/e1/ %U https://doi.org/10.2196/mental.8920 %U http://www.ncbi.nlm.nih.gov/pubmed/29317379 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e59 %T Partners in Parenting: A Multi-Level Web-Based Approach to Support Parents in Prevention and Early Intervention for Adolescent Depression and Anxiety %A Yap,Marie BH %A Lawrence,Katherine A %A Rapee,Ronald M %A Cardamone-Breen,Mairead C %A Green,Jacqueline %A Jorm,Anthony F %+ Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Level 5, 18 Innovation Walk, Clayton, 3800, Australia, 61 399050723, marie.yap@monash.edu %K family %K tailored %K internet %K mental health %K preventive health services %D 2017 %7 19.12.2017 %9 Viewpoint %J JMIR Ment Health %G English %X Depression and anxiety disorders in young people are a global health concern. Various risk and protective factors for these disorders are potentially modifiable by parents, underscoring the important role parents play in reducing the risk and impact of these disorders in their adolescent children. However, cost-effective, evidence-based interventions for parents that can be widely disseminated are lacking. In this paper, we propose a multi-level public health approach involving a Web-based parenting intervention, Partners in Parenting (PIP). We describe the components of the Web-based intervention and how each component was developed. Development of the intervention was guided by principles of the persuasive systems design model to maximize parental engagement and adherence. A consumer-engagement approach was used, including consultation with parents and adolescents about the content and presentation of the intervention. The PIP intervention can be used at varying levels of intensity to tailor to the different needs of parents across the population. Challenges and opportunities for the use of the intervention are discussed. The PIP Web-based intervention was developed to address the dearth of evidence-based resources to support parents in their important role in their adolescents’ mental health. The proposed public health approach utilizes this intervention at varying levels of intensity based on parents’ needs. Evaluation of each separate level of the model is ongoing. Further evaluation of the whole approach is required to assess the utility of the intervention as a public health approach, as well as its broader effects on adolescent functioning and socioeconomic outcomes. %M 29258974 %R 10.2196/mental.8492 %U http://mental.jmir.org/2017/4/e59/ %U https://doi.org/10.2196/mental.8492 %U http://www.ncbi.nlm.nih.gov/pubmed/29258974 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 12 %P e231 %T Direct to Public Peer Support and e-Therapy Program Versus Information to Aid Self-Management of Depression and Anxiety: Protocol for a Randomized Controlled Trial %A Kaylor-Hughes,Catherine J %A Rawsthorne,Mat %A Coulson,Neil S %A Simpson,Sandra %A Simons,Lucy %A Guo,Boliang %A James,Marilyn %A Moran,Paul %A Simpson,Jayne %A Hollis,Chris %A Avery,Anthony J %A Tata,Laila J %A Williams,Laura %A , %A Morriss,Richard K %+ National Institute for Health Research: Collaboration for Leadership in Applied Health Research and Care East Midlands, University of Nottingham, Institute of Mental Health Building, Triumph Road, Nottingham, NG7 2TU, United Kingdom, 44 01158232478, richard.morriss@nottingham.ac.uk %K depression %K anxiety %K peer support %K online %K self-management %D 2017 %7 18.12.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Regardless of geography or income, effective help for depression and anxiety only reaches a small proportion of those who might benefit from it. The scale of the problem suggests a role for effective, safe, anonymized public health–driven Web-based services such as Big White Wall (BWW), which offer immediate peer support at low cost. Objective: Using Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) methodology, the aim of this study was to determine the population reach, effectiveness, cost-effectiveness, and barriers and drivers to implementation of BWW compared with Web-based information compiled by UK’s National Health Service (NHS, NHS Choices Moodzone) in people with probable mild to moderate depression and anxiety disorder. Methods: A pragmatic, parallel-group, single-blind randomized controlled trial (RCT) is being conducted using a fully automated trial website in which eligible participants are randomized to receive either 6 months access to BWW or signposted to the NHS Moodzone site. The recruitment of 2200 people to the study will be facilitated by a public health engagement campaign involving general marketing and social media, primary care clinical champions, health care staff, large employers, and third sector groups. People will refer themselves to the study and will be eligible if they are older than 16 years, have probable mild to moderate depression or anxiety disorders, and have access to the Internet. Results: The primary outcome will be the Warwick-Edinburgh Mental Well-Being Scale at 6 weeks. We will also explore the reach, maintenance, cost-effectiveness, and barriers and drivers to implementation and possible mechanisms of actions using a range of qualitative and quantitative methods. Conclusions: This will be the first fully digital trial of a direct to public online peer support program for common mental disorders. The potential advantages of adding this to current NHS mental health services and the challenges of designing a public health campaign and RCT of two digital interventions using a fully automated digital enrollment and data collection process are considered for people with depression and anxiety. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 12673428; http://www.controlled-trials.com/ISRCTN12673428/12673428 (Archived by WebCite at http://www.webcitation.org/6uw6ZJk5a) %M 29254909 %R 10.2196/resprot.8061 %U http://www.researchprotocols.org/2017/12/e231/ %U https://doi.org/10.2196/resprot.8061 %U http://www.ncbi.nlm.nih.gov/pubmed/29254909 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e56 %T A Mobile Text Message Intervention to Reduce Repeat Suicidal Episodes: Design and Development of Reconnecting After a Suicide Attempt (RAFT) %A Larsen,Mark Erik %A Shand,Fiona %A Morley,Kirsten %A Batterham,Philip J %A Petrie,Katherine %A Reda,Bill %A Berrouiguet,Sofian %A Haber,Paul S %A Carter,Gregory %A Christensen,Helen %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney, 2031, Australia, 61 293828508, mark.larsen@blackdog.org.au %K suicide, attempted %K emergency service, hospital %K continuity of patient care %K text messaging %K Internet %D 2017 %7 13.12.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Suicide is a leading cause of death, particularly among young people. Continuity of care following discharge from hospital is critical, yet this is a time when individuals often lose contact with health care services. Offline brief contact interventions following a suicide attempt can reduce the number of repeat attempts, and text message (short message service, SMS) interventions are currently being evaluated. Objective: The aim of this study was to extend postattempt caring contacts by designing a brief Web-based intervention targeting proximal risk factors and the needs of this population during the postattempt period. This paper details the development process and describes the realized system. Methods: To inform the design of the intervention, a lived experience design group was established. Participants were asked about their experiences of support following their suicide attempt, their needs during this time, and how these could be addressed in a brief contact eHealth intervention. The intervention design was also informed by consultation with lived experience panels external to the project and a clinical design group. Results: Prompt outreach following discharge, initial distraction activities with low cognitive demands, and ongoing support over an extended period were identified as structural requirements of the intervention. Key content areas identified included coping with distressing feelings, safety planning, emotional regulation and acceptance, coping with suicidal thoughts, connecting with others and interpersonal relationships, and managing alcohol consumption. Conclusions: The RAFT (Reconnecting AFTer a suicide attempt) text message brief contact intervention combines SMS contacts with additional Web-based brief therapeutic content targeting key risk factors. It has the potential to reduce the number of repeat suicidal episodes and to provide accessible, acceptable, and cost-effective support for individuals who may not otherwise seek face-to-face treatment. A pilot study to test the feasibility and acceptability of the RAFT intervention is underway. %M 29237584 %R 10.2196/mental.7500 %U http://mental.jmir.org/2017/4/e56/ %U https://doi.org/10.2196/mental.7500 %U http://www.ncbi.nlm.nih.gov/pubmed/29237584 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 12 %P e381 %T Designing Microblog Direct Messages to Engage Social Media Users With Suicide Ideation: Interview and Survey Study on Weibo %A Tan,Ziying %A Liu,Xingyun %A Liu,Xiaoqian %A Cheng,Qijin %A Zhu,Tingshao %+ Institute of Psychology, Chinese Academy of Sciences, 16th Lincui Road, Chaoyang District, Beijing, China, Beijing,, China, 86 15010965509, tszhu@psych.ac.cn %K microblog direct message %K social media %K suicide prevention %D 2017 %7 12.12.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: While Web-based interventions can be efficacious, engaging a target population’s attention remains challenging. We argue that strategies to draw such a population’s attention should be tailored to meet its needs. Increasing user engagement in online suicide intervention development requires feedback from this group to prevent people who have suicide ideation from seeking treatment. Objective: The goal of this study was to solicit feedback on the acceptability of the content of messaging from social media users with suicide ideation. To overcome the common concern of lack of engagement in online interventions and to ensure effective learning from the message, this research employs a customized design of both content and length of the message. Methods: In study 1, 17 participants suffering from suicide ideation were recruited. The first (n=8) group conversed with a professional suicide intervention doctor about its attitudes and suggestions for a direct message intervention. To ensure the reliability and consistency of the result, an identical interview was conducted for the second group (n=9). Based on the collected data, questionnaires about this intervention were formed. Study 2 recruited 4222 microblog users with suicide ideation via the Internet. Results: The results of the group interviews in study 1 yielded little difference regarding the interview results; this difference may relate to the 2 groups’ varied perceptions of direct message design. However, most participants reported that they would be most drawn to an intervention where they knew that the account was reliable. Out of 4222 microblog users, we received responses from 725 with completed questionnaires; 78.62% (570/725) participants were not opposed to online suicide intervention and they valued the link for extra suicide intervention information as long as the account appeared to be trustworthy. Their attitudes toward the intervention and the account were similar to those from study 1, and 3 important elements were found pertaining to the direct message: reliability of account name, brevity of the message, and details of the phone numbers of psychological intervention centers and psychological assessment. Conclusions: This paper proposed strategies for engaging target populations in online suicide interventions. %M 29233805 %R 10.2196/jmir.8729 %U http://www.jmir.org/2017/12/e381/ %U https://doi.org/10.2196/jmir.8729 %U http://www.ncbi.nlm.nih.gov/pubmed/29233805 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 12 %P e250 %T The Effect of Group Support Psychotherapy Delivered by Trained Lay Health Workers for Depression Treatment Among People with HIV in Uganda: Protocol of a Pragmatic, Cluster Randomized Trial %A Nakimuli-Mpungu,Etheldreda %A Musisi,Seggane %A Wamala,Kizito %A Okello,James %A Ndyanabangi,Sheila %A Mojtabai,Ramin %A Nachega,Jean %A Harari,Ofir %A Mills,Edward %+ Department of Psychiatry, College of Health Sciences, Makerere University, Old Mulago Hospital Complex, Mulago Hill Road, Kampala, 256, Uganda, 256 788994050, ethelmpungu@yahoo.com %K cluster randomized trial %K group support psychotherapy %K lay health workers %K depression %K persons living with HIV/AIDS %K Uganda %D 2017 %7 11.12.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is limited information on the effectiveness of task shifting of mental health services in populations with HIV. Objective: This trial aims to evaluate the effectiveness of group support psychotherapy delivered by trained lay health workers to persons living with HIV (PLWH) with depression in primary care. Methods: Thirty eligible primary care health centers across three districts were randomly allocated to have their lay health workers trained to deliver group support psychotherapy (intervention arm) or group HIV education and treatment as usual (control arm) to PLWH with depression. Treated PLWH will be evaluated at baseline, after the end of treatment, and at 6-month intervals thereafter for 2 years. Primary outcomes will be the difference in follow-up proportions of participants with Mini International Neuropsychiatric Interview criteria for major depression and difference in follow-up function scores of participants in the intervention and control arms 6 months after the end of treatment. Secondary outcomes will include measures of self-esteem, posttraumatic stress symptoms, social support, stigma, adherence to antiretroviral therapy, viral load, and number of disability days, asset possession indices, and cost-effectiveness data. Primary and secondary outcomes as well as subgroup analyses will be conducted at the individual level using multilevel random effects regression analyses adjusting for clustering in health centers. A process evaluation using mixed methods to assess acceptability, feasibility, fidelity, causal mediating processes, and contextual influences in the trial will be conducted. Results: The trial has been approved by the Makerere College of Health Sciences School of Health Sciences Research Ethics Committee, the AIDS Support Organization, and the Uganda National Council of Science and Technology. A data and safety monitoring board has been put in place to monitor trial progress. A total of 1140 persons living with HIV have been recruited to the trial. An analysis of baseline and 6-month data is in progress. The results of this trial will not only be presented at national and international conferences but also submitted for publication in peer-reviewed journals and as a report to the funding agencies. Conclusions: This cluster randomized trial will provide critical evidence to support culturally sensitive group-based psychotherapy for depression treatment in sub-Saharan Africa. Process evaluation outcomes will provide contextual information that health care and public health stakeholders can use to guide implementation decisions for their particular setting. Trial Registration: Pan African Clinical Trials Registry (PACTR): 201608001738234; http://www.pactr.org/ATMWeb/ appmanager/atm/atmregistry?dar=true&tNo=PACTR201608001738234 (Archived by WebCite at http://www.webcitation.org/ 6vUAgAQlj) %M 29229589 %R 10.2196/resprot.8925 %U http://www.researchprotocols.org/2017/12/e250/ %U https://doi.org/10.2196/resprot.8925 %U http://www.ncbi.nlm.nih.gov/pubmed/29229589 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 12 %P e180 %T Web-Based Interventions Supporting Adolescents and Young People With Depressive Symptoms: Systematic Review and Meta-Analysis %A Välimäki,Maritta %A Anttila,Katriina %A Anttila,Minna %A Lahti,Mari %+ Hong Kong Polytechnic University, Kowloon, Hong Kong, China (SAR), 86 40 689 054, mava@utu.fi %K Internet %K adolescent %K depression %K meta-analysis %K information and communication technology %K intervention %K systematic review %K treatment as usual %D 2017 %7 08.12.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although previous studies on information and communication technology (ICT)–based intervention on mental health among adolescents with depressive symptoms have already been combined in a number of systematic reviews, coherent information is still missing about interventions used, participants’ engagement of these interventions, and how these interventions work. Objective: We conducted a systematic review and meta-analysis of trials to describe the effectiveness of Web-based interventions to support adolescents with depression or depressive symptoms, anxiety, and stress. We also explored the content of the interventions, as there has previously been a lack of coherent understanding of the detailed content of the Web-based interventions for these purposes. Methods: We included parallel randomized controlled trials targeted at adolescents, or young people in the age range of 10 and 24 years, with symptoms or diagnoses of depression and anxiety. The interventions were from original studies aimed to support mental health among adolescents, and they were delivered via Web-based information and communication technology. Results: Out of 2087 records identified, 27 papers (22 studies) met the inclusion criteria. On the basis of a narrative analysis of 22 studies, a variety of Web-based interventions were found; the most commonly used intervention was based on cognitive behavioral therapy. Meta-analysis was further conducted with 15 studies (4979 participants). At the end of the intervention, a statistically significant improvement was found in the intervention group (10 studies) regarding depressive symptoms (P=.02, median 1.68, 95% CI 3.11-0.25) and after 6 months (3 studies; P=.01, median 1.78, 95% CI 3.20-0.37). Anxiety symptoms (8 studies; P<.001, median 1.47, 95% CI 2.36-0.59) and moods and feelings (2 studies; P=.04, median 5.55, 95% CI 10.88-0.22) improved as well in the Web-based intervention group, but there was no difference in stress scores. However, adolescents in the intervention group left the study early more often, both in short-term studies (11 studies; P=.007, median 1.31, 95% CI 1.08-1.58) and mid-term studies (3 studies; P=.02, median 1.65, 95% CI 1.09-2.49). We did not find any studies that had assessed the costs of the Web-based interventions. Conclusions: Despite widely reported promises that information technology use is beneficial to adolescents with depression, the results of our review show only short-term effects on adolescents’ mental well-being, whereas long-term effects remain questionable because of the limited number of studies reviewed. Information about the economic benefits of Web-based interventions is still lacking. The quality of the studies, especially biases related to attrition rates and selective reporting, still needs serious attention. %M 29222079 %R 10.2196/mhealth.8624 %U http://mhealth.jmir.org/2017/12/e180/ %U https://doi.org/10.2196/mhealth.8624 %U http://www.ncbi.nlm.nih.gov/pubmed/29222079 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 12 %P e183 %T The Impact of a Mobile Diabetes Health Intervention on Diabetes Distress and Depression Among Adults: Secondary Analysis of a Cluster Randomized Controlled Trial %A Quinn,Charlene C %A Swasey,Krystal K %A Crabbe,J Christopher F %A Shardell,Michelle D %A Terrin,Michael L %A Barr,Erik A %A Gruber-Baldini,Ann L %+ Department of Epidemiology and Public Health, School of Medicine, University of Maryland, 660 W Redwood Street, Howard Hall Suite 200, Baltimore, MD, 21201, United States, 1 410 706 2406, cquinn@som.umaryland.edu %K diabetes distress %K mobile health %K depression %K diabetes %K Diabetes Distress Scale %K Patient Health Questionnaire %K women %K emotional well-being %D 2017 %7 07.12.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Diabetes is a complex, demanding disease that requires the constant attention of patients. The burden of self-management, including different medication regimens, routine self-care activities, and provider visits, has an impact on patients’ emotional well-being. Diabetes distress and depression are two important components of emotional well-being that may negatively affect diabetes outcomes. Objective: The aim was to determine the impact of the 1-year Mobile Diabetes Intervention Study cluster randomized clinical trial on emotional well-being measured by diabetes distress and depression among adults with type 2 diabetes (T2D). Methods: A total of 163 adults with not-well-managed T2D were enrolled from community primary care practices. Primary care practices were cluster randomized into either a usual care control group or intervention group. Intervention participants were given a mobile phone with coaching software including a Web portal to communicate with providers. A priori established secondary outcomes included distress measured by the Diabetes Distress Scale (DDS), with subscales measuring emotional burden, interpersonal distress, physician-related distress, and regimen-related distress, as well as depression measured by the Patient Health Questionnaire (PHQ-9). Linear mixed models were used to calculate the effect of the intervention on diabetes distress levels over time, both overall and separately by sex, and to determine if the intervention affected distress or depression. The impact of total DDS on changes in HbA1c was also studied. Results: There were no significant treatment group effects for DDS total (baseline: P=.07; differences over time: P=.38) or for depression (P=.06 over time). Significant declines in total DDS were observed over the 12-month intervention period (P=.01). Regimen-related distress significantly decreased for all study participants (P<.001), but no significant change over time was observed for emotional burden (P=.83), interpersonal distress (P=.64), or physician-related distress (P=.73). Women in both the usual care and intervention groups were more likely to have higher overall DDS, emotional burden, physician-related distress, and regimen-related distress, but not interpersonal distress. Women also reported higher baseline depression compared to men (P=.006). Overall, depression decreased over the treatment period (P=.007), but remained unaffected by group assignment (P=.06) or by sex (P=.97). Diabetes distress had no effect on the change in HbA1c (P=.91) over the treatment period. Conclusions: Although we found no definitive overall or sex-specific effect of the intervention on diabetes distress or depression, this study makes an important contribution to the understanding of mobile health interventions and the impact on emotional health. Our study verified previous work that although diabetes distress and depression are highly correlated, these measures are not evaluating the same construct. Design of future mobile technology provides an opportunity to personalize, contextualize, and intervene in the emotional well-being of persons with diabetes. Trial Registration: Clinicaltrials.gov NCT01107015; https://clinicaltrials.gov/ct2/show/NCT01107015 (Archived by WebCite at http://www.webcitation.org/6vVgRCLAF) %M 29217502 %R 10.2196/mhealth.8910 %U http://mhealth.jmir.org/2017/12/e183/ %U https://doi.org/10.2196/mhealth.8910 %U http://www.ncbi.nlm.nih.gov/pubmed/29217502 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 12 %P e187 %T Mobile Phone Apps for Quality of Life and Well-Being Assessment in Breast and Prostate Cancer Patients: Systematic Review %A Rincon,Esther %A Monteiro-Guerra,Francisco %A Rivera-Romero,Octavio %A Dorronzoro-Zubiete,Enrique %A Sanchez-Bocanegra,Carlos Luis %A Gabarron,Elia %+ Department of Psychology and Pedagogy, Universidad San Pablo Centro de Estudios Universitarios, Campus de Montepríncipe, Urbanización Montepríncipe, Pabellón MED, Despacho 0022, Alcorcón (Madrid), 28925, Spain, 34 913 724 700 ext 4609, maria.rinconfernande@ceu.es %K cancer %K mHealth %K app %K mobile phone %K quality of life %K well-being %D 2017 %7 04.12.2017 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Mobile phone health apps are increasingly gaining attention in oncological care as potential tools for supporting cancer patients. Although the number of publications and health apps focusing on cancer is increasing, there are still few specifically designed for the most prevalent cancers diagnosed: breast and prostate cancers. There is a need to review the effect of these apps on breast and prostate cancer patients’ quality of life (QoL) and well-being. Objective: The purposes of this study were to review the scientific literature on mobile phone apps targeting breast or prostate cancer patients and involving QoL and well-being (anxiety and depression symptoms) and analyze the clinical and technological characteristics, strengths, and weaknesses of these apps, as well as patients’ user experience with them. Methods: We conducted a systematic review of peer-reviewed literature from The Cochrane Library, Excerpta Medica Database, PsycINFO, PubMed, Scopus, and MEDLINE to identify studies involving apps focused on breast and/or prostate cancer patients and QoL and/or well-being published between January 1, 2000, and July 12, 2017. Only trial studies which met the inclusion criteria were selected. The systematic review was completed with a critical analysis of the apps previously identified in the health literature research that were available from the official app stores. Results: The systematic review of the literature yielded 3862 articles. After removal of duplicates, 3229 remained and were evaluated on the basis of title and abstract. Of these, 3211 were discarded as not meeting the inclusion criteria, and 18 records were selected for full text screening. Finally, 5 citations were included in this review, with a total of 644 patients, mean age 52.16 years. Four studies targeted breast cancer patients and 1 focused on prostate cancer patients. Four studies referred to apps that assessed QoL. Only 1 among the 5 analyzed apps was available from the official app store. In 3 studies, an app-related intervention was carried out, and 2 of them reported an improvement on QoL. The lengths of the app-related interventions varied from 4 to 12 weeks. Because 2 of the studies only tracked use of the app, no effect on QoL or well-being was found. Conclusions: Despite the existence of hundreds of studies involving cancer-focused mobile phone apps, there is a lack of rigorous trials regarding the QoL and/or well-being assessment in breast and/or prostate cancer patients. A strong and collective effort should be made by all health care providers to determine those cancer-focused apps that effectively represent useful, accurate, and reliable tools for cancer patients’ disease management. Trial Registration: PROSPERO CRD42017073069; https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID= CRD42017073069 (Archived by WebCite at http://www.webcitation.org/6v38Clb9T) %M 29203459 %R 10.2196/mhealth.8741 %U http://mhealth.jmir.org/2017/12/e187/ %U https://doi.org/10.2196/mhealth.8741 %U http://www.ncbi.nlm.nih.gov/pubmed/29203459 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e53 %T A Web-Based Study of Dog Ownership and Depression Among People Living With HIV %A Muldoon,Abigail L %A Kuhns,Lisa M %A Supple,Julie %A Jacobson,Kristen C %A Garofalo,Robert %+ Division of Adolescent Medicine, Ann & Robert H Lurie Children’s Hospital of Chicago, 225 East Chicago Avenue, Box 161, Chicago, IL, 60611-2991, United States, 1 7733036058, RGarofalo@luriechildrens.org %K HIV %K depression %K pet-human bonding %D 2017 %7 08.11.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: People living with human immunodeficiency virus (PLHIV) are approximately twice as likely to be depressed compared with HIV-negative individuals. Depression is consistently associated with low antiretroviral therapy (ART) adherence, an important step within the HIV care continuum related to HIV disease progression and overall health. One factor that may have positive psychosocial benefits and promote ART adherence is dog ownership. Research indicates that dog ownership is associated with lower depression, and initial evidence suggests its positive impact on psychosocial outcomes for PLHIV. Objective: The aim of our study was to expand the existing research by examining the relationship between current dog ownership and depression for a sample of PLHIV while controlling for demographic characteristics and other potential confounders. Methods: Participants aged 18 years or older and who self-reported an HIV diagnosis were recruited via social media into When Dogs Heal, a cross-sectional Web-based survey to collect data among adult PLHIV. The research visit was conducted via a Web-based survey, and there was no in-person interaction with the participant. Primary outcome measures included demographic questions (age, race, ethnicity, gender, and sexual orientation), pet ownership (type of pet owned and current dog ownership), depression (Center for Epidemiologic Studies Depression Scale, 10 items), and resilience (Resilience Research Centre Adult Resilience Measure, 28 items). Results: A total of 252 participants were enrolled into the study in January 2016, with a final analytic sample of 199 participants. Mean age was 49 years, 86.4% (172/199) of participants were male, and 80.4% (160/199) were white. Current dog ownership was prevalent among the sample (68.3%, 136/199). Bivariate analysis indicated that there was no significant relationship between depression and demographic characteristics (age, race, ethnicity, gender, and sexual orientation), with P>.05. The multivariate logistic regression, including age, race, ethnicity, gender, resilience, and current dog ownership, was significant, with P<.001. Of the 6 predictor variables, only 2 were statistically significant: dog ownership and resilience. Noncurrent dog owners had 3 times higher odds of depression in comparison with current dog owners: odds ratio 3.01; 95% CI 1.54-6.21. Conclusions: Growing evidence suggests that dog ownership reduces the likelihood of depression and, therefore, may confer long-term health benefits on PLHIV. Future studies should explore whether dog-specific interventions are a feasible and efficacious intervention to improve outcomes among PLHIV. %M 29117933 %R 10.2196/mental.8180 %U http://mental.jmir.org/2017/4/e53/ %U https://doi.org/10.2196/mental.8180 %U http://www.ncbi.nlm.nih.gov/pubmed/29117933 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 11 %P e373 %T Smartphone Cognitive Behavioral Therapy as an Adjunct to Pharmacotherapy for Refractory Depression: Randomized Controlled Trial %A Mantani,Akio %A Kato,Tadashi %A Furukawa,Toshi A %A Horikoshi,Masaru %A Imai,Hissei %A Hiroe,Takahiro %A Chino,Bun %A Funayama,Tadashi %A Yonemoto,Naohiro %A Zhou,Qi %A Kawanishi,Nao %+ Department of Health Promotion and Human Behavior, School of Public Health, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 6068501, Japan, 81 757538941, furukawa@kuhp.kyoto-u.ac.jp %K major depressive disorder %K pharmacotherapy-resistant depression %K mobile phone app %K cognitive behavioral therapy %K eHealth %D 2017 %7 03.11.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: In the treatment of major depression, antidepressants are effective but not curative. Cognitive behavioral therapy (CBT) is also effective, alone or in combination with pharmacotherapy, but accessibility is a problem. Objective: The aim is to evaluate the effectiveness of a smartphone CBT app as adjunctive therapy among patients with antidepressant-resistant major depression. Methods: A multisite, assessor-masked, parallel-group randomized controlled trial was conducted in 20 psychiatric clinics and hospitals in Japan. Participants were eligible if they had a primary diagnosis of major depression and were antidepressant-refractory after taking one or more antidepressants at an adequate dosage for four or more weeks. After a 1-week run-in in which participants started the medication switch and had access to the welcome session of the app, patients were randomized to medication switch alone or to medication switch plus smartphone CBT app via the centralized Web system. The smartphone app, called Kokoro-app (“kokoro” means “mind” in Japanese), included sessions on self-monitoring, behavioral activation, and cognitive restructuring presented by cartoon characters. The primary outcome was depression severity as assessed by masked telephone assessors with the Patient Health Questionnaire-9 (PHQ-9) at week 9. The secondary outcomes included the Beck Depression Inventory-II (BDI-II) and Frequency, Intensity, and Burden of Side Effects Ratings (FIBSER). Results: In the total sample (N=164), 81 participants were allocated to the smartphone CBT in addition to medication change and 83 to medication change alone. In the former group, all but one participant (80/81, 99%) completed at least half, and 71 (88%) completed at least six of eight sessions. In the intention-to-treat analysis, patients allocated the CBT app scored 2.48 points (95% CI 1.23-3.72, P<.001; standardized mean difference 0.40) lower on PHQ-9 than the control at week 9. The former group also scored 4.1 points (95% CI 1.5-6.6, P=.002) lower on BDI-II and 0.76 points (95% CI –0.05 to 1.58, P=.07) lower on FIBSER. In the per-protocol sample (comfortable with the smartphone app, still symptomatic, and adherent to medication with mild or less side effects after run-in), the intervention group (n=60) scored 1.72 points (95% CI 0.25-3.18, P=.02) lower on PHQ-9, 3.2 points (95% CI –0.01 to 6.3, P=.05) lower on BDI-II, and 0.75 points (95% CI 0.03-1.47, P=.04) lower on FIBSER than the control (n=57). The treatment benefits were maintained up to week 17. Conclusions: This is the first study to demonstrate the effectiveness of a smartphone CBT in the treatment of clinically diagnosed depression. Given the merits of the mobile mental health intervention, including accessibility, affordability, quality control, and effectiveness, it is clinically worthwhile to consider adjunctive use of a smartphone CBT app when treating patients with antidepressant-resistant depression. Research into its effectiveness in wider clinical contexts is warranted. Trial Registration: Japanese Clinical Trials Registry UMIN CTR 000013693; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ ctr_view.cgi?recptno=R000015984 (Archived by WebCite at http://www.webcitation.org/6u6pxVwik) %M 29101095 %R 10.2196/jmir.8602 %U http://www.jmir.org/2017/11/e373/ %U https://doi.org/10.2196/jmir.8602 %U http://www.ncbi.nlm.nih.gov/pubmed/29101095 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 11 %P e369 %T Preventing Depression in Final Year Secondary Students: School-Based Randomized Controlled Trial %A Perry,Yael %A Werner-Seidler,Aliza %A Calear,Alison %A Mackinnon,Andrew %A King,Catherine %A Scott,Jan %A Merry,Sally %A Fleming,Theresa %A Stasiak,Karolina %A Christensen,Helen %A Batterham,Philip J %+ Black Dog Institute, University of New South Wales, Hospital Road, Randwick,, Australia, 61 2 9382 8208, h.christensen@blackdog.org.au %K prevention %K depression %K adolescent %K digital cognitive behavior therapy %D 2017 %7 02.11.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression often emerges for the first time during adolescence. There is accumulating evidence that universal depression prevention programs may have the capacity to reduce the impact of depression when delivered in the school environment. Objective: This trial investigated the effectiveness of SPARX-R, a gamified online cognitive behavior therapy intervention for the prevention of depression relative to an attention-matched control intervention delivered to students prior to facing a significant stressor—final secondary school exams. It was hypothesized that delivering a prevention intervention in advance of a stressor would reduce depressive symptoms relative to the control group. Methods: A cluster randomized controlled trial was conducted in 10 government schools in Sydney, Australia. Participants were 540 final year secondary students (mean 16.7 [SD 0.51] years), and clusters at the school level were randomly allocated to SPARX-R or the control intervention. Interventions were delivered weekly in 7 modules, each taking approximately 20 to 30 minutes to complete. The primary outcome was symptoms of depression as measured by the Major Depression Inventory. Intention-to-treat analyses were performed. Results: Compared to controls, participants in the SPARX-R condition (n=242) showed significantly reduced depression symptoms relative to the control (n=298) at post-intervention (Cohen d=0.29) and 6 months post-baseline (d=0.21) but not at 18 months post-baseline (d=0.33). Conclusions: This is the first trial to demonstrate a preventive effect on depressive symptoms prior to a significant and universal stressor in adolescents. It demonstrates that an online intervention delivered in advance of a stressful experience can reduce the impact of such an event on the potential development or exacerbation of depression. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12614000316606; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365986 (Archived by WebCite at http://www.webcitation.org/ 6u7ou1aI9) %M 29097357 %R 10.2196/jmir.8241 %U http://www.jmir.org/2017/11/e369/ %U https://doi.org/10.2196/jmir.8241 %U http://www.ncbi.nlm.nih.gov/pubmed/29097357 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 10 %P e207 %T Internet-Delivered Dialectical Behavioral Therapy Skills Training for Suicidal and Heavy Episodic Drinkers: Protocol and Preliminary Results of a Randomized Controlled Trial %A Wilks,Chelsey %A Yin,Qingqing %A Ang,Sin Yee %A Matsumiya,Brandon %A Lungu,Anita %A Linehan,Marsha %+ Behavioral Research and Therapy Clinics, Department of Psychology, University of Washington, 3935 University Way, Seattle, WA, 98195, United States, 1 7027156241, wilksc@u.washington.edu %K dialectical behavioral therapy %K randomized controlled trial %K eMental health %K suicide %K heavy episodic drinking %K emotion dysregulation %D 2017 %7 25.10.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: The need to develop effective and accessible interventions for suicidal individuals engaging in heavy episodic drinking (HED) cannot be understated. While the link between alcohol use and suicidality is a complex one that remains to be elucidated, emotion dysregulation may play a key role in alcohol-related suicide risk in these individuals. Objective: In the current study, an 8-week Internet-delivered dialectical behavior therapy (DBT) skills training intervention was developed and preliminarily evaluated for suicidal individuals who engage in HED to regulate emotions. The aim of the study is to evaluate the feasibility and effectiveness of the therapist-assisted and Internet-delivered intervention, and to inform the design of a subsequent full-scale study. Methods: The study was a pilot randomized controlled trial comparing participants receiving immediate-treatment (n=30) to waitlist controls (n=29) over a period of 16 weeks. Intervention effects will be assessed longitudinally using hierarchical linear modeling and generalized estimating equations, along with analyses of effect sizes and clinically significant change. The primary outcomes are suicidal ideation, alcohol problems, and emotion dysregulation. Secondary outcomes include alcohol-related consequences, reasons for living, skills use, and depression. Results: The trial is ongoing. A total of 60 individuals returned their informed consent and were randomized, of whom 59 individuals were intended to treat. A total of 50 participants in the study were retained through the 16-week enrollment. Conclusions: There is a dearth of evidence-based treatment for individuals presenting with high risk and complex behaviors. Furthermore, computerized interventions may provide a beneficial alternative to traditional therapies. The particular clinical features and treatment needs of suicidal individuals who also engage in HED constitute key domains for further investigation that are needed to consolidate the design of appropriate interventions for this high-risk population. Trial Registration: Clinicaltrials.gov NCT02932241; https://clinicaltrials.gov/ct2/show/NCT02932241 (Archived by WebCite at http://www.webcitation.org/6uJHdQsC2) %M 29070480 %R 10.2196/resprot.7767 %U http://www.researchprotocols.org/2017/10/e207/ %U https://doi.org/10.2196/resprot.7767 %U http://www.ncbi.nlm.nih.gov/pubmed/29070480 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e42 %T Pregnant Women’s Perceptions of the Risks and Benefits of Disclosure During Web-Based Mental Health E-Screening Versus Paper-Based Screening: Randomized Controlled Trial %A Kingston,Dawn %A Biringer,Anne %A Veldhuyzen van Zanten,Sander %A Giallo,Rebecca %A McDonald,Sarah %A MacQueen,Glenda %A Vermeyden,Lydia %A Austin,Marie-Paule %+ University of Calgary, 2500 University Ave NW, Calgary, AB, T2N 1N4, Canada, 1 4032202634, dawn.kingston@ucalgary.ca %K pregnancy %K mental health %K screening %K prenatal care %K computers %D 2017 %7 20.10.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Pregnant women’s perceptions of the risks and benefits during mental health screening impact their willingness to disclose concerns. Early research in violence screening suggests that such perceptions may vary by mode of screening, whereby women view the anonymity of e-screening as less risky than other approaches. Understanding whether mode of screening influences perceptions of risk and benefit of disclosure is important in screening implementation. Objective: The objective of this randomized controlled trial was to compare the perceptions of pregnant women randomized to a Web-based screening intervention group and a paper-based screening control group on the level of risk and benefit they perceive in disclosing mental health concerns to their prenatal care provider. A secondary objective was to identify factors associated with women’s perceptions of risk and benefit of disclosure. Methods: Pregnant women recruited from maternity clinics, hospitals, and prenatal classes were computer-randomized to a fully automated Web-based e-screening intervention group or a paper-based control. The intervention group completed the Antenatal Psychosocial Health Assessment and the Edinburgh Postnatal Depression Scale on a computer tablet, whereas the control group completed them on paper. The primary outcome was women’s perceptions of the risk and benefits of mental health screening using the Disclosure Expectations Scale (DES). A completer analysis was conducted. Statistical significance was set at P<.05. We used t tests to compare the means of the risk and benefit subscales between groups. Results: Of the 675 eligible women approached, 636 (94.2%) agreed to participate and were randomized to the intervention (n=305) and control (n=331) groups. There were no significant baseline differences between groups. The mode of screening was not associated with either perceived risk or benefit of screening. There were no differences in groups in the mean scores of the risk and benefit of disclosure subscales. Over three-quarters of women in both intervention and control groups perceived that mental health screening was beneficial. However, 43.1% (272/631) of women in both groups reported feeling very, moderately, or somewhat vulnerable during mental health screening. We found that women of low income, those treated previously for depression or anxiety, and those pregnant with their first child were more likely to perceive greater risk. However, these associations were very small. Conclusions: Pregnant women in both the e-screening and paper-based screening groups perceived benefit and risk of disclosure similarly, suggesting that providers can implement the mode of screening that is most ideal for their clinical setting. Regardless of the mode of screening, a substantial number of women reported feeling vulnerable during mental health screening, highlighting the importance of the need to reduce women’s vulnerability throughout the screening process with strategies such as addressing women’s concerns, explaining the rationale for screening, and discussing how results will be used. Trial Registration: Clinicaltrials.gov NCT01899534; https://clinicaltrials.gov/ct2/show/NCT01899534 (Archived by WebCite at http://www.webcitation.org/6tRKtGC4M) %M 29054833 %R 10.2196/mental.6888 %U http://mental.jmir.org/2017/4/e42/ %U https://doi.org/10.2196/mental.6888 %U http://www.ncbi.nlm.nih.gov/pubmed/29054833 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e47 %T A Transmedia Storytelling Intervention With Interactive Elements to Benefit Latinas’ Mental Health: Feasibility, Acceptability, and Efficacy %A Heilemann,MarySue V %A Soderlund,Patricia D %A Kehoe,Priscilla %A Brecht,Mary-Lynn %+ School of Nursing, University of California, Los Angeles, Factor Building, Room 5252, Box 956919, Los Angeles, CA, 90095-6919, United States, 1 310 206 4735, mheilema@sonnet.ucla.edu %K depression %K anxiety %K transmedia %K Internet %K mental health %K mood disorders %K smartphone %D 2017 %7 19.10.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Latinos report higher rates of depression and anxiety than US whites but are less likely to receive care. Transmedia storytelling interventions accessible on the Internet via smartphones, tablets, and computers hold promise for reducing reluctance to explore or get help for symptoms because they are private, convenient, and can reach large numbers of people, including Latinas with mental health needs. Objective: The purpose of this study was to examine the feasibility, acceptability, and preliminary efficacy of a mental health transmedia intervention for Latinas with elevated symptoms of depression, anxiety, or both. Methods: A total of 28 symptomatic English-speaking Latina women aged 21 to 48 years participated in a 6-week study using a within-group design. All aspects of the study were completed via telephone or Internet. Participants used their personal devices to engage the Web-based transmedia intervention (in English) that included story-based videos, a data-informed psychotherapeutic video, an interactive video sequence, and a blog written from the point of view of one of the characters with links to mental health resources. Perceived confidence to get help and perceived importance for seeking immediate help were both measured using single-item questions. Participants completed surveys at baseline (via telephone) and 1 and 6 weeks after media engagement that measured various factors, including depression (Patient Health Questionnaire; PHQ-9 and PHQ-8) and anxiety (Generalized Anxiety Disorder scale; GAD-7). A telephone interview was conducted within 72 hours of media engagement. Action taken or intentions to get help (single-item question) and talking about the videos with others (single-item question) were measured 1 and 6 weeks after media engagement. Repeated measures analysis of variance was used to assess change in depression (PHQ-8) and anxiety (GAD-7) before transmedia engagement and 1 and 6 weeks after. Spearman correlations evaluated the association of confidence and importance of getting help with action taken, anxiety, and depression. Results: All 28 Latinas (English speakers) who engaged with the transmedia remained in the 6-week study. Within 1 week of transmedia engagement, 39% of women took action to get help, and 82% discussed the media with others. Symptoms of depression (F2,54=9.0, P<.001) and anxiety (F2,54=18.7, P<.001) significantly reduced across time. Higher levels of confidence were significantly associated with actions taken at 1 (P=.005) and 6 weeks (P=.04), and higher levels of importance were significantly associated with actions taken at 1 (P=.009) and 6 weeks (P=.003). Higher levels of confidence were associated with lower levels of depression (P=.04) and anxiety (P=.01) at 6 weeks. Conclusions: Preliminary findings indicate a culturally tailored mental health transmedia intervention is a feasible approach that holds promise for engaging large numbers of symptomatic English-speaking Latina women to begin the process of seeking help, as well as decreasing symptoms of anxiety and depression. %M 29051135 %R 10.2196/mental.8571 %U http://mental.jmir.org/2017/4/e47/ %U https://doi.org/10.2196/mental.8571 %U http://www.ncbi.nlm.nih.gov/pubmed/29051135 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e43 %T #MyDepressionLooksLike: Examining Public Discourse About Depression on Twitter %A Lachmar,E Megan %A Wittenborn,Andrea K %A Bogen,Katherine W %A McCauley,Heather L %+ Department of Human Development and Family Studies, Michigan State University, 552 W. Circle Dr., East Lansing, MI, 48823, United States, 1 5174323852, andreaw@msu.edu %K social media %K depression %K community networks %K social stigma %D 2017 %7 18.10.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Social media provides a context for billions of users to connect, express sentiments, and provide in-the-moment status updates. Because Twitter users tend to tweet emotional updates from daily life, the platform provides unique insights into experiences of mental health problems. Depression is not only one of the most prevalent health conditions but also carries a social stigma. Yet, opening up about one’s depression and seeking social support may provide relief from symptoms. Objective: The aim of this study was to examine the public discourse of the trending hashtag #MyDepressionLooksLike to look more closely at how users talk about their depressive symptoms on Twitter. Methods: We captured 3225 original content tweets for the hashtag #MyDepressionLooksLike that circulated in May of 2016. Eliminating public service announcements, spam, and tweets with links to pictures or videos resulted in a total of 1978 tweets. Using qualitative content analysis, we coded the tweets to detect themes. Results: The content analysis revealed seven themes: dysfunctional thoughts, lifestyle challenges, social struggles, hiding behind a mask, apathy and sadness, suicidal thoughts and behaviors, and seeking relief. Conclusions: The themes revealed important information about the content of the public messages that people share about depression on Twitter. More research is needed to understand the effects of the hashtag on increasing social support for users and reducing social stigma related to depression. %M 29046270 %R 10.2196/mental.8141 %U http://mental.jmir.org/2017/4/e43/ %U https://doi.org/10.2196/mental.8141 %U http://www.ncbi.nlm.nih.gov/pubmed/29046270 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e41 %T Transdiagnostic, Psychodynamic Web-Based Self-Help Intervention Following Inpatient Psychotherapy: Results of a Feasibility Study and Randomized Controlled Trial %A Zwerenz,Rüdiger %A Becker,Jan %A Johansson,Robert %A Frederick,Ronald J %A Andersson,Gerhard %A Beutel,Manfred E %+ Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Mainz, Johannes Gutenberg University Mainz, Untere Zahlbacher Str. 8, Mainz, 55131, Germany, 49 6131175981, ruediger.zwerenz@unimedizin-mainz.de %K psychoanalytic psychotherapy %K emotion-focused therapy %K inpatients %K aftercare %K Internet %K clinical trial %D 2017 %7 16.10.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mental disorders have become a major health issue, and a substantial number of afflicted individuals do not get appropriate treatment. Web-based interventions are promising supplementary tools for improving health care for patients with mental disorders, as they can be delivered at low costs and used independently of time and location. Although psychodynamic treatments are used frequently in the face-to-face setting, there has been a paucity of studies on psychodynamic Web-based self-help interventions. Objective: The objective of this study was to determine the feasibility and preliminary efficacy of a transdiagnostic affect-focused psychodynamic Web-based self-help intervention designed to increase emotional competence of patients with mental disorders. Methods: A total of 82 psychotherapy inpatients with mixed diagnoses were randomized into two groups. Following discharge, the intervention group (IG) got access to a guided version of the intervention for 10 weeks. After a waiting period of 10 weeks, the wait-list control group (WLCG) got access to an unguided version of the intervention. We reported the assessments at the beginning (T0) and at the end of the intervention, resp. the waiting period (T1). The primary outcome was satisfaction with the treatment at T1. Secondary outcome measures included emotional competence, depression, anxiety, and quality of life. Statistical analyses were performed with descriptive statistics (primary outcome) and analysis of covariance; a repeated measurement analysis of variance was used for the secondary outcomes. Effect sizes were calculated using Cohen d and data were analyzed as per protocol, as well as intention-to-treat (ITT). Results: Patients were chronically ill, diagnosed with multiple diagnoses, most frequently with depression (84%, 58/69), anxiety (68%, 47/69), personality disorder (38%, 26/69), and depersonalization-derealization disorder (22%, 15/69). A majority of the patients (86%, 36/42) logged into the program, of which 86% (31/36) completed the first unit. Satisfaction with the units mastered was rated as good (52%, 16/31) and very good (26%, 9/31). However, there was a steady decline of participation over the course of the program; only 36% of the participants (13/36) participated throughout the trial completing at least 50% of the sessions. According to the ITT analysis, participants improved statistically significantly and with moderate effect sizes (Cohen d) compared with the WLCG regarding depression (d=0.60), quality of life (d=0.53), and emotional competence (d=0.49). Effects were considerably stronger for the completers with respect to depression (d=1.33), quality of life (d=0.83), emotional competence (d=0.68), and general anxiety (d=0.62). Conclusions: Although overall program satisfaction and benefit of the program were favorable with respect to the indicators of emotional disorders, the rate of completion was low. Our findings point to the need to target the intervention more specifically to the needs and capabilities of participants and to the context of the intervention. Trial Registration: Clinicaltrials.gov NCT02671929; https://clinicaltrials.gov/ct2/show/NCT02671929 (Archived by WebCite at http://www.webcitation.org/6ntWg1yWb) %M 29038094 %R 10.2196/mental.7889 %U http://mental.jmir.org/2017/4/e41/ %U https://doi.org/10.2196/mental.7889 %U http://www.ncbi.nlm.nih.gov/pubmed/29038094 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 10 %P e130 %T Mobile Apps for Suicide Prevention: Review of Virtual Stores and Literature %A de la Torre,Isabel %A Castillo,Gema %A Arambarri,Jon %A López-Coronado,Miguel %A Franco,Manuel A %+ Department of Signal Theory and Communications, and Telematics Engineering, University of Valladolid, Paseo de Belén 15, Valladolid, 47011, Spain, 34 983423000 ext 3703, isator@tel.uva.es %K app %K literature %K prevention %K suicide %K virtual stores %D 2017 %7 10.10.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The best manner to prevent suicide is to recognize suicidal signs and signals, and know how to respond to them. Objective: We aim to study the existing mobile apps for suicide prevention in the literature and the most commonly used virtual stores. Methods: Two reviews were carried out. The first was done by searching the most commonly used commercial app stores, which are iTunes and Google Play. The second was a review of mobile health (mHealth) apps in published articles within the last 10 years in the following 7 scientific databases: Science Direct, Medline, PsycINFO, Embase, The Cochrane Library, IEEE Xplore, and Google Scholar. Results: A total of 124 apps related to suicide were found in the cited virtual stores but only 20 apps were specifically designed for suicide prevention. All apps were free and most were designed for Android. Furthermore, 6 relevant papers were found in the indicated scientific databases; in these studies, some real experiences with physicians, caregivers, and families were described. The importance of these people in suicide prevention was indicated. Conclusions: The number of apps regarding suicide prevention is small, and there was little information available from literature searches, indicating that technology-based suicide prevention remains understudied. Many of the apps provided no interactive features. It is important to verify the accuracy of the results of different apps that are available on iOS and Android. The confidence generated by these apps can benefit end users, either by improving their health monitoring or simply to verify their body condition. %M 29017992 %R 10.2196/mhealth.8036 %U https://mhealth.jmir.org/2017/10/e130/ %U https://doi.org/10.2196/mhealth.8036 %U http://www.ncbi.nlm.nih.gov/pubmed/29017992 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e40 %T Developing Social Media-Based Suicide Prevention Messages in Partnership With Young People: Exploratory Study %A Robinson,Jo %A Bailey,Eleanor %A Hetrick,Sarah %A Paix,Steve %A O'Donnell,Matt %A Cox,Georgina %A Ftanou,Maria %A Skehan,Jaelea %+ Orygen, The National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, University of Melbourne, 35 Poplar Road, Parkville, 3052, Australia, 61 9342 2866, jo.robinson@orygen.org.au %K suicide %K suicidal ideation %K social media %K youth %K adolescents %K mass media %D 2017 %7 04.10.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Social media is increasingly being used by young people for health-related issues, including communicating about suicide. Due to the concerns about causing distress or inducing suicidal thoughts or behaviors, to date young people neither have been engaged in the development of social media–based suicide prevention interventions nor have interventions focused on educating young people about safe ways to communicate about suicide online. Given the potential that social media holds to deliver messages to vast numbers of people across space and time and the fact that young people often prefer to seek help from their friends and peers, safely educating and engaging young people to develop suicide prevention messages that can be delivered via social media is an obvious next step. Objectives: The objectives of this study were to (1) provide education to a small number of secondary school students about safe ways to communicate about suicide via social media; (2) engage the same young people in the development of a suite of social media–based suicide prevention multimedia messages; (3) assess the impact of this on participants; and (4) assess the acceptability and safety of the messages developed. Methods: This study involved two phases. In phase 1, 20 participants recruited from two schools took part in an 8- to 10-week program during which they were provided with psychoeducation about mental health and suicide, including how to talk safely about suicide online, and they were then supported to design and develop their own media messages. These participants completed an evaluation questionnaire at the conclusion of the program. In phase 2, a larger group of participants (n=69), recruited via an opt-in process, viewed the media messages and completed a short questionnaire about each one. Results: Participants in phase 1 enjoyed the program and reported that they learned new skills, such as how to talk safely about suicide online, and felt more able to provide emotional support to others (16/20, 80%). No participants reported that the program made them feel suicidal. Participants in phase 2 generally rated the media messages as safe and acceptable, although some messages were rated more highly than others. Conclusions: This study suggests that young people can be safely engaged in developing suicide prevention messages, which can be disseminated via social media. Engaging young people in this process may improve the traction that such campaigns will have with other young people. The study also suggests that educating young people regarding how to talk safely about suicide online has multiple benefits and is not associated with distress. Overall, these findings pave the way for new approaches to prevent suicide among young people. %M 28978499 %R 10.2196/mental.7847 %U https://mental.jmir.org/2017/4/e40/ %U https://doi.org/10.2196/mental.7847 %U http://www.ncbi.nlm.nih.gov/pubmed/28978499 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 9 %P e302 %T Computerized Adaptive Testing Provides Reliable and Efficient Depression Measurement Using the CES-D Scale %A Loe,Bao Sheng %A Stillwell,David %A Gibbons,Chris %+ The Psychometrics Centre, Judge Business School, University of Cambridge, Trumpington Street, Cambridge,, United Kingdom, 44 01223765203, cg598@cam.ac.uk %K depression %K assessment %K psychometrics %K patient reported outcome measures %K patient outcome assessment %D 2017 %7 20.09.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: The Center for Epidemiologic Studies Depression Scale (CES-D) is a measure of depressive symptomatology which is widely used internationally. Though previous attempts were made to shorten the CES-D scale, few have attempted to develop a Computerized Adaptive Test (CAT) version for the CES-D. Objective: The aim of this study was to provide evidence on the efficiency and accuracy of the CES-D when administered using CAT using an American sample group. Methods: We obtained a sample of 2060 responses to the CESD-D from US participants using the myPersonality application. The average age of participants was 26 years (range 19-77). We randomly split the sample into two groups to evaluate and validate the psychometric models. We used evaluation group data (n=1018) to assess dimensionality with both confirmatory factor and Mokken analysis. We conducted further psychometric assessments using item response theory (IRT), including assessments of item and scale fit to Samejima’s graded response model (GRM), local dependency and differential item functioning. We subsequently conducted two CAT simulations to evaluate the CES-D CAT using the validation group (n=1042). Results: Initial CFA results indicated a poor fit to the model and Mokken analysis revealed 3 items which did not conform to the same dimension as the rest of the items. We removed the 3 items and fit the remaining 17 items to GRM. We found no evidence of differential item functioning (DIF) between age and gender groups. Estimates of the level of CES-D trait score provided by the simulated CAT algorithm and the original CES-D trait score derived from original scale were correlated highly. The second CAT simulation conducted using real participant data demonstrated higher precision at the higher levels of depression spectrum. Conclusions: Depression assessments using the CES-D CAT can be more accurate and efficient than those made using the fixed-length assessment. %M 28931496 %R 10.2196/jmir.7453 %U http://www.jmir.org/2017/9/e302/ %U https://doi.org/10.2196/jmir.7453 %U http://www.ncbi.nlm.nih.gov/pubmed/28931496 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 9 %P e309 %T User Acceptance of Computerized Cognitive Behavioral Therapy for Depression: Systematic Review %A Rost,Theresia %A Stein,Janine %A Löbner,Margrit %A Kersting,Anette %A Luck-Sikorski,Claudia %A Riedel-Heller,Steffi G %+ Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Building A, 3rd Fl., Philipp-Rosenthal-Str. 55, Leipzig, 04103, Germany, 49 3419715408, Steffi.Riedel-Heller@medizin.uni-leipzig.de %K computerized cognitive behavior therapy %K depression %K user acceptance %K systematic review %K review %K behavior therapy %K depressive disorder %D 2017 %7 13.09.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Computerized cognitive behavioral therapy (cCBT) has been proven to be effective in depression care. Moreover, cCBT packages are becoming increasingly popular. A central aspect concerning the take-up and success of any treatment is its user acceptance. Objective: The aim of this study was to update and expand on earlier work on user acceptance of cCBT for depression. Methods: This paper systematically reviewed quantitative and qualitative studies regarding the user acceptance of cCBT for depression. The initial search was conducted in January 2016 and involved the following databases: Web of Science, PubMed, the Cochrane Library, and PsycINFO. Studies were retained if they described the explicit examination of the user acceptance, experiences, or satisfaction related to a cCBT intervention, if they reported depression as a primary outcome, and if they were published in German or English from July 2007 onward. Results: A total of 1736 studies were identified, of which 29 studies were eligible for review. User acceptance was operationalized and analyzed very heterogeneously. Eight studies reported a very high level of acceptance, 17 indicated a high level of acceptance, and one study showed a moderate level of acceptance. Two qualitative studies considered the positive and negative aspects concerning the user acceptance of cCBT. However, a substantial proportion of reviewed studies revealed several methodical shortcomings. Conclusions: In general, people experience cCBT for depression as predominantly positive, which supports the potential role of these innovative treatments. However, methodological challenges do exist in terms of defining user acceptance, clear operationalization of concepts, and measurement. %M 28903893 %R 10.2196/jmir.7662 %U http://www.jmir.org/2017/9/e309/ %U https://doi.org/10.2196/jmir.7662 %U http://www.ncbi.nlm.nih.gov/pubmed/28903893 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 3 %P e36 %T Assessing the Equivalence of Paper, Mobile Phone, and Tablet Survey Responses at a Community Mental Health Center Using Equivalent Halves of a ‘Gold-Standard’ Depression Item Bank %A Brodey,Benjamin B %A Gonzalez,Nicole L %A Elkin,Kathryn Ann %A Sasiela,W Jordan %A Brodey,Inger S %+ TeleSage, Inc., 201 E Rosemary Street, Chapel Hill, NC, 27514, United States, 1 886 942 8849, bb@telesage.com %K mobile phone %K tablet %K PROMIS %K depression %K item response theory %K outcomes tracking %K PORTAL %K TeleSage %K behavioral health %K special issue on computing and mental health %D 2017 %7 06.09.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: The computerized administration of self-report psychiatric diagnostic and outcomes assessments has risen in popularity. If results are similar enough across different administration modalities, then new administration technologies can be used interchangeably and the choice of technology can be based on other factors, such as convenience in the study design. An assessment based on item response theory (IRT), such as the Patient-Reported Outcomes Measurement Information System (PROMIS) depression item bank, offers new possibilities for assessing the effect of technology choice upon results. Objective: To create equivalent halves of the PROMIS depression item bank and to use these halves to compare survey responses and user satisfaction among administration modalities—paper, mobile phone, or tablet—with a community mental health care population. Methods: The 28 PROMIS depression items were divided into 2 halves based on content and simulations with an established PROMIS response data set. A total of 129 participants were recruited from an outpatient public sector mental health clinic based in Memphis. All participants took both nonoverlapping halves of the PROMIS IRT-based depression items (Part A and Part B): once using paper and pencil, and once using either a mobile phone or tablet. An 8-cell randomization was done on technology used, order of technologies used, and order of PROMIS Parts A and B. Both Parts A and B were administered as fixed-length assessments and both were scored using published PROMIS IRT parameters and algorithms. Results: All 129 participants received either Part A or B via paper assessment. Participants were also administered the opposite assessment, 63 using a mobile phone and 66 using a tablet. There was no significant difference in item response scores for Part A versus B. All 3 of the technologies yielded essentially identical assessment results and equivalent satisfaction levels. Conclusions: Our findings show that the PROMIS depression assessment can be divided into 2 equivalent halves, with the potential to simplify future experimental methodologies. Among community mental health care recipients, the PROMIS items function similarly whether administered via paper, tablet, or mobile phone. User satisfaction across modalities was also similar. Because paper, tablet, and mobile phone administrations yielded similar results, the choice of technology should be based on factors such as convenience and can even be changed during a study without adversely affecting the comparability of results. %M 28877861 %R 10.2196/mental.6805 %U http://mental.jmir.org/2017/3/e36/ %U https://doi.org/10.2196/mental.6805 %U http://www.ncbi.nlm.nih.gov/pubmed/28877861 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 3 %P e35 %T A Validation Study of the Web Screening Questionnaire (WSQ) Compared With the Mini-International Neuropsychiatric Interview-Plus (MINI-Plus) %A Meuldijk,Denise %A Giltay,Erik J %A Carlier,Ingrid VE %A van Vliet,Irene M %A van Hemert,Albert M %A Zitman,Frans G %+ School of Psychology, Illawarra Health and Medical Research Institute, University of Wollongong, Northfields Avenue, Wollongong, New South Wales,, Australia, 61 242214086, meuldijk@uow.edu.au %K depressive disorders %K anxiety disorders %K surveys and questionnaires %K diagnostic, brief %K clinical practice %D 2017 %7 29.08.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is a need for brief screening methods for psychiatric disorders in clinical practice. This study assesses the validity and accuracy of a brief self-report screening questionnaire, the Web Screening Questionnaire (WSQ), in detecting psychiatric disorders in a study group comprising the general population and psychiatric outpatients aged 18 years and older. Objective: The aim of this study was to investigate whether the WSQ is an adequate test to screen for the presence of depressive and anxiety disorders in clinical practice. Methods: Participants were 1292 adults (1117 subjects from the general population and 175 psychiatric outpatients), aged 18 to 65 years. The discriminant characteristics of the WSQ were examined in relation to the (“gold standard”) Mini-International Neuropsychiatric Interview-Plus (MINI-Plus) disorders, by means of sensitivity, specificity, area under the curve (AUC), and positive and negative predictive values (PPVs, NPVs). Results: The specificity of the WSQ to individually detect depressive disorders, anxiety disorders, and alcohol abuse or dependence ranged from 0.89 to 0.97 for most disorders, with the exception of post-traumatic stress disorder (0.52) and specific phobia (0.73). The sensitivity values ranged from 0.67 to 1.00, with the exception of depressive disorder (0.56) and alcohol abuse or dependence (0.56). Given the low prevalence of separate disorders in the general population sample, NPVs were extremely high across disorders (≥0.97), whereas PPVs were of poor strength (range 0.02-0.33). Conclusions: In this study group, the WSQ was a relatively good screening tool to identify individuals without a depressive or anxiety disorder, as it accurately identified those unlikely to suffer from these disorders (except for post-traumatic stress disorders and specific phobias). However, in case of a positive WSQ screening result, further diagnostic procedures are required. %M 28851674 %R 10.2196/mental.5453 %U http://mental.jmir.org/2017/3/e35/ %U https://doi.org/10.2196/mental.5453 %U http://www.ncbi.nlm.nih.gov/pubmed/28851674 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 4 %N 3 %P e22 %T Usability of a Culturally Informed mHealth Intervention for Symptoms of Anxiety and Depression: Feedback From Young Sexual Minority Men %A Fleming,John B %A Hill,Yvette N %A Burns,Michelle Nicole %+ Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 503 3114, jbfleming@gmail.com %K mHealth %K eHealth %K homosexuality, male %K adolescents, male %K anxiety %K depression %D 2017 %7 25.08.2017 %9 Original Paper %J JMIR Hum Factors %G English %X Background: To date, we are aware of no interventions for anxiety and depression developed as mobile phone apps and tailored to young sexual minority men, a group especially at risk of anxiety and depression. We developed TODAY!, a culturally informed mobile phone intervention for young men who are attracted to men and who have clinically significant symptoms of anxiety or depression. The core of the intervention consists of daily psychoeducation informed by transdiagnostic cognitive behavioral therapy (CBT) and a set of tools to facilitate putting these concepts into action, with regular mood ratings that result in tailored feedback (eg, tips for current distress and visualizations of mood by context). Objective: The aim of this study was to conduct usability testing to understand how young sexual minority men interact with the app, to inform later stages of intervention development. Methods: Participants (n=9) were young sexual minority men aged 18-20 years (Mean=19.00, standard deviation [SD]=0.71; 44% black, 44% white, and 11.1% Latino), who endorsed at least mild depression and anxiety symptoms. Participants were recruited via flyers, emails to college lesbian, gay, bisexual, and transgender (LGBT) organizations, Web-based advertisements, another researcher’s database of sexual minority youth interested in research participation, and word of mouth. During recorded interviews, participants were asked to think out loud while interacting with the TODAY! app on a mobile phone or with paper prototypes. Feedback identified from these recordings and from associated field notes were subjected to thematic analysis using a general inductive approach. To aid interpretation of results, methods and results are reported according to the consolidated criteria for reporting qualitative research (COREQ). Results: Thematic analysis of usability feedback revealed a theme of general positive feedback, as well as six recurring themes that informed continued development: (1) functionality (eg, highlight new material when available), (2) personalization (eg, more tailored feedback), (3) presentation (eg, keep content brief), (4) aesthetics (eg, use brighter colors), (5) LGBT or youth content (eg, add content about coming out), and (6) barriers to use (eg, perceiving psychoeducation as homework). Conclusions: Feedback from usability testing was vital to understanding what young sexual minority men desire from a mobile phone intervention for symptoms of anxiety and depression and was used to inform the ongoing development of such an intervention. %M 28842389 %R 10.2196/humanfactors.7392 %U http://humanfactors.jmir.org/2017/3/e22/ %U https://doi.org/10.2196/humanfactors.7392 %U http://www.ncbi.nlm.nih.gov/pubmed/28842389 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 8 %P e295 %T The Use of Mobile Apps and SMS Messaging as Physical and Mental Health Interventions: Systematic Review %A Rathbone,Amy Leigh %A Prescott,Julie %+ School of Education and Psychology, University of Bolton, Deane Road, Bolton, BL3 5AB, United Kingdom, 44 01204903676, alr3wss@bolton.ac.uk %K mHealth %K smartphone %K health %K review %K systematic %K short message service %K treatment efficacy %K portable electronic applications %K intervention study %D 2017 %7 24.08.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: The initial introduction of the World Wide Web in 1990 brought around the biggest change in information acquisition. Due to the abundance of devices and ease of access they subsequently allow, the utility of mobile health (mHealth) has never been more endemic. A substantial amount of interactive and psychoeducational apps are readily available to download concerning a wide range of health issues. mHealth has the potential to reduce waiting times for appointments; eradicate the need to meet in person with a clinician, successively diminishing the workload of mental health professionals; be more cost effective to practices; and encourage self-care tactics. Previous research has given valid evidence with empirical studies proving the effectiveness of physical and mental health interventions using mobile apps. Alongside apps, there is evidence to show that receiving short message service (SMS) messages, which entail psychoeducation, medication reminders, and links to useful informative Web pages can also be advantageous to a patient’s mental and physical well-being. Available mHealth apps and SMS services and their ever improving quality necessitates a systematic review in the area in reference to reduction of symptomology, adherence to intervention, and usability. Objective: The aim of this review was to study the efficacy, usability, and feasibility of mobile apps and SMS messages as mHealth interventions for self-guided care. Methods: A systematic literature search was carried out in JMIR, PubMed, PsychINFO, PsychARTICLES, Google Scholar, MEDLINE, and SAGE. The search spanned from January 2008 to January 2017. The primary outcome measures consisted of weight management, (pregnancy) smoking cessation, medication adherence, depression, anxiety and stress. Where possible, adherence, feasibility, and usability outcomes of the apps or SMS services were evaluated. Between-group and within-group effect sizes (Cohen d) for the mHealth intervention method group were determined. Results: A total of 27 studies, inclusive of 4658 participants were reviewed. The papers included randomized controlled trials (RCTs) (n=19), within-group studies (n=7), and 1 within-group study with qualitative aspect. Studies show improvement in physical health and significant reductions of anxiety, stress, and depression. Within-group and between-group effect sizes ranged from 0.05-3.37 (immediately posttest), 0.05-3.25 (1-month follow-up), 0.08-3.08 (2-month follow-up), 0.00-3.10 (3-month follow-up), and 0.02-0.27 (6-month follow-up). Usability and feasibility of mHealth interventions, where reported, also gave promising, significant results. Conclusions: The review shows the promising and emerging efficacy of using mobile apps and SMS text messaging as mHealth interventions. %M 28838887 %R 10.2196/jmir.7740 %U http://www.jmir.org/2017/8/e295/ %U https://doi.org/10.2196/jmir.7740 %U http://www.ncbi.nlm.nih.gov/pubmed/28838887 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 8 %P e158 %T Conventional Cognitive Behavioral Therapy Facilitated by an Internet-Based Support System: Feasibility Study at a Psychiatric Outpatient Clinic %A Månsson,Kristoffer NT %A Klintmalm,Hugo %A Nordqvist,Ragnar %A Andersson,Gerhard %+ Department of Psychology, Stockholm University, Frescati Hagväg 8, Stockholm, 106 91, Sweden, 46 (0)705803267, kristoffer.mansson@psychology.su.se %K cognitive behavioral therapy %K Internet-treatment %K psychiatry %K blended therapy %D 2017 %7 24.08.2017 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Cognitive behavioral therapies have been shown to be effective for a variety of psychiatric and somatic disorders, but some obstacles can be noted in regular psychiatric care; for example, low adherence to treatment protocols may undermine effects. Treatments delivered via the Internet have shown promising results, and it is an open question if the blend of Internet-delivered and conventional face-to-face cognitive behavioral therapies may help to overcome some of the barriers of evidence-based treatments in psychiatric care. Objective: We evaluated the feasibility of an Internet-based support system at an outpatient psychiatric clinic in Sweden. For instance, the support system made it possible to send messages and share information between the therapist and the patient before and after therapy sessions at the clinic. Methods: Nine clinical psychologists participated and 33 patients were enrolled in the current study. We evaluated the usability and technology acceptance after 12 weeks of access. Moreover, clinical data on common psychiatric symptoms were assessed before and after the presentation of the support system. Results: In line with our previous study in a university setting, the Internet-based support system has the potential to be feasible also when delivered in a regular psychiatric setting. Notably, some components in the system were less frequently used. We also found that patients improved on common outcome measures for depressive and anxious symptoms (effect sizes, as determined by Cohen d, ranged from 0.20-0.69). Conclusions: This study adds to the literature suggesting that modern information technology could be aligned with conventional face-to-face services. %M 28838884 %R 10.2196/resprot.6035 %U http://www.researchprotocols.org/2017/8/e158/ %U https://doi.org/10.2196/resprot.6035 %U http://www.ncbi.nlm.nih.gov/pubmed/28838884 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 8 %P e149 %T The Spanish Version of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) Adapted as a School-Based Anxiety and Depression Prevention Program: Study Protocol for a Cluster Randomized Controlled Trial %A García-Escalera,Julia %A Valiente,Rosa M %A Chorot,Paloma %A Ehrenreich-May,Jill %A Kennedy,Sarah M %A Sandín,Bonifacio %+ Faculty of Psychology, Universidad Nacional de Educación a Distancia, Juan del Rosal, 10, Madrid, 28040, Spain, 34 913987940, pchorot@psi.uned.es %K universal prevention %K transdiagnostic %K cluster %K randomized controlled trial %K unified protocol %K adolescents %K anxiety %K depression %K emotional disorders %K school intervention %D 2017 %7 21.08.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Anxiety and depression are common, impairing conditions that evidence high comorbidity rates in adolescence. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) is one of the few existing resources aimed at applying transdiagnostic treatment principles to target core dysfunctions associated with both anxiety and depression within a single protocol. To our knowledge, this is the first study examining the efficacy of the UP-A adapted as a universal preventive intervention program. Objective: The primary aim of this study is to examine whether the Spanish version of the UP-A is more effective than a waitlist (WL) control group in reducing and preventing symptoms of anxiety and depression when employed as a universal, classroom-based preventive intervention. The secondary aim is to investigate changes in a broad range of secondary outcome measures, including negative and positive affect, anxiety sensitivity, emotional avoidance, top problems ratings, school grades, depression and anxiety-related interference, self-esteem, life satisfaction, quality of life, conduct problems, hyperactivity/inattention symptoms, peer problems, prosocial behavior, school adjustment, and discipline problems. Other aims are to assess a range of possible predictors of intervention effects and to examine the feasibility and the acceptability of implementing UP-A in a prevention group format and in a school setting. Methods: A cluster, randomized, WL, controlled trial design with classroom as the unit of randomization was used in this study. Five classes including a total of 152 adolescents were randomized to the experimental or WL control groups. Participants in the experimental group received 9 55-minute sessions delivered by advanced doctoral and masters students in clinical psychology. The WL control group will receive the intervention once the 3-month follow-up assessment is completed. Results: We have recruited participants to the cluster randomized controlled trial (RCT) and have conducted the intervention with the experimental group. We expect the WL control group to complete the intervention in July 2017. Data analysis will take place during the second semester of 2017. Conclusions: We expect the experimental group to outperform the WL control group at post-intervention and 3-month follow-up. We also expect the WL control group to show improvements in primary and secondary outcome measures after receiving the intervention. Results will have implications for researchers, families, and education providers. Trial Registration: Clinicaltrials.gov NCT03123991; https://clinicaltrials.gov/ct2/show/NCT03123991 (Archived by WebCite at http://www.webcitation.org/6qp7GIzcR) %M 28827212 %R 10.2196/resprot.7934 %U http://www.researchprotocols.org/2017/8/e149/ %U https://doi.org/10.2196/resprot.7934 %U http://www.ncbi.nlm.nih.gov/pubmed/28827212 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 4 %N 3 %P e18 %T Exploring User Learnability and Learning Performance in an App for Depression: Usability Study %A Stiles-Shields,Colleen %A Montague,Enid %A Lattie,Emily G %A Schueller,Stephen M %A Kwasny,Mary J %A Mohr,David C %+ Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 312 503 0414, ecsshields@uchicago.edu %K apps %K learning %K cognitive therapy %K usability testing %K depression %D 2017 %7 11.08.2017 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Mental health apps tend to be narrow in their functioning, with their focus mostly being on tracking, management, or psychoeducation. It is unclear what capability such apps have to facilitate a change in users, particularly in terms of learning key constructs relating to behavioral interventions. Thought Challenger (CBITs, Chicago) is a skill-building app that engages users in cognitive restructuring, a core component of cognitive therapy (CT) for depression. Objective: The purpose of this study was to evaluate the learnability and learning performance of users following initial use of Thought Challenger. Methods: Twenty adults completed in-lab usability testing of Thought Challenger, which comprised two interactions with the app. Learnability was measured via completion times, error rates, and psychologist ratings of user entries in the app; learning performance was measured via a test of CT knowledge and skills. Nonparametric tests were conducted to evaluate the difference between individuals with no or mild depression to those with moderate to severe depression, as well as differences in completion times and pre- and posttests. Results: Across the two interactions, the majority of completion times were found to be acceptable (5 min or less), with minimal errors (1.2%, 10/840) and successful completion of CT thought records. Furthermore, CT knowledge and skills significantly improved after the initial use of Thought Challenger (P=.009). Conclusions: The learning objectives for Thought Challenger during initial uses were successfully met in an evaluation with likely end users. The findings therefore suggest that apps are capable of providing users with opportunities for learning of intervention skills. %M 28801301 %R 10.2196/humanfactors.7951 %U http://humanfactors.jmir.org/2017/3/e18/ %U https://doi.org/10.2196/humanfactors.7951 %U http://www.ncbi.nlm.nih.gov/pubmed/28801301 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 3 %P e33 %T Preliminary Evaluation of a Brief Web and Mobile Phone Intervention for Men With Depression: Men’s Positive Coping Strategies and Associated Depression, Resilience, and Work and Social Functioning %A Fogarty,Andrea Susan %A Proudfoot,Judy %A Whittle,Erin Louise %A Clarke,Janine %A Player,Michael J %A Christensen,Helen %A Wilhelm,Kay %+ Black Dog Institute, UNSW, Hospital Rd, Randwick, 2031, Australia, 61 293829273, a.fogarty@unsw.edu.au %K depression %K eHealth %K men %K mental health %D 2017 %7 10.08.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Previous research has identified that men experiencing depression do not always access appropriate health services. Web-based interventions represent an alternative treatment option for men, are effective in reducing anxiety and depression, and have potential for wide dissemination. However, men do not access Web-based programs at the same rate as women. Programs with content explicitly tailored to men’s mental health needs are required. Objective: This study evaluated the applicability of Man Central, a new Web and mobile phone intervention for men with depression. The impact of the use of Man Central on depression, resilience, and work and social functioning was assessed. Methods: A recruitment flier was distributed via social media, email networks, newsletters, research registers, and partner organizations. A single-group, repeated measures design was used. The primary outcome was symptoms of depression. Secondary outcomes included externalizing symptoms, resilience, and work and social functioning. Man Central comprises regular mood, symptom, and behavior monitoring, combined with three 15-min interactive sessions. Clinical features are grounded in cognitive behavior therapy and problem-solving therapy. A distinguishing feature is the incorporation of positive strategies identified by men as useful in preventing and managing depression. Participants were directed to use Man Central for a period of 4 weeks. Linear mixed modeling with intention-to-treat analysis assessed associations between the intervention and the primary and secondary outcomes. Results: A total of 144 men aged between 18 and 68 years and with at least mild depression enrolled in the study. The symptoms most often monitored by men included motivation (471 instances), depression (399), sleep (323), anxiety (316), and stress (262). Reminders were scheduled by 60.4% (87/144). Significant improvements were observed in depression symptoms (P<.001, d=0.68), depression risk, and externalizing symptoms (P<.001, d=0.88) and work and social functioning (P<.001, d=0.78). No change was observed in measures of resilience. Participants reported satisfaction with the program, with a majority saying that it was easy (42/51, 82%) and convenient (41/51, 80%) to use. Study attrition was high; 27.1% (39/144) and 8.3% (12/144) of the participants provided complete follow-up data and partial follow-up data, respectively, whereas the majority (93/144, 64.6%) did not complete follow-up measures. Conclusions: This preliminary evaluation demonstrated the potential of using electronic health (eHealth) tools to deliver self-management strategies to men with depressive symptoms. Man Central may meet the treatment needs of a subgroup of depressed men who are willing to engage with an e-mental health program. With further research, it may provide an acceptable option to those unwilling or unable to access traditional mental health services. Given the limitations of the study design, prospective studies are required, using controlled designs to further elucidate the effect of the program over time. %M 28798009 %R 10.2196/mental.7769 %U http://mental.jmir.org/2017/3/e33/ %U https://doi.org/10.2196/mental.7769 %U http://www.ncbi.nlm.nih.gov/pubmed/28798009 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 8 %P e112 %T Mobile Phone Detection of Semantic Location and Its Relationship to Depression and Anxiety %A Saeb,Sohrab %A Lattie,Emily G %A Kording,Konrad P %A Mohr,David C %+ Center for Behavioral Intervention Technologies (CBITs), Department of Preventive Medicine, Northwestern University, 10th Fl., 750 N Lake Shore Dr., Chicago, IL, 60611, United States, 1 3125034626, s-saeb@northwestern.edu %K semantic location %K geographic positioning systems %K mobile phone %K classification %K decision tree ensembles %K extreme gradient boosting %K depression %K anxiety %D 2017 %7 10.08.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Is someone at home, at their friend’s place, at a restaurant, or enjoying the outdoors? Knowing the semantic location of an individual matters for delivering medical interventions, recommendations, and other context-aware services. This knowledge is particularly useful in mental health care for monitoring relevant behavioral indicators to improve treatment delivery. Local search-and-discovery services such as Foursquare can be used to detect semantic locations based on the global positioning system (GPS) coordinates, but GPS alone is often inaccurate. Mobile phones can also sense other signals (such as movement, light, and sound), and the use of these signals promises to lead to a better estimation of an individual’s semantic location. Objective: We aimed to examine the ability of mobile phone sensors to estimate semantic locations, and to evaluate the relationship between semantic location visit patterns and depression and anxiety. Methods: A total of 208 participants across the United States were asked to log the type of locations they visited daily, using their mobile phones for a period of 6 weeks, while their phone sensor data was recorded. Using the sensor data and Foursquare queries based on GPS coordinates, we trained models to predict these logged locations, and evaluated their prediction accuracy on participants that models had not seen during training. We also evaluated the relationship between the amount of time spent in each semantic location and depression and anxiety assessed at baseline, in the middle, and at the end of the study. Results: While Foursquare queries detected true semantic locations with an average area under the curve (AUC) of 0.62, using phone sensor data alone increased the AUC to 0.84. When we used Foursquare and sensor data together, the AUC further increased to 0.88. We found some significant relationships between the time spent in certain locations and depression and anxiety, although these relationships were not consistent. Conclusions: The accuracy of location services such as Foursquare can significantly benefit from using phone sensor data. However, our results suggest that the nature of the places people visit explains only a small part of the variation in their anxiety and depression symptoms. %M 28798010 %R 10.2196/mhealth.7297 %U http://mhealth.jmir.org/2017/8/e112/ %U https://doi.org/10.2196/mhealth.7297 %U http://www.ncbi.nlm.nih.gov/pubmed/28798010 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 8 %P e266 %T How do eHealth Programs for Adolescents With Depression Work? A Realist Review of Persuasive System Design Components in Internet-Based Psychological Therapies %A Wozney,Lori %A Huguet,Anna %A Bennett,Kathryn %A Radomski,Ashley D %A Hartling,Lisa %A Dyson,Michele %A McGrath,Patrick J %A Newton,Amanda S %+ Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 3-526 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, AB, T6G 1C9, Canada, 1 780 248 5581, mandi.newton@ualberta.ca %K persuasive systems %K mental health %K Internet-based intervention %K review %K psychological therapy %D 2017 %7 09.08.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Major depressive disorders are common among adolescents and can impact all aspects of their daily life. Traditional therapies, cognitive behavioral therapy (CBT), and interpersonal psychotherapy (IPT) have been delivered face-to-face. However, Internet-based (online) delivery of these therapies is emerging as an option for adolescents. Internet-based CBT and IPT involve therapeutic content, interaction between the user and the system, and different technological features embedded into the online program (eg, multimedia). Studies of Internet-based CBT and IPT for adolescent depression differ on all three aspects, and variable, positive therapy effects have been reported. A better understanding of the treatment conditions that influence therapy outcomes is important to designing and evaluating these novel therapies. Objective: Our aim was to examine the technological and program delivery features of Internet-based CBT and IPT for adolescent depression and to document their potential relation to treatment outcomes and program use. Methods: We performed a realist synthesis. We started with an extensive search of published and gray literature. We included intervention studies that evaluated Internet-based CBT or IPT for adolescent depression. We included mixed-methods and qualitative studies, theoretical papers, and policy/implementation documents if they included a focus on how Internet-based psychological therapy is proposed to work for adolescents with depression/depressive symptoms. We used the Mixed-Methods Appraisal Tool to assess the methodological quality of studies. We used the Persuasive System Design (PSD) model as a framework for data extraction and analysis to examine how Internet-based CBT and IPT, as technology-based systems, influence the attitudes and behaviors of system users. PSD components described for the therapies were linked to reported outcomes using a cross-case comparison method and thematic synthesis. Results: We identified 19 Internet-based CBT programs in 59 documents. Of those, 71% (42/59) were of moderate to high quality. The PSD features surface credibility (competent “look and feel”), dialogue support (online program + in-person support), liking and similarity (esthetics and content appeal to adolescent users), the reduction and tunneling of therapeutic content (reducing online content into simple tasks, guiding users), and use of self-monitoring were present in therapies that resulted in improved therapy engagement, satisfaction, and adherence, as well as symptom and functional impairments. Conclusions: When incorporated into Internet-based CBT for adolescent depression, PSD features may improve adolescent adherence, satisfaction, and depression-related outcomes. Testing of these features using hypothesis-driven dismantling approaches is recommended to advance our understanding of how these features contribute to therapy effectiveness. %M 28793983 %R 10.2196/jmir.7573 %U http://www.jmir.org/2017/8/e266/ %U https://doi.org/10.2196/jmir.7573 %U http://www.ncbi.nlm.nih.gov/pubmed/28793983 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 8 %P e279 %T Psychiatric Consultation at Your Fingertips: Descriptive Analysis of Electronic Consultation From Primary Care to Psychiatry %A Lowenstein,Margaret %A Bamgbose,Olusinmi %A Gleason,Nathaniel %A Feldman,Mitchell D %+ University of Pennsylvania Perelman School of Medicine, National Clinician Scholars Program, Blockley Hall, 423 Guardian Drive, Philadelphia, PA,, United States, 1 215 573 3977, margaw@mail.med.upenn.edu %K mental health %K primary care %K health care delivery %K teleconsultation %K telehealth %K Internet care delivery %D 2017 %7 04.08.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health problems are commonly encountered in primary care, with primary care providers (PCPs) experiencing challenges referring patients to specialty mental health care. Electronic consultation (eConsult) is one model that has been shown to improve timely access to subspecialty care in a number of medical subspecialties. eConsults generally involve a PCP-initiated referral for specialty consultation for a clinical question that is outside their expertise but may not require an in-person evaluation. Objective: Our aim was to describe the implementation of eConsults for psychiatry in a large academic health system. Methods: We performed a content analysis of the first 50 eConsults to psychiatry after program implementation. For each question and response, we coded consults as pertaining to diagnosis and/or management as well as categories of medication choice, drug side effects or interactions, and queries about referrals and navigating the health care system. We also performed a chart review to evaluate the timeliness of psychiatrist responses and PCP implementation of recommendations. Results: Depression was the most common consult template selected by PCPs (20/50, 40%), followed by the generic template (12/50, 24%) and anxiety (8/50, 16%). Most questions (49/50, 98%) pertained primarily to management, particularly for medications. Psychiatrists commented on both diagnosis (28/50, 56%) and management (50/50, 100%), responded in an average of 1.4 days, and recommended in-person consultation for 26% (13/50) of patients. PCPs implemented psychiatrist recommendations 76% (38/50) of the time. Conclusions: For the majority of patients, psychiatrists provided strategies for ongoing management in primary care without an in-person evaluation, and PCPs implemented most psychiatrist recommendations. eConsults show promise as one means of supporting PCPs to deliver mental health care to patients with common psychiatric disorders. %M 28778852 %R 10.2196/jmir.7921 %U http://www.jmir.org/2017/8/e279/ %U https://doi.org/10.2196/jmir.7921 %U http://www.ncbi.nlm.nih.gov/pubmed/28778852 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 8 %P e145 %T A Web-Based Public Health Intervention to Reduce Functional Impairment and Depressive Symptoms in Adults With Type 2 Diabetes (The SpringboarD Trial): Randomized Controlled Trial Protocol %A Proudfoot,Judy %A Clarke,Janine %A Gunn,Jane %A Fletcher,Susan %A Sanatkar,Samineh %A Wilhelm,Kay %A Campbell,Lesley %A Zwar,Nicholas %A Harris,Mark %A Lapsley,Helen %A Hadzi-Pavlovic,Dusan %A Christensen,Helen %+ Black Dog Institute, Hospital Road, Randwick, 2031, Australia, 61 2 9382 3767 ext 23767, janine.clarke@unsw.edu.au %K type 2 diabetes %K depression %K Web-based intervention %D 2017 %7 03.08.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depressive symptoms are common in people with type 2 diabetes and contribute to adverse health consequences that substantially impact social and vocational function. Despite the existence of effective depression treatments, the majority of people with type 2 diabetes do not access these when needed. Web-based alternatives to more traditional psychotherapies offer a potential solution to reducing the personal and economic burdens of type 2 diabetes. Objective: This paper outlines the protocol for a randomized controlled trial (RCT) of myCompass, a Web-based public health psychotherapy intervention, in people with type 2 diabetes. Fully automated, interactive, and delivered via the Internet without clinician support, myCompass teaches cognitive behavioral therapy-based skills and supports symptom monitoring to improve daily functioning and reduce mild-to-moderate mental health symptoms. Methods: A two-arm RCT will be conducted. People with type 2 diabetes and mild-to-moderately severe depressive symptoms will be recruited from the community and general practice settings. Screening and enrollment is via an open-access website. Participants will be randomized to use either myCompass or an active placebo program for 8 weeks, followed by a 4-week tailing-off period. The placebo program is matched to myCompass on mode of delivery, interactivity, and duration. Outcomes will be assessed at baseline and at 3-month, 6-month, and 12-month follow-up. The primary study outcome is work and social functioning. Secondary study outcomes include depressive and anxious symptoms, diabetes-related distress, self-care behaviors, and glycemic control. Results: Nationwide recruitment is currently underway with the aim of recruiting 600 people with type 2 diabetes. Recruitment will continue until October 2017. Conclusions: This is the first known trial of a Web-based psychotherapy program that is not diabetes specific for improving social and vocational function in people with type 2 diabetes and mild-to-moderately severe depressive symptoms. With the increasing prevalence of type 2 diabetes and depression, a potentially scalable public health intervention could play a very large role in reducing unmet mental health need and ameliorating the personal and societal impact of illness comorbidity. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) Number: ACTRN12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109 (Archived by WebCite at http://www.webcitation.org/ 6rh3imVMh) %M 28778848 %R 10.2196/resprot.7348 %U http://www.researchprotocols.org/2017/8/e145/ %U https://doi.org/10.2196/resprot.7348 %U http://www.ncbi.nlm.nih.gov/pubmed/28778848 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 7 %P e135 %T Randomized Trial Comparing the Electronic Composite Psychosocial Screener YouthCHAT With a Clinician-Interview Assessment for Young People: A Study Protocol %A Thabrew,Hiran %A Corter,Arden %A Goodyear-Smith,Felicity %A Goldfinch,Mary %+ University of Auckland, Department of Psychological Medicine, University of Auckland, Level 12, Support Block, Auckland Hospital, Park Road, Grafton, Auckland, 1142, New Zealand, 64 21402055, h.thabrew@auckland.ac.nz %K mass screening %K adolescents %K substance-related disorders %K depression %K anxiety %K primary health care %K school health %K services %K chronic disease %D 2017 %7 31.07.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Psychosocial problems such as depression, anxiety, and substance abuse are common and burdensome in young people, particularly those with long-term physical conditions such as asthma and diabetes. In New Zealand, “screening” for such problems is undertaken routinely only with Year 9 students in low-decile schools and opportunistically in pediatric settings using a nonvalidated and time-consuming clinician-administered Home, Education/employment, Eating, Activity, Drugs, Sexuality, Suicide/depression, Safety (HEEADSSS) interview. The Youth version, Case-finding and Help Assessment Tool (YouthCHAT) is a relatively new, locally developed, eTablet-based composite screener for identifying similar psychosocial issues to HEEADSSS. Based on individually validated screening instruments, it is self-administered within minutes. Preliminary testing has revealed its acceptability to young people, but further research is required to expand its modules to cover all HEEADSSS domains, to evaluate its acceptability for young people with and without long-term physical conditions, and to compare its effectiveness against HEEADSSS. Objective: Our aim is to (1) ascertain acceptability and utility of YouthCHAT for children with long-term physical illness and high school students, (2) validate three additional YouthCHAT domains against comparable HEEADSSS domains, and (3) compare the performance of YouthCHAT and HEEADSSS in the high school setting. Methods: During the first phase of the study, three additional YouthCHAT domains were codesigned with high school students. During the second phase of the study, the updated version of YouthCHAT will be administered to 30 young people with long-term physical conditions, and to 150 high school students either before or after HEEADSSS in the form of a randomized trial with counter-balanced design. Primary outcomes include comparability between HEEADSSS and YouthCHAT in detecting psychosocial issues, and time to administer; acceptability of YouthCHAT as an acceptable alternative or companion to HEEADSSS assessment; and the utility of YouthCHAT in helping streamline assessment processes. Results: Recruitment for the first phase of this project commenced in November 2016, and the phase will run from February to November 2017. Conclusions: If YouthCHAT is found to be acceptable to study participants and as effective as a HEEADSSS assessment, it could be an innovative and more efficient means of routine screening for common psychosocial health issues in young people with and without long-term physical conditions. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12616001243404p; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371422 (Archived by WebCite at http://www.webcitation.org/ 6rmlEiM1L) %M 28760727 %R 10.2196/resprot.7995 %U http://www.researchprotocols.org/2017/7/e135/ %U https://doi.org/10.2196/resprot.7995 %U http://www.ncbi.nlm.nih.gov/pubmed/28760727 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 7 %P e271 %T Improving Employee Well-Being and Effectiveness: Systematic Review and Meta-Analysis of Web-Based Psychological Interventions Delivered in the Workplace %A Carolan,Stephany %A Harris,Peter R %A Cavanagh,Kate %+ School of Psychology, University of Sussex, Falmer, Brighton, BN1 9QH, United Kingdom, 44 (0)1273 876638, sc587@sussex.ac.uk %K adherence %K engagement %K Internet %K meta-analysis %K psychological interventions %K stress %K systematic review %K wellbeing %K workplace %D 2017 %7 26.07.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Stress, depression, and anxiety among working populations can result in reduced work performance and increased absenteeism. Although there is evidence that these common mental health problems are preventable and treatable in the workplace, uptake of psychological treatments among the working population is low. One way to address this may be the delivery of occupational digital mental health interventions. While there is convincing evidence for delivering digital psychological interventions within a health and community context, there is no systematic review or meta-analysis of these interventions in an occupational setting. Objective: The aim of this study was to identify the effectiveness of occupational digital mental health interventions in enhancing employee psychological well-being and increasing work effectiveness and to identify intervention features associated with the highest rates of engagement and adherence. Methods: A systematic review of the literature was conducted using Cochrane guidelines. Papers published from January 2000 to May 2016 were searched in the PsychINFO, MEDLINE, PubMed, Science Direct, and the Cochrane databases, as well as the databases of the researchers and relevant websites. Unpublished data was sought using the Conference Proceedings Citation Index and the Clinical Trials and International Standard Randomized Controlled Trial Number (ISRCTN) research registers. A meta-analysis was conducted by applying a random-effects model to assess the pooled effect size for psychological well-being and the work effectiveness outcomes. A positive deviance approach was used to identify those intervention features associated with the highest rates of engagement and adherence. Results: In total, 21 randomized controlled trials (RCTs) met the search criteria. Occupational digital mental health interventions had a statistically significant effect post intervention on both psychological well-being (g=0.37, 95% CI 0.23-0.50) and work effectiveness (g=0.25, 95% CI 0.09-0.41) compared with the control condition. No statistically significant differences were found on either outcome between studies using cognitive behavioral therapy (CBT) approaches (as defined by the authors) compared with other psychological approaches, offering guidance compared with self-guidance, or recruiting from a targeted workplace population compared with a universal workplace population. In-depth analysis of the interventions identified by the positive deviance approach suggests that interventions that offer guidance are delivered over a shorter time frame (6 to 7 weeks), utilize secondary modalities for delivering the interventions and engaging users (ie, emails and text messages [short message service, SMS]), and use elements of persuasive technology (ie, self-monitoring and tailoring), which may achieve greater engagement and adherence. Conclusions: This review provides evidence that occupational digital mental health interventions can improve workers’ psychological well-being and increase work effectiveness. It identifies intervention characteristics that may increase engagement. Recommendations are made for future research, practice, and intervention development. %M 28747293 %R 10.2196/jmir.7583 %U http://www.jmir.org/2017/7/e271/ %U https://doi.org/10.2196/jmir.7583 %U http://www.ncbi.nlm.nih.gov/pubmed/28747293 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 7 %P e262 %T Smartphone-Based Monitoring of Objective and Subjective Data in Affective Disorders: Where Are We and Where Are We Going? Systematic Review %A Dogan,Ezgi %A Sander,Christian %A Wagner,Xenija %A Hegerl,Ulrich %A Kohls,Elisabeth %+ Medical Faculty, Department of Psychiatry and Psychotherapy, University Leipzig, Semmelweisstrasse 10, Haus 13, Leipzig, 04103, Germany, 49 341 9724558, Christian.Sander@medizin.uni-leipzig.de %K review %K mood disorders %K smartphone %K ecological momentary assessment %D 2017 %7 24.07.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Electronic mental health interventions for mood disorders have increased rapidly over the past decade, most recently in the form of various systems and apps that are delivered via smartphones. Objective: We aim to provide an overview of studies on smartphone-based systems that combine subjective ratings with objectively measured data for longitudinal monitoring of patients with affective disorders. Specifically, we aim to examine current knowledge on: (1) the feasibility of, and adherence to, such systems; (2) the association of monitored data with mood status; and (3) the effects of monitoring on clinical outcomes. Methods: We systematically searched PubMed, Web of Science, PsycINFO, and the Cochrane Central Register of Controlled Trials for relevant articles published in the last ten years (2007-2017) by applying Boolean search operators with an iterative combination of search terms, which was conducted in February 2017. Additional articles were identified via pearling, author correspondence, selected reference lists, and trial protocols. Results: A total of 3463 unique records were identified. Twenty-nine studies met the inclusion criteria and were included in the review. The majority of articles represented feasibility studies (n=27); two articles reported results from one randomized controlled trial (RCT). In total, six different self-monitoring systems for affective disorders that used subjective mood ratings and objective measurements were included. These objective parameters included physiological data (heart rate variability), behavioral data (phone usage, physical activity, voice features), and context/environmental information (light exposure and location). The included articles contained results regarding feasibility of such systems in affective disorders, showed reasonable accuracy in predicting mood status and mood fluctuations based on the objectively monitored data, and reported observations about the impact of monitoring on clinical state and adherence of patients to the system usage. Conclusions: The included observational studies and RCT substantiate the value of smartphone-based approaches for gathering long-term objective data (aside from self-ratings to monitor clinical symptoms) to predict changes in clinical states, and to investigate causal inferences about state changes in patients with affective disorders. Although promising, a much larger evidence-base is necessary to fully assess the potential and the risks of these approaches. Methodological limitations of the available studies (eg, small sample sizes, variations in the number of observations or monitoring duration, lack of RCT, and heterogeneity of methods) restrict the interpretability of the results. However, a number of study protocols stated ambitions to expand and intensify research in this emerging and promising field. %M 28739561 %R 10.2196/jmir.7006 %U http://www.jmir.org/2017/7/e262/ %U https://doi.org/10.2196/jmir.7006 %U http://www.ncbi.nlm.nih.gov/pubmed/28739561 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 7 %P e259 %T Ontology-Based Approach to Social Data Sentiment Analysis: Detection of Adolescent Depression Signals %A Jung,Hyesil %A Park,Hyeoun-Ae %A Song,Tae-Min %+ College of Nursing, Seoul National University, Daehak-ro 103, Jongno-gu, Seoul, 03080, Republic Of Korea, 82 27408827, hapark@snu.ac.kr %K ontology %K adolescent %K depression %K data mining %K social media data %D 2017 %7 24.07.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Social networking services (SNSs) contain abundant information about the feelings, thoughts, interests, and patterns of behavior of adolescents that can be obtained by analyzing SNS postings. An ontology that expresses the shared concepts and their relationships in a specific field could be used as a semantic framework for social media data analytics. Objective: The aim of this study was to refine an adolescent depression ontology and terminology as a framework for analyzing social media data and to evaluate description logics between classes and the applicability of this ontology to sentiment analysis. Methods: The domain and scope of the ontology were defined using competency questions. The concepts constituting the ontology and terminology were collected from clinical practice guidelines, the literature, and social media postings on adolescent depression. Class concepts, their hierarchy, and the relationships among class concepts were defined. An internal structure of the ontology was designed using the entity-attribute-value (EAV) triplet data model, and superclasses of the ontology were aligned with the upper ontology. Description logics between classes were evaluated by mapping concepts extracted from the answers to frequently asked questions (FAQs) onto the ontology concepts derived from description logic queries. The applicability of the ontology was validated by examining the representability of 1358 sentiment phrases using the ontology EAV model and conducting sentiment analyses of social media data using ontology class concepts. Results: We developed an adolescent depression ontology that comprised 443 classes and 60 relationships among the classes; the terminology comprised 1682 synonyms of the 443 classes. In the description logics test, no error in relationships between classes was found, and about 89% (55/62) of the concepts cited in the answers to FAQs mapped onto the ontology class. Regarding applicability, the EAV triplet models of the ontology class represented about 91.4% of the sentiment phrases included in the sentiment dictionary. In the sentiment analyses, “academic stresses” and “suicide” contributed negatively to the sentiment of adolescent depression. Conclusions: The ontology and terminology developed in this study provide a semantic foundation for analyzing social media data on adolescent depression. To be useful in social media data analysis, the ontology, especially the terminology, needs to be updated constantly to reflect rapidly changing terms used by adolescents in social media postings. In addition, more attributes and value sets reflecting depression-related sentiments should be added to the ontology. %M 28739560 %R 10.2196/jmir.7452 %U http://www.jmir.org/2017/7/e259/ %U https://doi.org/10.2196/jmir.7452 %U http://www.ncbi.nlm.nih.gov/pubmed/28739560 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 7 %P e257 %T Web-Based Therapist Training in Interpersonal Psychotherapy for Depression: Pilot Study %A Kobak,Kenneth A %A Lipsitz,Joshua D %A Markowitz,John C %A Bleiberg,Kathryn L %+ Center for Telepsychology, 22 North Harwood Circle, Madison, WI, 53717, United States, 1 6084062621, kobak@charter.net %K psychotherapy %K Internet %K depression %K education %K humans %K computer-assisted instruction %D 2017 %7 17.07.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Training mental health professionals to deliver evidence-based therapy (EBT) is now required by most academic accreditation bodies, and evaluating the effectiveness of such training is imperative. However, shortages of time, money, and trained EBT clinician teachers make these challenges daunting. New technologies may help. The authors have developed the first empirically evaluated comprehensive Internet therapist training program for interpersonal psychotherapy (IPT). Objective: The aim of this study was to examine whether (1) the training protocol would increase clinicians’ knowledge of IPT concepts and skills and (2) clinicians would deem the training feasible as measured by satisfaction and utility ratings. Methods: A total of 26 clinicians enrolled in the training, consisting of (1) a Web-based tutorial on IPT concepts and techniques; (2) live remote training via videoconference, with trainees practicing IPT techniques in a role-play using a case vignette; and (3) a Web-based portal for therapists posttraining use to help facilitate implementation of IPT and maintain adherence over time. Results: Trainees’ knowledge of IPT concepts and skills improved significantly (P<.001). The standardized effect size for the change was large: d=2.53, 95% CI 2.23-2.92. Users found the technical features easy to use, the content useful for helping them treat depressed clients, and felt the applied training component enhanced their professional expertise. Mean rating of applied learning was 3.9 (scale range from 1=very little to 5=a great deal). Overall satisfaction rating was 3.5 (range from 1=very dissatisfied to 4=very satisfied). Conclusions: Results support the efficacy and feasibility of this technology in training clinicians in EBTs and warrant further empirical evaluation. %M 28716769 %R 10.2196/jmir.7966 %U http://www.jmir.org/2017/7/e257/ %U https://doi.org/10.2196/jmir.7966 %U http://www.ncbi.nlm.nih.gov/pubmed/28716769 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 7 %P e247 %T Using New and Emerging Technologies to Identify and Respond to Suicidality Among Help-Seeking Young People: A Cross-Sectional Study %A Iorfino,Frank %A Davenport,Tracey A %A Ospina-Pinillos,Laura %A Hermens,Daniel F %A Cross,Shane %A Burns,Jane %A Hickie,Ian B %+ Brain and Mind Centre, The University of Sydney, 94 Mallett St, Camperdown, Sydney, 2050, Australia, 61 02 9351 0827, frank.iorfino@sydney.edu.au %K suicidal ideation %K mental health %K primary health care %K telemedicine %K health services %D 2017 %7 12.07.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicidal thoughts are common among young people presenting to face-to-face and online mental health services. The early detection and rapid response to these suicidal thoughts and other suicidal behaviors is a priority for suicide prevention and early intervention efforts internationally. Establishing how best to use new and emerging technologies to facilitate person-centered systematic assessment and early intervention for suicidality is crucial to these efforts. Objective: The aim of this study was to examine the use of a suicidality escalation protocol to respond to suicidality among help-seeking young people. Methods: A total of 232 young people in the age range of 16-25 years were recruited from either a primary mental health care service or online in the community. Each young person used the Synergy Online System and completed an initial clinical assessment online before their face-to-face or online clinical appointment. A suicidality escalation protocol was used to identify and respond to current and previous suicidal thoughts and behaviors. Results: A total of 153 young people (66%, 153/232) reported some degree of suicidality and were provided with a real-time alert online. Further levels of escalation (email or phone contact and clinical review) were initiated for the 35 young people (15%, 35/232) reporting high suicidality. Higher levels of psychological distress (P<.001) and a current alcohol or substance use problem (P=.02) predicted any level of suicidality compared with no suicidality. Furthermore, predictors of high suicidality compared with low suicidality were higher levels of psychological distress (P=.01), psychosis-like symptoms in the last 12 months (P=.01), a previous mental health problem (P=.01), and a history of suicide planning or attempts (P=.001). Conclusions: This study demonstrates the use of new and emerging technologies to facilitate the systematic assessment and detection of help-seeking young people presenting with suicidality. This protocol empowered the young person by suggesting pathways to care that were based on their current needs. The protocol also enabled an appropriate and timely response from service providers for young people reporting high suicidality that was associated with additional comorbid issues, including psychosis-like symptoms, and a history of suicide plans and attempts. %M 28701290 %R 10.2196/jmir.7897 %U http://www.jmir.org/2017/7/e247/ %U https://doi.org/10.2196/jmir.7897 %U http://www.ncbi.nlm.nih.gov/pubmed/28701290 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 7 %P e243 %T Assessing Suicide Risk and Emotional Distress in Chinese Social Media: A Text Mining and Machine Learning Study %A Cheng,Qijin %A Li,Tim MH %A Kwok,Chi-Leung %A Zhu,Tingshao %A Yip,Paul SF %+ HKJC Center for Suicide Research and Prevention, The University of Hong Kong, 2/F, The Hong Kong Jockey Club Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong, Hong Kong,, China (Hong Kong), 852 2831 5232, chengqj@connect.hku.hk %K suicide %K psychological stress %K social media %K Chinese %K natural language %K machine learning %D 2017 %7 10.07.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Early identification and intervention are imperative for suicide prevention. However, at-risk people often neither seek help nor take professional assessment. A tool to automatically assess their risk levels in natural settings can increase the opportunity for early intervention. Objective: The aim of this study was to explore whether computerized language analysis methods can be utilized to assess one’s suicide risk and emotional distress in Chinese social media. Methods: A Web-based survey of Chinese social media (ie, Weibo) users was conducted to measure their suicide risk factors including suicide probability, Weibo suicide communication (WSC), depression, anxiety, and stress levels. Participants’ Weibo posts published in the public domain were also downloaded with their consent. The Weibo posts were parsed and fitted into Simplified Chinese-Linguistic Inquiry and Word Count (SC-LIWC) categories. The associations between SC-LIWC features and the 5 suicide risk factors were examined by logistic regression. Furthermore, the support vector machine (SVM) model was applied based on the language features to automatically classify whether a Weibo user exhibited any of the 5 risk factors. Results: A total of 974 Weibo users participated in the survey. Those with high suicide probability were marked by a higher usage of pronoun (odds ratio, OR=1.18, P=.001), prepend words (OR=1.49, P=.02), multifunction words (OR=1.12, P=.04), a lower usage of verb (OR=0.78, P<.001), and a greater total word count (OR=1.007, P=.008). Second-person plural was positively associated with severe depression (OR=8.36, P=.01) and stress (OR=11, P=.005), whereas work-related words were negatively associated with WSC (OR=0.71, P=.008), severe depression (OR=0.56, P=.005), and anxiety (OR=0.77, P=.02). Inconsistently, third-person plural was found to be negatively associated with WSC (OR=0.02, P=.047) but positively with severe stress (OR=41.3, P=.04). Achievement-related words were positively associated with depression (OR=1.68, P=.003), whereas health- (OR=2.36, P=.004) and death-related (OR=2.60, P=.01) words positively associated with stress. The machine classifiers did not achieve satisfying performance in the full sample set but could classify high suicide probability (area under the curve, AUC=0.61, P=.04) and severe anxiety (AUC=0.75, P<.001) among those who have exhibited WSC. Conclusions: SC-LIWC is useful to examine language markers of suicide risk and emotional distress in Chinese social media and can identify characteristics different from previous findings in the English literature. Some findings are leading to new hypotheses for future verification. Machine classifiers based on SC-LIWC features are promising but still require further optimization for application in real life. %M 28694239 %R 10.2196/jmir.7276 %U http://www.jmir.org/2017/7/e243/ %U https://doi.org/10.2196/jmir.7276 %U http://www.ncbi.nlm.nih.gov/pubmed/28694239 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 6 %P e228 %T Researching Mental Health Disorders in the Era of Social Media: Systematic Review %A Wongkoblap,Akkapon %A Vadillo,Miguel A %A Curcin,Vasa %+ Department of Informatics, King's College London, Strand, London, WC2R 2LS, United Kingdom, 44 20 7848 2588, akkapon.wongkoblap@kcl.ac.uk %K mental health %K mental disorders %K social networking %K artificial intelligence %K machine learning %K public health informatics %K depression %K anxiety %K infodemiology %D 2017 %7 29.06.2017 %9 Review %J J Med Internet Res %G English %X Background: Mental illness is quickly becoming one of the most prevalent public health problems worldwide. Social network platforms, where users can express their emotions, feelings, and thoughts, are a valuable source of data for researching mental health, and techniques based on machine learning are increasingly used for this purpose. Objective: The objective of this review was to explore the scope and limits of cutting-edge techniques that researchers are using for predictive analytics in mental health and to review associated issues, such as ethical concerns, in this area of research. Methods: We performed a systematic literature review in March 2017, using keywords to search articles on data mining of social network data in the context of common mental health disorders, published between 2010 and March 8, 2017 in medical and computer science journals. Results: The initial search returned a total of 5386 articles. Following a careful analysis of the titles, abstracts, and main texts, we selected 48 articles for review. We coded the articles according to key characteristics, techniques used for data collection, data preprocessing, feature extraction, feature selection, model construction, and model verification. The most common analytical method was text analysis, with several studies using different flavors of image analysis and social interaction graph analysis. Conclusions: Despite an increasing number of studies investigating mental health issues using social network data, some common problems persist. Assembling large, high-quality datasets of social media users with mental disorder is problematic, not only due to biases associated with the collection methods, but also with regard to managing consent and selecting appropriate analytics techniques. %M 28663166 %R 10.2196/jmir.7215 %U http://www.jmir.org/2017/6/e228/ %U https://doi.org/10.2196/jmir.7215 %U http://www.ncbi.nlm.nih.gov/pubmed/28663166 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 2 %P e23 %T Use of New Technologies in the Prevention of Suicide in Europe: An Exploratory Study %A Muñoz-Sánchez,Juan-Luis %A Delgado,Carmen %A Sánchez-Prada,Andrés %A Pérez-López,Mercedes %A Franco-Martín,Manuel A %+ Complejo Asistencial de Zamora, Department of Psychiatry, Av Hernán Cortés, 44, Zamora, 49021, Spain, 34 980548572, jlmusa@icloud.com %K suicide %K suicide attempt %K self-harm %K prevention %K new technologies %K Europe %D 2017 %7 27.06.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: New technologies are an integral component of today’s society and can complement existing suicide prevention programs. Here, we analyzed the use of new technologies in the prevention of suicide in 8 different European countries. Objective: The aim of this paper was to assess the opinions of professionals in incorporating such resources into the design of a suicide prevention program for the region of Zamora in Spain. This investigation, encompassed within the European project entitled European Regions Enforcing Actions against Suicide (EUREGENAS), includes 11 regions from 8 different countries and attempts to advance the field of suicide prevention in Europe. Methods: Using a specifically designed questionnaire, we assessed the opinions of 3 different groups of stakeholders regarding the use, frequency of use, facilitators, content, and format of new technologies for the prevention of suicide. The stakeholders were comprised of policy and public management professionals, professionals working in the area of mental health, and professionals related to the social area and non-governmental organizations (NGOs). A total of 416 participants were recruited in 11 regions from 8 different European countries. Results: The utility of the new technologies was valued positively in all 8 countries, despite these resources being seldom used in those countries. In all the countries, the factors that contributed most to facilitating the use of new technologies were accessibility and free of charge. Regarding the format of new technologies, the most widely preferred formats for use as a tool for the prevention of suicide were websites and email. The availability of information about signs of alarm and risk factors was the most relevant content for the prevention of suicide through the use of new technologies. The presence of a reference mental health professional (MHP) was also considered to be a key aspect. The countries differed in the evaluations given to the different formats suggesting that the cultural characteristics of the country should be taken into account. Conclusions: New technologies are much appreciated resources; however they are not often underused in the field of suicide prevention. The results of this exploratory study show that new technologies are indeed useful resources and should be incorporated into suicide prevention programs. %M 28655705 %R 10.2196/mental.7716 %U http://mental.jmir.org/2017/2/e23/ %U https://doi.org/10.2196/mental.7716 %U http://www.ncbi.nlm.nih.gov/pubmed/28655705 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 2 %P e22 %T Health App Use Among Individuals With Symptoms of Depression and Anxiety: A Survey Study With Thematic Coding %A Rubanovich,Caryn Kseniya %A Mohr,David C %A Schueller,Stephen M %+ Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University, 750 N. Lake Shore Drive, CBITs, 10th Floor, Chicago, IL,, United States, 1 312 503 1232, schueller@northwestern.edu %K mHealth %K eHealth %K mobile health %K depression %K anxiety %D 2017 %7 23.06.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Researchers have largely turned to commercial app stores, randomized trials, and systematic reviews to make sense of the mHealth landscape. Few studies have approached understanding by collecting information from target end users. The end user perspective is critical as end user interest in and use of mHealth technologies will ultimately drive the efficacy of these tools. Objective: The purpose of this study was to obtain information from end users of mHealth technologies to better understand the physical and mental health apps people use and for what purposes. Methods: People with depressive or anxious symptoms (N=176) seeking entry into a trial of mental health and well-being apps for Android devices completed online questionnaires assessing depression and anxiety (Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7), past and current mental health treatment-seeking behavior, overall mobile device use, and use of mobile health apps. Participants reported the physical health and mental health apps on their devices and their reasons for using them. Data were extracted from the participant self-reports and apps and app purposes were coded in order to categorize them. Results: Participants were largely white, middle-aged females from the Midwest region of the United States recruited via a health care organization and Web-based advertising (135 female, 41 male, mean age 38.64 years, age range 19-75 years.) Over three-quarters (137/176, 77.8%) of participants indicated having a health app on their device. The top 3 kinds of apps were exercise, fitness, and pedometers or heart rate monitoring apps (93/176, 52.8%); diet, food, or calorie counting apps (65/177, 36.9%); and mental health/wellness apps (46/177, 26.1%). The mean number of mobile physical and mental health apps on a participant’s phone was 2.15 (SD 3.195). Of 176 participants, 107 (60.8%) specifically reported the top 5 health apps that they used and their purposes. Across the 107 participants, a total of 285 apps were reported, with 139 being unique apps. The majority of these apps were free (129/139, 92.8%). Almost two-thirds of participants (67/107, 62.6%) reported using health apps at least on a daily basis. Conclusions: Among those seeking support for their well-being via physical and mental health apps, people are using a variety of health apps. These people use health apps on a daily basis, especially free apps. The most common reason for using a health app is to track some health-related data; for mental health apps specifically, training or habit building was the most popular reason. Understanding the end user perspective is important because it allows us to build on the foundation of previously established mHealth research and may help guide future work in mHealth. Trial Registration: Clinicaltrials.gov NCT02176226; https://clinicaltrials.gov/ct2/show/NCT02176226 (Archived by WebCite at http://www.webcitation.org/6rGc1MGyM) %M 28645891 %R 10.2196/mental.7603 %U http://mental.jmir.org/2017/2/e22/ %U https://doi.org/10.2196/mental.7603 %U http://www.ncbi.nlm.nih.gov/pubmed/28645891 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 6 %P e114 %T Phone-Based Interventions in Adolescent Psychiatry: A Perspective and Proof of Concept Pilot Study With a Focus on Depression and Autism %A Chen,Robert Yuzen %A Feltes,Jordan Robert %A Tzeng,William Shun %A Lu,Zoe Yunzhu %A Pan,Michael %A Zhao,Nan %A Talkin,Rebecca %A Javaherian,Kavon %A Glowinski,Anne %A Ross,Will %+ Washington University School of Medicine, Farrell Learning and Teaching Center, 660 S Euclid Avenue, St. Louis, MO, 63110, United States, 1 425 753 4101, robert.chen@wustl.edu %K telemedicine %K depression %K autistic disorder %K mobile applications %K text messaging %K child %K mental health %D 2017 %7 16.06.2017 %9 Viewpoint %J JMIR Res Protoc %G English %X Background: Telemedicine has emerged as an innovative platform to diagnose and treat psychiatric disorders in a cost-effective fashion. Previous studies have laid the functional framework for monitoring and treating child psychiatric disorders electronically using videoconferencing, mobile phones (smartphones), and Web-based apps. However, phone call and text message (short message service, SMS) interventions in adolescent psychiatry are less studied than other electronic platforms. Further investigations on the development of these interventions are needed. Objective: The aim of this paper was to explore the utility of text message interventions in adolescent psychiatry and describe a user feedback-driven iterative design process for text message systems. Methods: We developed automated text message interventions using a platform for both depression (EpxDepression) and autism spectrum disorder (ASD; EpxAutism) and conducted 2 pilot studies for each intervention (N=3 and N=6, respectively). The interventions were prescribed by and accessible to the patients’ healthcare providers. EpxDepression and EpxAutism utilized an automated system to triage patients into 1 of 3 risk categories based on their text responses and alerted providers directly via phone and an online interface when patients met provider-specified risk criteria. Rapid text-based feedback from participants and interviews with providers allowed for quick iterative cycles to improve interventions. Results: Patients using EpxDepression had high weekly response rates (100% over 2 to 4 months), but exhibited message fatigue with daily prompts with mean (SD) overall response rates of 66.3% (21.6%) and 64.7% (8.2%) for mood and sleep questionnaires, respectively. In contrast, parents using EpxAutism displayed both high weekly and overall response rates (100% and 85%, respectively, over 1 to 4 months) that did not decay significantly with time. Monthly participant feedback surveys for EpxDepression (7 surveys) and EpxAutism (18 surveys) preliminarily indicated that for both interventions, daily messages constituted the “perfect amount” of contact and that EpxAutism, but not EpxDepression, improved patient communication with providers. Notably, EpxDepression detected thoughts of self-harm in patients before their case managers or caregivers were aware of such ideation. Conclusions: Text-message interventions in adolescent psychiatry can provide a cost-effective and engaging method to track symptoms, behavior, and ideation over time. Following the collection of pilot data and feedback from providers and patients, larger studies are already underway to validate the clinical utility of EpxDepression and EpxAutism. Trial Registration: Clinicaltrials.gov NCT03002311; https://clinicaltrials.gov/ct2/show/NCT03002311 (Archived by WebCite at http://www.webcitation.org/6qQtlCIS0) %M 28623183 %R 10.2196/resprot.7245 %U http://www.researchprotocols.org/2017/6/e114/ %U https://doi.org/10.2196/resprot.7245 %U http://www.ncbi.nlm.nih.gov/pubmed/28623183 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 6 %P e213 %T Effectiveness of a Web-Based Intervention in Reducing Depression and Sickness Absence: Randomized Controlled Trial %A Beiwinkel,Till %A Eißing,Tabea %A Telle,Nils-Torge %A Siegmund-Schultze,Elisabeth %A Rössler,Wulf %+ Innovation Incubator, Competence Tandem Integrated Care, Leuphana University of Lüneburg, Scharnhorststr 1, Lüneburg, 21335, Germany, 49 4131677 ext 7826, till.beiwinkel@leuphana.de %K Internet %K depression %K absenteeism %K cognitive therapy %K randomized controlled trial %D 2017 %7 15.06.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is highly prevalent in the working population and is associated with significant loss of workdays; however, access to evidence-based treatment is limited. Objective: This study evaluated the effectiveness of a Web-based intervention in reducing mild to moderate depression and sickness absence. Methods: In an open-label randomized controlled trial, participants were recruited from a large-scale statutory health insurance and were assigned to two groups. The intervention group had access to a 12 week Web-based program consisting of structured interactive sessions and therapist support upon request. The wait-list control group had access to unguided Web-based psycho-education. Depressive symptoms were self-assessed at baseline, post-treatment, and follow-up (12 weeks after treatment) using the Patient Health Questionnaire (PHQ-9) and Beck Depression Inventory (BDI-II) as primary outcome measures. Data on sickness absence was retrieved from health insurance records. Intention-to-treat (ITT) analysis and per-protocol (PP) analysis were performed. Results: Of the 180 participants who were randomized, 88 completed the post-assessment (retention rate: 48.8%, 88/180). ITT analysis showed a significant between-group difference in depressive symptoms during post-treatment in favor of the intervention group, corresponding to a moderate effect size (PHQ-9: d=0.55, 95% CI 0.25-0.85, P<.001, and BDI-II: d=0.41, CI 0.11-0.70, P=.004). PP analysis partially supported this result, but showed a non-significant effect on one primary outcome (PHQ-9: d=0.61, 95% CI 0.15-1.07, P=.04, and BDI-II: d=0.25 95% CI −0.18 to 0.65, P=.37). Analysis of clinical significance using reliable change index revealed that significantly more participants who used the Web-based intervention (63%, 63/100) responded to the treatment versus the control group (33%, 27/80; P<.001). The number needed to treat (NNT) was 4.08. Within both groups, there was a reduction in work absence frequency (IG: −67.23%, P<.001, CG: −82.61%, P<.001), but no statistical difference in sickness absence between groups was found (P=.07). Conclusions: The Web-based intervention was effective in reducing depressive symptoms among adults with sickness absence. As this trial achieved a lower power than calculated, its results should be replicated in a larger sample. Further validation of health insurance records as an outcome measure for eHealth trials is needed. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 02446836; http://www.isrctn.com/ISRCTN02446836 (Archived by WebCite at http://www.webcitation.org/6jx4SObnw) %M 28619701 %R 10.2196/jmir.6546 %U http://www.jmir.org/2017/6/e213/ %U https://doi.org/10.2196/jmir.6546 %U http://www.ncbi.nlm.nih.gov/pubmed/28619701 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 6 %P e206 %T Defining and Predicting Patterns of Early Response in a Web-Based Intervention for Depression %A Lutz,Wolfgang %A Arndt,Alice %A Rubel,Julian %A Berger,Thomas %A Schröder,Johanna %A Späth,Christina %A Meyer,Björn %A Greiner,Wolfgang %A Gräfe,Viola %A Hautzinger,Martin %A Fuhr,Kristina %A Rose,Matthias %A Nolte,Sandra %A Löwe,Bernd %A Hohagen,Fritz %A Klein,Jan Philipp %A Moritz,Steffen %+ Department of Psychology, University of Trier, Am Wissenschaftspark 25-27, Trier,, Germany, 49 651 201 2883, wolfgang.lutz@uni-trier.de %K patterns of early change %K depression %K web interventions %K psychotherapy research %D 2017 %7 09.06.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based interventions for individuals with depressive disorders have been a recent focus of research and may be an effective adjunct to face-to-face psychotherapy or pharmacological treatment. Objective: The aim of our study was to examine the early change patterns in Web-based interventions to identify differential effects. Methods: We applied piecewise growth mixture modeling (PGMM) to identify different latent classes of early change in individuals with mild-to-moderate depression (n=409) who underwent a CBT-based web intervention for depression. Results: Overall, three latent classes were identified (N=409): Two early response classes (n=158, n=185) and one early deterioration class (n=66). Latent classes differed in terms of outcome (P<.001) and adherence (P=.03) in regard to the number of modules (number of modules with a duration of at least 10 minutes) and the number of assessments (P<.001), but not in regard to the overall amount of time using the system. Class membership significantly improved outcome prediction by 24.8% over patient intake characteristics (P<.001) and significantly added to the prediction of adherence (P=.04). Conclusions: These findings suggest that in Web-based interventions outcome and adherence can be predicted by patterns of early change, which can inform treatment decisions and potentially help optimize the allocation of scarce clinical resources. %M 28600278 %R 10.2196/jmir.7367 %U http://www.jmir.org/2017/6/e206/ %U https://doi.org/10.2196/jmir.7367 %U http://www.ncbi.nlm.nih.gov/pubmed/28600278 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 2 %P e19 %T Delivering Cognitive Behavior Therapy to Young Adults With Symptoms of Depression and Anxiety Using a Fully Automated Conversational Agent (Woebot): A Randomized Controlled Trial %A Fitzpatrick,Kathleen Kara %A Darcy,Alison %A Vierhile,Molly %+ Woebot Labs Inc., 55 Fair Avenue, San Francisco, CA, 94110, United States, alison@woebot.io %K conversational agents %K mobile mental health %K mental health %K chatbots %K depression %K anxiety %K college students %K digital health %D 2017 %7 06.06.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Web-based cognitive-behavioral therapeutic (CBT) apps have demonstrated efficacy but are characterized by poor adherence. Conversational agents may offer a convenient, engaging way of getting support at any time. Objective: The objective of the study was to determine the feasibility, acceptability, and preliminary efficacy of a fully automated conversational agent to deliver a self-help program for college students who self-identify as having symptoms of anxiety and depression. Methods: In an unblinded trial, 70 individuals age 18-28 years were recruited online from a university community social media site and were randomized to receive either 2 weeks (up to 20 sessions) of self-help content derived from CBT principles in a conversational format with a text-based conversational agent (Woebot) (n=34) or were directed to the National Institute of Mental Health ebook, “Depression in College Students,” as an information-only control group (n=36). All participants completed Web-based versions of the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder scale (GAD-7), and the Positive and Negative Affect Scale at baseline and 2-3 weeks later (T2). Results: Participants were on average 22.2 years old (SD 2.33), 67% female (47/70), mostly non-Hispanic (93%, 54/58), and Caucasian (79%, 46/58). Participants in the Woebot group engaged with the conversational agent an average of 12.14 (SD 2.23) times over the study period. No significant differences existed between the groups at baseline, and 83% (58/70) of participants provided data at T2 (17% attrition). Intent-to-treat univariate analysis of covariance revealed a significant group difference on depression such that those in the Woebot group significantly reduced their symptoms of depression over the study period as measured by the PHQ-9 (F=6.47; P=.01) while those in the information control group did not. In an analysis of completers, participants in both groups significantly reduced anxiety as measured by the GAD-7 (F1,54= 9.24; P=.004). Participants’ comments suggest that process factors were more influential on their acceptability of the program than content factors mirroring traditional therapy. Conclusions: Conversational agents appear to be a feasible, engaging, and effective way to deliver CBT. %M 28588005 %R 10.2196/mental.7785 %U http://mental.jmir.org/2017/2/e19/ %U https://doi.org/10.2196/mental.7785 %U http://www.ncbi.nlm.nih.gov/pubmed/28588005 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e191 %T Toward the Design of Evidence-Based Mental Health Information Systems for People With Depression: A Systematic Literature Review and Meta-Analysis %A Wahle,Fabian %A Bollhalder,Lea %A Kowatsch,Tobias %A Fleisch,Elgar %+ Center for Digital Health Interventions, Institute of Technology Management, University of St Gallen, Dufourstrasse 40a, Büro 1-236, St Gallen, 9000, Switzerland, 41 712247244, tobias.kowatsch@unisg.ch %K literature review %K mental health %K design feature %K depression %K information systems %D 2017 %7 31.05.2017 %9 Review %J J Med Internet Res %G English %X Background: Existing research postulates a variety of components that show an impact on utilization of technology-mediated mental health information systems (MHIS) and treatment outcome. Although researchers assessed the effect of isolated design elements on the results of Web-based interventions and the associations between symptom reduction and use of components across computer and mobile phone platforms, there remains uncertainty with regard to which components of technology-mediated interventions for mental health exert the greatest therapeutic gain. Until now, no studies have presented results on the therapeutic benefit associated with specific service components of technology-mediated MHIS for depression. Objective: This systematic review aims at identifying components of technology-mediated MHIS for patients with depression. Consequently, all randomized controlled trials comparing technology-mediated treatments for depression to either waiting-list control, treatment as usual, or any other form of treatment for depression were reviewed. Updating prior reviews, this study aims to (1) assess the effectiveness of technology-supported interventions for the treatment of depression and (2) add to the debate on what components in technology-mediated MHIS for the treatment of depression should be standard of care. Methods: Systematic searches in MEDLINE, PsycINFO, and the Cochrane Library were conducted. Effect sizes for each comparison between a technology-enabled intervention and a control condition were computed using the standard mean difference (SMD). Chi-square tests were used to test for heterogeneity. Using subgroup analysis, potential sources of heterogeneity were analyzed. Publication bias was examined using visual inspection of funnel plots and Begg’s test. Qualitative data analysis was also used. In an explorative approach, a list of relevant components was extracted from the body of literature by consensus between two researchers. Results: Of 6387 studies initially identified, 45 met all inclusion criteria. Programs analyzed showed a significant trend toward reduced depressive symptoms (SMD –0.58, 95% CI –0.71 to –0.45, P<.001). Heterogeneity was large (I2≥76). A total of 15 components were identified. Conclusions: Technology-mediated MHIS for the treatment of depression has a consistent positive overall effect compared to controls. A total of 15 components have been identified. Further studies are needed to quantify the impact of individual components on treatment effects and to identify further components that are relevant for the design of future technology-mediated interventions for the treatment of depression and other mental disorders. %M 28566267 %R 10.2196/jmir.7381 %U http://www.jmir.org/2017/5/e191/ %U https://doi.org/10.2196/jmir.7381 %U http://www.ncbi.nlm.nih.gov/pubmed/28566267 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 3 %N 2 %P e29 %T Associations Between Maternal Depressive Symptoms and Nonresponsive Feeding Styles and Practices in Mothers of Young Children: A Systematic Review %A Lindsay,Ana Cristina %A Mesa,Tatiana %A Greaney,Mary L %A Wallington,Sherrie F %A Wright,Julie A %+ Exercise and Health Sciences, College of Nursing and Health Sciences, University of Massachusetts Boston, 100 Morrissey Boulevard, Boston, MA, 02125, United States, 1 617287579, Ana.Lindsay@umb.edu %K maternal depression %K child %K feeding behavior %K practices %K feeding styles %K obesity %D 2017 %7 26.05.2017 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Childhood obesity is a significant global public health problem due to increasing rates worldwide. Growing evidence suggests that nonresponsive parental feeding styles and practices are important influences on children’s eating behaviors and weight status, especially during early childhood. Therefore, understanding parental factors that may influence nonresponsive parental feeding styles and practices is significant for the development of interventions to prevent childhood obesity. Objective: The objectives of this systematic review were to (1) identify and review existing research examining the associations between maternal depressive symptoms and use of nonresponsive feeding styles and practices among mothers of young children (2-8 years of age), (2) highlight the limitations of reviewed studies, and (3) generate suggestions for future research. Methods: Using the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) guidelines, six electronic academic databases were searched for peer-reviewed, full-text papers published in English between January 2000 and June 2016. Only studies with mothers 18+ years old of normally developing children between 2 and 8 years of age were included. Of the 297 citations identified, 35 full-text papers were retrieved and 8 were reviewed. Results: The reviewed studies provided mixed evidence for associations between maternal depressive symptoms and nonresponsive feeding styles and practices. Two out of three studies reported positive associations with nonresponsive feeding styles, in that mothers with elevated depressive symptoms were more likely than mothers without those symptoms to exhibit uninvolved and permissive or indulgent feeding styles. Furthermore, results of reviewed studies provide good evidence for association between maternal depressive symptoms and instrumental feeding (3 of 3 reviewed studies) and nonresponsive family mealtime practices (3/3), but mixed evidence for pressuring children to eat (3/6) and emotional feeding (1/3). In addition, evidence for the association between maternal depressive symptoms and restricting child food intake was mixed: one study (1/6) found a positive association; two studies (2/6) found a negative association; whereas one study (1/6) found no association. Conclusions: This review indicates that the results of studies examining the associations between maternal depressive symptoms and parental feeding styles and practices are mixed. Limitations of studies included in this review should be noted: (1) the use of a diverse set of self-report questionnaires to assess parental feeding practices is problematic due to potential misclassification and makes it difficult to compare these outcomes across studies, thus caution must be taken in drawing conclusions; and (2) the majority of included studies (6/8) were cross-sectional. There is a need for additional longitudinal studies to disentangle the influence of depression on parental feeding styles and practices. Nevertheless, given that depressive symptoms and feeding styles and practices are potentially modifiable, it is important to understand their relationship to inform obesity prevention interventions and programs. %M 28550007 %R 10.2196/publichealth.6492 %U http://publichealth.jmir.org/2017/2/e29/ %U https://doi.org/10.2196/publichealth.6492 %U http://www.ncbi.nlm.nih.gov/pubmed/28550007 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 2 %P e15 %T Clinical Insight Into Latent Variables of Psychiatric Questionnaires for Mood Symptom Self-Assessment %A Tsanas,Athanasios %A Saunders,Kate %A Bilderbeck,Amy %A Palmius,Niclas %A Goodwin,Guy %A De Vos,Maarten %+ Usher Institute of Population Health Sciences and Informatics, Medical School, University of Edinburgh, Nine Edinburgh Bioquarter, 9 Little France road, Edinburgh, EH16 4UX, United Kingdom, 44 131 651 7884, Athanasios.Tsanas@ed.ac.uk %K bipolar disorder %K borderline personality disorder %K depression %K mania %K latent variable structure %K mood monitoring %K patient reported outcome measures %K mhealth %K mobile app %D 2017 %7 25.05.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: We recently described a new questionnaire to monitor mood called mood zoom (MZ). MZ comprises 6 items assessing mood symptoms on a 7-point Likert scale; we had previously used standard principal component analysis (PCA) to tentatively understand its properties, but the presence of multiple nonzero loadings obstructed the interpretation of its latent variables. Objective: The aim of this study was to rigorously investigate the internal properties and latent variables of MZ using an algorithmic approach which may lead to more interpretable results than PCA. Additionally, we explored three other widely used psychiatric questionnaires to investigate latent variable structure similarities with MZ: (1) Altman self-rating mania scale (ASRM), assessing mania; (2) quick inventory of depressive symptomatology (QIDS) self-report, assessing depression; and (3) generalized anxiety disorder (7-item) (GAD-7), assessing anxiety. Methods: We elicited responses from 131 participants: 48 bipolar disorder (BD), 32 borderline personality disorder (BPD), and 51 healthy controls (HC), collected longitudinally (median [interquartile range, IQR]: 363 [276] days). Participants were requested to complete ASRM, QIDS, and GAD-7 weekly (all 3 questionnaires were completed on the Web) and MZ daily (using a custom-based smartphone app). We applied sparse PCA (SPCA) to determine the latent variables for the four questionnaires, where a small subset of the original items contributes toward each latent variable. Results: We found that MZ had great consistency across the three cohorts studied. Three main principal components were derived using SPCA, which can be tentatively interpreted as (1) anxiety and sadness, (2) positive affect, and (3) irritability. The MZ principal component comprising anxiety and sadness explains most of the variance in BD and BPD, whereas the positive affect of MZ explains most of the variance in HC. The latent variables in ASRM were identical for the patient groups but different for HC; nevertheless, the latent variables shared common items across both the patient group and HC. On the contrary, QIDS had overall very different principal components across groups; sleep was a key element in HC and BD but was absent in BPD. In GAD-7, nervousness was the principal component explaining most of the variance in BD and HC. Conclusions: This study has important implications for understanding self-reported mood. MZ has a consistent, intuitively interpretable latent variable structure and hence may be a good instrument for generic mood assessment. Irritability appears to be the key distinguishing latent variable between BD and BPD and might be useful for differential diagnosis. Anxiety and sadness are closely interlinked, a finding that might inform treatment effects to jointly address these covarying symptoms. Anxiety and nervousness appear to be amongst the cardinal latent variable symptoms in BD and merit close attention in clinical practice. %M 28546141 %R 10.2196/mental.6917 %U http://mental.jmir.org/2017/2/e15/ %U https://doi.org/10.2196/mental.6917 %U http://www.ncbi.nlm.nih.gov/pubmed/28546141 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 5 %P e98 %T eMindLog: Self-Measurement of Anxiety and Depression Using Mobile Technology %A Penders,Thomas M %A Wuensch,Karl L %A Ninan,Philip T %+ Brody School of Medicine, Department of Psychiatry and Behavioral Medicine, East Carolina University, 621 W Main St, Washington, NC, 27889-4835, United States, 1 678 428 1655, ninanp@ecu.edu %K mobile %K anxiety %K depression %K internet %K measurement %D 2017 %7 24.05.2017 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Quantifying anxiety and depressive experiences permits individuals to calibrate where they are and monitor intervention-associated changes. eMindLog is a novel self-report measure for anxiety and depression that is grounded in psychology with an organizing structure based on neuroscience. Objective: Our aim was to explore the psychometric properties of eMindLog in a nonclinical sample of subjects. Methods: In a cross-sectional study of eMindLog, a convenience sample of 198 adults provided informed consent and completed eMindLog and the Hospital Anxiety and Depression Scale (HADS) as a reference. Brain systems (eg, negative and positive valence systems, cognitive systems) and their functional states that drive behavior are measured daily as emotions, thoughts, and behaviors. Associated symptoms, quality of life, and functioning are assessed weekly. eMindLog offers ease of use and expediency, using mobile technology across multiple platforms, with dashboard reporting of scores. It enhances precision by providing distinct, nonoverlapping description of terms, and accuracy through guidance for scoring severity. Results: eMindLog daily total score had a Cronbach alpha of .94. Pearson correlation coefficient for eMindLog indexes for anxiety and sadness/anhedonia were r=.66 (P<.001) and r=.62 (P<.001) contrasted with the HADS anxiety and depression subscales respectively. Of 195 subjects, 23 (11.8%) had cross-sectional symptoms above the threshold for Generalized Anxiety Disorder and 29 (29/195, 14.9%) for Major Depressive Disorder. Factor analysis supported the theoretically derived index derivatives for anxiety, anger, sadness, and anhedonia. Conclusions: eMindLog is a novel self-measurement tool to measure anxiety and depression, demonstrating excellent reliability and strong validity in a nonclinical population. Further studies in clinical populations are necessary for fuller validation of its psychometric properties. Self-measurement of anxiety and depressive symptoms with precision and accuracy has several potential benefits, including case detection, tracking change over time, efficacy assessment of interventions, and exploration of potential biomarkers. %M 28539304 %R 10.2196/resprot.7447 %U http://www.researchprotocols.org/2017/5/e98/ %U https://doi.org/10.2196/resprot.7447 %U http://www.ncbi.nlm.nih.gov/pubmed/28539304 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e157 %T Web-Based Cognitive Behavior Therapy for Depression in People With Diabetes Mellitus: A Randomized Controlled Trial %A Newby,Jill %A Robins,Lisa %A Wilhelm,Kay %A Smith,Jessica %A Fletcher,Therese %A Gillis,Inika %A Ma,Trevor %A Finch,Adam %A Campbell,Lesley %A Andrews,Gavin %+ School of Psychology, The University of New South Wales, 1302 Mathews Building, Randwick, 2052, Australia, 61 293853425, j.newby@unsw.edu.au %K depression %K diabetes mellitus %K cognitive behavior therapy %K diabetes-related distress %K computer-assisted therapy %D 2017 %7 15.05.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is twice as common in diabetes mellitus (DM) as the general population and is associated with adverse health outcomes, but access to evidence-based therapies such as cognitive behavioral therapy (CBT) is limited in routine diabetes care. Past research has shown that generic Internet-based cognitive behavioral therapy (iCBT) is an effective treatment for depression in the general population, but it has never been evaluated in people with comorbid depression and DM. Objective: The aim of our study was to examine the efficacy of a generic 6-lesson iCBT delivered over 10 weeks in people with major depressive disorder (MDD) and DM. Methods: Participants with comorbid MDD and DM (type 1 or 2) were recruited online and randomized to an iCBT program with therapist support provided by phone and email (n=42) or a treatment as usual (TAU, n=49) control group. Outcomes were assessed through Web-based self-report questionnaires and the trial was Web-based with no face-to-face components. Primary outcomes were self-reported depression (patient health questionnaire-9, PHQ-9), diabetes-related distress (problem areas in diabetes, PAID), and self-reported glycemic control (hemoglobin A1c, HbA1c). Secondary outcomes were general distress (Kessler 10-item psychological distress scale, K-10) and disability (short form 12-item, SF-12), generalized anxiety (generalized anxiety disorder 7-item, GAD-7), and somatization (PHQ-15). The iCBT group was assessed at 3 months. Results: A total of 27 participants (66%; 27/41) completed the iCBT program. Analyses indicated between-group superiority of iCBT over TAU at posttreatment on PHQ-9 (g=0.78), PAID (g=0.80), K-10 (g=1.06), GAD-7 (g=0.72), and SF-12 mental well-being scores (g=0.66), but no significant differences in self-reported HbA1c levels (g=0.14), SF-12 physical well-being, or PHQ-15 scores (g=0.03-0.21). Gains were maintained at 3-month follow-up in the iCBT group, and the 87% (27/31) of iCBT participants who were interviewed no longer met criteria for MDD. Clinically significant change following iCBT on PHQ-9 scores was 51% (21/41) versus 18% (9/49) in TAU. Conclusions: iCBT for depression is an efficacious, accessible treatment option for people with diabetes. Future studies should explore whether tailoring of iCBT programs improves acceptability and adherence, and evaluate the long-term outcomes following iCBT. Trial Registration: Australian and New Zealand Clinical Trials Registry (ACTRN): 12613001198718; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365208&isReview=true (Archived by WebCite at http://www.webcitation.org/6qCR8Fi9V) %M 28506956 %R 10.2196/jmir.7274 %U http://www.jmir.org/2017/5/e157/ %U https://doi.org/10.2196/jmir.7274 %U http://www.ncbi.nlm.nih.gov/pubmed/28506956 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e149 %T Computer Administered Safety Planning for Individuals at Risk for Suicide: Development and Usability Testing %A Boudreaux,Edwin D %A Brown,Gregory K %A Stanley,Barbara %A Sadasivam,Rajani S %A Camargo,Carlos A %A Miller,Ivan W %+ University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, United States, 1 508 334 3817, edwin.boudreaux@umassmed.edu %K technology %K safety %K health planning %K suicide %K computers %K telemedicine %D 2017 %7 15.05.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Safety planning is a brief intervention that has become an accepted practice in many clinical settings to help prevent suicide. Even though it is quick compared to other approaches, it frequently requires 20 min or more to complete, which can impede adoption. A self-administered, Web-based safety planning application could potentially reduce clinician time, help promote standardization and quality, and provide enhanced ability to share the created plan. Objective: The aim of this study was to design, build, and test the usability of a Web-based, self-administered safety planning application. Methods: We employed a user-centered software design strategy led by a multidisciplinary team. The application was tested for usability with a target sample of suicidal patients. Detailed observations, structured usability ratings, and Think Aloud procedures were used. Suicidal ideation intensity and perceived ability to cope were assessed pre-post engagement with the Web application. Results: A total of 30 participants were enrolled. Usability ratings were generally strong, and all patients successfully built a safety plan. However, the completeness of the safety plan varied. The mean number of steps completed was 5.5 (SD 0.9) out of 6, with 90% (27/30) of participants completing at least 5 steps and 67% (20/30) completing all 6 steps. Some safety planning steps were viewed as inapplicable to some individuals. Some confusion in instructions led to modifications to improve understandability of each step. Ratings of suicide intensity after completion of the application were significantly lower than preratings, pre: mean 5.11 (SD 2.9) versus post: mean 4.46 (SD 3.0), t27=2.49, P=.02. Ratings of ability to cope with suicidal thoughts after completion of the application were higher than preratings, with the difference approaching statistical significance, pre: mean 5.93 (SD 2.9), post: mean 6.64 (SD 2.4), t27=−2.03, P=.05. Conclusions: We have taken the first step toward identifying the components needed to maximize usability of a self-administered, Web-based safety planning application. Results support initial consideration of the application as an adjunct to clinical contact. This allows for the clinician or other personnel to provide clarification, when needed, to help the patient build the plan, and to help review and revise the draft. %M 28506957 %R 10.2196/jmir.6816 %U http://www.jmir.org/2017/5/e149/ %U https://doi.org/10.2196/jmir.6816 %U http://www.ncbi.nlm.nih.gov/pubmed/28506957 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e141 %T Efficacy of a Web-Based Guided Recommendation Service for a Curated List of Readily Available Mental Health and Well-Being Mobile Apps for Young People: Randomized Controlled Trial %A Bidargaddi,Niranjan %A Musiat,Peter %A Winsall,Megan %A Vogl,Gillian %A Blake,Victoria %A Quinn,Stephen %A Orlowski,Simone %A Antezana,Gaston %A Schrader,Geoffrey %+ Digital Psychiatry & Personal Health Informatics Group, School of Medicine, Flinders University, Flinders at Tonsley, 1284 South Road, Clovelly Park, 5042, Australia, 61 872218842, niranjan.bidargaddi@flinders.edu.au %K well-being %K mental health %K young people %K online intervention %K apps %K engagement %D 2017 %7 12.05.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental disorders are highly prevalent for the people who are aged between 16 and 25 years and can permanently disrupt the development of these individuals. Easily available mobile health (mHealth) apps for mobile phones have great potential for the prevention and early intervention of mental disorders in young adults, but interventions are required that can help individuals to both identify high-quality mobile apps and use them to change health and lifestyle behavior. Objectives: The study aimed to assess the efficacy of a Web-based self-guided app recommendation service (“The Toolbox”) in improving the well-being of young Australians aged between 16 and 25 years. The intervention was developed in collaboration with young adults and consists of a curated list of 46 readily available health and well-being apps, assessed and rated by professionals and young people. Participants are guided by an interactive quiz and subsequently receive recommendations for particular apps to download and use based on their personal goals. Methods: The study was a waitlist, parallel-arm, randomized controlled trial. Our primary outcome measure was change in well-being as measured by the Mental Health Continuum-Short Form (MHC-SF). We also employed ecological momentary assessments (EMAs) to track mood, energy, rest, and sleep. Participants were recruited from the general Australian population, via several Web-based and community strategies. The study was conducted through a Web-based platform consisting of a landing Web page and capabilities to administer study measures at different time points. Web-based measurements were self-assessed at baseline and 4 weeks, and EMAs were collected repeatedly at regular weekly intervals or ad hoc when participants interacted with the study platform. Primary outcomes were analyzed using linear mixed-models and intention-to-treat (ITT) analysis. Results: A total of 387 participants completed baseline scores and were randomized into the trial. Results demonstrated no significant effect of “The Toolbox” intervention on participant well-being at 4 weeks compared with the control group (P=.66). There were also no significant differences between the intervention and control groups at 4 weeks on any of the subscales of the MHC-SF (psychological: P=.95, social: P=.42, emotional: P=.95). Repeat engagement with the study platform resulted in a significant difference in mood, energy, rest, and sleep trajectories between intervention and control groups as measured by EMAs (P<.01). Conclusions: This was the first study to assess the effectiveness of a Web-based well-being intervention in a sample of young adults. The design of the intervention utilized expert rating of existing apps and end-user codesign approaches resulting in an app recommendation service. Our finding suggests that recommended readily available mental health and well-being apps may not lead to improvements in the well-being of a nonclinical sample of young people, but might halt a decline in mood, energy, rest, and sleep. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614000710628; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366145 (Archived by WebCite at http://www.webcitation.org/ 6pWDsnKme) %M 28500020 %R 10.2196/jmir.6775 %U http://www.jmir.org/2017/5/e141/ %U https://doi.org/10.2196/jmir.6775 %U http://www.ncbi.nlm.nih.gov/pubmed/28500020 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e151 %T Embodied Conversational Agents in Clinical Psychology: A Scoping Review %A Provoost,Simon %A Lau,Ho Ming %A Ruwaard,Jeroen %A Riper,Heleen %+ Department of Clinical, Neuro & Developmental Psychology, Section Clinical Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 1, Amsterdam, 1081 BT, Netherlands, 31 205985059, s.j.provoost@vu.nl %K eHealth %K review %K embodied conversational agent %K human computer interaction %K clinical psychology %K mental disorders %K intelligent agent %K health behavior %D 2017 %7 09.05.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Embodied conversational agents (ECAs) are computer-generated characters that simulate key properties of human face-to-face conversation, such as verbal and nonverbal behavior. In Internet-based eHealth interventions, ECAs may be used for the delivery of automated human support factors. Objective: We aim to provide an overview of the technological and clinical possibilities, as well as the evidence base for ECA applications in clinical psychology, to inform health professionals about the activity in this field of research. Methods: Given the large variety of applied methodologies, types of applications, and scientific disciplines involved in ECA research, we conducted a systematic scoping review. Scoping reviews aim to map key concepts and types of evidence underlying an area of research, and answer less-specific questions than traditional systematic reviews. Systematic searches for ECA applications in the treatment of mood, anxiety, psychotic, autism spectrum, and substance use disorders were conducted in databases in the fields of psychology and computer science, as well as in interdisciplinary databases. Studies were included if they conveyed primary research findings on an ECA application that targeted one of the disorders. We mapped each study’s background information, how the different disorders were addressed, how ECAs and users could interact with one another, methodological aspects, and the study’s aims and outcomes. Results: This study included N=54 publications (N=49 studies). More than half of the studies (n=26) focused on autism treatment, and ECAs were used most often for social skills training (n=23). Applications ranged from simple reinforcement of social behaviors through emotional expressions to sophisticated multimodal conversational systems. Most applications (n=43) were still in the development and piloting phase, that is, not yet ready for routine practice evaluation or application. Few studies conducted controlled research into clinical effects of ECAs, such as a reduction in symptom severity. Conclusions: ECAs for mental disorders are emerging. State-of-the-art techniques, involving, for example, communication through natural language or nonverbal behavior, are increasingly being considered and adopted for psychotherapeutic interventions in ECA research with promising results. However, evidence on their clinical application remains scarce. At present, their value to clinical practice lies mostly in the experimental determination of critical human support factors. In the context of using ECAs as an adjunct to existing interventions with the aim of supporting users, important questions remain with regard to the personalization of ECAs’ interaction with users, and the optimal timing and manner of providing support. To increase the evidence base with regard to Internet interventions, we propose an additional focus on low-tech ECA solutions that can be rapidly developed, tested, and applied in routine practice. %M 28487267 %R 10.2196/jmir.6553 %U http://www.jmir.org/2017/5/e151/ %U https://doi.org/10.2196/jmir.6553 %U http://www.ncbi.nlm.nih.gov/pubmed/28487267 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e148 %T Automated Text Messaging as an Adjunct to Cognitive Behavioral Therapy for Depression: A Clinical Trial %A Aguilera,Adrian %A Bruehlman-Senecal,Emma %A Demasi,Orianna %A Avila,Patricia %+ School of Social Welfare, University of California, Berkeley, 120 Haviland Hall, MC 7400, Berkeley, CA, 94720, United States, 1 5106428564, aguila@berkeley.edu %K depression %K text messaging %K cognitive behavioral therapy %K mhealth %K mental health %K Latinos %D 2017 %7 08.05.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive Behavioral Therapy (CBT) for depression is efficacious, but effectiveness is limited when implemented in low-income settings due to engagement difficulties including nonadherence with skill-building homework and early discontinuation of treatment. Automated messaging can be used in clinical settings to increase dosage of depression treatment and encourage sustained engagement with psychotherapy. Objectives: The aim of this study was to test whether a text messaging adjunct (mood monitoring text messages, treatment-related text messages, and a clinician dashboard to display patient data) increases engagement and improves clinical outcomes in a group CBT treatment for depression. Specifically, we aim to assess whether the text messaging adjunct led to an increase in group therapy sessions attended, an increase in duration of therapy attended, and reductions in Patient Health Questionnaire-9 item (PHQ-9) symptoms compared with the control condition of standard group CBT in a sample of low-income Spanish speaking Latino patients. Methods: Patients in an outpatient behavioral health clinic were assigned to standard group CBT for depression (control condition; n=40) or the same treatment with the addition of a text messaging adjunct (n=45). The adjunct consisted of a daily mood monitoring message, a daily message reiterating the theme of that week’s content, and medication and appointment reminders. Mood data and qualitative responses were sent to a Web-based platform (HealthySMS) for review by the therapist and displayed in session as a tool for teaching CBT skills. Results: Intent-to-treat analyses on therapy attendance during 16 sessions of weekly therapy found that patients assigned to the text messaging adjunct stayed in therapy significantly longer (median of 13.5 weeks before dropping out) than patients assigned to the control condition (median of 3 weeks before dropping out; Wilcoxon-Mann-Whitney z=−2.21, P=.03). Patients assigned to the text messaging adjunct also generally attended more sessions (median=6 sessions) during this period than patients assigned to the control condition (median =2.5 sessions), but the effect was not significant (Wilcoxon-Mann-Whitney z=−1.65, P=.10). Both patients assigned to the text messaging adjunct (B=−.29, 95% CI −0.38 to −0.19, z=−5.80, P<.001) and patients assigned to the control conditions (B=−.20, 95% CI −0.32 to −0.07, z=−3.12, P=.002) experienced significant decreases in depressive symptom severity over the course of treatment; however, the conditions did not significantly differ in their degree of symptom reduction. Conclusions: This study provides support for automated text messaging as a tool to sustain engagement in CBT for depression over time. There were no differences in depression outcomes between conditions, but this may be influenced by low follow-up rates of patients who dropped out of treatment. %M 28483742 %R 10.2196/jmir.6914 %U http://www.jmir.org/2017/5/e148/ %U https://doi.org/10.2196/jmir.6914 %U http://www.ncbi.nlm.nih.gov/pubmed/28483742 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 5 %P e76 %T Meeting the Needs of Mothers During the Postpartum Period: Using Co-Creation Workshops to Find Technological Solutions %A Slomian,Justine %A Emonts,Patrick %A Vigneron,Lara %A Acconcia,Alessandro %A Reginster,Jean-Yves %A Oumourgh,Mina %A Bruyère,Olivier %+ Epidemiology and Health Economics and Support Unit in Epidemiology and Biostatistics, Department of Public Health, University of Liège, CHU - Sart Tilman, Quartier Hôpital, Avenue Hippocrate 13, Bât. B23, Liège, 4000, Belgium, 32 43 66 49 33, jslomian@ulg.ac.be %K mothers’ needs %K technological solutions %K co-creating workshop %K co-creation %K postpartum needs %D 2017 %7 03.05.2017 %9 Original Paper %J JMIR Res Protoc %G English %X Background: The postnatal period is associated with many new needs for mothers. Objective: The aim of this study was to find technological solutions that meet the needs of mothers during the year following childbirth. Methods: Two co-creation workshops were undertaken with parents and professionals. The aim of the first workshop was to create a list of all the criteria the proposed solution would have to address to meet the needs of mothers after childbirth. The aim of the second workshop was to create solutions in response to the criteria selected during the first workshop. Results: Parents and health professionals want solutions that include empathy (ie, to help fight against the feelings of abnormality and loneliness), that help mothers in daily life, that are personalized and adapted to different situations, that are educational, and that assures some continuity in their contact with health professionals. In practice, we found that parents and professionals think the solution should be accessible to everyone and available at all times. To address these criteria, technology experts proposed different solutions, such as a forum dedicated to the postpartum period that is supervised by professionals, a centralized website, a system of videoconferencing, an online exchange group, a “gift voucher” system, a virtual reality app, or a companion robot. Conclusions: The human component seems to be very important during the postnatal period. Nevertheless, technology could be a great ally in helping mothers during the postpartum period. Technology can help reliably inform parents and may also give them the right tools to find supportive people. However, these technologies should be tested in clinical trials. %M 28468746 %R 10.2196/resprot.6831 %U http://www.researchprotocols.org/2017/5/e76/ %U https://doi.org/10.2196/resprot.6831 %U http://www.ncbi.nlm.nih.gov/pubmed/28468746 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 5 %P e59 %T Text Message Feedback to Support Mindfulness Practice in People With Depressive Symptoms: A Pilot Randomized Controlled Trial %A Kraft,Susanne %A Wolf,Markus %A Klein,Thomas %A Becker,Thomas %A Bauer,Stephanie %A Puschner,Bernd %+ Section Process-Outcome Research, Department of Psychiatry II, Ulm University, 3rd floor, Ludwig-Heilmeyer-Str 2, Günzburg, 89312, Germany, 49 8221 982866, bernd.puschner@bkh-guenzburg.de %K mindfulness %K text messaging %K pilot study %K randomized controlled trial %D 2017 %7 02.05.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: It has been shown that mindfulness practice can be helpful in preventing relapse from depression. However, practicing mindfulness regularly at home is often a challenge for people with depression. Mobile phone text messaging (short message service, SMS) may be a feasible approach to assist regular mindfulness home practice. Objective: The aim of this study was to evaluate the feasibility of text message–based feedback to support mindfulness practice in people with depressive symptoms after inpatient psychiatric treatment. Methods: Participants received a manualized group introduction to three mindfulness exercises during inpatient treatment and were randomized at hospital discharge. All participants were asked to practice the exercises daily during the 4-month follow-up period. Only participants allocated to the intervention group received reinforcing feedback via mobile phone text messages after reporting their mindfulness practice via text message. Participation rates and satisfaction with the interventions were evaluated, and effects on relevant outcomes were explored. Results: Of the 176 eligible inpatients invited to participate, 65.9% (116/176) attended the introductory mindfulness group at least once, 33.0% (58/176) were willing to participate in the study, and 41 were randomized. The majority 85% (35/41) of these participants completed the study. Among the participants allocated to the intervention group (n=21), 81% (17/21) used the text message support at least once. The average number of text messages sent during the intervention period was 14 (SD 21, range 0-91). Satisfaction rates were high. Preliminary analyses of the effects of the intervention yielded mixed results. Conclusions: Findings indicate that text messaging following inpatient treatment is feasible for some, but not for all people with depressive symptoms. Modest use of the text messaging intervention and its mixed effects imply that dose and ingredients of the intervention should be increased for this group of patients in a future full-size RCT. Such a larger study should also include a process evaluation to investigate moderators of the effect of mindfulness practice and text message feedback on clinical outcome. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 58808893; http://www.controlled-trials.com/ISRCTN58808893 (Archived by Webcite at http://www.webcitation.org/6pmrDRnGt) %M 28465278 %R 10.2196/mhealth.7095 %U http://mhealth.jmir.org/2017/5/e59/ %U https://doi.org/10.2196/mhealth.7095 %U http://www.ncbi.nlm.nih.gov/pubmed/28465278 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 4 %P e138 %T Therapist-Supported Internet-Based Cognitive Behavior Therapy for Stress, Anxiety, and Depressive Symptoms Among Postpartum Women: A Systematic Review and Meta-Analysis %A Lau,Ying %A Htun,Tha Pyai %A Wong,Suei Nee %A Tam,Wai San Wilson %A Klainin-Yobas,Piyanee %+ Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore, 117597, Singapore, 65 66011603, nurly@nus.edu.sg %K Internet %K post-traumatic stress disorders %K stress %K anxiety %K depression %K cognitive behavior therapy %K meta-analysis %D 2017 %7 28.04.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: A growing number of meta-analyses have supported the application of therapist-supported Internet-based cognitive behavior therapy (iCBT) for psychological disorders across different populations, but relatively few meta-analyses have concentrated on postpartum women. Objective: This meta-analysis evaluated the efficacy of therapist-supported iCBT in improving stress, anxiety, and depressive symptoms among postpartum women. Methods: A total of 10 electronic databases were used to search for published and unpublished trials. Cochrane Collaboration tool for assessing risk of bias was utilized to measure methodological quality. Meta-analysis was performed using the RevMan software (Review Manager version 5.3 for Windows from the Nordic Cochrane Centre, the Cochrane Collaboration, 2014). Among the 789 studies identified, 8 randomized controlled trials were selected, involving 1523 participants across 6 countries. Results: More than half (65%) of the eligible studies had a low risk of bias with no heterogeneity. Results revealed that therapist-supported iCBT significantly improved stress (d=0.84, n=5), anxiety (d=0.36, n=6), and depressive symptoms (d=0.63, n=8) of the intervention group compared with those of the control group at post-intervention. Conclusions: This review revealed that therapist-supported iCBT significantly improves stress, anxiety, and depressive symptoms among postpartum women with small to large effects. Future effectiveness studies should establish the essential components, format, and approach of iCBT with optimal levels of human support to maximize a long-term effect. %M 28455276 %R 10.2196/jmir.6712 %U http://www.jmir.org/2017/4/e138/ %U https://doi.org/10.2196/jmir.6712 %U http://www.ncbi.nlm.nih.gov/pubmed/28455276 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 2 %P e13 %T Gathering Opinions on Depression Information Needs and Preferences: Samples and Opinions in Clinic Versus Web-Based Surveys %A Bernstein,Matthew T %A Walker,John R %A Sexton,Kathryn A %A Katz,Alan %A Beatie,Brooke E %A , %+ Faculty of Health Sciences, Department of Clinical Health Psychology, University of Manitoba, M4 - St. Boniface Hospital, 409 Tache Ave, Winnipeg, MB, R2H 2A6, Canada, 1 204 955 9487, jwalker@cc.umanitoba.ca %K depression %K psychotherapy %K drug therapy %K Internet %K survey methodology %D 2017 %7 24.04.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: There has been limited research on the information needs and preferences of the public concerning treatment for depression. Very little research is available comparing samples and opinions when recruitment for surveys is done over the Web as opposed to a personal invitation to complete a paper survey. Objective: This study aimed to (1) to explore information needs and preferences among members of the public and (2) compare Clinic and Web samples on sample characteristics and survey findings. Methods: Web survey participants were recruited with a notice on three self-help association websites (N=280). Clinic survey participants were recruited by a research assistant in the waiting rooms of a family medicine clinic and a walk-in medical clinic (N=238) and completed a paper version of the survey. Results: The Clinic and Web samples were similar in age (39.0 years, SD 13.9 vs 40.2 years, SD 12.5, respectively), education, and proportion in full time employment. The Clinic sample was more diverse in demographic characteristics and closer to the demographic characteristics of the region (Winnipeg, Canada) with a higher proportion of males (102/238 [42.9%] vs 45/280 [16.1%]) and nonwhites (Aboriginal, Asian, and black) (69/238 [29.0%] vs 39/280 [13.9%]). The Web sample reported a higher level of emotional distress and had more previous psychological (224/280 [80.0%] vs 83/238 [34.9%]) and pharmacological (202/280 [72.1%] vs 57/238 [23.9%]) treatment. In terms of opinions, most respondents in both settings saw information on a wide range of topics around depression treatment as very important including information about treatment choices, effectiveness of treatment, how long it takes treatment to work, how long treatment continues, what happens when treatment stops, advantages and disadvantages of treatments, and potential side effects. Females, respondents with a white background, and those who had received or felt they would have benefited from therapy in the past saw more information topics as very important. Those who had received or thought they would have benefited in the past from medication treatment saw fewer topics as important. Participants in both groups expressed an interest in receiving information through discussion with a counselor or a physician, through written brochures, or through a recommended website. Conclusions: The recruitment strategies were helpful in obtaining opinions from members of the public with different concerns and perspectives, and the results from the two methods were complementary. Persons coping with emotional distress and individuals not specifically seeking help for depression would be interested in information to answer a wide range of important questions about depression treatment. The Clinic sample yielded more cultural diversity that is a closer match to the population. The Web sample was less costly to recruit and included persons who were most interested in receiving information. %M 28438729 %R 10.2196/mental.7231 %U http://mental.jmir.org/2017/2/e13/ %U https://doi.org/10.2196/mental.7231 %U http://www.ncbi.nlm.nih.gov/pubmed/28438729 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 4 %P e123 %T Usability, Acceptability, and Adherence to an Electronic Self-Monitoring System in Patients With Major Depression Discharged From Inpatient Wards %A Lauritsen,Lise %A Andersen,Louise %A Olsson,Emilia %A Søndergaard,Stine Rauff %A Nørregaard,Lasse Benn %A Løventoft,Philip Kaare %A Svendsen,Signe Dunker %A Frøkjær,Erik %A Jensen,Hans Mørch %A Hageman,Ida %A Kessing,Lars Vedel %A Martiny,Klaus %+ Psychiatric Center Copenhagen, Rigshospitalet, University of Copenhagen, Edel Sauntes Alle 10, Copenhagen, 2100 Ø, Denmark, 45 38647100, klaus.martiny@regionh.dk %K depressive disorder, major %K electronic monitoring %K graph drawing %K sleep %K self-assessment %K observational study %K inpatients %K patient participation %K chronotherapeutics %D 2017 %7 21.04.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Patients suffering from depression have a high risk of relapse and readmission in the weeks following discharge from inpatient wards. Electronic self-monitoring systems that offer patient-communication features are now available to offer daily support to patients, but the usability, acceptability, and adherence to these systems has only been sparsely investigated. Objective: We aim to test the usability, acceptability, adherence, and clinical outcome of a newly developed computer-based electronic self-assessment system (the Daybuilder system) in patients suffering from depression, in the period from discharge until commencing outpatient treatment in the Intensive Outpatient Unit for Affective Disorders. Methods: Patients suffering from unipolar major depression that were referred from inpatient wards to an intensive outpatient unit were included in this study before their discharge, and were followed for four weeks. User satisfaction was assessed using semiqualitative questionnaires and the System Usability Scale (SUS). Patients were interviewed at baseline and at endpoint with the Hamilton depression rating scale (HAM-D17), the Major Depression Inventory (MDI), and the 5-item World Health Organization Well-Being Index (WHO-5). In this four-week period patients used the Daybuilder system to self-monitor mood, sleep, activity, and medication adherence on a daily basis. The system displayed a graphical representation of the data that was simultaneously displayed to patients and clinicians. Patients were phoned weekly to discuss their data entries. The primary outcomes were usability, acceptability, and adherence to the system. The secondary outcomes were changes in: the electronically self-assessed mood, sleep, and activity scores; and scores from the HAM-D17, MDI, and WHO-5 scales. Results: In total, 76% of enrolled patients (34/45) completed the four-week study. Five patients were readmitted due to relapse. The 34 patients that completed the study entered data for mood on 93.8% of the days (872/930), sleep on 89.8% of the days (835/930), activity on 85.6% of the days (796/930), and medication on 88.0 % of the days (818/930). SUS scores were 86.2 (standard deviation [SD] 9.7) and 79% of the patients (27/34) found that the system lived up to their expectations. A significant improvement in depression severity was found on the HAM-D17 from 18.0 (SD 6.5) to 13.3 (SD 7.3; P<.01), on the MDI from 27.1 (SD 13.1) to 22.1 (SD 12.7; P=.006), and in quality of life on the WHO-5 from 31.3 (SD 22.9) to 43.4 (SD 22.1; P<.001) scales, but not on self-assessed mood (P=.08). Mood and sleep parameters were highly variable from day-to-day. Sleep-offset was significantly delayed from baseline, averaging 48 minutes (standard error 12 minutes; P<.001). Furthermore, when estimating delay of sleep-onset (with sleep quality included in the model) during the study period, this showed a significant negative effect on mood (P=.03) Conclusions: The Daybuilder systems performed well technically, and patients were satisfied with the system and had high adherence to self-assessments. The dropout rate and the gradual delay in sleep emphasize the need for continued clinical support for these patients, especially when considering sleep guidance. %M 28432040 %R 10.2196/jmir.6673 %U http://www.jmir.org/2017/4/e123/ %U https://doi.org/10.2196/jmir.6673 %U http://www.ncbi.nlm.nih.gov/pubmed/28432040 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 4 %P e128 %T Toward Game-Based Digital Mental Health Interventions: Player Habits and Preferences %A Mandryk,Regan Lee %A Birk,Max Valentin %+ Interaction Lab, Department of Computer Science, University of Saskatchewan, 176 Thorvaldson Bldg, 110 Science Place, Saskatoon, SK, S7N5C9, Canada, 1 3069664888, regan@cs.usask.ca %K computer games %K mental health %K depression %K anxiety %D 2017 %7 20.04.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Designers of digital interventions for mental health often leverage interactions from games because the intrinsic motivation that results from game-based interventions may increase participation and translate into improved treatment efficacy. However, there are outstanding questions about the suitability (eg, are desktop or mobile interventions more appropriate?) and intervention potential (eg, do people with depression activate enough to play?) of games for mental health. Objective: In this paper, we aimed to describe the presently unknown relationship between gaming activity and indicators of well-being so that designers make informed choices when designing game-based interventions for mental health. Methods: We gathered validated scales of well-being (Beck’s Depression Inventory [BDI-II], Patient Health Questionnaire [PHQ-9], trait anxiety [TA], and basic psychological needs satisfaction [BPNS]), play importance (control over game behavior: control; gamer identity: identity), and play behavior (play frequency, platform preferences, and genre preferences) in a Web-based survey (N=491). Results: The majority of our participants played games a few times a week (45.3%, 222/490) or daily (34.3%, 168/490). In terms of depression, play frequency was associated with PHQ-9 (P=.003); PHQ-9 scores were higher for those who played daily than for those who played a few times a week or less. Similarly, for BDI-II (P=.01), scores were higher for those who played daily than for those who played once a week or less. Genre preferences were not associated with PHQ-9 (P=.32) or BDI-II (P=.68); however, platform preference (ie, mobile, desktop, or console) was associated with PHQ-9 (P=.04); desktop-only players had higher PHQ-9 scores than those who used all platforms. Platform preference was not associated with BDI-II (P=.18). In terms of anxiety, TA was not associated with frequency (P=.23), platform preference (P=.07), or genre preference (P=.99). In terms of needs satisfaction, BPNS was not associated with frequency (P=.25) or genre preference (P=.53), but it was associated with platform preference (P=.01); desktop-only players had lower needs satisfaction than those who used all platforms. As expected, play frequency was associated with identity (P<.001) and control (P<.001); those who played more had identified more as a gamer and had less control over their gameplay. Genre preference was associated with identity (P<.001) and control (P<.001); those who played most common genres had higher control over their play and identified most as gamers. Platform preference was not associated with control (P=.80), but was with identity (P=.001); those who played on all devices identified more as a gamer than those who played on mobiles or consoles only. Conclusions: Our results suggest that games are a suitable approach for mental health interventions as they are played broadly by people across a range of indicators of mental health. We further unpack the platform preferences and genre preferences of players with varying levels of well-being. %M 28428161 %R 10.2196/jmir.6906 %U http://www.jmir.org/2017/4/e128/ %U https://doi.org/10.2196/jmir.6906 %U http://www.ncbi.nlm.nih.gov/pubmed/28428161 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 4 %P e44 %T Immediate Mood Scaler: Tracking Symptoms of Depression and Anxiety Using a Novel Mobile Mood Scale %A Nahum,Mor %A Van Vleet,Thomas M %A Sohal,Vikaas S %A Mirzabekov,Julie J %A Rao,Vikram R %A Wallace,Deanna L %A Lee,Morgan B %A Dawes,Heather %A Stark-Inbar,Alit %A Jordan,Joshua Thomas %A Biagianti,Bruno %A Merzenich,Michael %A Chang,Edward F %+ Posit Science Corporation, 160 Pine St, 2nd Floor, San Francisco, CA, 94111, United States, 1 4152692425, mor.nahum@positscience.com %K mood disorders %K mobile %K ecological momentary assessment %K depression %K anxiety %D 2017 %7 12.04.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mood disorders are dynamic disorders characterized by multimodal symptoms. Clinical assessment of symptoms is currently limited to relatively sparse, routine clinic visits, requiring retrospective recollection of symptoms present in the weeks preceding the visit. Novel advances in mobile tools now support ecological momentary assessment of mood, conducted frequently using mobile devices, outside the clinical setting. Such mood assessment may help circumvent problems associated with infrequent reporting and better characterize the dynamic presentation of mood symptoms, informing the delivery of novel treatment options. Objectives: The aim of our study was to validate the Immediate Mood Scaler (IMS), a newly developed, iPad-deliverable 22-item self-report tool designed to capture current mood states. Methods: A total of 110 individuals completed standardized questionnaires (Patient Health Questionnaire, 9-item [PHQ-9]; generalized anxiety disorder, 7-Item [GAD-7]; and rumination scale) and IMS at baseline. Of the total, 56 completed at least one additional session of IMS, and 17 completed one additional administration of PHQ-9 and GAD-7. We conducted exploratory Principal Axis Factor Analysis to assess dimensionality of IMS, and computed zero-order correlations to investigate associations between IMS and standardized scales. Linear Mixed Model (LMM) was used to assess IMS stability across time and to test predictability of PHQ-9 and GAD-7 score by IMS. Results: Strong correlations were found between standard mood scales and the IMS at baseline (r=.57-.59, P<.001). A factor analysis revealed a 12-item IMS (“IMS-12”) with two factors: a “depression” factor and an “anxiety” factor. IMS-12 depression subscale was more strongly correlated with PHQ-9 than with GAD-7 (z=1.88, P=.03), but the reverse pattern was not found for IMS-12 anxiety subscale. IMS-12 showed less stability over time compared with PHQ-9 and GAD-7 (.65 vs .91), potentially reflecting more sensitivity to mood dynamics. In addition, IMS-12 ratings indicated that individuals with mild to moderate depression had greater mood fluctuations compared with individuals with severe depression (.42 vs .79; P=.04). Finally, IMS-12 significantly contributed to the prediction of subsequent PHQ-9 (beta=1.03, P=.02) and GAD-7 scores (beta =.93, P=.01). Conclusions: Collectively, these data suggest that the 12-item IMS (IMS-12) is a valid tool to assess momentary mood symptoms related to anxiety and depression. Although IMS-12 shows good correlation with standardized scales, it further captures mood fluctuations better and significantly adds to the prediction of the scales. Results are discussed in the context of providing continuous symptom quantification that may inform novel treatment options and support personalized treatment plans. %M 28404542 %R 10.2196/mhealth.6544 %U http://mhealth.jmir.org/2017/4/e44/ %U https://doi.org/10.2196/mhealth.6544 %U http://www.ncbi.nlm.nih.gov/pubmed/28404542 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 4 %P e88 %T Pregnant Women’s Views on the Feasibility and Acceptability of Web-Based Mental Health E-Screening Versus Paper-Based Screening: A Randomized Controlled Trial %A Kingston,Dawn %A Austin,Marie-Paule %A Veldhuyzen van Zanten,Sander %A Harvalik,Paula %A Giallo,Rebecca %A McDonald,Sarah D %A MacQueen,Glenda %A Vermeyden,Lydia %A Lasiuk,Gerri %A Sword,Wendy %A Biringer,Anne %+ Faculty of Nursing, University of Calgary, 2500 University Ave NW, Calgary, AB, T2N 1N4, Canada, 1 4032202634, dawn.kingston@ucalgary.ca %K pregnancy %K mental health %K screening %K prenatal care %K computers %D 2017 %7 07.04.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Major international guidelines recommend mental health screening during the perinatal period. However, substantial barriers to screening have been reported by pregnant and postpartum women and perinatal care providers. E-screening offers benefits that may address implementation challenges. Objective: The primary objective of this randomized controlled trial was to evaluate the feasibility and acceptability of Web-based mental health e-screening compared with paper-based screening among pregnant women. A secondary objective was to identify factors associated with women’s preferences for e-screening and disclosure of mental health concerns. Methods: Pregnant women recruited from community and hospital-based antenatal clinics and hospital-based prenatal classes were computer-randomized to a fully automated Web-based e-screening intervention group or a paper-based control group. Women were eligible if they spoke or read English, were willing to be randomized to e-screening, and were willing to participate in a follow-up diagnostic interview. The intervention group completed the Antenatal Psychosocial Health Assessment and the Edinburgh Postnatal Depression Scale on a tablet computer, while controls completed them on paper. All women completed self-report baseline questions and were telephoned 1 week after randomization by a blinded research assistant for a MINI International Neuropsychiatric Interview. Renker and Tonkin’s tool of feasibility and acceptability of computerized screening was used to assess the feasibility and acceptability of e-screening compared with paper-based screening. Intention-to-treat analysis was used. To identify factors associated with preference for e-screening and disclosure, variables associated with each outcome at P<.20 were simultaneously entered into final multivariable models to estimate adjusted odds ratios (AORs) and 95% CIs. Results: Of the 675 eligible women approached, 636 agreed to participate (participation rate 94.2%) and were randomized to the intervention (n=305) or control (n=331) groups. There were no significant baseline differences between groups. More women in the e-screening group strongly or somewhat agreed that they would like to use a tablet for answering questions on emotional health (57.9%, 175/302 vs 37.2%, 121/325) and would prefer using a tablet to paper (46.0%, 139/302 vs 29.2%, 95/325), compared with women in the paper-based screening group. There were no differences between groups in women’s disclosure of emotional health concerns (94.1%, 284/302 vs 90.2%, 293/325). Women in the e-screening group consistently reported the features of e-screening more favorably than controls (more private or confidential, less impersonal, less time-consuming). In the multivariable models, being in the e-screening group was significantly associated with preferring e-screening (AOR 2.29, 95% CI 1.66-3.17), while no factors were significantly associated with disclosure. Conclusions: The findings suggest that mental health e-screening is feasible and acceptable to pregnant women. Trial Registration: Clinicaltrials.gov NCT01899534; https://clinicaltrials.gov/ct2/show/NCT01899534 (Archived by WebCite at http://www.webcitation.org/6ntWg1yWb) %M 28389421 %R 10.2196/jmir.6866 %U http://www.jmir.org/2017/4/e88/ %U https://doi.org/10.2196/jmir.6866 %U http://www.ncbi.nlm.nih.gov/pubmed/28389421 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 4 %P e51 %T Managing Depressive Symptoms in the Workplace Using a Web-Based Self-Care Tool: A Pilot Randomized Controlled Trial %A Hirsch,Abigail %A Luellen,Jason %A Holder,Jared M %A Steinberg,Gregory %A Dubiel,Teresa %A Blazejowskyj,Anna %A Schladweiler,Krista %+ myStrength, Inc, 1875 Lawrence Street, Suite 550, Denver, CO,, United States, 1 302 983 2954, kschladweiler@mystrength.com %K depression %K behavioral health %K health promotion %K workplace %K randomized controlled trial %D 2017 %7 04.04.2017 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Depression in the workplace creates a significant burden on employees and employers in terms of lost productivity and related costs. myStrength provides a robust, holistic Web- and mobile-based solution empowering users to learn, practice, and implement a range of evidence-based psychological interventions. Objective: The main aim of this study was to demonstrate improvement in depressive symptoms among employees at risk of depression through myStrength use. Methods: A 26-week, parallel-arm, pilot, randomized controlled trial was designed to assess the effectiveness of myStrength compared to a series of informational “Depression Tip/Fact of the Week” emails as the active control arm. Study participants (n=146) were commercially insured employees of a mid-sized financial software solutions firm. The primary outcome was self-reported change in depression score as best fit by a linear random effects model accounting for individual baseline symptoms. Results: The final sample consisted of 78 participants in the experimental arm, myStrength, and 68 participants in the active control arm. myStrength users demonstrated significantly steeper and more rapid reduction in depressive symptoms over time compared to the active control (P<.001), suggesting that the intervention generated improvement in behavioral health symptoms, even in a nonclinical sample. Conclusions: This pilot study builds foundational support for the scalable deployment of myStrength as a complementary behavioral health offering to promote overall mental health and well-being in the workplace. %M 28377368 %R 10.2196/resprot.7203 %U http://www.researchprotocols.org/2017/4/e51/ %U https://doi.org/10.2196/resprot.7203 %U http://www.ncbi.nlm.nih.gov/pubmed/28377368 %0 Journal Article %I %V %N %P %T %D %7 .. %9 %J %G English %X %U %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 3 %P e85 %T Assessing Feasibility and Acceptability of Web-Based Enhanced Relapse Prevention for Bipolar Disorder (ERPonline): A Randomized Controlled Trial %A Lobban,Fiona %A Dodd,Alyson L %A Sawczuk,Adam P %A Asar,Ozgur %A Dagnan,Dave %A Diggle,Peter J %A Griffiths,Martin %A Honary,Mahsa %A Knowles,Dawn %A Long,Rita %A Morriss,Richard %A Parker,Rob %A Jones,Steven %+ Spectrum Centre, Faculty of Health and Medicine, Lancaster University, Bailrigg Campus, Lancaster, LA14YT, United Kingdom, 44 01524593752, f.lobban@lancaster.ac.uk %K Internet %K randomized controlled trial %K feasibility studies %K bipolar disorder %D 2017 %7 24.03.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Interventions that teach people with bipolar disorder (BD) to recognize and respond to early warning signs (EWS) of relapse are recommended but implementation in clinical practice is poor. Objectives: The objective of this study was to test the feasibility and acceptability of a randomized controlled trial (RCT) to evaluate a Web-based enhanced relapse prevention intervention (ERPonline) and to report preliminary evidence of effectiveness. Methods: A single-blind, parallel, primarily online RCT (n=96) over 48 weeks comparing ERPonline plus usual treatment with “waitlist (WL) control” plus usual treatment for people with BD recruited through National Health Services (NHSs), voluntary organizations, and media. Randomization was independent, minimized on number of previous episodes (<8, 8-20, 21+). Primary outcomes were recruitment and retention rates, levels of intervention use, adverse events, and participant feedback. Process and clinical outcomes were assessed by telephone and Web and compared using linear models with intention-to-treat analysis. Results: A total of 280 people registered interest online, from which 96 met inclusion criteria, consented, and were randomized (49 to WL, 47 to ERPonline) over 17 months, with 80% retention in telephone and online follow-up at all time points, except at week 48 (76%). Acceptability was high for both ERPonline and trial methods. ERPonline cost approximately £19,340 to create, and £2176 per year to host and maintain the site. Qualitative data highlighted the importance of the relationship that the users have with Web-based interventions. Differences between the group means suggested that access to ERPonline was associated with: a more positive model of BD at 24 weeks (10.70, 95% CI 0.90 to 20.5) and 48 weeks (13.1, 95% CI 2.44 to 23.93); increased monitoring of EWS of depression at 48 weeks (−1.39, 95% CI −2.61 to −0.163) and of hypomania at 24 weeks (−1.72, 95% CI −2.98 to −0.47) and 48 weeks (−1.61, 95% CI −2.92 to −0.30), compared with WL. There was no evidence of impact of ERPonline on clinical outcomes or medication adherence, but relapse rates across both arms were low (15%) and the sample remained high functioning throughout. One person died by suicide before randomization and 5 people in ERPonline and 6 in WL reported ideas of suicide or self-harm. None were deemed study related by an independent Trial Steering Committee (TSC). Conclusions: ERPonline offers a cheap accessible option for people seeking ongoing support following successful treatment. However, given high functioning and low relapse rates in this study, testing clinical effectiveness for this population would require very large sample sizes. Building in human support to use ERPonline should be considered. Trial registration: International Standard Randomized Controlled Trial Number (ISRCTN): 56908625; http://www.isrctn.com/ISRCTN56908625 (Archived by WebCite at http://www.webcitation.org/6of1ON2S0) %M 28341619 %R 10.2196/jmir.7008 %U http://www.jmir.org/2017/3/e85/ %U https://doi.org/10.2196/jmir.7008 %U http://www.ncbi.nlm.nih.gov/pubmed/28341619 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 3 %P e71 %T Longitudinal Changes in Psychological States in Online Health Community Members: Understanding the Long-Term Effects of Participating in an Online Depression Community %A Park,Albert %A Conway,Mike %+ Department of Biomedical Informatics, School of Medicine, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108-3514, United States, 1 206 743 7843, alpark1216@gmail.com %K mental health %K depression %K consumer health information %K informatics %K information science %K social support %K psychosocial support system %K community networks %K self-help groups %K communications media %D 2017 %7 20.03.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Major depression is a serious challenge at both the individual and population levels. Although online health communities have shown the potential to reduce the symptoms of depression, emotional contagion theory suggests that negative emotion can spread within a community, and prolonged interactions with other depressed individuals has potential to worsen the symptoms of depression. Objective: The goals of our study were to investigate longitudinal changes in psychological states that are manifested through linguistic changes in depression community members who are interacting with other depressed individuals. Methods: We examined emotion-related language usages using the Linguistic Inquiry and Word Count (LIWC) program for each member of a depression community from Reddit. To measure the changes, we applied linear least-squares regression to the LIWC scores against the interaction sequence for each member. We measured the differences in linguistic changes against three online health communities focusing on positive emotion, diabetes, and irritable bowel syndrome. Results: On average, members of an online depression community showed improvement in 9 of 10 prespecified linguistic dimensions: “positive emotion,” “negative emotion,” “anxiety,” “anger,” “sadness,” “first person singular,” “negation,” “swear words,” and “death.” Moreover, these members improved either significantly or at least as much as members of other online health communities. Conclusions: We provide new insights into the impact of prolonged participation in an online depression community and highlight the positive emotion change in members. The findings of this study should be interpreted with caution, because participating in an online depression community is not the sole factor for improvement or worsening of depressive symptoms. Still, the consistent statistical results including comparative analyses with different communities could indicate that the emotion-related language usage of depression community members are improving either significantly or at least as much as members of other online communities. On the basis of these findings, we contribute practical suggestions for designing online depression communities to enhance psychosocial benefit gains for members. We consider these results to be an important step toward a better understanding of the impact of prolonged participation in an online depression community, in addition to providing insights into the long-term psychosocial well-being of members. %M 28320692 %R 10.2196/jmir.6826 %U http://www.jmir.org/2017/3/e71/ %U https://doi.org/10.2196/jmir.6826 %U http://www.ncbi.nlm.nih.gov/pubmed/28320692 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 3 %P e75 %T Behavioral Indicators on a Mobile Sensing Platform Predict Clinically Validated Psychiatric Symptoms of Mood and Anxiety Disorders %A Place,Skyler %A Blanch-Hartigan,Danielle %A Rubin,Channah %A Gorrostieta,Cristina %A Mead,Caroline %A Kane,John %A Marx,Brian P %A Feast,Joshua %A Deckersbach,Thilo %A Pentland,Alex “Sandy” %A Nierenberg,Andrew %A Azarbayejani,Ali %+ Department of Natural and Applied Sciences, Bentley University, 175 Forest Street, 106 Jennison, Waltham, MA, 02452, United States, 1 7818912066, danielleblanch@gmail.com %K mHealth %K post-traumatic stress disorders %K depression %K behavioral symptoms %D 2017 %7 16.03.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: There is a critical need for real-time tracking of behavioral indicators of mental disorders. Mobile sensing platforms that objectively and noninvasively collect, store, and analyze behavioral indicators have not yet been clinically validated or scalable. Objective: The aim of our study was to report on models of clinical symptoms for post-traumatic stress disorder (PTSD) and depression derived from a scalable mobile sensing platform. Methods: A total of 73 participants (67% [49/73] male, 48% [35/73] non-Hispanic white, 33% [24/73] veteran status) who reported at least one symptom of PTSD or depression completed a 12-week field trial. Behavioral indicators were collected through the noninvasive mobile sensing platform on participants’ mobile phones. Clinical symptoms were measured through validated clinical interviews with a licensed clinical social worker. A combination hypothesis and data-driven approach was used to derive key features for modeling symptoms, including the sum of outgoing calls, count of unique numbers texted, absolute distance traveled, dynamic variation of the voice, speaking rate, and voice quality. Participants also reported ease of use and data sharing concerns. Results: Behavioral indicators predicted clinically assessed symptoms of depression and PTSD (cross-validated area under the curve [AUC] for depressed mood=.74, fatigue=.56, interest in activities=.75, and social connectedness=.83). Participants reported comfort sharing individual data with physicians (Mean 3.08, SD 1.22), mental health providers (Mean 3.25, SD 1.39), and medical researchers (Mean 3.03, SD 1.36). Conclusions: Behavioral indicators passively collected through a mobile sensing platform predicted symptoms of depression and PTSD. The use of mobile sensing platforms can provide clinically validated behavioral indicators in real time; however, further validation of these models and this platform in large clinical samples is needed. %M 28302595 %R 10.2196/jmir.6678 %U http://www.jmir.org/2017/3/e75/ %U https://doi.org/10.2196/jmir.6678 %U http://www.ncbi.nlm.nih.gov/pubmed/28302595 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 3 %P e42 %T Writing for Health: Rationale and Protocol for a Randomized Controlled Trial of Internet-Based Benefit-Finding Writing for Adults With Type 1 or Type 2 Diabetes %A Crawford,Joanna %A Wilhelm,Kay %A Robins,Lisa %A Proudfoot,Judy %+ Faces in the Street, Urban Mental Health Research Institute, St. Vincent's Health Australia, Level 6, O'Brien Centre, St Vincent's Hospital, 394 Victoria Street, Darlinghurst, Sydney, 2010, Australia, 61 2 8382 1660, Joanna.Crawford@svha.org.au %K type 1 diabetes %K type 2 diabetes %K diabetes-related distress %K writing %K Internet intervention %K randomized controlled trial %D 2017 %7 14.03.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Diabetes mellitus is Australia’s fastest growing chronic disease, and has high comorbidity with depression. Both subthreshold depression and diabetes distress are common amongst people with type 1 or type 2 diabetes, and are associated with poorer diabetes self-care. A need exists for low-intensity self-help interventions for large numbers of people with diabetes and diabetes distress or subthreshold depression, as part of a stepped-care approach to meeting the psychological needs of people with diabetes. Benefit-finding writing is a very brief intervention that involves writing about any positive thoughts and feelings about a stressful experience, such as an illness. Benefit-finding writing has been associated with increases in positive affect and positive growth, and has demonstrated promising results in trials amongst other clinical populations. However, benefit-finding writing has not yet been examined in people with diabetes. Objective: The aim of this randomized controlled trial (RCT) is to evaluate the efficacy of an Internet-based benefit-finding writing (iBFW) intervention for adults with type 1 or type 2 diabetes (compared to a control writing condition) for reducing diabetes distress and increasing benefit-finding in diabetes, and also improving a range of secondary outcomes. Methods: A two-arm RCT will be conducted, using the online program Writing for Health. Adults with type 1 or type 2 diabetes living in Australia will be recruited using diabetes-related publications and websites, and through advertisements in diabetes services and general practitioners’ offices. Potential participants will be referred to the study-specific website for participant information and screening. All data will be collected online. Participants will be randomized to either iBFW about diabetes, or a control writing condition of writing about use-of-time. Both conditions involve three daily sessions (once per day for three consecutive days) of 15-minute online writing exercises. Outcome measures will be administered online at baseline, one-month, and three-month follow-ups. Results: This trial is currently underway. The primary outcomes will be diabetes distress and benefit-finding in diabetes. Secondary outcomes will be depression, anxiety, diabetes self-care, perceived health, and health care utilization. We aim to recruit 104 participants. All stages of the study will be conducted online using the Writing for Health program. Group differences will be analyzed on an intention-to-treat basis using mixed models repeated measures. Linguistic analyses of the writing exercise scripts, and examinations of the immediate emotional responses to the writing exercises, will also be undertaken. Conclusions: This RCT will be the first study to examine iBFW for adults with type 1 or type 2 diabetes. If iBFW is found to be efficacious in reducing diabetes distress and improving diabetes self-care and other outcomes, iBFW may offer the potential to be a low-cost, easily accessible self-help intervention to improve the wellbeing of adults with diabetes. Trial Registration: Australia and New Zealand Clinical Trials Registry (ACTRN12615000241538) %M 28292741 %R 10.2196/resprot.7151 %U http://www.researchprotocols.org/2017/3/e42/ %U https://doi.org/10.2196/resprot.7151 %U http://www.ncbi.nlm.nih.gov/pubmed/28292741 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 3 %P e62 %T Using Mobile Sensing to Test Clinical Models of Depression, Social Anxiety, State Affect, and Social Isolation Among College Students %A Chow,Philip I %A Fua,Karl %A Huang,Yu %A Bonelli,Wesley %A Xiong,Haoyi %A Barnes,Laura E %A Teachman,Bethany A %+ School of Engineering and Applied Science, University of Virginia, 151 Engineer's Way, Olsson Hall 101B, PO Box 400747, Charlottesville, VA, 22904-4747, United States, 1 434 924 1723, lbarnes@virginia.edu %K mental health %K depression %K social anxiety %K affect %K homestay %K mobile health %K mHealth %D 2017 %7 03.03.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Research in psychology demonstrates a strong link between state affect (moment-to-moment experiences of positive or negative emotionality) and trait affect (eg, relatively enduring depression and social anxiety symptoms), and a tendency to withdraw (eg, spending time at home). However, existing work is based almost exclusively on static, self-reported descriptions of emotions and behavior that limit generalizability. Despite adoption of increasingly sophisticated research designs and technology (eg, mobile sensing using a global positioning system [GPS]), little research has integrated these seemingly disparate forms of data to improve understanding of how emotional experiences in everyday life are associated with time spent at home, and whether this is influenced by depression or social anxiety symptoms. Objective: We hypothesized that more time spent at home would be associated with more negative and less positive affect. Methods: We recruited 72 undergraduate participants from a southeast university in the United States. We assessed depression and social anxiety symptoms using self-report instruments at baseline. An app (Sensus) installed on participants’ personal mobile phones repeatedly collected in situ self-reported state affect and GPS location data for up to 2 weeks. Time spent at home was a proxy for social isolation. Results: We tested separate models examining the relations between state affect and time spent at home, with levels of depression and social anxiety as moderators. Models differed only in the temporal links examined. One model focused on associations between changes in affect and time spent at home within short, 4-hour time windows. The other 3 models focused on associations between mean-level affect within a day and time spent at home (1) the same day, (2) the following day, and (3) the previous day. Overall, we obtained many of the expected main effects (although there were some null effects), in which higher social anxiety was associated with more time or greater likelihood of spending time at home, and more negative or less positive affect was linked to longer homestay. Interactions indicated that, among individuals higher in social anxiety, higher negative affect and lower positive affect within a day was associated with greater likelihood of spending time at home the following day. Conclusions: Results demonstrate the feasibility and utility of modeling the relationship between affect and homestay using fine-grained GPS data. Although these findings must be replicated in a larger study and with clinical samples, they suggest that integrating repeated state affect assessments in situ with continuous GPS data can increase understanding of how actual homestay is related to affect in everyday life and to symptoms of anxiety and depression. %M 28258049 %R 10.2196/jmir.6820 %U http://www.jmir.org/2017/3/e62/ %U https://doi.org/10.2196/jmir.6820 %U http://www.ncbi.nlm.nih.gov/pubmed/28258049 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 2 %P e48 %T Understanding Depressive Symptoms and Psychosocial Stressors on Twitter: A Corpus-Based Study %A Mowery,Danielle %A Smith,Hilary %A Cheney,Tyler %A Stoddard,Greg %A Coppersmith,Glen %A Bryan,Craig %A Conway,Mike %+ Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT, 84108, United States, 1 8015856739, danielle.mowery@utah.edu %K social media %K Twitter messaging %K natural language processing %K major depressive disorder %K data annotation %K machine learning %D 2017 %7 28.02.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: With a lifetime prevalence of 16.2%, major depressive disorder is the fifth biggest contributor to the disease burden in the United States. Objective: The aim of this study, building on previous work qualitatively analyzing depression-related Twitter data, was to describe the development of a comprehensive annotation scheme (ie, coding scheme) for manually annotating Twitter data with Diagnostic and Statistical Manual of Mental Disorders, Edition 5 (DSM 5) major depressive symptoms (eg, depressed mood, weight change, psychomotor agitation, or retardation) and Diagnostic and Statistical Manual of Mental Disorders, Edition IV (DSM-IV) psychosocial stressors (eg, educational problems, problems with primary support group, housing problems). Methods: Using this annotation scheme, we developed an annotated corpus, Depressive Symptom and Psychosocial Stressors Acquired Depression, the SAD corpus, consisting of 9300 tweets randomly sampled from the Twitter application programming interface (API) using depression-related keywords (eg, depressed, gloomy, grief). An analysis of our annotated corpus yielded several key results. Results: First, 72.09% (6829/9473) of tweets containing relevant keywords were nonindicative of depressive symptoms (eg, “we’re in for a new economic depression”). Second, the most prevalent symptoms in our dataset were depressed mood and fatigue or loss of energy. Third, less than 2% of tweets contained more than one depression related category (eg, diminished ability to think or concentrate, depressed mood). Finally, we found very high positive correlations between some depression-related symptoms in our annotated dataset (eg, fatigue or loss of energy and educational problems; educational problems and diminished ability to think). Conclusions: We successfully developed an annotation scheme and an annotated corpus, the SAD corpus, consisting of 9300 tweets randomly-selected from the Twitter application programming interface using depression-related keywords. Our analyses suggest that keyword queries alone might not be suitable for public health monitoring because context can change the meaning of keyword in a statement. However, postprocessing approaches could be useful for reducing the noise and improving the signal needed to detect depression symptoms using social media. %M 28246066 %R 10.2196/jmir.6895 %U http://www.jmir.org/2017/2/e48/ %U https://doi.org/10.2196/jmir.6895 %U http://www.ncbi.nlm.nih.gov/pubmed/28246066 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 1 %P e7 %T Applying Computerized Adaptive Testing to the Four-Dimensional Symptom Questionnaire (4DSQ): A Simulation Study %A Magnée,Tessa %A de Beurs,Derek P %A Terluin,Berend %A Verhaak,Peter F %+ Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118-114, Utrecht, 3500BN, Netherlands, 31 302729854, t.magnee@nivel.nl %K item response theory %K Four-Dimensional Symptom Questionnaire %K computerized adaptive testing %K mental health %K general practice %D 2017 %7 21.02.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Efficient screening questionnaires are useful in general practice. Computerized adaptive testing (CAT) is a method to improve the efficiency of questionnaires, as only the items that are particularly informative for a certain responder are dynamically selected. Objective: The objective of this study was to test whether CAT could improve the efficiency of the Four-Dimensional Symptom Questionnaire (4DSQ), a frequently used self-report questionnaire designed to assess common psychosocial problems in general practice. Methods: A simulation study was conducted using a sample of Dutch patients visiting a general practitioner (GP) with psychological problems (n=379). Responders completed a paper-and-pencil version of the 50-item 4DSQ and a psychometric evaluation was performed to check if the data agreed with item response theory (IRT) assumptions. Next, a CAT simulation was performed for each of the four 4DSQ scales (distress, depression, anxiety, and somatization), based on the given responses as if they had been collected through CAT. The following two stopping rules were applied for the administration of items: (1) stop if measurement precision is below a predefined level, or (2) stop if more than half of the items of the subscale are administered. Results: In general, the items of each of the four scales agreed with IRT assumptions. Application of the first stopping rule reduced the length of the questionnaire by 38% (from 50 to 31 items on average). When the second stopping rule was also applied, the total number of items could be reduced by 56% (from 50 to 22 items on average). Conclusions: CAT seems useful for improving the efficiency of the 4DSQ by 56% without losing a considerable amount of measurement precision. The CAT version of the 4DSQ may be useful as part of an online assessment to investigate the severity of mental health problems of patients visiting a GP. This simulation study is the first step needed for the development a CAT version of the 4DSQ. A CAT version of the 4DSQ could be of high value for Dutch GPs since increasing numbers of patients with mental health problems are visiting the general practice. In further research, the results of a real-time CAT should be compared with the results of the administration of the full scale. %M 28223264 %R 10.2196/mental.6545 %U http://mental.jmir.org/2017/1/e7/ %U https://doi.org/10.2196/mental.6545 %U http://www.ncbi.nlm.nih.gov/pubmed/28223264 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 1 %P e6 %T Use of Online Forums for Perinatal Mental Illness, Stigma, and Disclosure: An Exploratory Model %A Moore,Donna %A Drey,Nicholas %A Ayers,Susan %+ Centre for Maternal and Child Health, School of Health Sciences, City, University of London, Northampton Square, London,, United Kingdom, 44 20 7040 5, Donna.Moore.1@city.ac.uk %K Internet %K social stigma %K depression %K postpartum %K mood disorder %K female %D 2017 %7 20.02.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Perinatal mental illness is a global health concern; however, many women with the illness do not get the treatment they need to recover. Interventions that reduce the stigma around perinatal mental illness have the potential to enable women to disclose their symptoms to health care providers and consequently access treatment. There are many online forums for perinatal mental illness and thousands of women use them. Preliminary research suggests that online forums may promote help-seeking behavior, potentially because they have a role in challenging stigma. This study draws from these findings and theoretical concepts to present a model of forum use, stigma, and disclosure. Objective: This study tested a model that measured the mediating role of stigma between online forum use and disclosure of affective symptoms to health care providers. Methods: A Web-based survey of 200 women who were pregnant or had a child younger than 5 years and considered themselves to be experiencing psychological distress was conducted. Women were recruited through social media and questions measured forum usage, perinatal mental illness stigma, disclosure to health care providers, depression and anxiety symptoms, barriers to disclosure, and demographic information. Results: There was a significant positive indirect effect of length of forum use on disclosure of symptoms through internal stigma, b=0.40, bias-corrected and accelerated (BCa) 95% CI 0.13-0.85. Long-term forum users reported higher levels of internal stigma, and higher internal stigma was associated with disclosure of symptoms to health care providers when controlling for symptoms of depression and anxiety. Conclusions: Internal stigma mediates the relationship between length of forum use and disclosure to health care providers. Findings suggest that forums have the potential to enable women to recognize and reveal their internal stigma, which may in turn lead to greater disclosure of symptoms to health care providers. Clinicians could refer clients to trustworthy and moderated online forums that facilitate expression of perinatal mental illness stigma and promote disclosure to health care providers. %M 28219879 %R 10.2196/mental.5926 %U http://mental.jmir.org/2017/1/e6/ %U https://doi.org/10.2196/mental.5926 %U http://www.ncbi.nlm.nih.gov/pubmed/28219879 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 2 %N 1 %P e1 %T The Case for Jointly Targeting Diabetes and Depression Among Vulnerable Patients Using Digital Technology %A Aguilera,Adrian %A Lyles,Courtney Rees %+ School of Social Welfare, University of California, Berkeley, 120 Haviland Hall, MC 7400, Berkeley, CA,, United States, 1 510 642 8564, aguila@berkeley.edu %K diabetes %K depression %K chronic illness %K digital health %K vulnerable populations %D 2017 %7 17.01.2017 %9 Viewpoint %J JMIR Diabetes %G English %X It is well publicized that mobile and digital technologies hold great promise to improve health outcomes among patients with chronic illnesses such as diabetes. However, there is growing concern that digital health investments (both from federal research dollars and private venture investments) have not yet resulted in tangible health improvements. We see three major reasons for this limited real-world impact on health outcomes: (1) lack of solutions relevant for patients with multiple comorbidities or conditions, (2) lack of diverse patient populations involved in the design and early testing of products, and (3) inability to leverage existing clinical workflows to improve both patient enrollment and engagement in technology use. We discuss each of these in depth, followed by new research directions to increase effectiveness in this field. %M 30291080 %R 10.2196/diabetes.6916 %U http://diabetes.jmir.org/2017/1/e1/ %U https://doi.org/10.2196/diabetes.6916 %U http://www.ncbi.nlm.nih.gov/pubmed/30291080 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 1 %P e3 %T Tips and Traps: Lessons From Codesigning a Clinician E-Monitoring Tool for Computerized Cognitive Behavioral Therapy %A Sundram,Frederick %A Hawken,Susan J %A Stasiak,Karolina %A Lucassen,Mathijs FG %A Fleming,Theresa %A Shepherd,Matthew %A Greenwood,Andrea %A Osborne,Raechel %A Merry,Sally N %+ Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland, 1142, New Zealand, 64 9 923 7521, f.sundram@auckland.ac.nz %K e-therapy %K psychotherapy %K cognitive therapy %K depression %K psychology, adolescent %K primary health care %D 2017 %7 11.01.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Computerized cognitive behavioral therapy (cCBT) is an acceptable and promising treatment modality for adolescents with mild-to-moderate depression. Many cCBT programs are standalone packages with no way for clinicians to monitor progress or outcomes. We sought to develop an electronic monitoring (e-monitoring) tool in consultation with clinicians and adolescents to allow clinicians to monitor mood, risk, and treatment adherence of adolescents completing a cCBT program called SPARX (Smart, Positive, Active, Realistic, X-factor thoughts). Objective: The objectives of our study were as follows: (1) assess clinicians’ and adolescents’ views on using an e-monitoring tool and to use this information to help shape the development of the tool and (2) assess clinician experiences with a fully developed version of the tool that was implemented in their clinical service. Methods: A descriptive qualitative study using semistructured focus groups was conducted in New Zealand. In total, 7 focus groups included clinicians (n=50) who worked in primary care, and 3 separate groups included adolescents (n=29). Clinicians were general practitioners (GPs), school guidance counselors, clinical psychologists, youth workers, and nurses. Adolescents were recruited from health services and a high school. Focus groups were run to enable feedback at 3 phases that corresponded to the consultation, development, and postimplementation stages. Thematic analysis was applied to transcribed responses. Results: Focus groups during the consultation and development phases revealed the need for a simple e-monitoring registration process with guides for end users. Common concerns were raised in relation to clinical burden, monitoring risk (and effects on the therapeutic relationship), alongside confidentiality or privacy and technical considerations. Adolescents did not want to use their social media login credentials for e-monitoring, as they valued their privacy. However, adolescents did want information on seeking help and personalized monitoring and communication arrangements. Postimplementation, clinicians who had used the tool in practice revealed no adverse impact on the therapeutic relationship, and adolescents were not concerned about being e-monitored. Clinicians did need additional time to monitor adolescents, and the e-monitoring tool was used in a different way than was originally anticipated. Also, it was suggested that the registration process could be further streamlined and integrated with existing clinical data management systems, and the use of clinician alerts could be expanded beyond the scope of simply flagging adolescents of concern. Conclusions: An e-monitoring tool was developed in consultation with clinicians and adolescents. However, the study revealed the complexity of implementing the tool in clinical practice. Of salience were privacy, parallel monitoring systems, integration with existing electronic medical record systems, customization of the e-monitor, and preagreed monitoring arrangements between clinicians and adolescents. %M 28077345 %R 10.2196/mental.5878 %U http://mental.jmir.org/2017/1/e3/ %U https://doi.org/10.2196/mental.5878 %U http://www.ncbi.nlm.nih.gov/pubmed/28077345 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 1 %P e7 %T Variations in Facebook Posting Patterns Across Validated Patient Health Conditions: A Prospective Cohort Study %A Smith,Robert J %A Crutchley,Patrick %A Schwartz,H Andrew %A Ungar,Lyle %A Shofer,Frances %A Padrez,Kevin A %A Merchant,Raina M %+ Penn Medicine Social Media and Health Innovation Lab, Penn Medicine Center for Health Care Innovation, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, 19104, United States, 1 215 746 7990, raina.merchant@uphs.upenn.edu %K Facebook %K depression %K natural language processing %K social media %D 2017 %7 6.1.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Social media is emerging as an insightful platform for studying health. To develop targeted health interventions involving social media, we sought to identify the patient demographic and disease predictors of frequency of posting on Facebook. Objective: The aims were to explore the language topics correlated with frequency of social media use across a cohort of social media users within a health care setting, evaluate the differences in the quantity of social media postings across individuals with different disease diagnoses, and determine if patients could accurately predict their own levels of social media engagement. Methods: Patients seeking care at a single, academic, urban, tertiary care emergency department from March to October 2014 were queried on their willingness to share data from their Facebook accounts and electronic medical records (EMRs). For each participant, the total content of Facebook posts was extracted. Using the latent Dirichlet allocation natural language processing technique, Facebook language topics were correlated with frequency of Facebook use. The mean number of Facebook posts over 6 months prior to enrollment was then compared across validated health outcomes in the sample. Results: A total of 695 patients consented to provide access to their EMR and social media data. Significantly correlated language topics among participants with the highest quartile of posts contained health terms, such as “cough,” “headaches,” and “insomnia.” When adjusted for demographics, individuals with a history of depression had significantly higher posts (mean 38, 95% CI 28-50) than individuals without a history of depression (mean 22, 95% CI 19-26, P=.001). Except for depression, across prevalent health outcomes in the sample (hypertension, diabetes, asthma), there were no significant posting differences between individuals with or without each condition. Conclusions: High-frequency posters in our sample were more likely to post about health and to have a diagnosis of depression. The direction of causality between depression and social media use requires further evaluation. Our findings suggest that patients with depression may be appropriate targets for health-related interventions on social media. %M 28062392 %R 10.2196/jmir.6486 %U http://www.jmir.org/2017/1/e7/ %U https://doi.org/10.2196/jmir.6486 %U http://www.ncbi.nlm.nih.gov/pubmed/28062392 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 1 %P e10 %T IntelliCare: An Eclectic, Skills-Based App Suite for the Treatment of Depression and Anxiety %A Mohr,David C %A Tomasino,Kathryn Noth %A Lattie,Emily G %A Palac,Hannah L %A Kwasny,Mary J %A Weingardt,Kenneth %A Karr,Chris J %A Kaiser,Susan M %A Rossom,Rebecca C %A Bardsley,Leland R %A Caccamo,Lauren %A Stiles-Shields,Colleen %A Schueller,Stephen M %+ Center for Behavioral Intervention Technologies (CBITs), Department of Preventive Medicine, Northwestern University, 750 N Lakeshore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 312 503 1403, d-mohr@northwestern.edu %K mHealth %K eHealth %K mobile health %K depression %K anxiety %D 2017 %7 05.01.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital mental health tools have tended to use psychoeducational strategies based on treatment orientations developed and validated outside of digital health. These features do not map well to the brief but frequent ways that people use mobile phones and mobile phone apps today. To address these challenges, we developed a suite of apps for depression and anxiety called IntelliCare, each developed with a focused goal and interactional style. IntelliCare apps prioritize interactive skills training over education and are designed for frequent but short interactions. Objective: The overall objective of this study was to pilot a coach-assisted version of IntelliCare and evaluate its use and efficacy at reducing symptoms of depression and anxiety. Methods: Participants, recruited through a health care system, Web-based and community advertising, and clinical research registries, were included in this single-arm trial if they had elevated symptoms of depression or anxiety. Participants had access to the 14 IntelliCare apps from Google Play and received 8 weeks of coaching on the use of IntelliCare. Coaching included an initial phone call plus 2 or more texts per week over the 8 weeks, with some participants receiving an additional brief phone call. Primary outcomes included the Patient Health Questionnaire-9 (PHQ-9) for depression and the Generalized Anxiety Disorder-7 (GAD-7) for anxiety. Participants were compensated up to US $90 for completing all assessments; compensation was not for app use or treatment engagement. Results: Of the 99 participants who initiated treatment, 90.1% (90/99) completed 8 weeks. Participants showed substantial reductions in the PHQ-9 and GAD-7 (P<.001). Participants used the apps an average of 195.4 (SD 141) times over the 8 weeks. The average length of use was 1.1 (SD 2.1) minutes, and 95% of participants downloaded 5 or more of the IntelliCare apps. Conclusions: This study supports the IntelliCare framework of providing a suite of skills-focused apps that can be used frequently and briefly to reduce symptoms of depression and anxiety. The IntelliCare system is elemental, allowing individual apps to be used or not used based on their effectiveness and utility, and it is eclectic, viewing treatment strategies as elements that can be applied as needed rather than adhering to a singular, overarching, theoretical model. Trial Registration: Clinicaltrials.gov NCT02176226; http://clinicaltrials.gov/ct2/show/NCT02176226 (Archived by WebCite at http://www.webcitation/6mQZuBGk1) %M 28057609 %R 10.2196/jmir.6645 %U http://www.jmir.org/2017/1/e10/ %U https://doi.org/10.2196/jmir.6645 %U http://www.ncbi.nlm.nih.gov/pubmed/28057609 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 1 %P e4 %T Complaint-Directed Mini-Interventions for Depressive Complaints: A Randomized Controlled Trial of Unguided Web-Based Self-Help Interventions %A Lokman,Suzanne %A Leone,Stephanie S %A Sommers-Spijkerman,Marion %A van der Poel,Agnes %A Smit,Filip %A Boon,Brigitte %+ Department of Public Mental Health, Trimbos Institute: Netherlands Institute of Mental Health and Addiction, Da Costakade 45, Utrecht, 3521 VS, Netherlands, 31 30 2959385, slokman@trimbos.nl %K prevention %K depression %K Internet-based intervention %K randomized controlled trial %D 2017 %7 04.01.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Prevention of depression is important due to the substantial burden of disease associated with it. To this end, we developed a novel, brief, and low-threshold Web-based self-help approach for depressive complaints called complaint-directed mini-interventions (CDMIs). These CDMIs focus on highly prevalent complaints that are demonstrably associated with depression and have a substantial economic impact: stress, sleep problems, and worry. Objective: The aim was to evaluate the effectiveness of the Web-based self-help CDMIs in a sample of adults with mild-to-moderate depressive symptoms compared to a wait-list control group. Methods: A two-armed randomized controlled trial was conducted. An open recruitment strategy was used. Participants were randomized to either the Web-based CDMIs or the no-intervention wait-list control group. The CDMIs are online, unguided, self-help interventions, largely based on cognitive behavioral techniques, which consist of 3 to 4 modules with up to 6 exercises per module. Participants are free to choose between the modules and exercises. Assessments, using self-report questionnaires, took place at baseline and at 3 and 6 months after baseline. The control group was given access to the intervention following the 3-month assessment. The primary goal of the CDMIs is to reduce depressive complaints. The primary outcome of the study was a reduction in depressive complaints as measured by the Inventory of Depressive Symptomatology Self-Report (IDS-SR). Secondary outcomes included reductions in stress, worry, sleep problems, and anxiety complaints, and improvements in well-being. Data were analyzed using linear mixed models. Results: In total, 329 participants enrolled in the trial, of which 165 were randomized to the intervention group and 164 to the control group. Approximately three-quarters of the intervention group actually created an account. Of these participants, 91.3% (116/127) logged into their chosen CDMI at least once during the 3-month intervention period (median 3, range 0-166). After 3 months, there was a significant reduction in depressive symptomatology for participants in the intervention group compared to participants in the wait-list control group (reduction in depression: mean –4.47, 95% CI –6.54 to –2.40; Cohen d=–0.70). Furthermore, significant effects were observed for sleep problems, worry, anxiety, and well-being, with effect sizes ranging from –0.29 to –0.40. The intervention did not significantly reduce stress. At 6-month follow-up, the improvements in the intervention group were generally sustained. Conclusions: This study shows that the online self-help CDMIs have a positive impact on various mental health outcomes. Future research should focus on which specific strategies may boost adherence, and increase the reach of the CDMIs among people with low socioeconomic status. ClinicalTrial: Netherlands Trial Register (NTR): NTR4612; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4612 (Archived by WebCite at http://www.webcitation.org/6n4PVYddM) %M 28052840 %R 10.2196/jmir.6581 %U http://www.jmir.org/2017/1/e4/ %U https://doi.org/10.2196/jmir.6581 %U http://www.ncbi.nlm.nih.gov/pubmed/28052840 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 1 %P e5 %T Preventing Depression in Adults With Subthreshold Depression: Health-Economic Evaluation Alongside a Pragmatic Randomized Controlled Trial of a Web-Based Intervention %A Buntrock,Claudia %A Berking,Matthias %A Smit,Filip %A Lehr,Dirk %A Nobis,Stephanie %A Riper,Heleen %A Cuijpers,Pim %A Ebert,David %+ Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Nägelsbachstr. 25a, Erlangen, 91052, Germany, 49 91318567568, buntrockclaudia@gmail.com %K prevention %K major depressive disorders %K Internet %K early intervention %K cost effectiveness %D 2017 %7 04.01.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Psychological interventions for the prevention of depression might be a cost-effective way to reduce the burden associated with depressive disorders. Objective: To evaluate the cost-effectiveness of a Web-based guided self-help intervention to prevent major depressive disorder (MDD) in people with subthreshold depression (sD). Methods: A pragmatic randomized controlled trial was conducted with follow-up at 12 months. Participants were recruited from the general population via a large statutory health insurance company and an open access website. Participants were randomized to a Web-based guided self-help intervention (ie, cognitive-behavioral therapy and problem-solving therapy assisted by supervised graduate students or health care professionals) in addition to usual care or to usual care supplemented with Web-based psycho-education (enhanced usual care). Depression-free years (DFYs) were assessed by blinded diagnostic raters using the telephone-administered Structured Clinical Interview for DSM-IV Axis Disorders at 6- and 12-month follow-up, covering the period to the previous assessment. Costs were self-assessed through a questionnaire. Costs measured from a societal and health care perspective were related to DFYs and quality-adjusted life years (QALYs). Results: In total, 406 participants were enrolled in the trial. The mean treatment duration was 5.84 (SD 4.37) weeks. On average, participants completed 4.93 of 6 sessions. Significantly more DFYs were gained in the intervention group (0.82 vs 0.70). Likewise, QALY health gains were in favor of the intervention, but only statistically significant when measured with the more sensitive SF-6D. The incremental per-participant costs were €136 (£116). Taking the health care perspective and assuming a willingness-to-pay of €20,000 (£17,000), the intervention’s likelihood of being cost-effective was 99% for gaining a DFY and 64% or 99% for gaining an EQ-5D or a SF-6D QALY. Conclusions: Our study supports guidelines recommending Web-based treatment for sD and adds that this not only restores health in people with sD, but additionally reduces the risk of developing a MDD. Offering the intervention has an acceptable likelihood of being more cost-effective than enhanced usual care and could therefore reach community members on a wider scale. Trial registration: German Clinical Trials Register: DRKS00004709; http://www.drks.de/DRKS00004709 (Archived by WebCite at http://www.webcitation.org/6kAZVUxy9) %M 28052841 %R 10.2196/jmir.6587 %U http://www.jmir.org/2017/1/e5/ %U https://doi.org/10.2196/jmir.6587 %U http://www.ncbi.nlm.nih.gov/pubmed/28052841 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 12 %P e330 %T The Use and Effectiveness of Mobile Apps for Depression: Results From a Fully Remote Clinical Trial %A Arean,Patricia A %A Hallgren,Kevin A %A Jordan,Joshua T %A Gazzaley,Adam %A Atkins,David C %A Heagerty,Patrick J %A Anguera,Joaquin A %+ Department of Neurology, University of California San Francisco, 675 Nelson Rising Lane, San Francisco, CA, 94158, United States, 1 415 502 7322, joaquin.anguera@ucsf.edu %K depression %K mobile apps %K RCT %K randomized controlled trial %K cognitive training %K iPST %K problem-solving therapy %D 2016 %7 20.12.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile apps for mental health have the potential to overcome access barriers to mental health care, but there is little information on whether patients use the interventions as intended and the impact they have on mental health outcomes. Objective: The objective of our study was to document and compare use patterns and clinical outcomes across the United States between 3 different self-guided mobile apps for depression. Methods: Participants were recruited through Web-based advertisements and social media and were randomly assigned to 1 of 3 mood apps. Treatment and assessment were conducted remotely on each participant’s smartphone or tablet with minimal contact with study staff. We enrolled 626 English-speaking adults (≥18 years old) with mild to moderate depression as determined by a 9-item Patient Health Questionnaire (PHQ-9) score ≥5, or if their score on item 10 was ≥2. The apps were (1) Project: EVO, a cognitive training app theorized to mitigate depressive symptoms by improving cognitive control, (2) iPST, an app based on an evidence-based psychotherapy for depression, and (3) Health Tips, a treatment control. Outcomes were scores on the PHQ-9 and the Sheehan Disability Scale. Adherence to treatment was measured as number of times participants opened and used the apps as instructed. Results: We randomly assigned 211 participants to iPST, 209 to Project: EVO, and 206 to Health Tips. Among the participants, 77.0% (482/626) had a PHQ-9 score >10 (moderately depressed). Among the participants using the 2 active apps, 57.9% (243/420) did not download their assigned intervention app but did not differ demographically from those who did. Differential treatment effects were present in participants with baseline PHQ-9 score >10, with the cognitive training and problem-solving apps resulting in greater effects on mood than the information control app (χ22=6.46, P=.04). Conclusions: Mobile apps for depression appear to have their greatest impact on people with more moderate levels of depression. In particular, an app that is designed to engage cognitive correlates of depression had the strongest effect on depressed mood in this sample. This study suggests that mobile apps reach many people and are useful for more moderate levels of depression. ClinicalTrial: Clinicaltrials.gov NCT00540865; https://www.clinicaltrials.gov/ct2/show/NCT00540865 (Archived by WebCite at http://www.webcitation.org/6mj8IPqQr) %M 27998876 %R 10.2196/jmir.6482 %U http://www.jmir.org/2016/12/e330/ %U https://doi.org/10.2196/jmir.6482 %U http://www.ncbi.nlm.nih.gov/pubmed/27998876 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 4 %P e51 %T Ecological Momentary Assessment of Adolescent Problems, Coping Efficacy, and Mood States Using a Mobile Phone App: An Exploratory Study %A Kenny,Rachel %A Dooley,Barbara %A Fitzgerald,Amanda %+ Youth Mental Health Lab, School of Psychology, University College Dublin, Belfield, Dublin, Ireland, 353 1 7168147, rachel.kenny.3@ucdconnect.ie %K adolescent %K affect %K ecological momentary assessment %K mobile apps %D 2016 %7 29.11.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: Mobile technologies have the potential to be used as innovative tools for conducting research on the mental health and well-being of young people. In particular, they have utility for carrying out ecological momentary assessment (EMA) research by capturing data from participants in real time as they go about their daily lives. Objective: The aim of this study was to explore the utility of a mobile phone app as a means of collecting EMA data pertaining to mood, problems, and coping efficacy in a school-based sample of Irish young people. Methods: The study included a total of 208 participants who were aged 15-18 years, 64% female (113/208), recruited from second-level schools in Ireland, and who downloaded the CopeSmart mobile phone app as part of a randomized controlled trial. On the app, participants initially responded to 5 single-item measures of key protective factors in youth mental health (formal help-seeking, informal help-seeking, sleep, exercise, and sense of belonging). They were then encouraged to use the app daily to input data relating to mood states (happiness, sadness, anger, stress, and worry), daily problems, and coping self-efficacy. The app automatically collected data pertaining to user engagement over the course of the 28-day intervention period. Students also completed pen and paper questionnaires containing standardized measures of emotional distress (Depression, Anxiety, and Stress Scale; DASS-21), well-being (World Health Organization Well-Being Index; WHO-5), and coping (Coping Strategies Inventory; CSI). Results: On average the participants completed 18% (5/28) of daily ratings, and engagement levels did not differ across gender, age, school, socioeconomic status, ethnicity, or nationality. On a scale of 1 to 10, happiness was consistently the highest rated mood state (overall mean 6.56), and anger was consistently the lowest (overall mean 2.11). Pearson correlations revealed that average daily ratings of emotional states were associated with standardized measures of emotional distress (rhappiness=–.45, rsadness=.51, ranger=.32, rstress=.41, rworry=.48) and well-being (rhappiness=.39, rsadness =–.43, ranger=–.27, rstress=–.35, rworry=–.33). Inferential statistics indicated that single-item indicators of key protective factors were related to emotional distress, well-being, and average daily mood states, as measured by EMA ratings. Hierarchical regressions revealed that greater daily problems were associated with more negative daily mood ratings (all at the P<.001 level); however, when coping efficacy was taken into account, the relationship between problems and happiness, sadness, and anger became negligible. Conclusions: While engagement with the app was low, overall the EMA data collected in this exploratory study appeared valid and provided useful insights into the relationships between daily problems, coping efficacy, and mood states. Future research should explore ways to increase engagement with EMA mobile phone apps in adolescent populations to maximize the amount of data captured by these tools. Trial Registration: Clinicaltrials.gov NCT02265978; http://clinicaltrials.gov/ct2/show/NCT02265978 (Archived by WebCite at http://www.webcitation.org/6mMeYqseA). %M 27899340 %R 10.2196/mental.6361 %U http://mental.jmir.org/2016/4/e51/ %U https://doi.org/10.2196/mental.6361 %U http://www.ncbi.nlm.nih.gov/pubmed/27899340 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 4 %P e49 %T Development of a Mobile Phone App to Support Self-Monitoring of Emotional Well-Being: A Mental Health Digital Innovation %A Rickard,Nikki %A Arjmand,Hussain-Abdulah %A Bakker,David %A Seabrook,Elizabeth %+ Emotion and Well-being Research Unit, School of Psychological Sciences, Monash University, Building 18, Wellington Rd, Clayton, 3800, Australia, 61 400 191 768, nikki.rickard@monash.edu %K eHealth %K emotions %K mental health %K mobile phone %K feedback %D 2016 %7 23.11.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: Emotional well-being is a primary component of mental health and well-being. Monitoring changes in emotional state daily over extended periods is, however, difficult using traditional methodologies. Providing mental health support is also challenging when approximately only 1 in 2 people with mental health issues seek professional help. Mobile phone technology offers a sustainable means of enhancing self-management of emotional well-being. Objective: This paper aims to describe the development of a mobile phone tool designed to monitor emotional changes in a natural everyday context and in real time. Methods: This evidence-informed mobile phone app monitors emotional mental health and well-being, and it provides links to mental health organization websites and resources. The app obtains data via self-report psychological questionnaires, experience sampling methodology (ESM), and automated behavioral data collection. Results: Feedback from 11 individuals (age range 16-52 years; 4 males, 7 females), who tested the app over 30 days, confirmed via survey and focus group methods that the app was functional and usable. Conclusions: Recommendations for future researchers and developers of mental health apps to be used for research are also presented. The methodology described in this paper offers a powerful tool for a range of potential mental health research studies and provides a valuable standard against which development of future mental health apps should be considered. %M 27881358 %R 10.2196/mental.6202 %U http://mental.jmir.org/2016/4/e49/ %U https://doi.org/10.2196/mental.6202 %U http://www.ncbi.nlm.nih.gov/pubmed/27881358 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 4 %P e50 %T Social Networking Sites, Depression, and Anxiety: A Systematic Review %A Seabrook,Elizabeth M %A Kern,Margaret L %A Rickard,Nikki S %+ Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, 18 Innovation Walk, Monash University, Clayton, 3800, Australia, 61 413170668, elizabeth.seabrook@monash.edu %K depression %K anxiety %K social media %K social networking %K review, systematic %K mental health %K well-being %D 2016 %7 23.11.2016 %9 Review %J JMIR Ment Health %G English %X Background: Social networking sites (SNSs) have become a pervasive part of modern culture, which may also affect mental health. Objective: The aim of this systematic review was to identify and summarize research examining depression and anxiety in the context of SNSs. It also aimed to identify studies that complement the assessment of mental illness with measures of well-being and examine moderators and mediators that add to the complexity of this environment. Methods: A multidatabase search was performed. Papers published between January 2005 and June 2016 relevant to mental illness (depression and anxiety only) were extracted and reviewed. Results: Positive interactions, social support, and social connectedness on SNSs were consistently related to lower levels of depression and anxiety, whereas negative interaction and social comparisons on SNSs were related to higher levels of depression and anxiety. SNS use related to less loneliness and greater self-esteem and life satisfaction. Findings were mixed for frequency of SNS use and number of SNS friends. Different patterns in the way individuals with depression and individuals with social anxiety engage with SNSs are beginning to emerge. Conclusions: The systematic review revealed many mixed findings between depression, anxiety, and SNS use. Methodology has predominantly focused on self-report cross-sectional approaches; future research will benefit from leveraging real-time SNS data over time. The evidence suggests that SNS use correlates with mental illness and well-being; however, whether this effect is beneficial or detrimental depends at least partly on the quality of social factors in the SNS environment. Understanding these relationships will lead to better utilization of SNSs in their potential to positively influence mental health. %M 27881357 %R 10.2196/mental.5842 %U http://mental.jmir.org/2016/4/e50/ %U https://doi.org/10.2196/mental.5842 %U http://www.ncbi.nlm.nih.gov/pubmed/27881357 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 11 %P e309 %T Do We Still Have a Digital Divide in Mental Health? A Five-Year Survey Follow-up %A Robotham,Dan %A Satkunanathan,Safarina %A Doughty,Lisa %A Wykes,Til %+ Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, United Kingdom, 44 207848 ext 0219, dan.robotham@kcl.ac.uk %K digital divide %K socioeconomic factors %K technology %K mobile phone %K psychotic disorders %K distance counseling %D 2016 %7 22.11.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Nearly everyone in society uses the Internet in one form or another. The Internet is heralded as an efficient way of providing mental health treatments and services. However, some people are still excluded from using Internet-enabled technology through lack of resources, skills, and confidence. Objective: Five years ago, we showed that people with severe mental illness were at risk of digital exclusion, especially middle-aged patients with psychosis and/or people from black or minority ethnic groups with psychosis. An understanding of the breadth of potential digital exclusion is vital for the implementation of digital health services. The aim of this study is to understand the context of digital exclusion for people who experience mental illness. Methods: We conducted a survey involving people with a primary diagnosis of psychosis or depression in London, United Kingdom. A total of 241 participants were recruited: 121 with psychosis and 120 with depression. The majority of surveys were collected face-to-face (psychosis: n=109; depression: n=71). Participants answered questions regarding familiarity, access, use, motivation, and confidence with Internet-enabled technologies (ie, computers and mobile phones). Variables predicting digital exclusion were identified in regression analyses. The results were compared with the survey conducted in 2011. Results: Digital exclusion has declined since 2011. Online survey collection introduced biases into the sample, masking those who were likely to be excluded. Only 18.3% (20/109) of people with psychosis in our sample were digitally excluded, compared with 30% (28/93) in 2011 (χ21=3.8, P=.04). People with psychosis had less confidence in using the Internet than people with depression (χ21=7.4, P=.004). Only 9.9% (24/241) of participants in the total sample were digitally excluded, but the majority of these people had psychosis (n=20). Those with psychosis who were digitally excluded were significantly older than their included peers (t30=3.3, P=.002) and had used services for longer (t97=2.5, P=.02). Younger people were more likely to use mobile phones. Digitally excluded participants cited a lack of knowledge as a barrier to digital inclusion, and most wanted to use the Internet via computers (rather than mobile phones). Conclusions: Digital exclusion is lower, but some remain excluded. Facilitating inclusion among this population means helping them develop skills and confidence in using technology, and providing them with access. Providing mobile phones without basic information technology training may be counterproductive because excluded people may be excluded from mobile technology too. An evidence-based digital inclusion strategy is needed within the National Health Service to help digitally excluded populations access Internet-enabled services. %M 27876684 %R 10.2196/jmir.6511 %U http://www.jmir.org/2016/11/e309/ %U https://doi.org/10.2196/jmir.6511 %U http://www.ncbi.nlm.nih.gov/pubmed/27876684 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 4 %P e218 %T The Effects of an E-Mental Health Program and Job Coaching on the Risk of Major Depression and Productivity in Canadian Male Workers: Protocol for a Randomized Controlled Trial %A Wang,JianLi %A Patten,Scott B %A Lam,Raymond W %A Attridge,Mark %A Ho,Kendall %A Schmitz,Norbert %A Marchand,Alain %A Lashewicz,Bonnie M %+ Department of Psychiatry, University of Calgary, Room 4D69, TRW Building, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada, 1 4032108653, jlwang@ucalgary.ca %K Internet %K RCT %K men %K workplace %K major depression %K prevention %D 2016 %7 15.11.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: Major depression (MDE) is prevalent in men and affects men’s health and productivity. Because of the stigma against depression and social/gender norms, men are less likely to seek help for emotion and stress-related issues. Therefore, innovative solutions tailored for men are needed. With rapid development of the Internet and information technologies, one promising solution that has drawn considerable attentions is electronic mental (e-mental) health programs and services. Objective: The objective of our study is to evaluate the effectiveness of the e-mental health program BroHealth on reducing the risk of having MDE and improving productivity and return to investment. Methods: The target population is Canadian working men who are at high risk of having MDE (N=1200). Participants will be recruited using the method of random digit dialing across the country and workplace advertisement. Eligible participants will be randomly allocated into the following groups: (1) a control group, (2) a group receiving BroHealth only, and (3) a group receiving BroHealth and telephone-based job coaching service. The groups will be assessed at 6 and 12 months after randomization. The primary outcome is the risk proportion of MDE over 12 months, which will be assessed by the World Health Organization's (WHO’s) Composite International Diagnostic Interview-Short Form for Major Depression. Intention-to-treat principle will be used in the analysis. The 12-month proportions of MDE in the groups will be estimated and compared. Logistic regression modeling will be used to examine the effect of the intervention on the outcome, controlling for the effects of baseline confounders. Results: It is anticipated that the randomized controlled trial (RCT) will be completed by 2018. This study has been approved by the Conjoint Health Research Ethics Review Board of the University of Calgary. The trial is funded by a team grant from the Movember Foundation, a global charity for men’s health. BroHealth was developed at the Digital Emergency Medicine, University of British Columbia, and the usability testing has been completed. Conclusions: BroHealth was developed based on men’s needs. We hypothesized that BroHealth will be an effective, acceptable, and sustainable product for early prevention of MDE in workplaces. ClinicalTrial: Clinicaltrials.gov NCT02777112; https://clinicaltrials.gov/ct2/show/NCT02777112 (Archived by WebCite at http://www.webcitation.org/6lbOQpiCG) %M 27847352 %R 10.2196/resprot.6350 %U http://www.researchprotocols.org/2016/4/e218/ %U https://doi.org/10.2196/resprot.6350 %U http://www.ncbi.nlm.nih.gov/pubmed/27847352 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 4 %P e215 %T Overcoming Perfectionism: Protocol of a Randomized Controlled Trial of an Internet-Based Guided Self-Help Cognitive Behavioral Therapy Intervention %A Kothari,Radha %A Egan,Sarah %A Wade,Tracey %A Andersson,Gerhard %A Shafran,Roz %+ Institute of Child Health Population, Policy and Practice Programme, University College London, 4th Floor, 30 Guilford Street, London, United Kingdom, 44 020 7905 2311 ext 2169, r.shafran@ucl.ac.uk %K perfectionism %K cognitive behavioral therapy %K randomized controlled trial %K Internet-based intervention %K anxiety %K depression %D 2016 %7 11.11.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: Perfectionism is elevated across, and increases risk for, a range of psychological disorders as well as having a direct negative effect on day-to-day function. A growing body of evidence shows that cognitive behavioral therapy (CBT) reduces perfectionism and psychological disorders, with medium to large effect sizes. Given the increased desire for Web-based interventions to facilitate access to evidence-based therapy, Internet-based CBT self-help interventions for perfectionism have been designed. Existing Web-based interventions have not included personalized guidance which has been shown to improve outcome rates. Objective: To assess the efficacy of an Internet-based guided self-help CBT intervention for perfectionism at reducing symptoms of perfectionism and psychological disorders posttreatment and at 6-month follow-up. Methods: A randomized controlled trial method is employed, comparing the treatment arm (Internet-based guided self-help CBT) with a waiting list control group. Outcomes are examined at 3 time points, T1 (baseline), T2 (postintervention at 12 weeks), T3 (follow-up at 24 weeks). Participants will be recruited through universities, online platforms, and social media and if eligible will be randomized using an automatic randomizer. Results: Data will be analyzed to estimate the between group (intervention, control) effect on perfectionism, depression, and anxiety. Completer and intent-to-treat analyses will be conducted. Additional analysis will be conducted to investigate whether the number of modules completed is associated with change. Data collection should be finalized by December 2016, with submission of results for publication expected in mid-year 2017. Results will be reported in line with recommendations in the Consolidated Standards of Reporting Trials Statement for Randomized Controlled Trials of Electronic and Mobile Health Applications and Online TeleHealth (CONSORT-EHEALTH). Conclusions: Findings will contribute to the literature on treatment of perfectionism, the effect of treating perfectionism on depression and anxiety, and the efficacy of Internet-based guided self-help interventions. ClinicalTrial: ClinicalTrials.gov NCT02756871; https://clinicaltrials.gov/ct2/show/NCT02756871 (Archived by WebCite at http://www.webcitation.org/6lmIlSRAa) %M 27836815 %R 10.2196/resprot.6378 %U http://www.researchprotocols.org/2016/4/e215/ %U https://doi.org/10.2196/resprot.6378 %U http://www.ncbi.nlm.nih.gov/pubmed/27836815 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 4 %P e209 %T Cognitive Behavior Therapy for Anxious and Depressed Youth: Improving Homework Adherence Through Mobile Technology %A Wilansky,Pamela %A Eklund,J Mikael %A Milner,Tracy %A Kreindler,David %A Cheung,Amy %A Kovacs,Tim %A Shooshtari,Shahin %A Astell,Arlene %A Ohinmaa,Arto %A Henderson,Joanna %A Strauss,John %A Mills,Rosemary SL %+ Child, Youth and Family Services, Centre for Addiction and Mental Health, University of Toronto, Intergenerational Wellness Building, 6th floor rm 6232, 80 Workman Way, Toronto, ON, M6J 1H4, Canada, 1 416 322 5176, pwilansky@frameworkcentre.com %K mHealth %K mobile app %K youth %K anxiety %K depression %K cognitive behavior therapy %K homework %D 2016 %7 10.11.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: Anxiety and mood disorders are the most common mental illnesses, peaking during adolescence and affecting approximately 25% of Canadians aged 14-17 years. If not successfully treated at this age, they often persist into adulthood, exerting a great social and economic toll. Given the long-term impact, finding ways to increase the success and cost-effectiveness of mental health care is a pressing need. Cognitive behavior therapy (CBT) is an evidence-based treatment for mood and anxiety disorders throughout the lifespan. Mental health technologies can be used to make such treatments more successful by delivering them in a format that increases utilization. Young people embrace technologies, and many want to actively manage their mental health. Mobile software apps have the potential to improve youth adherence to CBT and, in turn, improve outcomes of treatment. Objective: The purpose of this project is to improve homework adherence in CBT for youth anxiety and/or depression. The objectives are to (1) design and optimize the usability of a mobile app for delivering the homework component of CBT for youth with anxiety and/or depression, (2) assess the app’s impact on homework completion, and (3) implement the app in CBT programs. We hypothesize that homework adherence will be greater in the app group than in the no-app group. Methods: Phase 1: exploratory interviews will be conducted with adolescents and therapists familiar with CBT to obtain views and perspectives on the requirements and features of a usable app and the challenges involved in implementation. The information obtained will guide the design of a prototype. The prototype will be optimized via think-aloud procedures involving an iterative process of evaluation, modification, and re-evaluation, culminating in a fully functional version of the prototype that is ready for optimization in a clinical context. Phase 2: a usability study will be conducted to optimize the prototype in the context of treatment at clinics that provide CBT treatment for youth with anxiety and/or depression. This phase will result in a usable app that is ready to be tested for its effectiveness in increasing homework adherence. Phase 3: a pragmatic clinical trial will be conducted at several clinics to evaluate the impact of the app on homework adherence. Participants in the app group are expected to show greater homework completion than those in the no-app group. Results: Phase 3 will be completed by September 2019. Conclusions: The app will be a unique adjunct to treatment for adolescents in CBT, focusing on both anxiety and depression, developed in partnership with end users at every stage from design to implementation, customizable for different cognitive profiles, and designed with depression symptom tracking measures for youth made interoperable with electronic medical records. %M 27833071 %R 10.2196/resprot.5841 %U http://www.researchprotocols.org/2016/4/e209/ %U https://doi.org/10.2196/resprot.5841 %U http://www.ncbi.nlm.nih.gov/pubmed/27833071 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 2 %N 2 %P e164 %T Efficacy of Web-Based Collection of Strength-Based Testimonials for Text Message Extension of Youth Suicide Prevention Program: Randomized Controlled Experiment %A Thiha,Phyo %A Pisani,Anthony R %A Gurditta,Kunali %A Cherry,Erin %A Peterson,Derick R %A Kautz,Henry %A Wyman,Peter A %+ Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 300 Crittenden Blvd., Box PSYC, Rochester, NY, 14642, United States, 1 585 275 3644, anthony_pisani@urmc.rochester.edu %K mental health %K adolescent health %K user interface design %K suicide %K text messaging %D 2016 %7 09.11.2016 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Equipping members of a target population to deliver effective public health messaging to peers is an established approach in health promotion. The Sources of Strength program has demonstrated the promise of this approach for “upstream” youth suicide prevention. Text messaging is a well-established medium for promoting behavior change and is the dominant communication medium for youth. In order for peer ‘opinion leader’ programs like Sources of Strength to use scalable, wide-reaching media such as text messaging to spread peer-to-peer messages, they need techniques for assisting peer opinion leaders in creating effective testimonials to engage peers and match program goals. We developed a Web interface, called Stories of Personal Resilience in Managing Emotions (StoryPRIME), which helps peer opinion leaders write effective, short-form messages that can be delivered to the target population in youth suicide prevention program like Sources of Strength. Objective: To determine the efficacy of StoryPRIME, a Web-based interface for remotely eliciting high school peer leaders, and helping them produce high-quality, personal testimonials for use in a text messaging extension of an evidence-based, peer-led suicide prevention program. Methods: In a double-blind randomized controlled experiment, 36 high school students wrote testimonials with or without eliciting from the StoryPRIME interface. The interface was created in the context of Sources of Strength–an evidence-based youth suicide prevention program–and 24 ninth graders rated these testimonials on relatability, usefulness/relevance, intrigue, and likability. Results: Testimonials written with the StoryPRIME interface were rated as more relatable, useful/relevant, intriguing, and likable than testimonials written without StoryPRIME, P=.054. Conclusions: StoryPRIME is a promising way to elicit high-quality, personal testimonials from youth for prevention programs that draw on members of a target population to spread public health messages. %M 27829575 %R 10.2196/publichealth.6207 %U http://publichealth.jmir.org/2016/2/e164/ %U https://doi.org/10.2196/publichealth.6207 %U http://www.ncbi.nlm.nih.gov/pubmed/27829575 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 4 %P e48 %T Awareness, Access and Use of Internet Self-Help Websites for Depression by University Students %A Culjak,Gordana %A Kowalenko,Nick %A Tennant,Christopher %+ Discipline of Psychiatry, Sydney Medical School, University of Sydney, New South Wales, Sydney, 2006, Australia, 61 9351 2222, gordana.culjak@uni.sydney.edu.au %K depression %K awareness %K Internet %K self-help %K university %K students %K eHealth %K health promotion %K prevention %D 2016 %7 27.10.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: University students have a higher prevalence rate of depression than the average 18 to 24 year old. Internet self-help has been demonstrated to be effective in decreasing self-rated measures of depression in this population, so it is important to explore the awareness, access and use of such self-help resources in this population. Objective: The objective of this study is to explore university students’ awareness, access and use of Internet self-help websites for depression and related problems. Methods: A total of 2691 university students were surveyed at 3 time points. Results: When asked about browsing behavior, 69.6% (1494/2146) of students reported using the Internet for entertainment. Most students were not familiar with self-help websites for emotional health, although this awareness increased as they completed further assessments. Most students considered user-friendliness, content and interactivity as very important in the design of a self-help website. After being exposed to a self-help website, more students reported visiting websites for emotional health than those who had not been exposed. Conclusions: More students reported visiting self-help websites after becoming aware of such resources. Increased awareness of depression and related treatment resources may increase use of such resources. It is important to increase public awareness with the aim of increasing access to targeted strategies for young people. %M 27789425 %R 10.2196/mental.5311 %U http://mental.jmir.org/2016/4/e48/ %U https://doi.org/10.2196/mental.5311 %U http://www.ncbi.nlm.nih.gov/pubmed/27789425 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 3 %P e47 %T Web-Based Intervention to Reduce Substance Abuse and Depressive Symptoms in Mexico: Development and Usability Test %A Tiburcio,Marcela %A Lara,Ma Asunción %A Aguilar Abrego,Araceli %A Fernández,Morise %A Martínez Vélez,Nora %A Sánchez,Alejandro %+ Ramón de la Fuente Muñiz, National Institute of Psychiatry, Department of Social Sciences in Health, Direction of Epidemiological and Psychosocial Research, Calz Mexico-Xochimilco 101, Col San Lorenzo Huipulco, Del Tlalpan, Mexico City, 14370, Mexico, 52 5541605162, tibsam@imp.edu.mx %K substance abuse %K depressive symptoms %K Internet %K cognitive behavioral therapy %K usability %D 2016 %7 29.09.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: The development of Web-based interventions for substance abuse in Latin America is a new field of interest with great potential for expansion to other Spanish-speaking countries. Objective: This paper describes a project aimed to develop and evaluate the usability of the Web-based Help Program for Drug Abuse and Depression (Programa de Ayuda para Abuso de Drogas y Depresión, PAADD, in Spanish) and also to construct a systematic frame of reference for the development of future Web-based programs. Methods: The PAADD aims to reduce substance use and depressive symptoms with cognitive behavioral techniques translated into Web applications, aided by the participation of a counselor to provide support and guidance. This Web-based intervention includes 4 steps: (1) My Starting Point, (2) Where Do I Want to Be? (3) Strategies for Change, and (4) Maintaining Change. The development of the program was an interactive multistage process. The first stage defined the core structure and contents, which were validated in stage 2 by a group of 8 experts in addiction treatment. Programming of the applications took place in stage 3, taking into account 3 types of end users: administrators, counselors, and substance users. Stage 4 consisted of functionality testing. In stage 5, a total of 9 health professionals and 20 drug users currently in treatment voluntarily interacted with the program in a usability test, providing feedback about adjustments needed to improve users’ experience. Results: The main finding of stage 2 was the consensus of the health professionals about the cognitive behavioral strategies and techniques included in PAADD being appropriate for changing substance use behaviors. In stage 5, the health professionals found the functionalities easy to learn; their suggestions were related to the page layout, inclusion of confirmation messages at the end of activities, avoiding “read more” links, and providing feedback about every activity. On the other hand, the users said the information presented within the modules was easy to follow and suggested more dynamic features with concrete instructions and feedback. Conclusions: The resulting Web-based program may have advantages over traditional face-to-face therapies owing to its low cost, wide accessibility, anonymity, and independence of time and distance factors. The detailed description of the process of designing a Web-based program is an important contribution to others interested in this field. The potential benefits must be verified in specific studies. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 25429892; http://www.controlled-trials.com/ISRCTN25429892 (Archived by WebCite at http://www.webcitation.org/6ko1Fsvym) %M 27687965 %R 10.2196/mental.6001 %U http://mental.jmir.org/2016/3/e47/ %U https://doi.org/10.2196/mental.6001 %U http://www.ncbi.nlm.nih.gov/pubmed/27687965 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 9 %P e255 %T Post-9/11 Veterans and Their Partners Improve Mental Health Outcomes with a Self-directed Mobile and Web-based Wellness Training Program: A Randomized Controlled Trial %A Kahn,Janet R %A Collinge,William %A Soltysik,Robert %+ College of Medicine, Department of Psychiatry, University of Vermont, 240 Maple Street, Burlington, VT, 05401, United States, 1 802 578 2990, Janet.Kahn@uvm.edu %K veterans %K PTSD %K moral injury %K mind-body therapies %K mindfulness %K patient-centered care %K compassion %K Web-based program %K reintegration %D 2016 %7 27.09.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Veterans with history of deployment in the Global War on Terror face significant and ongoing challenges with high prevalences of adverse psychological, physical, spiritual, and family impacts. Together, these challenges contribute to an emerging public health crisis likely to extend well into the future. Innovative approaches are needed that reach veterans and their family members with strategies they can employ over time in their daily lives to promote improved adjustment and well-being. Objective: The objective of this study was to evaluate effects of use of a Web-based, self-directed program of instruction in mind- and body-based wellness skills to be employed by Global War on Terror veterans and their significant relationship partners on mental health and wellness outcomes associated with postdeployment readjustment. Methods: We recruited 160 veteran-partner dyads in 4 regions of the United States (San Diego, CA; Dallas, TX; Fayetteville, NC; and New York, NY) through publicity by the Iraq and Afghanistan Veterans of America to its membership. Dyads were randomly allocated to 1 of 4 study arms: Mission Reconnect (MR) program alone, MR plus the Prevention and Relationship Enhancement Program (PREP) for Strong Bonds weekend program for military couples, PREP alone, and waitlist control. We administered a battery of standardized and investigator-generated instruments assessing mental health outcomes at baseline, 8 weeks, and 16 weeks. Dyads in the MR arms were provided Web-based and mobile app video and audio instruction in a set of mindfulness-related stress reduction and contemplative practices, as well as partner massage for reciprocal use. All participants provided weekly reports on frequency and duration of self-care practices for the first 8 weeks, and at 16 weeks. Results: During the first 8-week reporting period, veterans and partners assigned to MR arms used some aspect of the program a mean of 20 times per week, totaling nearly 2.5 hours per week, with only modest declines in use at 16 weeks. Significant improvements were seen at 8 and 16 weeks in measures of posttraumatic stress disorder, depression, sleep quality, perceived stress, resilience, self-compassion, and pain for participants assigned to MR arms. In addition, significant reductions in self-reported levels of pain, tension, irritability, anxiety, and depression were associated with use of partner massage. Conclusions: Both veterans and partners were able to learn and make sustained use of a range of wellness practices taught in the MR program. Home-based, self-directed interventions may be of particular service to veterans who are distant from, averse to, or prohibited by schedule from using professional services. Leveraging the partner relationship may enhance sustained use of self-directed interventions for this population. Use of the MR program appears to be an accessible, low-cost approach that supports well-being and reduces multiple symptoms among post-9/11 veterans and their partners. Trial Registration: Clinicaltrials.gov NCT01680419; https://clinicaltrials.gov/ct2/show/NCT01680419 (Archived by WebCite at http://www.webcitation.org/6jJuadfzj) %M 27678169 %R 10.2196/jmir.5800 %U http://www.jmir.org/2016/9/e255/ %U https://doi.org/10.2196/jmir.5800 %U http://www.ncbi.nlm.nih.gov/pubmed/27678169 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 4 %N 3 %P e111 %T Mobile Sensing and Support for People With Depression: A Pilot Trial in the Wild %A Wahle,Fabian %A Kowatsch,Tobias %A Fleisch,Elgar %A Rufer,Michael %A Weidt,Steffi %+ University of St Gallen, Institute of Technology Management, Dufourstrasse 40a, Büro 1-236, St Gallen, 9000, Switzerland, 41 712247244, tobias.kowatsch@unisg.ch %K depression %K mHealth %K  activities of daily living %K classification %K context awareness %K cognitive behavioral therapy %D 2016 %7 21.09.2016 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depression is a burdensome, recurring mental health disorder with high prevalence. Even in developed countries, patients have to wait for several months to receive treatment. In many parts of the world there is only one mental health professional for over 200 people. Smartphones are ubiquitous and have a large complement of sensors that can potentially be useful in monitoring behavioral patterns that might be indicative of depressive symptoms and providing context-sensitive intervention support. Objective: The objective of this study is 2-fold, first to explore the detection of daily-life behavior based on sensor information to identify subjects with a clinically meaningful depression level, second to explore the potential of context sensitive intervention delivery to provide in-situ support for people with depressive symptoms. Methods: A total of 126 adults (age 20-57) were recruited to use the smartphone app Mobile Sensing and Support (MOSS), collecting context-sensitive sensor information and providing just-in-time interventions derived from cognitive behavior therapy. Real-time learning-systems were deployed to adapt to each subject’s preferences to optimize recommendations with respect to time, location, and personal preference. Biweekly, participants were asked to complete a self-reported depression survey (PHQ-9) to track symptom progression. Wilcoxon tests were conducted to compare scores before and after intervention. Correlation analysis was used to test the relationship between adherence and change in PHQ-9. One hundred twenty features were constructed based on smartphone usage and sensors including accelerometer, Wifi, and global positioning systems (GPS). Machine-learning models used these features to infer behavior and context for PHQ-9 level prediction and tailored intervention delivery. Results: A total of 36 subjects used MOSS for ≥2 weeks. For subjects with clinical depression (PHQ-9≥11) at baseline and adherence ≥8 weeks (n=12), a significant drop in PHQ-9 was observed (P=.01). This group showed a negative trend between adherence and change in PHQ-9 scores (rho=−.498, P=.099). Binary classification performance for biweekly PHQ-9 samples (n=143), with a cutoff of PHQ-9≥11, based on Random Forest and Support Vector Machine leave-one-out cross validation resulted in 60.1% and 59.1% accuracy, respectively. Conclusions: Proxies for social and physical behavior derived from smartphone sensor data was successfully deployed to deliver context-sensitive and personalized interventions to people with depressive symptoms. Subjects who used the app for an extended period of time showed significant reduction in self-reported symptom severity. Nonlinear classification models trained on features extracted from smartphone sensor data including Wifi, accelerometer, GPS, and phone use, demonstrated a proof of concept for the detection of depression superior to random classification. While findings of effectiveness must be reproduced in a RCT to proof causation, they pave the way for a new generation of digital health interventions leveraging smartphone sensors to provide context sensitive information for in-situ support and unobtrusive monitoring of critical mental health states. %M 27655245 %R 10.2196/mhealth.5960 %U http://mhealth.jmir.org/2016/3/e111/ %U https://doi.org/10.2196/mhealth.5960 %U http://www.ncbi.nlm.nih.gov/pubmed/27655245 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 9 %P e236 %T The Implementation of Internet Interventions for Depression: A Scoping Review %A Drozd,Filip %A Vaskinn,Linda %A Bergsund,Hans Bugge %A Haga,Silje Marie %A Slinning,Kari %A Bjørkli,Cato Alexander %+ National Network for Infant Mental Health, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, PO Box 4623 Nydalen, Oslo, 0405, Norway, 47 975 16 188, filip.drozd@r-bup.no %K depression %K scoping review %K implementation %K Internet interventions %D 2016 %7 08.09.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is one of the most common mental health problems among adults, but effective treatments are not widely accessible. The Internet holds promise as a cost-effective and convenient delivery platform of interventions for depression. However, studies suggest that Internet interventions are not widely available in routine settings. Objective: The aim of this study was to review the literature and examine whether there are systematic differences in reporting of the various implementation components on Internet interventions for depression, and then to examine what is known about and is characteristic of the implementation of these Internet interventions in regular care settings. Methods: We performed a scoping review, drawing upon a broad range of the literature on Internet interventions for depression in regular care, and used the active implementation framework to extract data. Results: Overall, the results suggested that knowledge about the implementation of Internet interventions for depression in regular care is limited. However, guided support from health professionals emphasizing program adherence and recruitment of end users to the interventions emerged as 2 main themes. We identified 3 additional themes among practitioners, including their qualifications, training, and supervision, but these were scarcely described in the literature. The competency drivers (ie, staff and user selection, training, and supervision) have received the most attention, while little attention has been given to organizational (ie, decision support, administration, and system intervention) and leadership drivers. Conclusions: Research has placed little emphasis on reporting on the implementation of interventions in practice. Leadership and organizational drivers, in particular, have been largely neglected. The results of this scoping review have implications for future research and efforts to successfully implement Internet interventions for depression in regular care. %M 27608548 %R 10.2196/jmir.5670 %U http://www.jmir.org/2016/9/e236/ %U https://doi.org/10.2196/jmir.5670 %U http://www.ncbi.nlm.nih.gov/pubmed/27608548 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 8 %P e231 %T An Internet-Based Intervention for Depression in Primary Care in Spain: A Randomized Controlled Trial %A Montero-Marín,Jesús %A Araya,Ricardo %A Pérez-Yus,María C %A Mayoral,Fermín %A Gili,Margalida %A Botella,Cristina %A Baños,Rosa %A Castro,Adoración %A Romero-Sanchiz,Pablo %A López-Del-Hoyo,Yolanda %A Nogueira-Arjona,Raquel %A Vives,Margarita %A Riera,Antoni %A García-Campayo,Javier %+ Aragon Health Sciences Institute, Avda. San Juan Bosco, 13. 50009. Zaragoza., Zaragoza,, Spain, 34 (+34) 976715895, mcperezy@gmail.com %D 2016 %7 26.08.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is the most prevalent cause of illness-induced disability worldwide. Face-to-face psychotherapeutic interventions for depression can be challenging, so there is a need for other alternatives that allow these interventions to be offered. One feasible alternative is Internet-based psychological interventions. This is the first randomized controlled trial (RCT) on the effectiveness of an Internet-based intervention on depression in primary health care in Spain. Objective: Our aim was to compare the effectiveness of a low-intensity therapist-guided (LITG) Internet-based program and a completely self-guided (CSG) Internet-based program with improved treatment as usual (iTAU) care for depression. Methods: Multicenter, three-arm, parallel, RCT design, carried out between November 2012 and January 2014, with a follow-up of 15 months. In total, 296 adults from primary care settings in four Spanish regions, with mild or moderate major depression, were randomized to LITG (n=96), CSG (n=98), or iTAU (n=102). Research completers at follow-up were 63.5%. The intervention was Smiling is Fun, an Internet program based on cognitive behavioral therapy. All patients received iTAU by their general practitioners. Moreover, LITG received Smiling is Fun and the possibility of psychotherapeutic support on request by email, whereas CSG received only Smiling is Fun. The main outcome was the Beck Depression Inventory-II at 3 months from baseline. Mixed-effects multilevel analysis for repeated measures were undertaken. Results: There was no benefit for either CSG [(B coefficient=-1.15; P=.444)] or LITG [(B=-0.71; P=.634)] compared to iTAU, at 3 months. There were differences at 6 months [iTAU vs CSG (B=-4.22; P=.007); iTAU vs LITG (B=-4.34; P=.005)] and 15 months [iTAU vs CSG (B=-5.10; P=.001); iTAU vs LITG (B=-4.62; P=.002)]. There were no differences between CSG and LITG at any time. Adjusted and intention-to-treat models confirmed these findings. Conclusions: An Internet-based intervention for depression combined with iTAU conferred a benefit over iTAU alone in the Spanish primary health care system. Trial Registration: Clinicaltrials.gov NCT01611818; https://register.clinicaltrials.gov/prs/app/action/SelectProtocol? selectaction=Edit&uid=U0001NPQ&ts=2&cx=gctdh2&sid=S0003KJ6 (Archived by WebCite at http://www.webcitation.org/6jbsUvUDz) %M 27565118 %R 10.2196/jmir.5695 %U http://www.jmir.org/2016/8/e231/ %U https://doi.org/10.2196/jmir.5695 %U http://www.ncbi.nlm.nih.gov/pubmed/27565118 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 8 %P e221 %T Effectiveness of Web-Delivered Acceptance and Commitment Therapy in Relation to Mental Health and Well-Being: A Systematic Review and Meta-Analysis %A Brown,Menna %A Glendenning,Alexander %A Hoon,Alice E %A John,Ann %+ Swansea University, Medical School, ILS2, Swansea, SA2 8PP, United Kingdom, 44 179260 ext 6213, menna.brown@swansea.ac.uk %K acceptance and commitment therapy %K systematic review %K meta-analysis %K depression %K anxiety %K quality of life %K Internet-based %K mobile-based %D 2016 %7 24.08.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: The need for effective interventions to improve mental health and emotional well-being at a population level are gaining prominence both in the United Kingdom and globally. Advances in technology and widespread adoption of Internet capable devices have facilitated rapid development of Web-delivered psychological therapies. Interventions designed to manage a range of affective disorders by applying diverse therapeutic approaches are widely available. Objective: The main aim of this review was to evaluate the evidence base of acceptance and commitment therapy (ACT) in a Web-based delivery format. Method: A systematic review of the literature and meta-analysis was conducted. Two electronic databases were searched for Web-delivered interventions utilizing ACT for the management of affective disorders or well-being. Only Randomized Controlled Trials (RCTs) were included. Results: The search strategy identified 59 articles. Of these, 10 articles met the inclusion criteria specified. The range of conditions and outcome measures that were identified limited the ability to draw firm conclusions about the efficacy of Web-delivered ACT-based intervention for anxiety or well-being. Conclusions: ACT in a Web-based delivery format was found to be effective in the management of depression. Rates of adherence to study protocols and completion were high overall suggesting that this therapeutic approach is highly acceptable for patients and the general public. %M 27558740 %R 10.2196/jmir.6200 %U http://www.jmir.org/2016/8/e221/ %U https://doi.org/10.2196/jmir.6200 %U http://www.ncbi.nlm.nih.gov/pubmed/27558740 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 8 %P e229 %T Use and Appreciation of a Tailored Self-Management eHealth Intervention for Early Cancer Survivors: Process Evaluation of a Randomized Controlled Trial %A Kanera,Iris Maria %A Willems,Roy A %A Bolman,Catherine A W %A Mesters,Ilse %A Zambon,Victor %A Gijsen,Brigitte CM %A Lechner,Lilian %+ Faculty of Psychology and Educational Sciences, Open University of the Netherlands, Valkenburgerweg 177, Heerlen, 6401 DL, Netherlands, 31 455762448, iris.kanera@ou.nl %K eHealth %K web-based intervention %K computer tailoring %K cancer survivorship %K intervention usage %K appreciation %K multiple behavior intervention %K process evaluation %K self-management %D 2016 %7 23.08.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: A fully automated computer-tailored Web-based self-management intervention, Kanker Nazorg Wijzer (KNW [Cancer Aftercare Guide]), was developed to support early cancer survivors to adequately cope with psychosocial complaints and to promote a healthy lifestyle. The KNW self-management training modules target the following topics: return to work, fatigue, anxiety and depression, relationships, physical activity, diet, and smoking cessation. Participants were guided to relevant modules by personalized module referral advice that was based on participants’ current complaints and identified needs. Objective: The aim of this study was to evaluate the adherence to the module referral advice, examine the KNW module use and its predictors, and describe the appreciation of the KNW and its predictors. Additionally, we explored predictors of personal relevance. Methods: This process evaluation was conducted as part of a randomized controlled trial. Early cancer survivors with various types of cancer were recruited from 21 Dutch hospitals. Data from online self-report questionnaires and logging data were analyzed from participants allocated to the intervention condition. Chi-square tests were applied to assess the adherence to the module referral advice, negative binominal regression analysis was used to identify predictors of module use, multiple linear regression analysis was applied to identify predictors of the appreciation, and ordered logistic regression analysis was conducted to explore possible predictors of perceived personal relevance. Results: From the respondents (N=231; mean age 55.6, SD 11.5; 79.2% female [183/231]), 98.3% (227/231) were referred to one or more KNW modules (mean 2.9, SD 1.5), and 85.7% (198/231) of participants visited at least one module (mean 2.1, SD 1.6). Significant positive associations were found between the referral to specific modules (range 1-7) and the use of corresponding modules. The likelihoods of visiting modules were higher when respondents were referred to those modules by the module referral advice. Predictors of visiting a higher number of modules were a higher number of referrals by the module referral advice (β=.136, P=.009), and having a partner was significantly related with a lower number of modules used (β=-.256, P=.044). Overall appreciation was high (mean 7.5, SD 1.2; scale 1-10) and was significantly predicted by a higher perceived personal relevance (β=.623, P=.000). None of the demographic and cancer-related characteristics significantly predicted the perceived personal relevance. Conclusions: The KNW in general and more specifically the KNW modules were well used and highly appreciated by early cancer survivors. Indications were found that the module referral advice might be a meaningful intervention component to guide the users in following a preferred selection of modules. These results indicate that the fully automated Web-based KNW provides personal relevant and valuable information and support for early cancer survivors. Therefore, this intervention can complement usual cancer aftercare and may serve as a first step in a stepped-care approach. Trial Registration: Nederlands Trial Register: NTR3375; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3375 (Archived by WebCite at http://www.webcitation.org/6jo4jO7kb) %M 27554525 %R 10.2196/jmir.5975 %U http://www.jmir.org/2016/8/e229/ %U https://doi.org/10.2196/jmir.5975 %U http://www.ncbi.nlm.nih.gov/pubmed/27554525 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 3 %P e160 %T Predicting Negative Emotions Based on Mobile Phone Usage Patterns: An Exploratory Study %A Hung,Galen Chin-Lun %A Yang,Pei-Ching %A Chang,Chia-Chi %A Chiang,Jung-Hsien %A Chen,Ying-Yeh %+ Department of General Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, No. 309,, Songde Rd., Xinyi Dst.,, Taipei, 106, Taiwan, 886 2 27263141 ext 1270, galenhung@tpech.gov.tw %K mobile phone usage %K depression %K emotion %K machine learning %K affective computing %D 2016 %7 10.08.2016 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Prompt recognition and intervention of negative emotions is crucial for patients with depression. Mobile phones and mobile apps are suitable technologies that can be used to recognize negative emotions and intervene if necessary. Objective: Mobile phone usage patterns can be associated with concurrent emotional states. The objective of this study is to adapt machine-learning methods to analyze such patterns for the prediction of negative emotion. Methods: We developed an Android-based app to capture emotional states and mobile phone usage patterns, which included call logs (and use of apps). Visual analog scales (VASs) were used to report negative emotions in dimensions of depression, anxiety, and stress. In the system-training phase, participants were requested to tag their emotions for 14 consecutive days. Five feature-selection methods were used to determine individual usage patterns and four machine-learning methods were tested. Finally, rank product scoring was used to select the best combination to construct the prediction model. In the system evaluation phase, participants were then requested to verify the predicted negative emotions for at least 5 days. Results: Out of 40 enrolled healthy participants, we analyzed data from 28 participants, including 30% (9/28) women with a mean (SD) age of 29.2 (5.1) years with sufficient emotion tags. The combination of time slots of 2 hours, greedy forward selection, and Naïve Bayes method was chosen for the prediction model. We further validated the personalized models in 18 participants who performed at least 5 days of model evaluation. Overall, the predictive accuracy for negative emotions was 86.17%. Conclusion: We developed a system capable of predicting negative emotions based on mobile phone usage patterns. This system has potential for ecological momentary intervention (EMI) for depressive disorders by automatically recognizing negative emotions and providing people with preventive treatments before it escalates to clinical depression. %M 27511748 %R 10.2196/resprot.5551 %U http://www.researchprotocols.org/2016/3/e160/ %U https://doi.org/10.2196/resprot.5551 %U http://www.ncbi.nlm.nih.gov/pubmed/27511748 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 8 %P e216 %T Depression Screening Using Daily Mental-Health Ratings from a Smartphone Application for Breast Cancer Patients %A Kim,Junetae %A Lim,Sanghee %A Min,Yul Ha %A Shin,Yong-Wook %A Lee,Byungtae %A Sohn,Guiyun %A Jung,Kyung Hae %A Lee,Jae-Ho %A Son,Byung Ho %A Ahn,Sei Hyun %A Shin,Soo-Yong %A Lee,Jong Won %+ Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic Of Korea, 82 2 3010 5603, jongwonlee116@gmail.com %K depression %K smartphone applications %K mental health %K breast cancer (neoplasms) %D 2016 %7 04.08.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile mental-health trackers are mobile phone apps that gather self-reported mental-health ratings from users. They have received great attention from clinicians as tools to screen for depression in individual patients. While several apps that ask simple questions using face emoticons have been developed, there has been no study examining the validity of their screening performance. Objective: In this study, we (1) evaluate the potential of a mobile mental-health tracker that uses three daily mental-health ratings (sleep satisfaction, mood, and anxiety) as indicators for depression, (2) discuss three approaches to data processing (ratio, average, and frequency) for generating indicator variables, and (3) examine the impact of adherence on reporting using a mobile mental-health tracker and accuracy in depression screening. Methods: We analyzed 5792 sets of daily mental-health ratings collected from 78 breast cancer patients over a 48-week period. Using the Patient Health Questionnaire-9 (PHQ-9) as the measure of true depression status, we conducted a random-effect logistic panel regression and receiver operating characteristic (ROC) analysis to evaluate the screening performance of the mobile mental-health tracker. In addition, we classified patients into two subgroups based on their adherence level (higher adherence and lower adherence) using a k-means clustering algorithm and compared the screening accuracy between the two groups. Results: With the ratio approach, the area under the ROC curve (AUC) is 0.8012, indicating that the performance of depression screening using daily mental-health ratings gathered via mobile mental-health trackers is comparable to the results of PHQ-9 tests. Also, the AUC is significantly higher (P=.002) for the higher adherence group (AUC=0.8524) than for the lower adherence group (AUC=0.7234). This result shows that adherence to self-reporting is associated with a higher accuracy of depression screening. Conclusions: Our results support the potential of a mobile mental-health tracker as a tool for screening for depression in practice. Also, this study provides clinicians with a guideline for generating indicator variables from daily mental-health ratings. Furthermore, our results provide empirical evidence for the critical role of adherence to self-reporting, which represents crucial information for both doctors and patients. %M 27492880 %R 10.2196/jmir.5598 %U http://www.jmir.org/2016/8/e216/ %U https://doi.org/10.2196/jmir.5598 %U http://www.ncbi.nlm.nih.gov/pubmed/27492880 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 3 %P e36 %T Home-Based Psychiatric Outpatient Care Through Videoconferencing for Depression: A Randomized Controlled Follow-Up Trial %A Hungerbuehler,Ines %A Valiengo,Leandro %A Loch,Alexandre A %A Rössler,Wulf %A Gattaz,Wagner F %+ Laboratory of Neuroscience, Institute of Psychiatry, University of Sao Paulo, Rua Dr. Ovidio Pires de Campos 785, São Paulo, 05403-010, Brazil, 55 11 2661 8010, ines.hungerbuehler@gmail.com %K telemedicine %K telehealth %K eHealth, videoconferencing %K psychiatry %K outpatient %K home-care services %K mental health %K depression %D 2016 %7 03.08.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is a tremendous opportunity for innovative mental health care solutions such as psychiatric care through videoconferencing to increase the number of people who have access to quality care. However, studies are needed to generate empirical evidence on the use of psychiatric outpatient care via videoconferencing, particularly in low- and middle-income countries and clinically unsupervised settings. Objective: The objective of this study was to evaluate the effectiveness and feasibility of home-based treatment for mild depression through psychiatric consultations via videoconferencing. Methods: A randomized controlled trial with a 6- and 12-month follow-up including adults with mild depression treated in an ambulatory setting was conducted. In total, 107 participants were randomly allocated to the videoconferencing intervention group (n=53) or the face-to-face group (F2F; n=54). The groups did not differ with respect to demographic characteristics at baseline. The F2F group completed monthly follow-up consultations in person. The videoconferencing group received monthly follow-up consultations with a psychiatrist through videoconferencing at home. At baseline and after 6 and 12 months, in-person assessments were conducted with all participants. Clinical outcomes (severity of depression, mental health status, medication course, and relapses), satisfaction with treatment, therapeutic relationship, treatment adherence (appointment compliance and dropouts), and medication adherence were assessed. Results: The severity of depression decreased significantly over the 12-month follow-up in both the groups. There was a significant difference between groups regarding treatment outcomes throughout the follow-up period, with better results in the videoconferencing group. There were 4 relapses in the F2F group and only 1 in the videoconferencing group. No significant differences between groups regarding mental health status, satisfaction with treatment, therapeutic relationship, treatment adherence, or medication compliance were found. However, after 6 months, the rate of dropouts was significantly higher in the F2F group (18.5% vs 5.7% in the videoconferencing group, P<.05). Conclusions: Psychiatric treatment through videoconferencing in clinically unsupervised settings can be considered feasible and as effective as standard care (in-person treatment) for depressed outpatients with respect to clinical outcomes, patient satisfaction, therapeutic relationship, treatment adherence, and medication compliance. These results indicate the potential of telepsychiatry to extend access to psychiatric care to remote and underserved populations. ClinicalTrial: Clinicaltrials.gov NCT01901315; https://clinicaltrials.gov/ct2/show/NCT01901315 (Archived by WebCite at http://www.webcitation.org/6jBTrIVwg) %M 27489204 %R 10.2196/mental.5675 %U http://mental.jmir.org/2016/3/e36/ %U https://doi.org/10.2196/mental.5675 %U http://www.ncbi.nlm.nih.gov/pubmed/27489204 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 8 %P e194 %T The Effect of Guided Web-Based Cognitive Behavioral Therapy on Patients With Depressive Symptoms and Heart Failure: A Pilot Randomized Controlled Trial %A Lundgren,Johan Gustav %A Dahlström,Örjan %A Andersson,Gerhard %A Jaarsma,Tiny %A Kärner Köhler,Anita %A Johansson,Peter %+ Division of Nursing Science, Department of Social and Welfare Studies, Linköping University, Department of Social and Welfare Studies, Linköping University, Norrköping, SE 601 74, Sweden, 46 011363592, johan.lundgren@liu.se %K heart failure %K depression %K Internet-based cognitive behavioral therapy %K cognitive behavioral therapy %K Internet %K eHealth %D 2016 %7 03.08.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Depressive symptoms, and the associated coexistence of symptoms of anxiety and decreased quality of life (QoL), are common in patients with heart failure (HF). However, treatment strategies for depressive symptoms in patients with HF still remain to be established. Internet-based cognitive behavioral therapy (ICBT), as guided self-help CBT programs, has shown good effects in the treatment of depression. Until now, ICBT has not been evaluated in patients with HF with depressive symptoms. Objective: The aims of this study were to (1) evaluate the effect of a 9-week guided ICBT program on depressive symptoms in patients with HF; (2) investigate the effect of the ICBT program on cardiac anxiety and QoL; and (3) assess factors associated with the change in depressive symptoms. Methods: Fifty participants were randomized into 2 treatment arms: ICBT or a Web-based moderated discussion forum (DF). The Patient Health Questionnaire-9 was used to measure depressive symptoms, the Cardiac Anxiety Questionnaire (CAQ) was used to measure cardiac-related anxiety, and the Minnesota Living with Heart Failure questionnaire was used to measure QoL. Data were collected at baseline and at follow-up at the end of the 9-week intervention. Intention-to-treat analysis was used, and missing data were imputed by the Expectation-Maximization method. Between-group differences were determined by analysis of covariance with control for baseline score and regression to the mean. Results: No significant difference in depressive symptoms between the ICBT and the DF group at the follow-up was found, [F(1,47)=1.63, P=.21] and Cohen´s d=0.26. Secondary within-group analysis of depressive symptoms showed that such symptoms decreased significantly in the ICBT group from baseline to the follow-up (baseline M=10.8, standard deviation [SD]=5.7 vs follow-up M=8.6, SD=4.6, t(24)=2.6, P=.02, Cohen´s d=0.43), whereas in the DF group, there was no significant change (baseline M=10.6, SD=5.0, vs follow-up M=9.8, SD=4.3, t(24)=0.93, P=.36. Cohen´s d=0.18). With regard to CAQ and QoL no significant differences were found between the groups (CAQ [d(1,47)=0.5, P=.48] and QoL [F(1,47)=2.87, P=.09]). In the ICBT group in the CAQ subscale of fear, a significant within-group decrease was shown (baseline M=1.55 vs follow-up M=1.35, P=.04). In the ICBT group, the number of logins to the Web portal correlated significantly with improvement in depressive symptoms (P=.02), whereas higher age (P=.01) and male sex (P=.048) were associated with less change in depressive symptoms. This study is underpowered because of difficulties in the recruitment of patients. Conclusions: Guided ICBT adapted for persons with HF and depressive symptoms was not statistically superior to participation in a Web-based DF. However, within the ICBT group, a statically significant improvement of depressive symptoms was detected. ClinicalTrial: Clinicaltrials.gov NCT01681771; https://clinicaltrials.gov/ct2/show/NCT01681771 (Archived by WebCite at http://www.webcitation.org/6ikzbcuLN) %M 27489077 %R 10.2196/jmir.5556 %U http://www.jmir.org/2016/8/e194/ %U https://doi.org/10.2196/jmir.5556 %U http://www.ncbi.nlm.nih.gov/pubmed/27489077 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 4 %N 3 %P e88 %T Psychologist in a Pocket: Lexicon Development and Content Validation of a Mobile-Based App for Depression Screening %A Cheng,Paula Glenda Ferrer %A Ramos,Roann Munoz %A Bitsch,Jó Ágila %A Jonas,Stephan Michael %A Ix,Tim %A See,Portia Lynn Quetulio %A Wehrle,Klaus %+ The Graduate School, University of Santo Tomas, Thomas Aquinas Research Complex, Espana Boulevard, Manila, 1015, Philippines, 63 7315396 ext 8247, chengpaulaferrer@gmail.com %K depression %K Psychologist in a Pocket %K lexicon development %K text analysis %D 2016 %7 20.07.2016 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Language reflects the state of one’s mental health and personal characteristics. It also reveals preoccupations with a particular schema, thus possibly providing insights into psychological conditions. Using text or lexical analysis in exploring depression, negative schemas and self-focusing tendencies may be depicted. As mobile technology has become highly integrated in daily routine, mobile devices have the capacity for ecological momentary assessment (EMA), specifically the experience sampling method (ESM), where behavior is captured in real-time or closer in time to experience in one’s natural environment. Extending mobile technology to psychological health could augment initial clinical assessment, particularly of mood disturbances, such as depression and analyze daily activities, such as language use in communication. Here, we present the process of lexicon generation and development and the initial validation of Psychologist in a Pocket (PiaP), a mobile app designed to screen signs of depression through text analysis. Objective: The main objectives of the study are (1) to generate and develop a depressive lexicon that can be used for screening text-input in mobile apps to be used in the PiaP; and (2) to conduct content validation as initial validation. Methods: The first phase of our research focused on lexicon development. Words related to depression and its symptoms based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and in the ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines classification systems were gathered from focus group discussions with Filipino college students, interviews with mental health professionals, and the review of established scales for depression and other related constructs. Results: The lexicon development phase yielded a database consisting of 13 categories based on the criteria depressive symptoms in the DSM-5 and ICD-10. For the draft of the depression lexicon for PiaP, we were able to gather 1762 main keywords and 9655 derivatives of main keywords. In addition, we compiled 823,869 spelling variations. Keywords included negatively-valenced words like “sad”, “unworthy”, or “tired” which are almost always accompanied by personal pronouns, such as “I”, “I’m” or “my” and in Filipino, “ako” or “ko”. For the content validation, only keywords with CVR equal to or more than 0.75 were included in the depression lexicon test-run version. The mean of all CVRs yielded a high overall CVI of 0.90. A total of 1498 main keywords, 8911 derivatives of main keywords, and 783,140 spelling variations, with a total of 793, 553 keywords now comprise the test-run version. Conclusions: The generation of the depression lexicon is relatively exhaustive. The breadth of keywords used in text analysis incorporates the characteristic expressions of depression and its related constructs by a particular culture and age group. A content-validated mobile health app, PiaP may help augment a more effective and early detection of depressive symptoms. %M 27439444 %R 10.2196/mhealth.5284 %U http://mhealth.jmir.org/2016/3/e88/ %U https://doi.org/10.2196/mhealth.5284 %U http://www.ncbi.nlm.nih.gov/pubmed/27439444 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 3 %P e19 %T Predicting Risk of Suicide Attempt Using History of Physical Illnesses From Electronic Medical Records %A Karmakar,Chandan %A Luo,Wei %A Tran,Truyen %A Berk,Michael %A Venkatesh,Svetha %+ Centre for Pattern Recognition and Data Analytics, Deakin University, Waurn Ponds, Geelong,, Australia, 61 352273079, karmakar@deakin.edu.au %K suicide risk %K electronic medical record %K history of physical illnesses %K ICD-10 codes %K suicide risk prediction model %D 2016 %7 11.07.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Although physical illnesses, routinely documented in electronic medical records (EMR), have been found to be a contributing factor to suicides, no automated systems use this information to predict suicide risk. Objective: The aim of this study is to quantify the impact of physical illnesses on suicide risk, and develop a predictive model that captures this relationship using EMR data. Methods: We used history of physical illnesses (except chapter V: Mental and behavioral disorders) from EMR data over different time-periods to build a lookup table that contains the probability of suicide risk for each chapter of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) codes. The lookup table was then used to predict the probability of suicide risk for any new assessment. Based on the different lengths of history of physical illnesses, we developed six different models to predict suicide risk. We tested the performance of developed models to predict 90-day risk using historical data over differing time-periods ranging from 3 to 48 months. A total of 16,858 assessments from 7399 mental health patients with at least one risk assessment was used for the validation of the developed model. The performance was measured using area under the receiver operating characteristic curve (AUC). Results: The best predictive results were derived (AUC=0.71) using combined data across all time-periods, which significantly outperformed the clinical baseline derived from routine risk assessment (AUC=0.56). The proposed approach thus shows potential to be incorporated in the broader risk assessment processes used by clinicians. Conclusions: This study provides a novel approach to exploit the history of physical illnesses extracted from EMR (ICD-10 codes without chapter V-mental and behavioral disorders) to predict suicide risk, and this model outperforms existing clinical assessments of suicide risk. %M 27400764 %R 10.2196/mental.5475 %U http://mental.jmir.org/2016/3/e19/ %U https://doi.org/10.2196/mental.5475 %U http://www.ncbi.nlm.nih.gov/pubmed/27400764 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 3 %P e30 %T Exploring the Use of Information and Communication Technology by People With Mood Disorder: A Systematic Review and Metasynthesis %A Fulford,Hamish %A McSwiggan,Linda %A Kroll,Thilo %A MacGillivray,Stephen %+ School of Nursing and Health Sciences, Centre for Health and Related Research, University of Dundee, Airlie Place, Dundee,, United Kingdom, 44 01382388534, s.a.macgillivray@dundee.ac.uk %K information and communication technology %K ICTs %K mood disorder %K metasynthesis %K self-management %D 2016 %7 01.07.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is a growing body of evidence relating to how information and communication technology (ICT) can be used to support people with physical health conditions. Less is known regarding mental health, and in particular, mood disorder. Objective: To conduct a metasynthesis of all qualitative studies exploring the use of ICTs by people with mood disorder. Methods: Searches were run in eight electronic databases using a systematic search strategy. Qualitative and mixed-method studies published in English between 2007 and 2014 were included. Thematic synthesis was used to interpret and synthesis the results of the included studies. Results: Thirty-four studies were included in the synthesis. The methodological design of the studies was qualitative or mixed-methods. A global assessment of study quality identified 22 studies as strong and 12 weak with most having a typology of findings either at topical or thematic survey levels of data transformation. A typology of ICT use by people with mood disorder was created as a result of synthesis. Conclusions: The systematic review and metasynthesis clearly identified a gap in the research literature as no studies were identified, which specifically researched how people with mood disorder use mobile ICT. Further qualitative research is recommended to understand the meaning this type of technology holds for people. Such research might provide valuable information on how people use mobile technology in their lives in general and also, more specifically, how they are being used to help with their mood disorders. %M 27370327 %R 10.2196/mental.5966 %U http://mental.jmir.org/2016/3/e30/ %U https://doi.org/10.2196/mental.5966 %U http://www.ncbi.nlm.nih.gov/pubmed/27370327 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 6 %P e178 %T Trajectories of Suicidal Ideation in People Seeking Web-Based Help for Suicidality: Secondary Analysis of a Dutch Randomized Controlled Trial %A Madsen,Trine %A van Spijker,Bregje %A Karstoft,Karen-Inge %A Nordentoft,Merete %A Kerkhof,Ad JFM %+ Copenhagen Mental Health Center, Copenhagen University Hospital, Kildegårdsvej 28, opgang 15, 4.sal, Hellerup, 2900, Denmark, 45 35316236, trine.madsen@regionh.dk %K suicidal ideation %K online self-help %K trajectories %K latent growth mixture modeling %D 2016 %7 30.06.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicidal ideation (SI) is a common mental health problem. Variability in intensity of SI over time has been linked to suicidal behavior, yet little is known about the temporal course of SI. Objective: The primary aim was to identify prototypical trajectories of SI in the general population and, secondarily, to examine whether receiving Web-based self-help for SI, psychiatric symptoms, or sociodemographics predicted membership in the identified SI trajectories. Methods: We enrolled 236 people, from the general Dutch population seeking Web-based help for SI, in a randomized controlled trial comparing a Web-based self-help for SI group with a control group. We assessed participants at inclusion and at 2, 4, and 6 weeks. The Beck Scale for Suicide Ideation was applied at all assessments and was included in latent growth mixture modeling analysis to empirically identify trajectories. Results: We identified 4 SI trajectories. The high stable trajectory represented 51.7% (122/236) of participants and was characterized by constant high level of SI. The high decreasing trajectory (50/236, 21.2%) consisted of people with a high baseline SI score followed by a gradual decrease to a very low score. The third trajectory, high increasing (12/236, 5.1%), also had high initial SI score, followed by an increase to the highest level of SI at 6 weeks. The fourth trajectory, low stable (52/236, 22.0%) had a constant low level of SI. Previous attempted suicide and having received Web-based self-help for SI predicted membership in the high decreasing trajectory. Conclusions: Many adults experience high persisting levels of SI, though results encouragingly indicate that receiving Web-based self-help for SI increased membership in a decreasing trajectory of SI. %M 27363482 %R 10.2196/jmir.5904 %U http://www.jmir.org/2016/6/e178/ %U https://doi.org/10.2196/jmir.5904 %U http://www.ncbi.nlm.nih.gov/pubmed/27363482 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 6 %P e163 %T Being Human: A Qualitative Interview Study Exploring Why a Telehealth Intervention for Management of Chronic Conditions Had a Modest Effect %A O'Cathain,Alicia %A Drabble,Sarah J %A Foster,Alexis %A Horspool,Kimberley %A Edwards,Louisa %A Thomas,Clare %A Salisbury,Chris %+ Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom, 44 114 222 0770, a.ocathain@sheffield.ac.uk %K telehealth %K depression %K cardiovascular diseases %K qualitative research %K chronic disease %K randomized controlled trials %K primary health care %D 2016 %7 30.06.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Evidence of benefit for telehealth for chronic conditions is mixed. Two linked randomized controlled trials tested the Healthlines Service for 2 chronic conditions: depression and high risk of cardiovascular disease (CVD). This new telehealth service consisted of regular telephone calls from nonclinical, trained health advisers who followed standardized scripts generated by interactive software. Advisors facilitated self-management by supporting participants to use Web-based resources and helped to optimize medication, improve treatment adherence, and encourage healthier lifestyles. Participants were recruited from primary care. The trials identified moderate (for depression) or partial (for CVD risk) effectiveness of the Healthlines Service. Objective: An embedded qualitative study was undertaken to help explain the results of the 2 trials by exploring mechanisms of action, context, and implementation of the intervention. Methods: Qualitative interview study of 21 staff providing usual health care or involved in the intervention and 24 patients receiving the intervention. Results: Interviewees described improved outcomes in some patients, which they attributed to the intervention, describing how components of the model on which the intervention was based helped to achieve benefits. Implementation of the intervention occurred largely as planned. However, contextual issues in patients’ lives and some problems with implementation may have reduced the size of effect of the intervention. For depression, patients’ lives and preferences affected engagement with the intervention: these largely working-age patients had busy and complex lives, which affected their ability to engage, and some patients preferred a therapist-based approach to the cognitive behavioral therapy on offer. For CVD risk, patients’ motivations adversely affected the intervention whereby some patients joined the trial for general health improvement or from altruism, rather than motivation to make lifestyle changes to address their specific risk factors. Implementation was not optimal in the early part of the CVD risk trial owing to technical difficulties and the need to adapt the intervention for use in practice. For both conditions, enthusiastic and motivated staff offering continuity of intervention delivery tailored to individual patients’ needs were identified as important for patient engagement with telehealth; this was not delivered consistently, particularly in the early stages of the trials. Finally, there was a lack of active engagement from primary care. Conclusions: The conceptual model was supported and could be used to develop further telehealth interventions for chronic conditions. It may be possible to increase the effectiveness of this, and similar interventions, by attending to the human as well as the technical aspects of telehealth: offering it to patients actively wanting the intervention, ensuring continuity of delivery by enthusiastic and motivated staff, and encouraging active engagement from primary care staff. %M 27363434 %R 10.2196/jmir.5879 %U http://www.jmir.org/2016/6/e163/ %U https://doi.org/10.2196/jmir.5879 %U http://www.ncbi.nlm.nih.gov/pubmed/27363434 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 6 %P e156 %T Does a Mobile Phone Depression-Screening App Motivate Mobile Phone Users With High Depressive Symptoms to Seek a Health Care Professional’s Help? %A BinDhim,Nasser F %A Alanazi,Eman M %A Aljadhey,Hisham %A Basyouni,Mada H %A Kowalski,Stefan R %A Pont,Lisa G %A Shaman,Ahmed M %A Trevena,Lyndal %A Alhawassi,Tariq M %+ College of Health Sciences, Health Informatics, Saudi Electronic University, Abu Baker St, Riyadh, 11673, Saudi Arabia, 966 112613500 ext 1065, nbin6641@uni.sydney.edu.au %K mental health %K depression %K mobile phone %K public health informatics %K patients’ screening %D 2016 %7 27.06.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: The objective of disease screening is to encourage high-risk subjects to seek health care diagnosis and treatment. Mobile phone apps can effectively screen mental health conditions, including depression. However, it is not known how effective such screening methods are in motivating users to discuss the obtained results of such apps with health care professionals. Does a mobile phone depression-screening app motivate users with high depressive symptoms to seek health care professional advice? This study aimed to address this question. Method: This was a single-cohort, prospective, observational study of a free mobile phone depression app developed in English and released on Apple’s App Store. Apple App Store users (aged 18 or above) in 5 countries, that is, Australia, Canada, New Zealand (NZ), the United Kingdom (UK), and the United States (US), were recruited directly via the app’s download page. The participants then completed the Patient Health Questionnaire (PHQ-9), and their depression screening score was displayed to them. If their score was 11 or above and they had never been diagnosed with depression before, they were advised to take their results to their health care professional. They were to follow up after 1 month. Results: A group of 2538 participants from the 5 countries completed PHQ-9 depression screening with the app. Of them, 322 participants were found to have high depressive symptoms and had never been diagnosed with depression, and received advice to discuss their results with health care professionals. About 74% of those completed the follow-up; approximately 38% of these self-reported consulting their health care professionals about their depression score. Only positive attitude toward depression as a real disease was associated with increased follow-up response rate (odds ratio (OR) 3.2, CI 1.38-8.29). Conclusions: A mobile phone depression-screening app motivated some users to seek a depression diagnosis. However, further study should investigate how other app users use the screening results provided by such apps. %M 27349441 %R 10.2196/jmir.5726 %U http://www.jmir.org/2016/6/e156/ %U https://doi.org/10.2196/jmir.5726 %U http://www.ncbi.nlm.nih.gov/pubmed/27349441 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 6 %P e152 %T Changing Mental Health and Positive Psychological Well-Being Using Ecological Momentary Interventions: A Systematic Review and Meta-analysis %A Versluis,Anke %A Verkuil,Bart %A Spinhoven,Philip %A van der Ploeg,Melanie M %A Brosschot,Jos F %+ Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Wassenaarseweg 52, Leiden, 2333 AK, Netherlands, 31 715276343, a.versluis@fsw.leidenuniv.nl %K mHealth %K ecological momentary intervention %K mental health %K anxiety %K depression %K stress %K meta-analysis %K systematic review %D 2016 %7 27.06.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health problems are highly prevalent, and there is need for the self-management of (mental) health. Ecological momentary interventions (EMIs) can be used to deliver interventions in the daily life of individuals using mobile devices. Objectives: The aim of this study was to systematically assess and meta-analyze the effect of EMI on 3 highly prevalent mental health outcomes (anxiety, depression, and perceived stress) and positive psychological outcomes (eg, acceptance). Methods: PsycINFO and Web of Science were searched for relevant publications, and the last search was done in September 2015. Three concepts were used to find publications: (1) mental health, (2) mobile phones, and (3) interventions. A total of 33 studies (using either a within- or between-subject design) including 43 samples that received an EMI were identified (n=1301), and relevant study characteristics were coded using a standardized form. Quality assessment was done with the Cochrane Collaboration tool. Results: Most of the EMIs focused on a clinical sample, used an active intervention (that offered exercises), and in over half of the studies, additional support by a mental health professional (MHP) was given. The EMI lasted on average 7.48 weeks (SD=6.46), with 2.80 training episodes per day (SD=2.12) and 108.25 total training episodes (SD=123.00). Overall, 27 studies were included in the meta-analysis, and after removing 6 outliers, a medium effect was found on mental health in the within-subject analyses (n=1008), with g=0.57 and 95% CI (0.45-0.70). This effect did not differ as function of outcome type (ie, anxiety, depression, perceived stress, acceptance, relaxation, and quality of life). The only moderator for which the effect varied significantly was additional support by an MHP (MHP-supported EMI, g=0.73, 95% CI: 0.57-0.88; stand-alone EMI, g=0.45, 95% CI: 0.22-0.69; stand-alone EMI with access to care as usual, g=0.38, 95% CI: 0.11-0.64). In the between-subject studies, 13 studies were included, and a small to medium effect was found (g=0.40, 95% CI: 0.22-0.57). Yet, these between-subject analyses were at risk for publication bias and were not suited for moderator analyses. Furthermore, the overall quality of the studies was relatively low. Conclusions: Results showed that there was a small to medium effect of EMIs on mental health and positive psychological well-being and that the effect was not different between outcome types. Moreover, the effect was larger with additional support by an MHP. Future randomized controlled trials are needed to further strengthen the results and to determine potential moderator variables. Overall, EMIs offer great potential for providing easy and cost-effective interventions to improve mental health and increase positive psychological well-being. %M 27349305 %R 10.2196/jmir.5642 %U http://www.jmir.org/2016/6/e152/ %U https://doi.org/10.2196/jmir.5642 %U http://www.ncbi.nlm.nih.gov/pubmed/27349305 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 2 %P e112 %T A Web-Based Psychoeducational Intervention Program for Depression and Anxiety in an Adult Community in Selangor, Malaysia: Protocol of a Randomized Controlled Trial %A Kader Maideen,Siti Fatimah %A Mohd-Sidik,Sherina %A Rampal,Lekhraj %A Mukhtar,Firdaus %A Ibrahim,Normala %A Phang,Cheng-Kar %A Tan,Kit-Aun %A Ahmad,Rozali %+ Universiti Putra Malaysia, Selangor, 43400, Malaysia, 60 89472530, sherina@upm.edu.my %K Web-based intervention %K randomized controlled trial %K depression %K anxiety %K psychoeducation %K community %K Malaysia %D 2016 %7 21.06.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mental disorders are a major public health problem and are debilitating in many nations throughout the world. Many individuals either do not or are not able to access treatment. The Internet can be a medium to convey to the community accessible evidenced-based interventions to reduce these burdens. Objective: The objective of this study is to investigate the effectiveness of 4 weeks of a Web-based psychoeducational intervention program for depressive and anxiety symptoms in the community of Selangor, Malaysia. Methods: A two-arm randomized controlled trial of a single-blind study will be conducted to meet the objective of this study. We aim to recruit 84 participants each for the intervention and control groups. The recruitment will be from participants who participated in the first phase of this research. The primary outcomes of this study are depressive and anxiety scores, which will be assessed using the Patient Health Questionnaire 9 and Generalized Anxiety Disorder 7, respectively. The secondary outcome includes mental health literacy of the participants, which will be assessed using the self-developed and adapted Mental Health Literacy Questionnaire. The psychoeducational intervention program consists of four sessions, which will be accessed each week. The depressive and anxiety symptoms will be compared between participants who participated in the psychoeducational program compared with the control group. Depressive and anxiety scores and mental health literacy will be assessed at week 1 and at follow-ups at week 5 and week 12, respectively. Results: The psychoeducational intervention program consists of four sessions, which will be accessed at each week. The depressive and anxiety symptoms will be compared between the intervention and control groups using a series of mixed ANOVAs. Depressive and anxiety scores and mental health literacy will be assessed at week 1 and at two follow-ups at week 5 and week 12, respectively. Conclusions: To our knowledge, this study will be the first randomized controlled trial of a Web-based psychoeducational intervention program for depression and anxiety in an adult community in Malaysia. The results from this study will determine the effectiveness of a psychoeducational intervention program in the management of depression and anxiety among adults in the community. If proven to be effective, the intervention can serve as a new modality to manage and reduce the burden of these disorders in the community. ClinicalTrial: International Standard Randomized Controlled Trial Number (ISRCTN): 39656144; http://www.isrctn.com/ISRCTN39656144 (Archived by WebCite at http://www.webcitation.org/6hSVhV71K) %M 27329333 %R 10.2196/resprot.4622 %U http://www.researchprotocols.org/2016/2/e112/ %U https://doi.org/10.2196/resprot.4622 %U http://www.ncbi.nlm.nih.gov/pubmed/27329333 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 6 %P e153 %T Primary Care Provider Views About Usefulness and Dissemination of a Web-Based Depression Treatment Information Decision Aid %A Beaulac,Julie %A Westmacott,Robin %A Walker,John R %A Vardanyan,Gohar %A , %+ The Ottawa Hospital, Psychology Department, 501 Smyth Road, Room 7300 General Campus, Ottawa, ON, K1H 8L6, Canada, 1 613 737 8899 ext 75078, jbeaulac@toh.on.ca %K decision aid %K depression %K treatment %K dissemination %D 2016 %7 08.06.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Decisions related to mental health are often complex, problems often remain undetected and untreated, information unavailable or not used, and treatment decisions frequently not informed by best practice or patient preferences. Objective: The objective of this paper was to obtain the opinions of health professionals working in primary health care settings about a Web-based information decision aid (IDA) for patients concerning treatment options for depression and the dissemination of the resources in primary care settings. Methods: Participants were recruited from primary care clinics in Winnipeg and Ottawa, Canada, and included 48 family physicians, nurses, and primary care staff. The study design was a qualitative framework analytic approach of 5 focus groups. Focus groups were conducted during regular staff meetings, were digitally recorded, and transcripts created. Analysis involved a content and theme analysis. Results: Seven key themes emerged including the key role of the primary care provider, common questions about treatments, treatment barriers, sources of patient information, concern about quality and quantity of available information, positive opinions about the IDA, and disseminating the IDA. The most common questions mentioned were about medication and side effects and alternatives to medication. Patients have limited access to alternative treatment options owing to cost and availability. Conclusions: Practitioners evaluated the IDA positively. The resources were described as useful, supportive of providers’ messages, and accessible for patients. There was unanimous consensus that information needs to be available electronically through the Internet. %M 27277709 %R 10.2196/jmir.5458 %U http://www.jmir.org/2016/6/e153/ %U https://doi.org/10.2196/jmir.5458 %U http://www.ncbi.nlm.nih.gov/pubmed/27277709 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 6 %P e132 %T Preferred Features of E-Mental Health Programs for Prevention of Major Depression in Male Workers: Results From a Canadian National Survey %A Wang,JianLi %A Lam,Raymond W %A Ho,Kendall %A Attridge,Mark %A Lashewicz,Bonnie M %A Patten,Scott B %A Marchand,Alain %A Aiken,Alice %A Schmitz,Norbert %A Gundu,Sarika %A Rewari,Nitika %A Hodgins,David %A Bulloch,Andrew %A Merali,Zul %+ Department of Psychiatry, University of Calgary, 3280 Hospital Dr. NW, Calgary, AB, T2N4Z6, Canada, 1 403 2108653, jlwang@ucalgary.ca %K depression %K Internet %K prevention %K e-mental health programs %K design features %K men %D 2016 %7 06.06.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Major depression is a prevalent mental disorder and imposes considerable burden on health and productivity. Men are not immune to major depression, yet they often delay seeking help because of perceived stigma and gender norms. E-mental health programs hold potential for early prevention of major depression. However, we have little knowledge about men’s preferences for design features of e-mental health programs. Objectives: The objective of this study was to (1) estimate and compare the proportions of Internet use for medical information, preferred design features, and likely use of e-mental health programs; (2) examine factors associated with the likely use of e-mental health programs; and (3) understand potential barriers to the use of e-mental health programs among Canadian working men, who were at high risk of a major depressive episode (MDE). Methods: A cross-sectional survey in 10 Canadian provinces was conducted between March and December 2015. Random digit dialing method was used through household landlines and cell phones to collect data from 511 working men who were at high risk of having an MDE and 330 working men who were at low risk of having an MDE. Results: High-risk men were more likely to endorse the importance of accessing health resources on the Internet than low-risk men (83.4% vs 75.0%, respectively; P=.01). Of the 17 different features assessed, the top three features most likely to be used by high-risk men were: “information about improving sleep hygiene” (61.3%), “practice and exercise to help reduce symptoms of stress and depression” (59.5%), and “having access to quality information and resources about work stress issues” (57.8%). Compared with men at low risk for MDE, men at high risk for MDE were much more likely to consider using almost every one of the different design features. Differences in preferences for the design features by age among men at high risk of MDE were found only for 3 of 17 features. Differences in preferences for design features between English- and French-speaking participants were found only for 4 out of the 17 features. Analysis of qualitative data revealed that privacy issues, perceived stigma, ease of navigation, personal relevance, and lack of personal interaction, time, and knowledge were identified as barriers to the use of e-mental health programs in working men who were at high risk of MDE. Conclusion: E-mental health programs may be a promising strategy for prevention of depression in working men. Development of e-mental health programs should consider men’s preferences and perceived barriers to enhance the acceptability of this approach. %M 27267782 %R 10.2196/jmir.5685 %U http://www.jmir.org/2016/6/e132/ %U https://doi.org/10.2196/jmir.5685 %U http://www.ncbi.nlm.nih.gov/pubmed/27267782 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 2 %P e96 %T Prevalence of Depression in Medical Students at the Lebanese University and Exploring its Correlation With Facebook Relevance: A Questionnaire Study %A Naja,Wadih J %A Kansoun,Alaa H %A Haddad,Ramzi S %+ Faculty of Medical Sciences, Lebanese University, Lebanon, Beirut, Hadath, Lebanese University Dorms, Beirut,, Lebanon, 961 3619661, a.kanso@hotmail.com %K depression %K Facebook %K PHQ-9 %K FbRQ %K Lebanese University Faculty of Medicine %D 2016 %7 31.05.2016 %9 Original Paper %J JMIR Res Protoc %G English %X Background: The prevalence of major depression is particularly high in medical students, affecting around one-third of this population. Moreover, online social media, in particular Facebook, is becoming an intrinsic part in the life of a growing proportion of individuals worldwide. Objective: Our primary objective is to identify the prevalence of depression in medical students at the Lebanese University Faculty of Medicine, a unique state university in Lebanon, its correlation with the utilization of the interactive features of Facebook, and the way students may resort to these features. Methods: Students of the Lebanese University Faculty of Medicine were assessed for (1) depression and (2) Facebook activity. To screen for major depression, we used the Patient Health Questionnaire-9 (PHQ-9) scale. To test for Facebook activity, we developed the Facebook Resorting Questionnaire (FbRQ), which measures the degree to which students resort to Facebook. Results: A total of 365 out of 480 students (76.0%) participated in the survey. A total of 25 students were excluded, hence 340 students were included in the final analysis. Current depression was reported in 117 students out of 340 (34.4%) and t tests showed female predominance. Moreover, PHQ-9 score multiple regression analysis showed that feeling depressed is explained 63.5% of the time by specific independent variables studied from the PHQ-9 and the FbRQ. Depression varied significantly among the different academic years (P<.001) and it peaked in the third-year students. One-way analysis of variance (ANOVA) showed that depression and resorting to Facebook had a positive and significant relationship (P=.003) and the different FbRQ categories had significant differences in resorting-to-Facebook power. The like, add friend, and check-in features students used when resorting to Facebook were significantly associated with depression. Conclusions: This study showed that depression was highly prevalent among students of the Faculty of Medicine at the Lebanese University. Moreover, Facebook may be a promising, helpful, psychological tool for optimizing the management of depression. Our study brought to bear further questions that now prompt further observation and scrutiny to know more about the high rates of depression in this student population, more so in the part of the world studied, and to the growing role of social media. %M 27246394 %R 10.2196/resprot.4551 %U http://www.researchprotocols.org/2016/2/e96/ %U https://doi.org/10.2196/resprot.4551 %U http://www.ncbi.nlm.nih.gov/pubmed/27246394 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 2 %P e23 %T Mobile Phone and Web-based Cognitive Behavior Therapy for Depressive Symptoms and Mental Health Comorbidities in People Living With Diabetes: Results of a Feasibility Study %A Clarke,Janine %A Proudfoot,Judith %A Ma,Howard %+ Black Dog Institute, Hospital Road, Randwick, 2031, Australia, 61 2 9382 3767, janine.clarke@unsw.edu.au %K diabetes %K depression %K Internet interventions %K eHealth %K CBT %D 2016 %7 31.05.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is often comorbid with diabetes; however, undertreatment of depressive symptoms in people affected is common. Objective: We studied preliminary acceptability and effectiveness of a fully automated, mobile phone, and web-based public health intervention, myCompass, for reducing depressive symptoms and improving mental health comorbidities in people with diabetes. Methods: In this single-group feasibility study, 89 volunteers with type 1 (n=34) or type 2 (n=55) diabetes and at least mild depressive symptoms used myCompass for 7 weeks. Web-based measures of depressive and anxious symptoms, functional impairment, diabetes-specific variables, and user satisfaction were completed at baseline, postintervention, and 3-month follow-up. Results: Retention rates were 54% (n=48) at postintervention and 36% (n=32) at follow-up. Depressive symptoms were significantly improved at postintervention (P<.001; within-group effect size d=1.05), with gains persisting at follow-up. Mental health comorbidities, including anxiety (P<.001), functioning (P<.001), and diabetes-specific distress (P<.001), also showed significant and sustained improvement. Satisfaction with myCompass was high, with convenience and ease of program use, and relevance of program content rated positively by participants. Conclusions: The myCompass program shows promise as an acceptable and effective treatment for depression and comorbid mental health problems in people with diabetes. The program is broadly available, free to use, and may benefit patients with diabetes who do not access services and/or wish to manage their mental health themselves. Replication of these findings in a controlled study is warranted. %M 27245948 %R 10.2196/mental.5131 %U http://mental.jmir.org/2016/2/e23/ %U https://doi.org/10.2196/mental.5131 %U http://www.ncbi.nlm.nih.gov/pubmed/27245948 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 2 %N 1 %P e7 %T Assessment of Cancer Survivors’ Experiences of Using a Publicly Available Physical Activity Mobile Application %A Puszkiewicz,Patrycja %A Roberts,Anna L %A Smith,Lee %A Wardle,Jane %A Fisher,Abigail %+ Health Behaviour Research Centre, Department of Epidemiology & Public Health, University College London, Gower Street, London, WC1E 6BT, United Kingdom, 44 02076791723, anna.roberts.15@ucl.ac.uk %K cancer survivors %K mobile applications %K mHealth %K physical activity %K sleep %D 2016 %7 31.05.2016 %9 Original Paper %J JMIR Cancer %G English %X Background: Regular participation in physical activity (PA) is associated with improved physical and psychosocial outcomes in cancer survivors. However, PA levels are low during and after cancer treatment. Interventions to promote PA in this population are needed. PA mobile apps are popular and have potential to increase PA participation, but little is known about how appropriate or relevant they are for cancer survivors. Objective: This study aims to (1) assess recruitment, study uptake, and engagement for a publicly available PA mobile app (GAINFitness) intervention in cancer survivors; (2) assess cancer survivors’ attitudes towards the app; (3) understand how the app could be adapted to better meet the needs of cancer survivors; and (4) to determine the potential for change in PA participation and psychosocial outcomes over a 6-week period of using the app. Methods: The present study was a one-arm, pre-post design. Cancer survivors (N=11) aged 33 to 62 years with a mean (SD) age of 45 (9.4), and 82% (9/11) female, were recruited (via community/online convenience sampling to use the app for 6 weeks). Engagement with the app was measured using self-reported frequency and duration of usage. Qualitative semi-structured telephone interviews were conducted after the 6-week study period and were analyzed using thematic analysis. PA, well-being, fatigue, quality of life (QOL), sleep quality, and anxiety and depression were self-reported at baseline and at a 6-week follow-up using the Godin Leisure Time Exercise Questionnaire (GLTEQ), the Functional Assessment of Cancer Therapy-General (FACT-G), the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale Questionnaire, the Health and Quality of Life Outcomes (EQ5D) Questionnaire, the Pittsburgh Sleep Quality Index (PSQI), and the Hospital Anxiety and Depression Scale (HADS), respectively. Results: Of the people who responded to the study advertisement, 73% (16/22) agreed to participate and 100% (11/11) of the participants who started the study completed all baseline and follow-up outcome measures and the telephone interview. On average, participants used the app twice a week for 25 minutes per session. Four themes were identified from the qualitative interviews surrounding the suitability of the app for cancer survivors and how it could be adapted: (1) barriers to PA, (2) receiving advice about PA from reliable sources, (3) tailoring the application to one’s lifestyle, and (4) receiving social support from others. Pre-post comparison showed significant increases in strenuous PA, improvements in sleep quality, and reductions in mild PA. There were no significant changes in moderate PA or other psychosocial outcomes. Conclusions: All participants engaged with the app and qualitative interviews highlighted that the app was well-received. A generic PA mobile app could bring about positive improvements in PA participation and psychosocial outcomes among cancer survivors. However, a targeted PA app aimed specifically towards cancer survivors may increase the relevance and suitability of the app for this population. %M 28410168 %R 10.2196/cancer.5380 %U http://cancer.jmir.org/2016/1/e7/ %U https://doi.org/10.2196/cancer.5380 %U http://www.ncbi.nlm.nih.gov/pubmed/28410168 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 5 %P e121 %T Acceptability of Interventions Delivered Online and Through Mobile Phones for People Who Experience Severe Mental Health Problems: A Systematic Review %A Berry,Natalie %A Lobban,Fiona %A Emsley,Richard %A Bucci,Sandra %+ School of Psychological Sciences, Faculty of Medical and Human Sciences, University of Manchester, Room S42, Zochonis Building, Brunswick Street, Manchester, M13 9PL, United Kingdom, 44 16130 ext 60428, natalie.berry@manchester.ac.uk %K mHealth %K eHealth %K severe mental health %K psychosis %K bipolar disorder %K personality disorder %K severe mental health problems (SMI) %K acceptability %D 2016 %7 31.05.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Psychological interventions are recommended for people with severe mental health problems (SMI). However, barriers exist in the provision of these services and access is limited. Therefore, researchers are beginning to develop and deliver interventions online and via mobile phones. Previous research has indicated that interventions delivered in this format are acceptable for people with SMI. However, a comprehensive systematic review is needed to investigate the acceptability of online and mobile phone-delivered interventions for SMI in depth. Objective: This systematic review aimed to 1) identify the hypothetical acceptability (acceptability prior to or without the delivery of an intervention) and actual acceptability (acceptability where an intervention was delivered) of online and mobile phone-delivered interventions for SMI, 2) investigate the impact of factors such as demographic and clinical characteristics on acceptability, and 3) identify common participant views in qualitative studies that pinpoint factors influencing acceptability. Methods: We conducted a systematic search of the databases PubMed, Embase, PsycINFO, CINAHL, and Web of Science in April 2015, which yielded a total of 8017 search results, with 49 studies meeting the full inclusion criteria. Studies were included if they measured acceptability through participant views, module completion rates, or intervention use. Studies delivering interventions were included if the delivery method was online or via mobile phones. Results: The hypothetical acceptability of online and mobile phone-delivered interventions for SMI was relatively low, while actual acceptability tended to be high. Hypothetical acceptability was higher for interventions delivered via text messages than by emails. The majority of studies that assessed the impact of demographic characteristics on acceptability reported no significant relationships between the two. Additionally, actual acceptability was higher when participants were provided remote online support. Common qualitative factors relating to acceptability were safety and privacy concerns, the importance of an engaging and appealing delivery format, the inclusion of peer support, computer and mobile phone literacy, technical issues, and concerns about the impact of psychological state on intervention use. Conclusions: This systematic review provides an in-depth focus on the acceptability of online and mobile phone-delivered interventions for SMI and identified the need for further research in this area. Based on the results from this review, we recommend that researchers measure both hypothetical and actual acceptability to identify whether initial perceptions of online and mobile phone-delivered interventions change after access. In addition, more focus is needed on the potential impact of demographic and clinical characteristics on acceptability. The review also identified issues with module completion rates and intervention use as measures of acceptability. We therefore advise researchers to obtain qualitative reports of acceptability throughout each phase of intervention development and testing. Further implications and opportunities for future research are discussed. %M 27245693 %R 10.2196/jmir.5250 %U http://www.jmir.org/2016/5/e121/ %U https://doi.org/10.2196/jmir.5250 %U http://www.ncbi.nlm.nih.gov/pubmed/27245693 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 2 %P e20 %T Community Structure of a Mental Health Internet Support Group: Modularity in User Thread Participation %A Carron-Arthur,Bradley %A Reynolds,Julia %A Bennett,Kylie %A Bennett,Anthony %A Cunningham,John Alastair %A Griffiths,Kathleen Margaret %+ National Institute for Mental Health Research, Research School of Population Health, The Australian National University, 63 Eggleston road, Acton, 2601, Australia, 61 2 6125 6825, Bradley.Carron-Arthur@anu.edu.au %K internet %K support group %K social network %K modularity %K mental health %K super user %D 2016 %7 30.05.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Little is known about the community structure of mental health Internet support groups, quantitatively. A greater understanding of the factors, which lead to user interaction, is needed to explain the design information of these services and future research concerning their utility. Objective: A study was conducted to determine the characteristics of users associated with the subgroup community structure of an Internet support group for mental health issues. Methods: A social network analysis of the Internet support group BlueBoard (blueboard.anu.edu.au) was performed to determine the modularity of the community using the Louvain method. Demographic characteristics age, gender, residential location, type of user (consumer, carer, or other), registration date, and posting frequency in subforums (depression, generalized anxiety, social anxiety, panic disorder, bipolar disorder, obsessive compulsive disorder, borderline personality disorder, eating disorders, carers, general (eg, “chit chat”), and suggestions box) of the BlueBoard users were assessed as potential predictors of the resulting subgroup structure. Results: The analysis of modularity identified five main subgroups in the BlueBoard community. Registration date was found to be the largest contributor to the modularity outcome as observed by multinomial logistic regression. The addition of this variable to the final model containing all other factors improved its classification accuracy by 46.3%, that is, from 37.9% to 84.2%. Further investigation of this variable revealed that the most active and central users registered significantly earlier than the median registration time in each group. Conclusions: The five subgroups resembled five generations of BlueBoard in distinct eras that transcended discussion about different mental health issues. This finding may be due to the activity of highly engaged and central users who communicate with many other users. Future research should seek to determine the generalizability of this finding and investigate the role that highly active and central users may play in the formation of this phenomenon. %M 27242012 %R 10.2196/mental.4961 %U http://mental.jmir.org/2016/2/e20/ %U https://doi.org/10.2196/mental.4961 %U http://www.ncbi.nlm.nih.gov/pubmed/27242012 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 2 %P e18 %T A Thematic Analysis of Stigma and Disclosure for Perinatal Depression on an Online Forum %A Moore,Donna %A Ayers,Susan %A Drey,Nicholas %+ Centre for Maternal and Child Health, School of Health Sciences, City University London, Northampton Square, London, EC1V OHB, United Kingdom, 44 207 040 5060, Donna.Moore.1@city.ac.uk %K perinatal %K online %K Internet %K depression %K eHealth %D 2016 %7 19.05.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Perinatal mental illness is a global health concern; however, many women do not get the treatment they need to recover. Some women choose not to seek professional help and get no treatment because they feel stigmatized. Online forums for various health conditions, including perinatal mental health, can be beneficial for members. Little is known about the role that online forums for perinatal mental illness play in reducing stigma and subsequent disclosure of symptoms to health care providers and treatment uptake. Objective: This study aimed to examine stigma and disclosure in forums and describe any potential disadvantages of forum use. Methods: An online forum for mothers was examined and 1546 messages extracted from 102 threads from the antenatal and postnatal depression section. These messages were subjected to deductive systematic thematic analysis to identify common themes regarding stigma and disclosure of symptoms and potential disadvantages of forum use. Results: Two major themes were identified: stigma and negative experiences of disclosure. Stigma had 3 subthemes: internal stigma, external stigma, and treatment stigma. Many women were concerned about feeling like a “bad” or “failed” mother and worried that if they disclosed their symptoms to a health care provider they would be stigmatized. Posts in response to this frequently encouraged women to disclose their symptoms to health care providers and accept professional treatment. Forum discourse reconstructed the ideology of motherhood as compatible with perinatal mental illness, especially if the woman sought help and adhered to treatment. Many women overcame stigma and replied that they had taken advice and disclosed to a health care provider and/or taken treatment. Conclusions: Forum use may increase women's disclosure to health care providers by challenging their internal and external stigma and this may strengthen professional treatment uptake and adherence. However, a few posts described negative experiences when disclosing to health care providers. %M 27197516 %R 10.2196/mental.5611 %U http://mental.jmir.org/2016/2/e18/ %U https://doi.org/10.2196/mental.5611 %U http://www.ncbi.nlm.nih.gov/pubmed/27197516 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 2 %P e12 %T Direction to an Internet Support Group Compared With Online Expressive Writing for People With Depression and Anxiety: A Randomized Trial %A Dean,Jeremy %A Potts,Henry WW %A Barker,Chris %+ Department of Clinical, Educational, and Health Psychology, University College London, Gower Street, London, WC1E 6BT, United Kingdom, 44 20 7679 5962, c.barker@ucl.ac.uk %K depression %K anxiety %K Internet support %K online support %K expressive writing %D 2016 %7 17.05.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Depression and anxiety are common, often comorbid, conditions, and Internet support groups for them are well used. However, little rigorous research has been conducted on the outcome of these groups. Objective: This study aimed to evaluate the efficacy of an Internet support group in reducing depression and anxiety, and increasing social support and life satisfaction. Methods: A randomized trial compared direction to an existing Internet support group for depression and anxiety with an online expressive writing condition. A total of 863 (628 female) United Kingdom, United States, and Canadian volunteers were recruited via the Internet. Online, self-report measures of depression, anxiety, social support, and satisfaction with life were administered at baseline, 3, and 6 months. Results: All four outcomes – depression, anxiety, social support, and satisfaction with life – improved over the 6 months of the study (all P<.001). There was no difference in outcome between the two conditions: participants responded similarly to the expressive writing and the Internet support group. Engagement with the Internet support group was low, it had high 6-month attrition (692/795, 87%) and low adherence, and it received mixed and often negative feedback. The main problems reported were a lack of comfort and connection with others, negative social comparisons, and the potential for receiving bad advice. Expressive writing had lower attrition (194/295, 65%) and participants reported that it was more acceptable. Conclusions: Until further evidence accumulates, directing people with depression and anxiety to Internet support groups cannot be recommended. On the other hand, online expressive writing seems to have potential, and its use for people with depression and anxiety warrants further investigation. Trial Registration: Trial Registration: Clinicaltrials.gov NCT01149265; https://clinicaltrials.gov/ct2/show/NCT01149265 (Archived by WebCite at http://www.webcitation.org/6hYISlNFT) %M 27189142 %R 10.2196/mental.5133 %U http://mental.jmir.org/2016/2/e12/ %U https://doi.org/10.2196/mental.5133 %U http://www.ncbi.nlm.nih.gov/pubmed/27189142 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 2 %P e21 %T Validating Machine Learning Algorithms for Twitter Data Against Established Measures of Suicidality %A Braithwaite,Scott R %A Giraud-Carrier,Christophe %A West,Josh %A Barnes,Michael D %A Hanson,Carl Lee %+ Computational Health Science Research Group, Department of Health Science, Brigham Young University, 4103B Life Sciences Building, Provo, UT, 84602, United States, 1 (801) 422 9103, carl_hanson@byu.edu %K suicide %K social media %K twitter %K machine learning %D 2016 %7 16.05.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: One of the leading causes of death in the United States (US) is suicide and new methods of assessment are needed to track its risk in real time. Objective: Our objective is to validate the use of machine learning algorithms for Twitter data against empirically validated measures of suicidality in the US population. Methods: Using a machine learning algorithm, the Twitter feeds of 135 Mechanical Turk (MTurk) participants were compared with validated, self-report measures of suicide risk. Results: Our findings show that people who are at high suicidal risk can be easily differentiated from those who are not by machine learning algorithms, which accurately identify the clinically significant suicidal rate in 92% of cases (sensitivity: 53%, specificity: 97%, positive predictive value: 75%, negative predictive value: 93%). Conclusions: Machine learning algorithms are efficient in differentiating people who are at a suicidal risk from those who are not. Evidence for suicidality can be measured in nonclinical populations using social media data. %M 27185366 %R 10.2196/mental.4822 %U http://mental.jmir.org/2016/2/e21/ %U https://doi.org/10.2196/mental.4822 %U http://www.ncbi.nlm.nih.gov/pubmed/27185366 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 5 %N 2 %P e65 %T Comparing Brief Internet-Based Compassionate Mind Training and Cognitive Behavioral Therapy for Perinatal Women: Study Protocol for a Randomized Controlled Trial %A Kelman,Alex R %A Stanley,Meagan L %A Barrera,Alinne Z %A Cree,Michelle %A Heineberg,Yotam %A Gilbert,Paul %+ Palo Alto University, 1791 Arastradero Road, Palo Alto, CA, 94304, United States, 1 650 396 9349, akelman@paloaltou.edu %K perinatal depression %K comparative trial %K Internet intervention %K Amazon Mechanical Turk %D 2016 %7 15.04.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression that occurs during the perinatal period has substantial costs for both the mother and her baby. Since in-person care often falls short of meeting the global need of perinatal women, Internet interventions may function as an alternate to help women who currently lack adequate access to face-to-face psychological resources. However, at present there are insufficient empirically supported Internet-based resources for perinatal women. Objective: The aim of this study is to compare the relative efficacy of Internet-based cognitive behavioral therapy (CBT) to a novel Internet-based compassionate mind training approach (CMT) across measures of affect, self-reassurance, self-criticizing, self-attacking, self-compassion, depression, and anxiety. While CBT has been tested and has some support as an Internet tool for perinatal women, this is the first trial to look at CMT for perinatal women over the Internet. Methods: Participants were recruited through Amazon Mechanical Turk (MTurk) and professional networks. Following completion of demographic items, participants were randomly assigned to either the CBT or CMT condition. Each condition consisted of 45-minute interactive didactic and follow-up exercises to be completed over the course of two weeks. Results: Post course data was gathered at two weeks. A 2x2 repeated measures analysis of variance will be conducted to analyze differences between conditions at post course. Conclusions: The implications of the trial will be discussed as well as the strengths and limitations of MTurk as a tool for recruitment. We will also briefly introduce the future directions along this same line of research. Trial Registration: ClinicalTrials.gov NCT02469324; https://clinicaltrials.gov/ct2/show/NCT02469324 (Archived by WebCite at http://www.webcitation.org/6fkSG3yuW) %M 27084301 %R 10.2196/resprot.5332 %U http://www.researchprotocols.org/2016/2/e65/ %U https://doi.org/10.2196/resprot.5332 %U http://www.ncbi.nlm.nih.gov/pubmed/27084301 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 3 %P e80 %T Effectiveness of a Web-Based Guided Self-help Intervention for Outpatients With a Depressive Disorder: Short-term Results From a Randomized Controlled Trial %A Kenter,Robin Maria Francisca %A Cuijpers,Pim %A Beekman,Aartjan %A van Straten,Annemieke %+ Faculty of Behavioural and Movement Sciences, Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Van der Boechorststraat 1, Amsterdam, 1081 BT, Netherlands, 31 20 59 88970, robin.kenter@vu.nl %K depression %K outpatient clinics %K Internet-based treatment %K problem solving therapy %K specialized mental health care %D 2016 %7 31.03.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Research has convincingly demonstrated that symptoms of depression can be reduced through guided Internet-based interventions. However, most of those studies recruited people form the general population. There is insufficient evidence for the effectiveness when delivered in routine clinical practice in outpatient clinics. Objective: The objective of this randomized controlled trial was to study patients with a depressive disorder (as defined by the Diagnostic and Statistical Manual of Disorders, fourth edition), as assessed by trained interviewers with the Composite International Diagnostic Interview, who registered for treatment at an outpatient mental health clinic. We aimed to examine the effectiveness of guided Internet-based self-help before starting face-to-face treatment. Methods: We recruited 269 outpatients, aged between 18 and 79 years, from outpatient clinics and randomly allocated them to Internet-based problem solving therapy (n=136), with weekly student support, or to a control condition, who remained on the waitlist with a self-help booklet (control group; n=133). Participants in both conditions were allowed to take up face-to-face treatment at the outpatient clinics afterward. We measured the primary outcome, depressive symptoms, by Center for Epidemiological Studies Depression scale (CES-D). Secondary outcome measures were the Hospital Anxiety and Depression Scale Anxiety subscale (HADS-A), Insomnia Severity Index questionnaire (ISI), and EuroQol visual analog scale (EQ-5D VAS). All outcomes were assessed by telephone at posttest (8 weeks after baseline). Results: Posttest measures were completed by 184 (68.4%) participants. We found a moderate to large within-group effect size for both the intervention (d=0.75) and the control (d=0.69) group. However, the between-group effect size was very small (d=0.07), and regression analysis on posttreatment CES-D scores revealed no significant differences between the groups (b=1.134, 95% CI –2.495 to 4.763). The per-protocol analysis (≥4 sessions completed) results were also not significant (b=1.154, 95% CI –1.978 to 7.637). Between-group differences were small and not significant for all secondary outcomes. Adherence to the intervention was low. Only 36% (49/136) received an adequate dosage of the intervention (≥4 of 5 sessions). The overall treatment satisfaction was moderate. Conclusions: Internet-based problem solving therapy is not more effective in reducing symptoms of depression than receiving an unguided self-help book during the waitlist period at outpatient mental health clinics. The effect sizes are much smaller than those found in earlier research in the general population, and the low rates of adherence indicate that the acceptability of the intervention at this stage of treatment for depressed outpatients is low. However, taking into account that there is much evidence for the efficacy of Internet-based treatments, it is too early to draw firm conclusions about the effectiveness of these treatments in outpatient clinics as a whole. Trial Registration: Netherlands Trial Register NTR2824; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2824 (Archived by WebCite at http://www.webcitation/ 6g3WEuiqH) %M 27032449 %R 10.2196/jmir.4861 %U http://www.jmir.org/2016/3/e80/ %U https://doi.org/10.2196/jmir.4861 %U http://www.ncbi.nlm.nih.gov/pubmed/27032449 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 3 %P e72 %T Mobile Phone-Based Unobtrusive Ecological Momentary Assessment of Day-to-Day Mood: An Explorative Study %A Asselbergs,Joost %A Ruwaard,Jeroen %A Ejdys,Michal %A Schrader,Niels %A Sijbrandij,Marit %A Riper,Heleen %+ Faculty of Behavioural and Movement Sciences, Section Clinical Psychology, Vrije Universiteit Amsterdam, Van der Boechorststraat 1, Amsterdam, 1081 BT, Netherlands, 31 20 59 88774, j.a.g.j.asselbergs@vu.nl %K affect %K data mining %K ecological momentary assessment %K experience sampling %K mobile phone sensing %D 2016 %7 29.03.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Ecological momentary assessment (EMA) is a useful method to tap the dynamics of psychological and behavioral phenomena in real-world contexts. However, the response burden of (self-report) EMA limits its clinical utility. Objective: The aim was to explore mobile phone-based unobtrusive EMA, in which mobile phone usage logs are considered as proxy measures of clinically relevant user states and contexts. Methods: This was an uncontrolled explorative pilot study. Our study consisted of 6 weeks of EMA/unobtrusive EMA data collection in a Dutch student population (N=33), followed by a regression modeling analysis. Participants self-monitored their mood on their mobile phone (EMA) with a one-dimensional mood measure (1 to 10) and a two-dimensional circumplex measure (arousal/valence, –2 to 2). Meanwhile, with participants’ consent, a mobile phone app unobtrusively collected (meta) data from six smartphone sensor logs (unobtrusive EMA: calls/short message service (SMS) text messages, screen time, application usage, accelerometer, and phone camera events). Through forward stepwise regression (FSR), we built personalized regression models from the unobtrusive EMA variables to predict day-to-day variation in EMA mood ratings. The predictive performance of these models (ie, cross-validated mean squared error and percentage of correct predictions) was compared to naive benchmark regression models (the mean model and a lag-2 history model). Results: A total of 27 participants (81%) provided a mean 35.5 days (SD 3.8) of valid EMA/unobtrusive EMA data. The FSR models accurately predicted 55% to 76% of EMA mood scores. However, the predictive performance of these models was significantly inferior to that of naive benchmark models. Conclusions: Mobile phone-based unobtrusive EMA is a technically feasible and potentially powerful EMA variant. The method is young and positive findings may not replicate. At present, we do not recommend the application of FSR-based mood prediction in real-world clinical settings. Further psychometric studies and more advanced data mining techniques are needed to unlock unobtrusive EMA’s true potential. %M 27025287 %R 10.2196/jmir.5505 %U http://www.jmir.org/2016/3/e72/ %U https://doi.org/10.2196/jmir.5505 %U http://www.ncbi.nlm.nih.gov/pubmed/27025287 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 3 %P e71 %T An Online Intervention for Co-Occurring Depression and Problematic Alcohol Use in Young People: Primary Outcomes From a Randomized Controlled Trial %A Deady,Mark %A Mills,Katherine L %A Teesson,Maree %A Kay-Lambkin,Frances %+ National Health and Medical Research Council Centre for Research Excellence in Mental Health and Substance Use, National Drug and Alcohol Research Centre, University of New South Wales, Kensington, 2052, Australia, 61 293850320, m.deady@unsw.edu.au %K depression %K alcohol use, alcohol abuse, problem drinking %K young people at risk populations %K Internet %K intervention online therapy, eHealth %K comorbidity %D 2016 %7 23.03.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression and problematic alcohol use represent two of the major causes of disease burden in young adults. These conditions frequently co-occur and this is associated with increased harm and poorer outcomes than either disorder in isolation. Integrated treatments have been shown to be effective; however, there remains a significant gap between those in need of treatment and those receiving it. The increased availability of eHealth programs presents a unique opportunity to treat these conditions. Objective: This study aimed to evaluate the feasibility and preliminary efficacy of an automated Web-based self-help intervention (DEAL Project) in treating co-occurring depressive symptoms and problematic alcohol use in young people. Methods: Young people (aged 18 to 25 years) with moderate depression symptoms and drinking at hazardous levels (recruited largely via social media) were randomly allocated to the DEAL Project (n=60) or a Web-based attention-control condition (HealthWatch; n=44). The trial consisted of a 4-week intervention phase with follow-up assessment at posttreatment and at 3 and 6 months postbaseline. The primary outcomes were change in depression severity according to the Patient Health Questionnaire-9 as well as quantity and frequency of alcohol use (TOT-AL). Results: The DEAL Project was associated with statistically significant improvement in depression symptom severity (d=0.71) and reductions in alcohol use quantity (d=0.99) and frequency (d=0.76) in the short term compared to the control group. At 6-month follow-up, the improvements in the intervention group were maintained; however, the differences between the intervention and control groups were no longer statistically significant, such that between-group effects were in the small to moderate range at 6 months (depression symptoms: d=0.39; alcohol quantity: d=–0.09; alcohol frequency: d=0.24). Conclusions: Overall, the DEAL Project was associated with more rapid improvement in both depression symptoms and alcohol use outcomes in young people with these co-occurring conditions relative to an attention-control condition. However, long-term outcomes are less clear. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000033741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363461 (Archived by WebCite at http://www.webcitation.org/6fpsLEGOy) %M 27009465 %R 10.2196/jmir.5178 %U http://www.jmir.org/2016/3/e71/ %U https://doi.org/10.2196/jmir.5178 %U http://www.ncbi.nlm.nih.gov/pubmed/27009465 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 1 %P e11 %T Adjusting an Available Online Peer Support Platform in a Program to Supplement the Treatment of Perinatal Depression and Anxiety %A Baumel,Amit %A Schueller,Stephen M %+ The Feinstein Institute for Medical Research, 350 Community Dr, Manhasset, NY, 11030, United States, 1 7184708267, abaumel@northwell.edu %K online %K peer %K support %K perinatal %K postpartum %K depression %K anxiety %D 2016 %7 21.03.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Perinatal depression and anxiety are common and debilitating conditions. Novel, cost effective services could improve the uptake and the impact of mental health resources among women who suffer from these conditions. E-mental health products are one example of such services. Many publically available e-mental health products exist, but these products lack validation and are not designed to be integrated into existing health care settings. Objective: The objective of the study was to present a program to use 7 Cups of Tea (7Cups), an available technological platform that provides online peer (ie, listener) based emotional support, to supplement treatment for women experiencing perinatal depression or anxiety and to summarize patient’s feedback on the resultant program. Methods: This study consisted of two stages. First, five clinicians specializing in the treatment of perinatal mood disorders received an overview of 7Cups. They provided feedback on the 7Cups platform and ways it could complement the existing treatment efforts to inform further adjustments. In the second stage, nine women with perinatal depression or anxiety used the platform for a single session and provided feedback. Results: In response to clinicians’ feedback, guidelines for referring patients to use 7Cups as a supplement for treatment were created, and a training program for listeners was developed. Patients found the platform usable and useful and their attitudes toward the trained listeners were positive. Overall, patients noted a need for support outside the scheduled therapy time and believed that freely available online emotional support could help meet this need. Most patients were interested in receiving support from first time mothers and those who suffered in the past from perinatal mood disorders. Conclusions: The study results highlight the use of 7Cups as a tool to introduce accessible and available support into existing treatment for women who suffer from perinatal mood disorders. Further research should focus on the benefits accrued from such a service. However, this article highlights how a publicly available eHealth product can be leveraged to create new services in a health care setting. %M 27001373 %R 10.2196/mental.5335 %U http://mental.jmir.org/2016/1/e11/ %U https://doi.org/10.2196/mental.5335 %U http://www.ncbi.nlm.nih.gov/pubmed/27001373 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 3 %P e63 %T Understanding Online Health Groups for Depression: Social Network and Linguistic Perspectives %A Xu,Ronghua %A Zhang,Qingpeng %+ Department of Systems Engineering and Engineering Management, City University of Hong Kong, 83 Tat Chee Avenue, Kowloon, , China (Hong Kong), 852 34424727, qingpeng.zhang@cityu.edu.hk %K mental health %K depression %K social media %K information science %K online health group %K social network analysis %D 2016 %7 10.03.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health problems have become increasingly prevalent in the past decade. With the advance of Web 2.0 technologies, social media present a novel platform for Web users to form online health groups. Members of online health groups discuss health-related issues and mutually help one another by anonymously revealing their mental conditions, sharing personal experiences, exchanging health information, and providing suggestions and support. The conversations in online health groups contain valuable information to facilitate the understanding of their mutual help behaviors and their mental health problems. Objective: We aimed to characterize the conversations in a major online health group for major depressive disorder (MDD) patients in a popular Chinese social media platform. In particular, we intended to explain how Web users discuss depression-related issues from the perspective of the social networks and linguistic patterns revealed by the members’ conversations. Methods: Social network analysis and linguistic analysis were employed to characterize the social structure and linguistic patterns, respectively. Furthermore, we integrated both perspectives to exploit the hidden relations between them. Results: We found an intensive use of self-focus words and negative affect words. In general, group members used a higher proportion of negative affect words than positive affect words. The social network of the MDD group for depression possessed small-world and scale-free properties, with a much higher reciprocity ratio and clustering coefficient value as compared to the networks of other social media platforms and classic network models. We observed a number of interesting relationships, either strong correlations or convergent trends, between the topological properties and linguistic properties of the MDD group members. Conclusions: (1) The MDD group members have the characteristics of self-preoccupation and negative thought content, according to Beck’s cognitive theory of depression; (2) the social structure of the MDD group is much stickier than those of other social media groups, indicating the tendency of mutual communications and efficient spread of information in the MDD group; and (3) the linguistic patterns of MDD members are associated with their topological positions in the social network. %M 26966078 %R 10.2196/jmir.5042 %U http://www.jmir.org/2016/3/e63/ %U https://doi.org/10.2196/jmir.5042 %U http://www.ncbi.nlm.nih.gov/pubmed/26966078 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 3 %P e54 %T Internet Cognitive Behavioral Therapy for Women With Postnatal Depression: A Randomized Controlled Trial of MumMoodBooster %A Milgrom,Jeannette %A Danaher,Brian G %A Gemmill,Alan W %A Holt,Charlene %A Holt,Christopher J %A Seeley,John R %A Tyler,Milagra S %A Ross,Jessica %A Ericksen,Jennifer %+ Parent-Infant Research Institute, Department of Clinical & Health Psychology, Heidelberg Repatriation Hospital Austin Health 330 Waterdale Road Heidelberg Heights, Melbourne, 3081, Australia, 61 03 9496 ext 4468, alan.gemmill@austin.org.au %K postnatal depression %K postpartum depression %K cognitive behavioral therapy %K Internet-based intervention %K randomized controlled trial %D 2016 %7 07.03.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: There are few published controlled trials examining the efficacy of Internet-based treatment for postnatal depression (PND) and none that assess diagnostic status (clinical remission) as the primary outcome. This is despite the need to improve treatment uptake and accessibility because fewer than 50% of postnatally depressed women seek help, even when identified as depressed. Objective: In a randomized controlled trial (RCT), we aimed to test the efficacy of a 6-session Internet intervention (the MumMoodBooster program, previously evaluated in a feasibility trial) in a sample of postnatal women with a clinical diagnosis of depression. The MumMoodBooster program is a cognitive behavioral therapy (CBT) intervention, is highly interactive, includes a partner website, and was supported by low-intensity telephone coaching. Methods: This was a parallel 2-group RCT (N=43) comparing the Internet CBT treatment (n=21) to treatment as usual (n=22). At baseline and at 12 weeks after enrollment, women’s diagnostic status was assessed by telephone with the Standardized Clinical Interview for DSM-IV (SCID-IV) and symptom severity with the Beck Depression Inventory (BDI-II). Depression symptoms were measured repeatedly throughout the study period with the Patient Health Questionnaire (PHQ-9). Results: At the end of the study, 79% (15/19) of women who received the Internet CBT treatment no longer met diagnostic criteria for depression on the SCID-IV (these outcome data were missing for 2 intervention participants). This contrasted with only 18% (4/22) remission in the treatment as usual condition. Depression scores on the BDI-II showed a large effect favoring the intervention group (d=.83, 95% CI 0.20-1.45). Small to medium effects were found on the PHQ-9 and on measures of anxiety and stress. Adherence to the program was very good with 86% (18/21) of users completing all sessions; satisfaction with the program was rated 3.1 out of 4 on average. Conclusions: Our results suggest that our Internet CBT program, MumMoodBooster, is an effective treatment option for women clinically diagnosed with PND. This is one of only two controlled evaluations of specialized online psychological treatment among women clinically diagnosed with PND. MumMoodBooster appears to be a feasible, effective treatment option, which is potentially accessible to large numbers of women in metropolitan, rural, and remote areas. Future work might be focused profitably on establishing comparability with face-to-face treatments and purely self-guided delivery. We have commenced a larger RCT comparing MumMoodBooster with face-to-face CBT. Trial Registration: Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000113752; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363561 (Archived by WebCite® at http://www.webcitation.org/6f64kuyLf). %M 26952645 %R 10.2196/jmir.4993 %U http://www.jmir.org/2016/3/e54/ %U https://doi.org/10.2196/jmir.4993 %U http://www.ncbi.nlm.nih.gov/pubmed/26952645 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 1 %P e10 %T Therapeutic Alliance With a Fully Automated Mobile Phone and Web-Based Intervention: Secondary Analysis of a Randomized Controlled Trial %A Clarke,Janine %A Proudfoot,Judith %A Whitton,Alexis %A Birch,Mary-Rose %A Boyd,Megan %A Parker,Gordon %A Manicavasagar,Vijaya %A Hadzi-Pavlovic,Dusan %A Fogarty,Andrea %+ Black Dog Institute, UNSW Australia, Hospital Road, Randwick NSW 2031, Australia, 61 2 9382 3767, Janine.clarke@unsw.edu.au %K therapeutic alliance %K e-therapy %K Internet interventions %K depression %K computerized cognitive behavior therapy %D 2016 %7 25.02.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Studies of Internet-delivered psychotherapies suggest that clients report development of a therapeutic alliance in the Internet environment. Because a majority of the interventions studied to date have been therapist-assisted to some degree, it remains unclear whether a therapeutic alliance can develop within the context of an Internet-delivered self-guided intervention with no therapist support, and whether this has consequences for program outcomes. Objective: This study reports findings of a secondary analysis of data from 90 participants with mild-to-moderate depression, anxiety, and/or stress who used a fully automated mobile phone and Web-based cognitive behavior therapy (CBT) intervention called “myCompass” in a recent randomized controlled trial (RCT). Methods: Symptoms, functioning, and positive well-being were assessed at baseline and post-intervention using the Depression, Anxiety and Stress Scale (DASS), the Work and Social Adjustment Scale (WSAS), and the Mental Health Continuum-Short Form (MHC-SF). Therapeutic alliance was measured at post-intervention using the Agnew Relationship Measure (ARM), and this was supplemented with qualitative data obtained from 16 participant interviews. Extent of participant engagement with the program was also assessed. Results: Mean ratings on the ARM subscales were above the neutral midpoints, and the interviewees provided rich detail of a meaningful and collaborative therapeutic relationship with the myCompass program. Whereas scores on the ARM subscales did not correlate with treatment outcomes, participants’ ratings of the quality of their emotional connection with the program correlated significantly and positively with program logins, frequency of self-monitoring, and number of treatment modules completed (r values between .32-.38, P≤.002). The alliance (ARM) subscales measuring perceived empowerment (r=.26, P=.02) and perceived freedom to self-disclose (r=.25, P=.04) also correlated significantly in a positive direction with self-monitoring frequency. Conclusions: Quantitative and qualitative findings from this analysis showed that a positive therapeutic alliance can develop in the Internet environment in the absence of therapist support, and that components of the alliance may have implications for program usage. Further investigation of alliance features in the Internet environment and the consequences of these for treatment outcomes and user engagement is warranted. Trial Registration: Australian New Zealand Clinical Trials Registry Number (ACTRN): 12610000625077; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=335772&isReview=true (Archived by WebCite at http://www.webcitation.org/6efAc5xj4). %M 26917096 %R 10.2196/mental.4656 %U http://mental.jmir.org/2016/1/e10/ %U https://doi.org/10.2196/mental.4656 %U http://www.ncbi.nlm.nih.gov/pubmed/26917096 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 2 %P e35 %T Examining the Relationship Between Past Orientation and US Suicide Rates: An Analysis Using Big Data-Driven Google Search Queries %A Lee,Donghyun %A Lee,Hojun %A Choi,Munkee %+ Korea Advanced Institute of Science and Technology, Graduate School of Innovation and Technology Management, Number 2115, N5 Building, 291, Daehak-ro, Yuseong-gu, Daejeon, 34141, Republic Of Korea, 82 42 350 4341, mk1515@kaist.ac.kr %K attitude %K big data %K Google search query %K Internet search %K past orientation %K suicide %D 2016 %7 11.02.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet search query data reflect the attitudes of the users, using which we can measure the past orientation to commit suicide. Examinations of past orientation often highlight certain predispositions of attitude, many of which can be suicide risk factors. Objective: To investigate the relationship between past orientation and suicide rate by examining Google search queries. Methods: We measured the past orientation using Google search query data by comparing the search volumes of the past year and those of the future year, across the 50 US states and the District of Columbia during the period from 2004 to 2012. We constructed a panel dataset with independent variables as control variables; we then undertook an analysis using multiple ordinary least squares regression and methods that leverage the Akaike information criterion and the Bayesian information criterion. Results: It was found that past orientation had a positive relationship with the suicide rate (P≤.001) and that it improves the goodness-of-fit of the model regarding the suicide rate. Unemployment rate (P≤.001 in Models 3 and 4), Gini coefficient (P≤.001), and population growth rate (P≤.001) had a positive relationship with the suicide rate, whereas the gross state product (P≤.001) showed a negative relationship with the suicide rate. Conclusions: We empirically identified the positive relationship between the suicide rate and past orientation, which was measured by big data-driven Google search query. %M 26868917 %R 10.2196/jmir.4981 %U http://www.jmir.org/2016/2/e35/ %U https://doi.org/10.2196/jmir.4981 %U http://www.ncbi.nlm.nih.gov/pubmed/26868917 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 1 %P e15 %T Interrater Reliability of mHealth App Rating Measures: Analysis of Top Depression and Smoking Cessation Apps %A Powell,Adam C %A Torous,John %A Chan,Steven %A Raynor,Geoffrey Stephen %A Shwarts,Erik %A Shanahan,Meghan %A Landman,Adam B %+ Payer+Provider Syndicate, 8 Garrison St Ste 101, Boston, MA, MA, United States, 1 6179399168, powell@payerprovider.com %K mobile applications %K mental health %K evaluation studies %K health apps %K ratings %D 2016 %7 10.02.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: There are over 165,000 mHealth apps currently available to patients, but few have undergone an external quality review. Furthermore, no standardized review method exists, and little has been done to examine the consistency of the evaluation systems themselves. Objective: We sought to determine which measures for evaluating the quality of mHealth apps have the greatest interrater reliability. Methods: We identified 22 measures for evaluating the quality of apps from the literature. A panel of 6 reviewers reviewed the top 10 depression apps and 10 smoking cessation apps from the Apple iTunes App Store on these measures. Krippendorff’s alpha was calculated for each of the measures and reported by app category and in aggregate. Results: The measure for interactiveness and feedback was found to have the greatest overall interrater reliability (alpha=.69). Presence of password protection (alpha=.65), whether the app was uploaded by a health care agency (alpha=.63), the number of consumer ratings (alpha=.59), and several other measures had moderate interrater reliability (alphas>.5). There was the least agreement over whether apps had errors or performance issues (alpha=.15), stated advertising policies (alpha=.16), and were easy to use (alpha=.18). There were substantial differences in the interrater reliabilities of a number of measures when they were applied to depression versus smoking apps. Conclusions: We found wide variation in the interrater reliability of measures used to evaluate apps, and some measures are more robust across categories of apps than others. The measures with the highest degree of interrater reliability tended to be those that involved the least rater discretion. Clinical quality measures such as effectiveness, ease of use, and performance had relatively poor interrater reliability. Subsequent research is needed to determine consistent means for evaluating the performance of apps. Patients and clinicians should consider conducting their own assessments of apps, in conjunction with evaluating information from reviews. %M 26863986 %R 10.2196/mhealth.5176 %U http://mhealth.jmir.org/2016/1/e15/ %U https://doi.org/10.2196/mhealth.5176 %U http://www.ncbi.nlm.nih.gov/pubmed/26863986 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 1 %P e8 %T Efficacy of Adolescent Suicide Prevention E-Learning Modules for Gatekeepers: A Randomized Controlled Trial %A Ghoncheh,Rezvan %A Gould,Madelyn S %A Twisk,Jos WR %A Kerkhof,Ad JFM %A Koot,Hans M %+ Department of Clinical Developmental Psychology, Faculty of Behavioural and Movement Sciences, VU University Amsterdam, Van der Boechorststraat 1, Amsterdam, 1081, BT, Netherlands, 31 636503652, ghonchehr@gmail.com %K Adolescent %K E-learning %K Gatekeepers %K Learning %K Modules %K Online Systems %K Suicide %K Prevention %K Training %K Web-based %K Referral and Consultation %D 2016 %7 29.01.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Face-to-face gatekeeper training can be an effective strategy in the enhancement of gatekeepers’ knowledge and self-efficacy in adolescent suicide prevention. However, barriers related to access (eg, time, resources) may hamper participation in face-to-face training sessions. The transition to a Web-based setting could address obstacles associated with face-to-face gatekeeper training. Although Web-based suicide prevention training targeting adolescents exists, so far no randomized controlled trials (RCTs) have been conducted to investigate their efficacy. Objective: This RCT study investigated the efficacy of a Web-based adolescent suicide prevention program entitled Mental Health Online, which aimed to improve the knowledge and self-confidence of gatekeepers working with adolescents (12-20 years old). The program consisted of 8 short e-learning modules each capturing an important aspect of the process of early recognition, guidance, and referral of suicidal adolescents, alongside additional information on the topic of (adolescent) suicide prevention. Methods: A total of 190 gatekeepers (ages 21 to 62 years) participated in this study and were randomized to either the experimental group or waitlist control group. The intervention was not masked. Participants from both groups completed 3 Web-based assessments (pretest, posttest, and 3-month follow-up). The outcome measures of this study were actual knowledge, and participants’ ratings of perceived knowledge and perceived self-confidence using questionnaires developed specifically for this study. Results: The actual knowledge, perceived knowledge, and perceived self-confidence of gatekeepers in the experimental group improved significantly compared to those in the waitlist control group at posttest, and the effects remained significant at 3-month follow-up. The overall effect sizes were 0.76, 1.20, and 1.02, respectively, across assessments. Conclusions: The findings of this study indicate that Web-based suicide prevention e-learning modules can be an effective educational method to enhance knowledge and self-confidence of gatekeepers with regard to adolescent suicide prevention. Gatekeepers with limited time and resources can benefit from the accessibility, simplicity, and flexibility of Web-based training. Trial Registration: Netherlands Trial Register NTR3625; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3625 (Archived by WebCite at http://www.webcitation.org/6eHvyRh6M) %M 26825006 %R 10.2196/mental.4614 %U http://mental.jmir.org/2016/1/e8/ %U https://doi.org/10.2196/mental.4614 %U http://www.ncbi.nlm.nih.gov/pubmed/26825006 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 1 %P e8 %T MoodHacker Mobile Web App With Email for Adults to Self-Manage Mild-to-Moderate Depression: Randomized Controlled Trial %A Birney,Amelia J %A Gunn,Rebecca %A Russell,Jeremy K %A Ary,Dennis V %+ ORCAS, P.O. Box 1226, Eugene, OR, 97440, United States, 1 541 349 4826, abirney@orcasinc.com %K depression %K cognitive behavioral therapy %K behavioral activation %K positive psychology %K mobile apps %K Internet %K computers %D 2016 %7 26.01.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Worldwide, depression is rated as the fourth leading cause of disease burden and is projected to be the second leading cause of disability by 2020. Annual depression-related costs in the United States are estimated at US $210.5 billion, with employers bearing over 50% of these costs in productivity loss, absenteeism, and disability. Because most adults with depression never receive treatment, there is a need to develop effective interventions that can be more widely disseminated through new channels, such as employee assistance programs (EAPs), and directly to individuals who will not seek face-to-face care. Objective: This study evaluated a self-guided intervention, using the MoodHacker mobile Web app to activate the use of cognitive behavioral therapy (CBT) skills in working adults with mild-to-moderate depression. It was hypothesized that MoodHacker users would experience reduced depression symptoms and negative cognitions, and increased behavioral activation, knowledge of depression, and functioning in the workplace. Methods: A parallel two-group randomized controlled trial was conducted with 300 employed adults exhibiting mild-to-moderate depression. Participants were recruited from August 2012 through April 2013 in partnership with an EAP and with outreach through a variety of additional non-EAP organizations. Participants were blocked on race/ethnicity and then randomly assigned within each block to receive, without clinical support, either the MoodHacker intervention (n=150) or alternative care consisting of links to vetted websites on depression (n=150). Participants in both groups completed online self-assessment surveys at baseline, 6 weeks after baseline, and 10 weeks after baseline. Surveys assessed (1) depression symptoms, (2) behavioral activation, (3) negative thoughts, (4) worksite outcomes, (5) depression knowledge, and (6) user satisfaction and usability. After randomization, all interactions with subjects were automated with the exception of safety-related follow-up calls to subjects reporting current suicidal ideation and/or severe depression symptoms. Results: At 6-week follow-up, significant effects were found on depression, behavioral activation, negative thoughts, knowledge, work productivity, work absence, and workplace distress. MoodHacker yielded significant effects on depression symptoms, work productivity, work absence, and workplace distress for those who reported access to an EAP, but no significant effects on these outcome measures for those without EAP access. Participants in the treatment arm used the MoodHacker app an average of 16.0 times (SD 13.3), totaling an average of 1.3 hours (SD 1.3) of use between pretest and 6-week follow-up. Significant effects on work absence in those with EAP access persisted at 10-week follow-up. Conclusions: This randomized effectiveness trial found that the MoodHacker app produced significant effects on depression symptoms (partial eta2 = .021) among employed adults at 6-week follow-up when compared to subjects with access to relevant depression Internet sites. The app had stronger effects for individuals with access to an EAP (partial eta2 = .093). For all users, the MoodHacker program also yielded greater improvement on work absence, as well as the mediating factors of behavioral activation, negative thoughts, and knowledge of depression self-care. Significant effects were maintained at 10-week follow-up for work absence. General attenuation of effects at 10-week follow-up underscores the importance of extending program contacts to maintain user engagement. This study suggests that light-touch, CBT-based mobile interventions like MoodHacker may be appropriate for implementation within EAPs and similar environments. In addition, it seems likely that supporting MoodHacker users with guidance from counselors may improve effectiveness for those who seek in-person support. Trial Registration: ClinicalTrials.gov NCT02335554; https://clinicaltrials.gov/ct2/show/NCT02335554 (Archived by WebCite at http://www.webcitation.org/6dGXKWjWE) %M 26813737 %R 10.2196/mhealth.4231 %U http://mhealth.jmir.org/2016/1/e8/ %U https://doi.org/10.2196/mhealth.4231 %U http://www.ncbi.nlm.nih.gov/pubmed/26813737 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 1 %P e6 %T Automated Remote Monitoring of Depression: Acceptance Among Low-Income Patients in Diabetes Disease Management %A Ramirez,Magaly %A Wu,Shinyi %A Jin,Haomiao %A Ell,Kathleen %A Gross-Schulman,Sandra %A Myerchin Sklaroff,Laura %A Guterman,Jeffrey %+ Edward R Roybal Institute on Aging, School of Social Work, University of Southern California, 1150 S Olive Street, Suite 1400, Los Angeles, CA, 90015, United States, 1 213 821 6442, shinyiwu@usc.edu %K technology assessment %K telecommunications %K telemedicine %K patient care management %K clinical decision support systems %K depression %K diabetes mellitus %K safety-net clinics %D 2016 %7 25.01.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Remote patient monitoring is increasingly integrated into health care delivery to expand access and increase effectiveness. Automation can add efficiency to remote monitoring, but patient acceptance of automated tools is critical for success. From 2010 to 2013, the Diabetes-Depression Care-management Adoption Trial (DCAT)–a quasi-experimental comparative effectiveness research trial aimed at accelerating the adoption of collaborative depression care in a safety-net health care system–tested a fully automated telephonic assessment (ATA) depression monitoring system serving low-income patients with diabetes. Objective: The aim of this study was to determine patient acceptance of ATA calls over time, and to identify factors predicting long-term patient acceptance of ATA calls. Methods: We conducted two analyses using data from the DCAT technology-facilitated care arm, in which for 12 months the ATA system periodically assessed depression symptoms, monitored treatment adherence, prompted self-care behaviors, and inquired about patients’ needs for provider contact. Patients received assessments at 6, 12, and 18 months using Likert-scale measures of willingness to use ATA calls, preferred mode of reach, perceived ease of use, usefulness, nonintrusiveness, privacy/security, and long-term usefulness. For the first analysis (patient acceptance over time), we computed descriptive statistics of these measures. In the second analysis (predictive factors), we collapsed patients into two groups: those reporting “high” versus “low” willingness to use ATA calls. To compare them, we used independent t tests for continuous variables and Pearson chi-square tests for categorical variables. Next, we jointly entered independent factors found to be significantly associated with 18-month willingness to use ATA calls at the univariate level into a logistic regression model with backward selection to identify predictive factors. We performed a final logistic regression model with the identified significant predictive factors and reported the odds ratio estimates and 95% confidence intervals. Results: At 6 and 12 months, respectively, 89.6% (69/77) and 63.7% (49/77) of patients “agreed” or “strongly agreed” that they would be willing to use ATA calls in the future. At 18 months, 51.0% (64/125) of patients perceived ATA calls as useful and 59.7% (46/77) were willing to use the technology. Moreover, in the first 6 months, most patients reported that ATA calls felt private/secure (75.9%, 82/108) and were easy to use (86.2%, 94/109), useful (65.1%, 71/109), and nonintrusive (87.2%, 95/109). Perceived usefulness, however, decreased to 54.1% (59/109) in the second 6 months of the trial. Factors predicting willingness to use ATA calls at the 18-month follow-up were perceived privacy/security and long-term perceived usefulness of ATA calls. No patient characteristics were significant predictors of long-term acceptance. Conclusions: In the short term, patients are generally accepting of ATA calls for depression monitoring, with ATA call design and the care management intervention being primary factors influencing patient acceptance. Acceptance over the long term requires that the system be perceived as private/secure, and that it be constantly useful for patients’ needs of awareness of feelings, self-care reminders, and connectivity with health care providers. Trial Registration: ClinicalTrials.gov NCT01781013; https://clinicaltrials.gov/ct2/show/NCT01781013 (Archived by WebCite at http://www.webcitation.org/6e7NGku56) %M 26810139 %R 10.2196/mental.4823 %U http://mental.jmir.org/2016/1/e6/ %U https://doi.org/10.2196/mental.4823 %U http://www.ncbi.nlm.nih.gov/pubmed/26810139 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 1 %P e4 %T Reducing Depression Through an Online Intervention: Benefits From a User Perspective %A Crisp,Dimity A %A Griffiths,Kathleen M %+ Centre for Applied Psychology, Faculty of Health, University of Canberra, Canberra, 2601, Australia, 61 62012069, Dimity.Crisp@canberra.edu.au %K Internet interventions %K depression %D 2016 %7 08.01.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Internet interventions are increasingly being recognized as effective in the treatment and prevention of mental health conditions; however, the usefulness of such programs from the perspective of the participants is often not reported. Objective: This study explores the experiences of participants of a 12-week randomized controlled trial of an automated self-help training program (e-couch), with and without an Internet support group, targeting depression. Methods: The study comprised a community sample of 298 participants who completed an online survey both prior to and on completion of an intervention for preventing or reducing depressive symptoms. Results: Overall, participants reported a high level of confidence in the ability of an online intervention to improve a person’s understanding of depression. However, confidence that a website could help people learn skills for preventing depression was lower. Benefits reported by participants engaged in the intervention included increased knowledge regarding depression and its treatment, reduced depressive symptoms, increased work productivity, and improved ability to cope with everyday stress. A minority of participants reported concerns or problems resulting from participation in the interventions. Conclusions: The findings provide consumer support for the effectiveness of this online intervention. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 65657330;http://www.isrctn.com/ISRCTN65657330 (Archived by WebCite at http://www.webcitation.org/6cwH8xwF0) %M 26747378 %R 10.2196/mental.4356 %U http://mental.jmir.org/2016/1/e4/ %U https://doi.org/10.2196/mental.4356 %U http://www.ncbi.nlm.nih.gov/pubmed/26747378 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 11 %P e255 %T e-CBT (myCompass), Antidepressant Medication, and Face-to-Face Psychological Treatment for Depression in Australia: A Cost-Effectiveness Comparison %A Solomon,Daniela %A Proudfoot,Judith %A Clarke,Janine %A Christensen,Helen %+ Black Dog Institute, University of New South Wales, Hospital Rd Randwick, Sydney, , Australia, 61 0293829274, d.solomon@blackdog.org.au %K cost-utility analysis %K depression %K self-help %K computer-assisted therapy %D 2015 %7 11.11.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: The economic cost of depression is becoming an ever more important determinant for health policy and decision makers. Internet-based interventions with and without therapist support have been found to be effective options for the treatment of mild to moderate depression. With increasing demands on health resources and shortages of mental health care professionals, the integration of cost-effective treatment options such as Internet-based programs into primary health care could increase efficiency in terms of resource use and costs. Objective: Our aim was to evaluate the cost-effectiveness of an Internet-based intervention (myCompass) for the treatment of mild-to-moderate depression compared to treatment as usual and cognitive behavior therapy in a stepped care model. Methods: A decision model was constructed using a cost utility framework to show both costs and health outcomes. In accordance with current treatment guidelines, a stepped care model included myCompass as the first low-intervention step in care for a proportion of the model cohort, with participants beginning from a low-intensity intervention to increasing levels of treatment. Model parameters were based on data from the recent randomized controlled trial of myCompass, which showed that the intervention reduced symptoms of depression, anxiety, and stress and improved work and social functioning for people with symptoms in the mild-to-moderate range. Results: The average net monetary benefit (NMB) was calculated, identifying myCompass as the strategy with the highest net benefit. The mean incremental NMB per individual for the myCompass group was AUD 1165.88 compared to treatment as usual and AUD 522.58 for the cognitive behavioral therapy model. Conclusions: Internet-based interventions can provide cost-effective access to treatment when provided as part of a stepped care model. Widespread dissemination of Internet-based programs can potentially reduce demands on primary and tertiary services and reduce unmet need. %M 26561555 %R 10.2196/jmir.4207 %U http://www.jmir.org/2015/11/e255/ %U https://doi.org/10.2196/jmir.4207 %U http://www.ncbi.nlm.nih.gov/pubmed/26561555 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 4 %P e123 %T Twitter-Delivered Behavioral Weight-Loss Interventions: A Pilot Series %A Pagoto,Sherry L %A Waring,Molly E %A Schneider,Kristin L %A Oleski,Jessica L %A Olendzki,Effie %A Hayes,Rashelle B %A Appelhans,Bradley M %A Whited,Matthew C %A Busch,Andrew M %A Lemon,Stephenie C %+ Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, United States, 1 508 856 2092, Sherry.Pagoto@umassmed.edu %K social networks %K Twitter %K obesity %K weight loss %K online social networking %K peer-to-peer health care %K digital health %D 2015 %7 23.10.2015 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Lifestyle interventions are efficacious at reducing risk for diabetes and cardiovascular disease but have not had a significant public health impact given high cost and patient and provider burden. Objective: Online social networks may reduce the burden of lifestyle interventions to the extent that they displace in-person visits and may enhance opportunities for social support for weight loss. Methods: We conducted an iterative series of pilot studies to evaluate the feasibility and acceptability of using online social networks to deliver a lifestyle intervention. Results: In Study 1 (n=10), obese participants with depression received lifestyle counseling via 12 weekly group visits and a private group formed using the online social network, Twitter. Mean weight loss was 2.3 pounds (SD 7.7; range -19.2 to 8.2) or 1.2% (SD 3.6) of baseline weight. A total of 67% (6/9) of participants completing exit interviews found the support of the Twitter group at least somewhat useful. In Study 2 (n=11), participants were not depressed and were required to be regular users of social media. Participants lost, on average, 5.6 pounds (SD 6.3; range -15 to 0) or 3.0% (SD 3.4) of baseline weight, and 100% (9/9) completing exit interviews found the support of the Twitter group at least somewhat useful. To explore the feasibility of eliminating in-person visits, in Study 3 (n=12), we delivered a 12-week lifestyle intervention almost entirely via Twitter by limiting the number of group visits to one, while using the same inclusion criteria as that used in Study 2. Participants lost, on average, 5.4 pounds (SD 6.4; range -14.2 to 3.9) or 3.0% (SD 3.1) of baseline weight, and 90% (9/10) completing exit interviews found the support of the Twitter group at least somewhat useful. Findings revealed that a private Twitter weight-loss group was both feasible and acceptable for many patients, particularly among regular users of social media. Conclusions: Future research should evaluate the efficacy and cost-effectiveness of online social network-delivered lifestyle interventions relative to traditional modalities. %M 26500186 %R 10.2196/resprot.4864 %U http://www.researchprotocols.org/2015/4/e123/ %U https://doi.org/10.2196/resprot.4864 %U http://www.ncbi.nlm.nih.gov/pubmed/26500186 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 4 %P e120 %T An Internet-Based Intervention (Mamma Mia) for Postpartum Depression: Mapping the Development from Theory to Practice %A Drozd,Filip %A Haga,Silje Marie %A Brendryen,Håvar %A Slinning,Kari %+ National Network for Infant Mental Health, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, PO Box 4623 Nydalen, Oslo, N-0405, Norway, 47 975 16 188, filip.drozd@r-bup.no %K early intervention %K Internet %K intervention mapping %K Mamma Mia %K postpartum depression %K pregnancy %K well-being %D 2015 %7 12.10.2015 %9 Original Paper %J JMIR Res Protoc %G English %X Background: As much as 10-15% of new mothers experience depression postpartum. An Internet-based intervention (Mamma Mia) was developed with the primary aims of preventing depressive symptoms and enhancing subjective well-being among pregnant and postpartum women. A secondary aim of Mamma Mia was to ease the transition of becoming a mother by providing knowledge, techniques, and support during pregnancy and after birth. Objective: The aim of the paper is to provide a systematic and comprehensive description of the intervention rationale and the development of Mamma Mia. Methods: For this purpose, we used the intervention mapping (IM) protocol as descriptive tool, which consists of the following 6 steps: (1) a needs assessment, (2) definition of change objectives, (3) selection of theoretical methods and practical strategies, (4) development of program components, (5) planning adoption and implementation, and (6) planning evaluation. Results: Mamma Mia is a fully automated Internet intervention available for computers, tablets, and smartphones, intended for individual use by the mother. It starts in gestational week 18-24 and lasts up to when the baby becomes 6 months old. This intervention applies a tunneled design to guide the woman through the program in a step-by-step fashion in accordance with the psychological preparations of becoming a mother. The intervention is delivered by email and interactive websites, combining text, pictures, prerecorded audio files, and user input. It targets risk and protective factors for postpartum depression such as prepartum and postpartum attachment, couple satisfaction, social support, and subjective well-being, as identified in the needs assessment. The plan is to implement Mamma Mia directly to users and as part of ordinary services at well-baby clinics, and to evaluate the effectiveness of Mamma Mia in a randomized controlled trial and assess users’ experiences with the program. Conclusions: The IM of Mamma Mia has made clear the rationale for the intervention, and linked theories and empirical evidence to the contents and materials of the program. This meets the recent calls for intervention descriptions and may inform future studies, development of interventions, and systematic reviews. %M 26476481 %R 10.2196/resprot.4858 %U http://www.researchprotocols.org/2015/4/e120/ %U https://doi.org/10.2196/resprot.4858 %U http://www.ncbi.nlm.nih.gov/pubmed/26476481 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 9 %P e197 %T Predictors of Response to Web-Based Cognitive Behavioral Therapy With High-Intensity Face-to-Face Therapist Guidance for Depression: A Bayesian Analysis %A Høifødt,Ragnhild Sørensen %A Mittner,Matthias %A Lillevoll,Kjersti %A Katla,Susanne Kvam %A Kolstrup,Nils %A Eisemann,Martin %A Friborg,Oddgeir %A Waterloo,Knut %+ Department of Psychology, Faculty of Health Sciences, UiT The Arctic University of Norway, 9037 Tromsø, Tromsø, 9037, Norway, 47 776 49230, ragnhild.s.hoifodt@uit.no %K treatment outcome %K computer-assisted therapy %K cognitive behavior therapy %K depression %K primary health care %K Bayesian analysis %D 2015 %7 02.09.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Several studies have demonstrated the effect of guided Internet-based cognitive behavioral therapy (ICBT) for depression. However, ICBT is not suitable for all depressed patients and there is a considerable level of nonresponse. Research on predictors and moderators of outcome in ICBT is inconclusive. Objective: This paper explored predictors of response to an intervention combining the Web-based program MoodGYM and face-to-face therapist guidance in a sample of primary care patients with mild to moderate depressive symptoms. Methods: Participants (N=106) aged between 18 and 65 years were recruited from primary care and randomly allocated to a treatment condition or to a delayed treatment condition. The intervention included the Norwegian version of the MoodGYM program, face-to-face guidance from a psychologist, and reminder emails. In this paper, data from the treatment phase of the 2 groups was merged to increase the sample size (n=82). Outcome was improvement in depressive symptoms during treatment as assessed with the Beck Depression Inventory-II (BDI-II). Predictors included demographic variables, severity variables (eg, number of depressive episodes and pretreatment depression and anxiety severity), cognitive variables (eg, dysfunctional thinking), module completion, and treatment expectancy and motivation. Using Bayesian analysis, predictors of response were explored with a latent-class approach and by analyzing whether predictors affected the slope of response. Results: A 2-class model distinguished well between responders (74%, 61/82) and nonresponders (26%, 21/82). Our results indicate that having had more depressive episodes, being married or cohabiting, and scoring higher on a measure of life satisfaction had high odds for positively affecting the probability of response. Higher levels of dysfunctional thinking had high odds for a negative effect on the probability of responding. Prediction of the slope of response yielded largely similar results. Bayes factors indicated substantial evidence that being married or cohabiting predicted a more positive treatment response. The effects of life satisfaction and number of depressive episodes were more uncertain. There was substantial evidence that several variables were unrelated to treatment response, including gender, age, and pretreatment symptoms of depression and anxiety. Conclusions: Treatment response to ICBT with face-to-face guidance may be comparable across varying levels of depressive severity and irrespective of the presence and severity of comorbid anxiety. Being married or cohabiting, reporting higher life satisfaction, and having had more depressive episodes may predict a more favorable response, whereas higher levels of dysfunctional thinking may be a predictor of poorer response. More studies exploring predictors and moderators of Internet-based treatments are needed to inform for whom this treatment is most effective. Trial Registration: Australian New Zealand Clinical Trials Registry number: ACTRN12610000257066; https://www.anzctr.org.au/trial_view.aspx?id=335255 (Archived by WebCite at http://www.webcitation.org/6GR48iZH4). %M 26333818 %R 10.2196/jmir.4351 %U http://www.jmir.org/2015/9/e197/ %U https://doi.org/10.2196/jmir.4351 %U http://www.ncbi.nlm.nih.gov/pubmed/26333818 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 3 %P e22 %T Feasibility of "CopeSmart": A Telemental Health App for Adolescents %A Kenny,Rachel %A Dooley,Barbara %A Fitzgerald,Amanda %+ School of Psychology, University College Dublin, Belfield, Dublin 4, , Ireland, 353 1 7168147, rachel.kenny.3@ucdconnect.ie %K adolescents %K emotional self-monitoring %K feasibility %K mobile apps %K positive mental health %D 2015 %7 10.08.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: Early intervention is important in order to improve mental health outcomes for young people. Given the recent rise in mobile phone ownership among adolescents, an innovative means of delivering such intervention is through the use of mobile phone applications (apps). Objective: The aim of this study was to evaluate the feasibility of “CopeSmart”, a telemental health app developed to foster positive mental health in adolescents through emotional self-monitoring and the promotion of positive coping strategies. Methods: Forty-three adolescents (88% female) aged 15-17 years downloaded the app and used it over a one-week period. They then completed self-report questionnaires containing both open-ended and closed-ended questions about their experiences of using the app. The app itself captured data related to user engagement. Results: On average participants engaged with the app on 4 of the 7 days within the intervention period. Feedback from users was reasonably positive, with 70% of participants reporting that they would use the app again and 70% reporting that they would recommend it to a friend. Thematic analysis of qualitative data identified themes pertaining to users’ experiences of the app, which were both positive (eg, easy to use, attractive layout, emotional self-monitoring, helpful information, notifications, unique) and negative (eg, content issues, did not make user feel better, mood rating issues, password entry, interface issues, engagement issues, technical fixes). Conclusions: Overall findings suggest that telemental health apps have potential as a feasible medium for promoting positive mental health, with the majority of young people identifying such technologies as at least somewhat useful and displaying a moderate level of engagement with them. Future research should aim to evaluate the efficacy of such technologies as tools for improving mental health outcomes in young people. %M 26552425 %R 10.2196/mental.4370 %U http://mental.jmir.org/2015/3/e22/ %U https://doi.org/10.2196/mental.4370 %U http://www.ncbi.nlm.nih.gov/pubmed/26552425 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 3 %P e99 %T Depression Awareness and Self-Management Through the Internet: Protocol for an Internationally Standardized Approach %A Arensman,Ella %A Koburger,Nicole %A Larkin,Celine %A Karwig,Gillian %A Coffey,Claire %A Maxwell,Margaret %A Harris,Fiona %A Rummel-Kluge,Christine %A van Audenhove,Chantal %A Sisask,Merike %A Alexandrova-Karamanova,Anna %A Perez,Victor %A Purebl,György %A Cebria,Annabel %A Palao,Diego %A Costa,Susana %A Mark,Lauraliisa %A Tóth,Mónika Ditta %A Gecheva,Marieta %A Ibelshäuser,Angela %A Gusmão,Ricardo %A Hegerl,Ulrich %+ National Suicide Research Foundation, University College Cork, 4.28 Western Gateway Building, Cork, , Ireland, 353 (0)21 4205541, EArensman@ucc.ie %K cognitive behavioral therapy %K computerized %K depression %K Internet-based %K primary care %K self-management %D 2015 %7 06.08.2015 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression incurs significant morbidity and confers increased risk of suicide. Many individuals experiencing depression remain untreated due to systemic and personal barriers to care. Guided Internet-based psychotherapeutic programs represent a promising means of overcoming such barriers and increasing the capacity for self-management of depression. However, existing programs tend to be available only in English and can be expensive to access. Furthermore, despite evidence of the effectiveness of a number of Internet-based programs, there is limited evidence regarding both the acceptability of such programs and feasibility of their use, for users and health care professionals. Objective: This paper will present the protocol for the development, implementation, and evaluation of the iFightDepression tool, an Internet-based self-management tool. This is a cost-free, multilingual, guided, self-management program for mild to moderate depression cases. Methods: The Preventing Depression and Improving Awareness through Networking in the European Union consortium undertook a comprehensive systematic review of the available evidence regarding computerized cognitive behavior therapy in addition to a consensus process involving mental health experts and service users to inform the development of the iFightDepression tool. The tool was implemented and evaluated for acceptability and feasibility of its use in a pilot phase in 5 European regions, with recruitment of users occurring through general practitioners and health care professionals who participated in a standardized training program. Results: Targeting mild to moderate depression, the iFightDepression tool is based on cognitive behavioral therapy and addresses behavioral activation (monitoring and planning daily activities), cognitive restructuring (identifying and challenging unhelpful thoughts), sleep regulation, mood monitoring, and healthy lifestyle habits. There is also a tailored version of the tool for young people, incorporating less formal language and additional age-appropriate modules on relationships and social anxiety. The tool is accompanied by a 3-hour training intervention for health care professionals. Conclusions: It is intended that the iFightDepression tool and associated training for health care professionals will represent a valuable resource for the management of depression that will complement existing resources for health care professionals. It is also intended that the iFightDepression tool and training will represent an additional resource within a multifaceted approach to improving the care of depression and preventing suicidal behavior in Europe. %M 26251104 %R 10.2196/resprot.4358 %U http://www.researchprotocols.org/2015/3/e99/ %U https://doi.org/10.2196/resprot.4358 %U http://www.ncbi.nlm.nih.gov/pubmed/26251104 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 7 %P e175 %T Mobile Phone Sensor Correlates of Depressive Symptom Severity in Daily-Life Behavior: An Exploratory Study %A Saeb,Sohrab %A Zhang,Mi %A Karr,Christopher J %A Schueller,Stephen M %A Corden,Marya E %A Kording,Konrad P %A Mohr,David C %+ Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University, 750 N Lake Shore Drive, Chicago, IL, 60611, United States, 1 312 503 1403, d-mohr@northwestern.edu %K depression %K mobile health (mHealth) %K activities of daily living %K cluster analysis %K classification %D 2015 %7 15.07.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is a common, burdensome, often recurring mental health disorder that frequently goes undetected and untreated. Mobile phones are ubiquitous and have an increasingly large complement of sensors that can potentially be useful in monitoring behavioral patterns that might be indicative of depressive symptoms. Objective: The objective of this study was to explore the detection of daily-life behavioral markers using mobile phone global positioning systems (GPS) and usage sensors, and their use in identifying depressive symptom severity. Methods: A total of 40 adult participants were recruited from the general community to carry a mobile phone with a sensor data acquisition app (Purple Robot) for 2 weeks. Of these participants, 28 had sufficient sensor data received to conduct analysis. At the beginning of the 2-week period, participants completed a self-reported depression survey (PHQ-9). Behavioral features were developed and extracted from GPS location and phone usage data. Results: A number of features from GPS data were related to depressive symptom severity, including circadian movement (regularity in 24-hour rhythm; r=-.63, P=.005), normalized entropy (mobility between favorite locations; r=-.58, P=.012), and location variance (GPS mobility independent of location; r=-.58, P=.012). Phone usage features, usage duration, and usage frequency were also correlated (r=.54, P=.011, and r=.52, P=.015, respectively). Using the normalized entropy feature and a classifier that distinguished participants with depressive symptoms (PHQ-9 score ≥5) from those without (PHQ-9 score <5), we achieved an accuracy of 86.5%. Furthermore, a regression model that used the same feature to estimate the participants’ PHQ-9 scores obtained an average error of 23.5%. Conclusions: Features extracted from mobile phone sensor data, including GPS and phone usage, provided behavioral markers that were strongly related to depressive symptom severity. While these findings must be replicated in a larger study among participants with confirmed clinical symptoms, they suggest that phone sensors offer numerous clinical opportunities, including continuous monitoring of at-risk populations with little patient burden and interventions that can provide just-in-time outreach. %M 26180009 %R 10.2196/jmir.4273 %U http://www.jmir.org/2015/7/e175/ %U https://doi.org/10.2196/jmir.4273 %U http://www.ncbi.nlm.nih.gov/pubmed/26180009 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 3 %P e83 %T Measuring Life Events and Their Association With Clinical Disorder: A Protocol for Development of an Online Approach %A Spence,Ruth %A Bunn,Amanda %A Nunn,Stephen %A Hosang,Georgina M %A Kagan,Lisa %A Fisher,Helen L %A Taylor,Matthew %A Bifulco,Antonia %+ Centre for Abuse and Trauma Studies, Middlesex University, The Burroughs, London, NW4 4BT, United Kingdom, 44 208411 ext 4116, r.spence@mdx.ac.uk %K disorder %K interview %K life events %K online systems %K stress %D 2015 %7 14.07.2015 %9 Protocol %J JMIR Res Protoc %G English %X Background: Severe life events are acknowledged as important etiological factors in the development of clinical disorders, including major depression. Interview methods capable of assessing context and meaning of events have demonstrated superior validity compared with checklist questionnaire methods and arguments for interview approaches have resurfaced because choosing the appropriate assessment tool provides clarity of information about gene-environment interactions in depression. Such approaches also have greater potential for understanding and treating clinical cases or for use in interventions. Objective: (1) To argue that life events need sophisticated measurement not satisfactorily captured in checklist approaches. (2) To review life-events measures and key findings related to disorder, exemplifying depression. (3) To describe an ongoing study with a new online measure and to assess its psychometric properties and the association of life events in relation to disorder and educational outcomes. Methods: The Computerised Life Events Assessment Record (CLEAR) is under development as a tool for online assessment of adult life events. Based on the Life Events and Difficulties Schedule interview, CLEAR seeks to assess life events to self and close others, link these to other events and difficulties, and utilize calendar-based timing, to improve upon checklist approaches. Results: The CLEAR study is in the preliminary stages and its results are expected to be made available by the end of 2015. Conclusions: There is currently no sophisticated technological application of social risk factor assessment, such as life events and difficulties. CLEAR is designed to gather reliable and valid life-event data while combating the limitations of interviews (eg, time consuming and costly) and life-event checklists (eg, inability to accurately measure severity and independence of life events). The advantages of using such innovative methodology for research, clinical practice, and interventions are discussed. %M 26175304 %R 10.2196/resprot.4085 %U http://www.researchprotocols.org/2015/3/e83/ %U https://doi.org/10.2196/resprot.4085 %U http://www.ncbi.nlm.nih.gov/pubmed/26175304 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 6 %P e139 %T Computerized Cognitive Behavior Therapy for Anxiety and Depression in Rural Areas: A Systematic Review %A Vallury,Kari Dee %A Jones,Martin %A Oosterbroek,Chloe %+ Department of Rural Health (DRH), Division of Health Sciences, University of South Australia, Department of Rural Health, 111 Nicolson Avenue, Whyalla Norrie, 5608, Australia, 61 0433773061, kari.vallury@unisa.edu.au %K eHealth %K mHealth %K depression %K anxiety %K cognitive therapy %K rural health %K mental health %D 2015 %7 05.06.2015 %9 Review %J J Med Internet Res %G English %X Background: People living in rural and remote communities have greater difficulty accessing mental health services and evidence-based therapies, such as cognitive behavior therapy (CBT), than their urban counterparts. Computerized CBT (CCBT) can be used to effectively treat depression and anxiety and may be particularly useful in rural settings where there are a lack of suitably trained practitioners. Objective: To systematically review the global evidence regarding the clinical effectiveness and acceptability of CCBT interventions for anxiety and/or depression for people living in rural and remote locations. Methods: We searched seven online databases: Medline, Embase Classic and Embase, PsycINFO, CINAHL, Web of Science, Scopus, and the Cochrane Library. We also hand searched reference lists, Internet search engines, and trial protocols. Two stages of selection were undertaken. In the first, the three authors screened citations. Studies were retained if they reported the efficacy, effectiveness or acceptability of CCBT for depression and/or anxiety disorders, were peer reviewed, and written in English. The qualitative data analysis software, NVivo 10, was then used to run automated text searches for the word “rural,” its synonyms, and stemmed words. All studies identified were read in full and were included in the study if they measured or meaningfully discussed the efficacy or acceptability of CCBT among rural participants. Results: A total of 2594 studies were identified, of which 11 met the selection criteria and were included in the review. The studies that disaggregated efficacy data by location of participant reported that CCBT was equally effective for rural and urban participants. Rural location was found to both positively and negatively predict adherence across studies. CCBT may be more acceptable among rural than urban participants—studies to date showed that rural participants were less likely to want more face-to-face contact with a practitioner and found that computerized delivery addressed confidentiality concerns. Conclusions: CCBT can be effective for addressing depression and anxiety and is acceptable among rural participants. Further work is required to confirm these results across a wider range of countries, and to determine the most feasible model of CCBT delivery, in partnership with people who live and work in rural and remote communities. %M 26048193 %R 10.2196/jmir.4145 %U http://www.jmir.org/2015/6/e139/ %U https://doi.org/10.2196/jmir.4145 %U http://www.ncbi.nlm.nih.gov/pubmed/26048193 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 2 %P e55 %T Supportive Text Messages to Reduce Mood Symptoms and Problem Drinking in Patients With Primary Depression or Alcohol Use Disorder: Protocol for an Implementation Research Study %A Agyapong,Vincent Israel Opoku %A Mrklas,Kelly %A Suen,Victoria Yung Mei %A Rose,Marianne Sarah %A Jahn,Megan %A Gladue,Irene %A Kozak,Jody %A Leslie,Maureen %A Dursun,Serdar %A Ohinmaa,Arto %A Greenshaw,Andrew %+ Faculty of Health Sciences, Department of Psychiatry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Centre (WMC), 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 780 215 7771, agyapong@ualberta.ca %K depression %K alcohol use disorder %K supportive text messages %K intervention %D 2015 %7 15.05.2015 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression and Alcohol Use Disorders (AUDs) are two leading causes of disability worldwide and are associated with significant treatment challenges requiring new, innovative, cost-effective and technologically-based therapies including the use of supportive text messages. Objective: To determine the feasibility and effectiveness of supportive text messages in long-term follow-up to reduce mood symptoms and problem drinking in patients with Depression or AUD respectively and to explore the usefulness of self-reports of health services utilization as an outcomes measure. Methods: This will be a longitudinal, prospective, parallel-design, two-arm, placebo-controlled single-rater-blinded randomized clinical trial with a recruitment period of 6 months and an observation period of 12 months for each participant, with two strata based on primary diagnosis of Major Depressive Disorder or AUD. The sample size will be 120, with about 60 patients randomized from each primary diagnostic grouping. Patients in all intervention groups will receive twice-daily supportive SMS text messages for 3 months and then daily supportive text messages for the next three months. Patients will also receive a phone call every two weeks from the research assistant assigning treatment allocation to confirm that they are still receiving the text messages and to thank them for taking part in the study. Patients in the control group will receive no text messages but will also receive a phone call from the same research assistant every two weeks to thank them for taking part in the study. Results: The study starts in April 2015 and ends in September 2016. It is envisaged that both qualitative and quantitative primary and secondary outcomes, including patient perceptions of the intervention, will shed light on the feasibility of using automated supportive text message interventions in long term for patients with Depression and AUD. This will inform a full-scale clinical trial. Conclusions: The paradigm for behavior change using text messages as a patient-direct intervention is consistent with a cognitive behavior therapy approach and addictions counselling principles. Given the automaticity of the messages, we anticipate that if the intervention proves successful, it will represent a low cost strategy that will be readily available and can bring relief to patients in hard-to-reach areas with limited access to psychological therapies. Trial Registration: ClinicalTrials.gov: NCT02327858; https://clinicaltrials.gov/ct2/show/NCT02327858 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT02327858). %M 25979786 %R 10.2196/resprot.4371 %U http://www.researchprotocols.org/2015/2/e55/ %U https://doi.org/10.2196/resprot.4371 %U http://www.ncbi.nlm.nih.gov/pubmed/25979786 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 2 %P e15 %T Adjustment Disorders Are Uniquely Suited for eHealth Interventions: Concept and Case Study %A Maercker,Andreas %A Bachem,Rahel C %A Lorenz,Louisa %A Moser,Christian T %A Berger,Thomas %+ Division of Psychopathology and Clinical Intervention, Department of Psychology, University of Zurich, Institute of Psychology, Binzmühlestrasse 14/17, Zurich, 8050, Switzerland, 41 44 635 7310, maercker@psychologie.uzh.ch %K adjustment disorders %K intervention %K e-mental health %K unguided self-help %K depression %D 2015 %7 08.05.2015 %9 Viewpoint %J JMIR Mental Health %G English %X Background: Adjustment disorders (also known as mental distress in response to a stressor) are among the most frequently diagnosed mental disorders in psychiatry and clinical psychology worldwide. They are also commonly diagnosed in clients engaging in deliberate self-harm and in those consulting general practitioners. However, their reputation in research-oriented mental health remains weak since they are largely underresearched. This may change when the International Statistical Classification of Diseases-11 (ICD-11) by the World Health Organization is introduced, including a new conceptualization of adjustment disorders as a stress-response disorder with positively defined core symptoms. Objective: This paper provides an overview of evidence-based interventions for adjustment disorders. Methods: We reviewed the new ICD-11 concept of adjustment disorder and discuss the the rationale and case study of an unguided self-help protocol for burglary victims with adjustment disorder, and its possible implementation as an eHealth intervention. Results: Overall, the treatment with the self-help manual reduced symptoms of adjustment disorder, namely preoccupation and failure to adapt, as well as symptoms of depression, anxiety, and stress. Conclusions: E-mental health options are considered uniquely suited for offering early intervention after the experiences of stressful life events that potentially trigger adjustment disorders. %M 26543920 %R 10.2196/mental.4157 %U http://mental.jmir.org/2015/2/e15/ %U https://doi.org/10.2196/mental.4157 %U http://www.ncbi.nlm.nih.gov/pubmed/26543920 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 2 %P e14 %T An Online, Moderated Peer-to-Peer Support Bulletin Board for Depression: User-Perceived Advantages and Disadvantages %A Griffiths,Kathleen Margaret %A Reynolds,Julia %A Vassallo,Sara %+ National Institute for Mental Health Research (NIMHR), Research School of Population Health, Australian National University, Eggleston Road, Acton, Canberra, 2601, Australia, 61 2 6125 9723, kathy.griffiths@anu.edu.au %K Internet %K support group %K mental health %K depression %D 2015 %7 24.04.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: Online, peer-to-peer support groups for depression are common on the World Wide Web and there is some evidence of their effectiveness. However, little is known about the mechanisms by which Internet support groups (ISGs) might work. Objective: This study aimed to investigate consumer perceptions of the benefits and disadvantages of online peer-to-peer support by undertaking a content analysis of the spontaneous posts on BlueBoard, a well-established, moderated, online depression bulletin board. Methods: The research set comprised all posts on the board (n=3645) for each of 3 months selected at 4 monthly intervals over 2011. The data were analyzed using content analysis and multiple coders. Results: A total of 586 relevant posts were identified, 453 (77.3%) reporting advantages and 133 (22.7%) reporting disadvantages. Positive personal change (335/453, 74.0%) and valued social interactions and support (296/453, 65.3%) emerged as perceived advantages. Other identified benefits were valued opportunities to disclose/express feelings or views (29/453, 6.4%) and advantages of the BlueBoard environment (45/453, 9.9%). Disadvantages were negative personal change (50/133, 37.6%), perceived disadvantages of board rules/moderation (42/133, 31.6%), unhelpful social interactions/contact with other members (40/133, 30.1%), and technical obstacles to using the board (14/133, 10.5%). Conclusions: Consumers value the opportunity to participate in an online mutual support group for mental health concerns. Further research is required to better understand how and if these perceived advantages translate into positive outcomes for consumers, and whether the perceived disadvantages of such boards can be addressed without compromising the safety and positive outcomes of the board. %M 26543919 %R 10.2196/mental.4266 %U http://mental.jmir.org/2015/2/e14/ %U https://doi.org/10.2196/mental.4266 %U http://www.ncbi.nlm.nih.gov/pubmed/26543919 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 2 %P e44 %T Internet-Based Cognitive Behavioral Therapy for Residual Symptoms in Bipolar Disorder Type II: A Single-Subject Design Pilot Study %A Holländare,Fredrik %A Eriksson,Annsofi %A Lövgren,Lisa %A Humble,Mats B %A Boersma,Katja %+ Psychiatric Research Centre, School of Health and Medical Science, Örebro University, S House, Södra Grev Rosengatan, Örebro, 70116, Sweden, 46 196025890, fredrik.hollandare@orebroll.se %K bipolar disorder %K Internet %K cognitive therapy %K behavioral therapy %K pilot projects %D 2015 %7 23.04.2015 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Bipolar disorder is a chronic condition with recurring episodes that often lead to suffering, decreased functioning, and sick leave. Pharmacotherapy in the form of mood stabilizers is widely available, but does not eliminate the risk of a new depressive or (hypo)manic episode. One way to reduce the risk of future episodes is to combine pharmacological treatment with individual or group psychological interventions. However, access to such interventions is often limited due to a shortage of trained therapists. In unipolar depression there is now robust evidence of the effectiveness of Internet-based psychological interventions, usually comprising psychoeducation and cognitive behavioral therapy (CBT). Internet-based interventions for persons suffering from bipolar disorder could increase access to psychological treatment. Objective: The aim of this study was to investigate the feasibility of an Internet-based intervention, as well as its effect on residual depressive symptoms in persons diagnosed with bipolar disorder type II (BP-II). The most important outcomes were depressive symptoms, treatment adherence, and whether the patient perceived the intervention as helpful. Methods: A total of 7 patients diagnosed with bipolar disorder type II at a Swedish psychiatric outpatient clinic were offered the opportunity to participate. Of the 7 patients, 3 (43%) dropped out before treatment began, and 4 (57%) were treated by means of an online, Internet-based intervention based on CBT (iCBT). The intervention was primarily aimed at psychoeducation, treatment of residual depressive symptoms, emotion regulation, and improved sleep. All patients had ongoing pharmacological treatment at recruitment and established contact with a psychiatrist. The duration of BP-II among the treated patients was between 6 and 31 years. A single-subject design was used and the results of the 4 participating patients were presented individually. Results: Initiating treatment was perceived as too demanding under current life circumstances for 3 patients who consequently dropped out during baseline assessment. Self-ratings using the Montgomery-Åsberg Depression Rating Scale—Self-rated (MADRS-S) showed symptom reduction in 3 (75%) of the 4 treated cases during iCBT. In the evaluation of the treatment, 2 patients reported that they perceived that the treatment had reduced symptoms a little, 1 that it had reduced symptoms very much, and 1 not at all. Treatment adherence (ie, module completion) was fairly high in 3 cases. In general, the modules were perceived as fairly helpful or very helpful by the patients. In one case, there was a reliable change—according to the Reliable Change Index—in self-rated symptoms of depression and perseverative thinking. Conclusions: The treatment seemed to have acceptable feasibility. The iCBT intervention could be an effective way to treat residual symptoms in some patients with bipolar disorder type II. This should be investigated in a larger study. Trial Registration: ClinicalTrials.gov NCT01742351; https://clinicaltrials.gov/ct2/show/NCT01742351 (Archived by WebCite at http://www.webcitation.org/6XnVpv4C3). %M 25908235 %R 10.2196/resprot.3910 %U http://www.researchprotocols.org/2015/2/e44/ %U https://doi.org/10.2196/resprot.3910 %U http://www.ncbi.nlm.nih.gov/pubmed/25908235 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 2 %P e11 %T Integrating Health Behavior Theory and Design Elements in Serious Games %A Cheek,Colleen %A Fleming,Theresa %A Lucassen,Mathijs FG %A Bridgman,Heather %A Stasiak,Karolina %A Shepherd,Matthew %A Orpin,Peter %+ Rural Clinical School, School of Medicine, University of Tasmania, Private Bag 3513, Burnie, , Australia, 61 3 6430 5922, Colleen.Cheek@utas.edu.au %K depression %K adolescent %K cognitive behavior therapy %K online intervention %K user-centered %K self-efficacy %K motivation %K adherence %K SPARX %D 2015 %7 21.04.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: Internet interventions for improving health and well-being have the potential to reach many people and fill gaps in service provision. Serious gaming interfaces provide opportunities to optimize user adherence and impact. Health interventions based in theory and evidence and tailored to psychological constructs have been found to be more effective to promote behavior change. Defining the design elements which engage users and help them to meet their goals can contribute to better informed serious games. Objective: To elucidate design elements important in SPARX, a serious game for adolescents with depression, from a user-centered perspective. Methods: We proposed a model based on an established theory of health behavior change and practical features of serious game design to organize ideas and rationale. We analyzed data from 5 studies comprising a total of 22 focus groups and 66 semistructured interviews conducted with youth and families in New Zealand and Australia who had viewed or used SPARX. User perceptions of the game were applied to this framework. Results: A coherent framework was established using the three constructs of self-determination theory (SDT), autonomy, competence, and relatedness, to organize user perceptions and design elements within four areas important in design: computer game, accessibility, working alliance, and learning in immersion. User perceptions mapped well to the framework, which may assist developers in understanding the context of user needs. By mapping these elements against the constructs of SDT, we were able to propose a sound theoretical base for the model. Conclusions: This study’s method allowed for the articulation of design elements in a serious game from a user-centered perspective within a coherent overarching framework. The framework can be used to deliberately incorporate serious game design elements that support a user’s sense of autonomy, competence, and relatedness, key constructs which have been found to mediate motivation at all stages of the change process. The resulting model introduces promising avenues for future exploration. Involving users in program design remains an imperative if serious games are to be fit for purpose. %M 26543916 %R 10.2196/mental.4133 %U http://mental.jmir.org/2015/2/e11/ %U https://doi.org/10.2196/mental.4133 %U http://www.ncbi.nlm.nih.gov/pubmed/26543916 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 3 %P e72 %T Efficacy of a Web-Based, Crowdsourced Peer-To-Peer Cognitive Reappraisal Platform for Depression: Randomized Controlled Trial %A Morris,Robert R %A Schueller,Stephen M %A Picard,Rosalind W %+ MIT Media Lab, Massachusetts Institute of Technology, E14-348A, 75 Amherst St, Cambridge, MA, 02139, United States, 1 6172530611, rmorris@media.mit.edu %K Web-based intervention %K crowdsourcing %K randomized controlled trial %K depression %K cognitive behavioral therapy %K mental health %K social networks %D 2015 %7 30.03.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Self-guided, Web-based interventions for depression show promising results but suffer from high attrition and low user engagement. Online peer support networks can be highly engaging, but they show mixed results and lack evidence-based content. Objective: Our aim was to introduce and evaluate a novel Web-based, peer-to-peer cognitive reappraisal platform designed to promote evidence-based techniques, with the hypotheses that (1) repeated use of the platform increases reappraisal and reduces depression and (2) that the social, crowdsourced interactions enhance engagement. Methods: Participants aged 18-35 were recruited online and were randomly assigned to the treatment group, “Panoply” (n=84), or an active control group, online expressive writing (n=82). Both are fully automated Web-based platforms. Participants were asked to use their assigned platform for a minimum of 25 minutes per week for 3 weeks. Both platforms involved posting descriptions of stressful thoughts and situations. Participants on the Panoply platform additionally received crowdsourced reappraisal support immediately after submitting a post (median response time=9 minutes). Panoply participants could also practice reappraising stressful situations submitted by other users. Online questionnaires administered at baseline and 3 weeks assessed depression symptoms, reappraisal, and perseverative thinking. Engagement was assessed through self-report measures, session data, and activity levels. Results: The Panoply platform produced significant improvements from pre to post for depression (P=.001), reappraisal (P<.001), and perseverative thinking (P<.001). The expressive writing platform yielded significant pre to post improvements for depression (P=.02) and perseverative thinking (P<.001), but not reappraisal (P=.45). The two groups did not diverge significantly at post-test on measures of depression or perseverative thinking, though Panoply users had significantly higher reappraisal scores (P=.02) than expressive writing. We also found significant group by treatment interactions. Individuals with elevated depression symptoms showed greater comparative benefit from Panoply for depression (P=.02) and perseverative thinking (P=.008). Individuals with baseline reappraisal deficits showed greater comparative benefit from Panoply for depression (P=.002) and perseverative thinking (P=.002). Changes in reappraisal mediated the effects of Panoply, but not the expressive writing platform, for both outcomes of depression (ab=-1.04, SE 0.58, 95% CI -2.67 to -.12) and perseverative thinking (ab=-1.02, SE 0.61, 95% CI -2.88 to -.20). Dropout rates were similar for the two platforms; however, Panoply yielded significantly more usage activity (P<.001) and significantly greater user experience scores (P<.001). Conclusions: Panoply engaged its users and was especially helpful for depressed individuals and for those who might ordinarily underutilize reappraisal techniques. Further investigation is needed to examine the long-term effects of such a platform and whether the benefits generalize to a more diverse population of users. Trial Registration: ClinicalTrials.gov NCT02302248; https://clinicaltrials.gov/ct2/show/NCT02302248 (Archived by WebCite at http://www.webcitation.org/6Wtkj6CXU). %M 25835472 %R 10.2196/jmir.4167 %U http://www.jmir.org/2015/3/e72/ %U https://doi.org/10.2196/jmir.4167 %U http://www.ncbi.nlm.nih.gov/pubmed/25835472 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 1 %P e8 %T Utilizing a Personal Smartphone Custom App to Assess the Patient Health Questionnaire-9 (PHQ-9) Depressive Symptoms in Patients With Major Depressive Disorder %A Torous,John %A Staples,Patrick %A Shanahan,Meghan %A Lin,Charlie %A Peck,Pamela %A Keshavan,Matcheri %A Onnela,Jukka-Pekka %+ Harvard Longwood Psychiatry Residency Training Prorgam, 330 Brookline Ave, Boston, MA, 02115, United States, 1 (617) 667 6700 ext 11315, jtorous@bidmc.harvard.edu %K medical informatics %K mobile health %K depression %D 2015 %7 24.03.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: Accurate reporting of patient symptoms is critical for diagnosis and therapeutic monitoring in psychiatry. Smartphones offer an accessible, low-cost means to collect patient symptoms in real time and aid in care. Objective: To investigate adherence among psychiatric outpatients diagnosed with major depressive disorder in utilizing their personal smartphones to run a custom app to monitor Patient Health Questionnaire-9 (PHQ-9) depression symptoms, as well as to examine the correlation of these scores to traditionally administered (paper-and-pencil) PHQ-9 scores. Methods: A total of 13 patients with major depressive disorder, referred by their clinicians, received standard outpatient treatment and, in addition, utilized their personal smartphones to run the study app to monitor their symptoms. Subjects downloaded and used the Mindful Moods app on their personal smartphone to complete up to three survey sessions per day, during which a randomized subset of PHQ-9 symptoms of major depressive disorder were assessed on a Likert scale. The study lasted 29 or 30 days without additional follow-up. Outcome measures included adherence, measured by the percentage of completed survey sessions, and estimates of daily PHQ-9 scores collected from the smartphone app, as well as from the traditionally administered PHQ-9. Results: Overall adherence was 77.78% (903/1161) and varied with time of day. PHQ-9 estimates collected from the app strongly correlated (r=.84) with traditionally administered PHQ-9 scores, but app-collected scores were 3.02 (SD 2.25) points higher on average. More subjects reported suicidal ideation using the app than they did on the traditionally administered PHQ-9. Conclusions: Patients with major depressive disorder are able to utilize an app on their personal smartphones to self-assess their symptoms of major depressive disorder with high levels of adherence. These app-collected results correlate with the traditionally administered PHQ-9. Scores recorded from the app may potentially be more sensitive and better able to capture suicidality than the traditional PHQ-9. %M 26543914 %R 10.2196/mental.3889 %U http://mental.jmir.org/2015/1/e8/ %U https://doi.org/10.2196/mental.3889 %U http://www.ncbi.nlm.nih.gov/pubmed/26543914 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 1 %P e5 %T Evaluation of an Online Campaign for Promoting Help-Seeking Attitudes for Depression Using a Facebook Advertisement: An Online Randomized Controlled Experiment %A Hui,Alison %A Wong,Paul Wai-Ching %A Fu,King-Wa %+ Journalism and Media Studies Centre, The University of Hong Kong, Eliot Hall, Pokfulam Road, Hong Kong, , China (Hong Kong), 852 39171643, kwfu@hku.hk %K depression %K help-seeking %K randomized controlled experiment %D 2015 %7 18.03.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: A depression-awareness campaign delivered through the Internet has been recommended as a public health approach that would enhance mental health literacy and encourage help-seeking attitudes. However, the outcomes of such a campaign remain understudied. Objective: The main aim of this study was to evaluate the effectiveness of an online depression awareness campaign, which was informed by the theory of planned behavior, to encourage help-seeking attitudes for depression and to enhance mental health literacy in Hong Kong. The second aim was to examine click-through behaviors by varying the affective facial expressions of people in the Facebook advertisements. Methods: Potential participants were recruited through Facebook advertisements, using either a happy or sad face illustration. Volunteer participants registered for the study by clicking on the advertisement and were invited to leave their personal email addresses to receive educational content about depression. The participants were randomly assigned into two groups (campaign or control), and over a four consecutive week period, received either the campaign material or official information developed by the Hospital Authority in Hong Kong. Pretests and posttests were conducted before and after the campaign to measure the differences in help-seeking attitudes and mental health literacy among the campaign and control groups. Results: Of the 199 participants that registered and completed the pretest, 116 (55 campaign and 62 control) completed the campaign and the posttest. At the posttest, we found no significant changes in help-seeking attitudes between the campaign and control groups, but the campaign group participants demonstrated a statistically significant improvement in mental health literacy (P=.031) and a higher willingness to access additional information (P<.001) than the control group. Moreover, the happy face Facebook advertisement attracted more click-throughs by users into the website than did the sad face advertisement (P=.03). Conclusions: The present study provides evidence that an online campaign can enhance people’s mental health literacy. It also demonstrates the practicality and effectiveness of an online depression awareness campaign using a Facebook-based recruitment strategy and distribution of educational materials through emails. It is important for future studies to take advantage of the popularity of online social media and conduct evaluative research on mental health promotion campaigns. %M 26543911 %R 10.2196/mental.3649 %U http://mental.jmir.org/2015/1/e5/ %U https://doi.org/10.2196/mental.3649 %U http://www.ncbi.nlm.nih.gov/pubmed/26543911 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 1 %P e4 %T Feasibility and Perception of Using Text Messages as an Adjunct Therapy for Low-Income, Minority Mothers With Postpartum Depression %A Broom,Matthew A %A Ladley,Amy S %A Rhyne,Elizabeth A %A Halloran,Donna R %+ SSM Cardinal Glennon Children's Medical Center, Department of Pediatrics, Saint Louis University School of Medicine, 1465 S. Grand Blvd, St. Louis, MO, 63104, United States, 1 314 268 4150, broomma@slu.edu %K short message service %K health care disparities %K mobile health %K mental illness %D 2015 %7 16.03.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: Postpartum depression (PPD) is the most common medical problem among new mothers that can have a negative impact on infant health. Traditional treatments are often difficult for low-income mothers to complete, particularly given the numerous barriers families face. Objective: Among low-income, primarily racial, and ethnic minority mothers with postpartum depression, our aim was to evaluate (1) the feasibility of sending supportive text messages, and (2) the perception of receiving private, supportive text messages for postpartum depression. Methods: Mothers found to be at risk for postpartum depression received supportive text messages four times weekly for 6 months in addition to receiving access to traditional counseling services based within an academic pediatric office. Feasibility was evaluated along with cellular and text messaging use, access, and perception of the message protocol. Perception of the message protocol was evaluated at study completion via a Likert scale questionnaire and open-ended qualitative survey. Results: In total, 4158/4790 (86.81%) text messages were successfully delivered to 54 mothers over a 6-month period at a low cost (US $777.60). Among the 96 scripted messages, 37 unique messages (38.54%) allowed for a response. Of all sent messages that allowed for responses, 7.30% (118/1616) were responded to, and 66.1% of those responses requested a call back; 46% (25/54) of mothers responded at least once to a text message. Mothers felt that messages were easily received and read (25/28, 89%) and relevant to them personally (23/28, 82%). Most shared texts with others (21/28, 75%). Conclusions: Text messaging is feasible, well-accepted, and may serve as a simple, inexpensive adjunct therapy well-suited to cross socioeconomic boundaries and provide private support for at-risk mothers suffering from postpartum depression. %M 26543910 %R 10.2196/mental.4074 %U http://mental.jmir.org/2015/1/e4/ %U https://doi.org/10.2196/mental.4074 %U http://www.ncbi.nlm.nih.gov/pubmed/26543910 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 3 %P e66 %T Improving Self-Help E-Therapy for Depression and Anxiety Among Sexual Minorities: An Analysis of Focus Groups With Lesbians and Gay Men %A Rozbroj,Tomas %A Lyons,Anthony %A Pitts,Marian %A Mitchell,Anne %A Christensen,Helen %+ Australian Research Centre in Sex, Health and Society, La Trobe University, 215 Franklin Street, Melbourne, 3000, Australia, 61 9479 8700, t.rozbroj@latrobe.edu.au %K Internet therapy %K e-therapy %K cCBT %K mental health %K gay men %K lesbian %K minority stress %K depression %K anxiety %K focus groups %D 2015 %7 11.03.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: E-therapies for depression and anxiety rarely account for lesbian and gay users. This is despite lesbians and gay men being at heightened risk of mood disorders and likely to benefit from having access to tailored self-help resources. Objective: We sought to determine how e-therapies for depression and anxiety could be improved to address the therapeutic needs of lesbians and gay men. Methods: We conducted eight focus groups with lesbians and gay men aged 18 years and older. Focus groups were presented with key modules from the popular e-therapy “MoodGYM”. They were asked to evaluate the inclusiveness and relevance of these modules for lesbians and gay men and to think about ways that e-therapies in general could be modified. The focus groups were analyzed qualitatively using a thematic analysis approach to identify major themes. Results: The focus groups indicated that some but not all aspects of MoodGYM were suitable, and suggested ways of improving e-therapies for lesbian and gay users. Suggestions included avoiding language or examples that assumed or implied users were heterosexual, improving inclusiveness by representing non-heterosexual relationships, providing referrals to specialized support services and addressing stigma-related stress, such as “coming out” and experiences of discrimination and harassment. Focus group participants suggested that dedicated e-therapies for lesbians and gay men should be developed or general e-therapies be made more inclusive by using adaptive logic to deliver content appropriate for a user’s sexual identity. Conclusions: Findings from this study offer in-depth guidance for developing e-therapies that more effectively address mental health problems among lesbians and gay men. %M 25761775 %R 10.2196/jmir.4013 %U http://www.jmir.org/2015/3/e66/ %U https://doi.org/10.2196/jmir.4013 %U http://www.ncbi.nlm.nih.gov/pubmed/25761775 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 3 %P e67 %T Expectations Among Patients and Health Professionals Regarding Web-Based Interventions for Depression in Primary Care: A Qualitative Study %A Montero-Marín,Jesús %A Prado-Abril,Javier %A Botella,Cristina %A Mayoral-Cleries,Fermin %A Baños,Rosa %A Herrera-Mercadal,Paola %A Romero-Sanchiz,Pablo %A Gili,Margalida %A Castro,Adoración %A Nogueira,Raquel %A García-Campayo,Javier %+ Psychiatry Service, Miguel Servet University Hospital, Avda Isabel La Católica 1, Zaragoza, 50009, Spain, 34 976253621, jgarcamp@gmail.com %K depression %K computer-delivered psychotherapy %K qualitative methods %K expectations %D 2015 %7 10.03.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: One-quarter of the world’s population will suffer from depression symptoms at some point in their lives. Mental health services in developed countries are overburdened. Therefore, cost-effective interventions that provide mental health care solutions such as Web-based psychotherapy programs have been proposed. Objective: The intent of the study was to identify expectations regarding Web-based psychotherapy for the treatment of depression in primary care among patients and health professionals that might facilitate or hinder its effects. Methods: The expectations of untreated patients and health professionals were examined by means of interviews and focus groups. There were 43 participants (20 patients with mild and moderate levels of depression, 11 primary care physicians, and 12 managers; 22 of them for interviews and 21 for groups). A thematic content analysis from the grounded theory for interviews, and an analysis of the discursive positions of participants based on the sociological model for groups were performed. Interpretations were achieved by agreement between three independent analysts. Results: All participants showed a good general acceptance of Web-based psychotherapy, appreciating possible advantages and improvements. Patients, physicians, and managers shared the same conceptualization of their expectations, although highlighting different aspects. Patients focused on the need for individualized and personalized interaction, while professionals highlighted the need for the standardization of the program. Physicians were concerned with extra workload, while managers were worried about optimizing cost-effectiveness. Conclusions: Expectations of the different participants can conflict with each other. Finding a balanced position among them is needed if we are to harmoniously implement effective Web-based interventions for depression in routine clinical practice. %M 25757358 %R 10.2196/jmir.3985 %U http://www.jmir.org/2015/3/e67/ %U https://doi.org/10.2196/jmir.3985 %U http://www.ncbi.nlm.nih.gov/pubmed/25757358 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 1 %P e3 %T Breaking Open the Black Box: Isolating the Most Potent Features of a Web and Mobile Phone-Based Intervention for Depression, Anxiety, and Stress %A Whitton,Alexis E %A Proudfoot,Judith %A Clarke,Janine %A Birch,Mary-Rose %A Parker,Gordon %A Manicavasagar,Vijaya %A Hadzi-Pavlovic,Dusan %+ The Black Dog Institute, University of New South Wales, Hospital Road, Prince of Wales Hospital, Sydney, 2031, Australia, 61 2 9382 3767, alexis.e.whitton@gmail.com %K eHealth %K depression %K anxiety %K stress %K psychological stress %K self-help %K Web-based %K mental health %D 2015 %7 04.03.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: Internet-delivered mental health (eMental Health) interventions produce treatment effects similar to those observed in face-to-face treatment. However, there is a large degree of variation in treatment effects observed from program to program, and eMental Health interventions remain somewhat of a black box in terms of the mechanisms by which they exert their therapeutic benefit. Trials of eMental Health interventions typically use large sample sizes and therefore provide an ideal context within which to systematically investigate the therapeutic benefit of specific program features. Furthermore, the growth and impact of mobile phone technology within eMental Health interventions provides an opportunity to examine associations between symptom improvement and the use of program features delivered across computer and mobile phone platforms. Objective: The objective of this study was to identify the patterns of program usage associated with treatment outcome in a randomized controlled trial (RCT) of a fully automated, mobile phone- and Web-based self-help program, “myCompass”, for individuals with mild-to-moderate symptoms of depression, anxiety, and/or stress. The core features of the program include interactive psychotherapy modules, a symptom tracking feature, short motivational messages, symptom tracking reminders, and a diary, with many of these features accessible via both computer and mobile phone. Methods: Patterns of program usage were recorded for 231 participants with mild-to-moderate depression, anxiety, and/or stress, and who were randomly allocated to receive access to myCompass for seven weeks during the RCT. Depression, anxiety, stress, and functional impairment were examined at baseline and at eight weeks. Results: Log data indicated that the most commonly used components were the short motivational messages (used by 68.4%, 158/231 of participants) and the symptom tracking feature (used by 61.5%, 142/231 of participants). Further, after controlling for baseline symptom severity, increased use of these alert features was associated with significant improvements in anxiety and functional impairment. Associations between use of symptom tracking reminders and improved treatment outcome remained significant after controlling for frequency of symptom tracking. Although correlations were not statistically significant, reminders received via SMS (ie, text message) were more strongly associated with symptom reduction than were reminders received via email. Conclusions: These findings indicate that alerts may be an especially potent component of eMental Health interventions, both via their association with enhanced program usage, as well as independently. Although there was evidence of a stronger association between symptom improvement and use of alerts via the mobile phone platform, the degree of overlap between use of email and SMS alerts may have precluded identification of alert delivery modalities that were most strongly associated with symptom reduction. Future research using random assignment to computer and mobile delivery is needed to fully determine the most ideal platform for delivery of this and other features of online interventions. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN): 12610000625077; http://www.anzctr.org.au/TrialSearch.aspx? (Archived by WebCite http://www.webcitation.org/6WPqHK0mQ). %M 26543909 %R 10.2196/mental.3573 %U http://mental.jmir.org/2015/1/e3/ %U https://doi.org/10.2196/mental.3573 %U http://www.ncbi.nlm.nih.gov/pubmed/26543909 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 1 %P e1 %T The Design and Relevance of a Computerized Gamified Depression Therapy Program for Indigenous Māori Adolescents %A Shepherd,Matthew %A Fleming,Theresa %A Lucassen,Mathijs %A Stasiak,Karolina %A Lambie,Ian %A Merry,Sally N %+ School of Counselling, Human Services and Social Work, Department of Education, University of Auckland, 5th floor, N Building, Epsom Campus, Epsom, Auckland, Private Bag 92601, New Zealand, 64 9 623 8899 ext 46368, m.shepherd@auckland.ac.nz %K computerized cognitive behavioral therapy %K Māori %K indigenous populations %K depression %K consumer opinions %K participatory design %D 2015 %7 03.03.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a major health issue among Māori indigenous adolescents, yet there has been little investigation into the relevance or effectiveness of psychological treatments for them. Further, consumer views are critical for engagement and adherence to therapy. However, there is little research regarding indigenous communities’ opinions about psychological interventions for depression. Objective: The objective of this study was to conduct semistructured interviews with Māori (indigenous New Zealand) young people (taitamariki) and their families to find out their opinions of a prototype computerized cognitive behavioral therapy (cCBT) program called Smart, Positive, Active, Realistic, X-factor thoughts (SPARX), a free online computer game intended to help young persons with mild to moderate depression, feeling down, stress or anxiety. The program will teach them how to resolve their issues on their own using Cognitive Behavioural Therapy as psychotherapeutic approach. Methods: There were seven focus groups on the subject of the design and cultural relevance of SPARX that were held, with a total of 26 participants (19 taitamarki, 7 parents/caregivers, all Māori). There were five of the groups that were with whānau (family groups) (n=14), one group was with Māori teenage mothers (n=4), and one group was with taitamariki (n=8). The general inductive approach was used to analyze focus group data. Results: SPARX computerized therapy has good face validity and is seen as potentially effective and appealing for Māori people. Cultural relevance was viewed as being important for the engagement of Māori young people with SPARX. Whānau are important for young peoples’ well-being. Participants generated ideas for improving SPARX for Māori and for the inclusion of whānau in its delivery. Conclusions: SPARX computerized therapy had good face validity for indigenous young people and families. In general, Māori participants were positive about the SPARX prototype and considered it both appealing and applicable to them. The results of this study were used to refine SPARX prior to it being delivered to taitamariki and non-Māori young people. Trial Registration: The New Zealand Northern Y Regional Ethics Committee; http://ethics.health.govt.nz/home; NTY/09/003; (Archived by WebCite at http://www.webcitation/6VYgHXKaR). %M 25736225 %R 10.2196/games.3804 %U http://games.jmir.org/2015/1/e1/ %U https://doi.org/10.2196/games.3804 %U http://www.ncbi.nlm.nih.gov/pubmed/25736225 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 3 %N 1 %P e16 %T Finding a Depression App: A Review and Content Analysis of the Depression App Marketplace %A Shen,Nelson %A Levitan,Michael-Jane %A Johnson,Andrew %A Bender,Jacqueline Lorene %A Hamilton-Page,Michelle %A Jadad,Alejandro (Alex) R %A Wiljer,David %+ Centre for Addictions and Mental Health (CAMH), CAMH Education, 33 Russell St., Toronto, ON, M5S 2S1, Canada, 1 416 535 8501 ext 32178, david.wiljer@camh.ca %K mobile apps %K depression %K health information %K consumer %K mental health %D 2015 %7 16.02.2015 %9 Review %J JMIR mHealth uHealth %G English %X Background: Depression is highly prevalent and causes considerable suffering and disease burden despite the existence of wide-ranging treatment options. Mobile phone apps offer the potential to help close this treatment gap by confronting key barriers to accessing support for depression. Objectives: Our goal was to identify and characterize the different types of mobile phone depression apps available in the marketplace. Methods: A search for depression apps was conducted on the app stores of the five major mobile phone platforms: Android, iPhone, BlackBerry, Nokia, and Windows. Apps were included if they focused on depression and were available to people who self-identify as having depression. Data were extracted from the app descriptions found in the app stores. Results: Of the 1054 apps identified by the search strategy, nearly one-quarter (23.0%, 243/1054) unique depression apps met the inclusion criteria. Over one-quarter (27.7%, 210/758) of the excluded apps failed to mention depression in the title or description. Two-thirds of the apps had as their main purpose providing therapeutic treatment (33.7%, 82/243) or psychoeducation (32.1%, 78/243). The other main purpose categories were medical assessment (16.9%, 41/243), symptom management (8.2%, 20/243), and supportive resources (1.6%, 4/243). A majority of the apps failed to sufficiently describe their organizational affiliation (65.0%, 158/243) and content source (61.7%, 150/243). There was a significant relationship (χ25=50.5, P<.001) between the main purpose of the app and the reporting of content source, with most medical assessment apps reporting their content source (80.5%, 33/41). A fifth of the apps featured an e-book (20.6%, 50/243), audio therapy (16.9%, 41/243), or screening (16.9%, 41/243) function. Most apps had a dynamic user interface (72.4%, 176/243) and used text as the main type of media (51.9%, 126/243), and over a third (14.4%, 35/243) incorporated more than one form of media. Conclusion: Without guidance, finding an appropriate depression app may be challenging, as the search results yielded non-depression–specific apps to depression apps at a 3:1 ratio. Inadequate reporting of organization affiliation and content source increases the difficulty of assessing the credibility and reliability of the app. While certification and vetting initiatives are underway, this study demonstrates the need for standardized reporting in app stores to help consumers select appropriate tools, particularly among those classified as medical devices. %M 25689790 %R 10.2196/mhealth.3713 %U http://mhealth.jmir.org/2015/1/e16/ %U https://doi.org/10.2196/mhealth.3713 %U http://www.ncbi.nlm.nih.gov/pubmed/25689790 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 1 %P e1 %T Client Perceptions of the Mental Health Engagement Network: A Secondary Analysis of an Intervention Using Smartphones and Desktop Devices for Individuals Experiencing Mood or Psychotic Disorders in Canada %A Forchuk,Cheryl %A Donelle,Lorie %A Ethridge,Paige %A Warner,Laura %+ Lawson Health Research Institute, Suite 102, 750 Baseline Road East, London, ON, N6C 2R5, Canada, 1 519 685 8500 ext 77034, cforchuk@uwo.ca %K mental health %K mobile health %K eHealth %K personal health records %K mood disorders %K psychotic disorders %K mental disorders %D 2015 %7 21.01.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: The use of innovative technologies in mental health care has the potential to improve system efficiency, enhance quality of care, and increase patient engagement. The Mental Health Engagement Network (MHEN) project developed, delivered, and evaluated an interactive Web-based personal health record, the Lawson SMART Record (LSR), to assist mental health clients in managing their care and connecting with their care providers. This paper presents a secondary analysis of data collected in the MHEN project regarding clients’ perceptions of technology and the use of these technologies in their care. Objective: We aimed to answer six questions: (1) What is the level of comfort with technology within a sample of individuals experiencing mood or psychotic disorders? (2) How easy to use and helpful are the MHEN technologies from the perspective of individuals experiencing a mental illness? (3) Are there differences in how helpful or useful individuals find the smartphone compared to the LSR? (4) Are there specific functions of MHEN technologies (eg, reminders for medications or appointments) that are more valued than others? (5) What are the other ways that individuals are using MHEN technologies in their daily lives? (6) How likely are individuals to be able to retain and maintain their smartphone? Methods: Mental health clients aged 18-80 (N=400) and diagnosed with a mood or psychotic disorder were provided with a smartphone (iPhone 4S) and participating care providers (n=52) were provided with a tablet (iPad) in order to access and engage with the LSR. A delayed implementation design with mixed methods was used. Survey and interview data were collected over the course of 18 months through semistructured interviews conducted by experienced research assistants every 6 months post-implementation of the intervention. Paired t tests were used to determine differences between 6 and 12-month data for perceptions of the MHEN technologies. A paired t test was used to examine whether differences existed between perceptions of the smartphone and the LSR at 12 months post-implementation. Results: Due to dropout or loss of contact, 394 out of 400 individuals completed the study. At the end of the study, 52 devices were lost or unusable. Prior to the intervention, participants reported being comfortable using technology. Perceptions of the MHEN technologies and their functions were generally positive. Positive perceptions of the smartphone increased over time (P=.002), while positive perceptions of the LSR decreased over time (P<.001). Conclusions: Quantitative and qualitative findings from this analysis demonstrated that these technologies positively impacted the lives of individuals experiencing severe mental illnesses and dispeled some of the myths regarding retention of technology among marginalized populations. This secondary analysis supported the acceptability of using mental health technologies within this population and provided considerations for future development. Trial Registration: ClinicalTrials.gov NCT01473550; http://clinicaltrials.gov/show/NCT01473550 (Archived by WebCite at http://www.webcitation.org/6SLNcoKb8). %M 26543906 %R 10.2196/mental.3926 %U http://mental.jmir.org/2015/1/e1/ %U https://doi.org/10.2196/mental.3926 %U http://www.ncbi.nlm.nih.gov/pubmed/26543906 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 1 %P e9 %T An Integrated Web-Based Mental Health Intervention of Assessment-Referral-Care to Reduce Stress, Anxiety, and Depression in Hospitalized Pregnant Women With Medically High-Risk Pregnancies: A Feasibility Study Protocol of Hospital-Based Implementation %A Kingston,Dawn %A Janes-Kelley,Selikke %A Tyrrell,Janie %A Clark,Lorna %A Hamza,Deena %A Holmes,Penny %A Parkes,Cheryl %A Moyo,Nomagugu %A McDonald,Sheila %A Austin,Marie-Paule %+ University of Alberta, 5-258 Edmonton Clinic Health Academy, 11405-87th Avenue, Edmonton, AB, T6G 1C9, Canada, 1 780 492 4731, dawn.kingston@ualberta.ca %K Web-based %K screening %K cognitive behavior therapy %K pregnancy %K depression %K anxiety %K psychological stress %K quasi-experimental studies %D 2015 %7 16.01.2015 %9 Protocol %J JMIR Res Protoc %G English %X Background: At prevalence rates of up to 40%, rates of depression and anxiety among women with medically complex pregnancies are 3 times greater than those in community-based samples of pregnant women. However, mental health care is not a component of routine hospital-based antenatal care for medically high-risk pregnant women. Objective: The purpose of this study is to evaluate the effectiveness and feasibility of the hospital-based implementation of a Web-based integrated mental health intervention comprising psychosocial assessment, referral, and cognitive behavioral therapy (CBT) for antenatal inpatients. Methods: This study is a quasi-experimental design. Pregnant women are eligible to participate if they are (1) <37 weeks gestation, (2) admitted to the antenatal inpatient unit for >72 hours, (3) able to speak and read English or be willing to use a translation service to assist with completion of the questionnaires and intervention, (4) able to complete follow-up email questionnaires, (5) >16 years of age, and (6) not actively suicidal. Women admitted to the unit for induction (eg, <72-hour length of stay) are excluded. A minimum sample of 54 women will be recruited from the antenatal high-risk unit of a large, urban tertiary care hospital. All women will complete a Web-based psychosocial assessment and 6 Web-based CBT modules. Results of the psychosocial assessment will be used by a Web-based clinical decision support system to generate a clinical risk score and clinician prompts to provide recommendations for the best treatment and referral options. The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6-8 weeks postrecruitment. Secondary outcomes are postpartum depression, anxiety, and stress symptoms; self-efficacy; mastery; self-esteem; sleep; relationship quality; coping; resilience; Apgar score; gestational age; birth weight; maternal-infant attachment; infant behavior and development; parenting stress/competence at 3-months postpartum; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. All women will complete email questionnaires at 6-8 weeks postrecruitment and 3-months postpartum. Qualitative interviews with 10-15 health care providers and 15-30 women will provide data on feasibility and acceptability of the intervention. Results: The study was funded in September, 2014 and ethics was approved in November, 2014. Subject recruitment will begin January, 2015 and results are expected in December, 2015. Results of this study will determine (1) the effectiveness of an integrated Web-based prenatal mental health intervention on maternal and infant outcomes and (2) the feasibility of implementation of the intervention on a high-risk antenatal unit. Conclusions: This study will provide evidence and guidance regarding the implementation of a Web-based mental health program into routine hospital-based care for women with medically high-risk pregnancies. %M 25595167 %R 10.2196/resprot.4037 %U http://www.researchprotocols.org/2015/1/e9/ %U https://doi.org/10.2196/resprot.4037 %U http://www.ncbi.nlm.nih.gov/pubmed/25595167 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 4 %P e46 %T Qualitative Feedback From a Text Messaging Intervention for Depression: Benefits, Drawbacks, and Cultural Differences %A Aguilera,Adrian %A Berridge,Clara %+ University of California, Berkeley, School of Social Welfare, 120 Haviland Hall, MC7400, Berkeley, CA, 94720, United States, 1 5106428564, aguila@berkeley.edu %K mobile health %K depression %K text messaging %K culture %K digital health %K cognitive behavioral therapy %K disparities %K mental health %K behavior change %D 2014 %7 05.11.2014 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Mobile health interventions are often standardized and assumed to work the same for all users; however, we may be missing cultural differences in the experiences of interventions that may impact how and if an intervention is effective. Objective: The objective of the study was to assess qualitative feedback from participants to determine if there were differences between Spanish speakers and English speakers. Daily text messages were sent to patients as an adjunct to group Cognitive Behavioral Therapy (CBT) for depression. Methods: Messages inquired about mood and about specific themes (thoughts, activities, social interactions) of a manualized group CBT intervention. There were thirty-nine patients who participated in the text messaging pilot study. The average age of the participants was 53 years (SD 10.4; range of 23-72). Results: Qualitative feedback from Spanish speakers highlighted feelings of social support, whereas English speakers noted increased introspection and self-awareness of their mood state. Conclusions: These cultural differences should be explored further, as they may impact the effect of supportive mobile health interventions. Trial Registration: Trial Registration: Clinicaltrials.gov NCT01083628; http://clinicaltrials.gov/ct2/show/study/NCT01083628 (Archived by WebCite at http://www.webcitation.org/6StpbdHuq). %M 25373390 %R 10.2196/mhealth.3660 %U http://mhealth.jmir.org/2014/4/e46/ %U https://doi.org/10.2196/mhealth.3660 %U http://www.ncbi.nlm.nih.gov/pubmed/25373390 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 16 %N 9 %P e209 %T Web-Based Intervention Programs for Depression: A Scoping Review and Evaluation %A Renton,Tian %A Tang,Herman %A Ennis,Naomi %A Cusimano,Michael D %A Bhalerao,Shree %A Schweizer,Tom A %A Topolovec-Vranic,Jane %+ Trauma and Neurosurgery Program, St Michael's Hospital, Bond 3-012, 30 Bond Street, Toronto, ON, M5B 1W8, Canada, 1 416 864 6060 ext 3421, topolovec-vranicj@smh.ca %K depression %K Web-based interventions %K interactive treatment %K health care access %K mental health %K technology %D 2014 %7 23.09.2014 %9 Review %J J Med Internet Res %G English %X Background: Although depression is known to affect millions of people worldwide, individuals seeking aid from qualified health care professionals are faced with a number of barriers to treatment including a lack of treatment resources, limited number of qualified service providers, stigma associated with diagnosis and treatment, prolonged wait times, cost, and barriers to accessibility such as transportation and clinic locations. The delivery of depression interventions through the Internet may provide a practical solution to addressing some of these barriers. Objective: The purpose of this scoping review was to answer the following questions: (1) What Web-delivered programs are currently available that offer an interactive treatment component for depression?, (2) What are the contents, accessibility, and usability of each identified program?, and (3) What tools, supports, and research evidence are available for each identified program? Methods: Using the popular search engines Google, Yahoo, and Bing (Canadian platforms), two reviewers independently searched for interactive Web-based interventions targeting the treatment of depression. The Beacon website, an information portal for online health applications, was also consulted. For each identified program, accessibility, usability, tools, support, and research evidence were evaluated and programs were categorized as evidence-based versus non-evidence-based if they had been the subject of at least one randomized controlled trial. Programs were scored using a 28-point rating system, and evidence- versus non-evidence-based programs were compared and contrasted. Although this review included all programs meeting exclusion and inclusion criteria found using the described search method, only English language Web-delivered depression programs were awarded an evaluation score. Results: The review identified 32 programs meeting inclusion criteria. There was a great deal of variability among the programs captured in this evaluation. Many of the programs were developed for general adolescent or adult audiences, with few (n=2) focusing on special populations (eg, military personnel, older adults). Cognitive behavioral therapy was the most common therapeutic approach used in the programs described. Program interactive components included mood assessments and supplementary homework sheets such as activity planning and goal setting. Only 12 of the programs had published evidence in support of their efficacy and treatment of depressive symptoms. Conclusions: There are a number of interactive depression interventions available through the Internet. Recommendations for future programs, or the adaptation of existing programs include offering a greater selection of alternative languages, removing registration restrictions, free trial periods for programs requiring user fees, and amending programs to meet the needs of special populations (eg, those with cognitive and/or visual impairments). Furthermore, discussion of specific and relevant topics to the target audience while also enhancing overall user control would contribute to a more accessible intervention tool. %M 25249003 %R 10.2196/jmir.3147 %U http://www.jmir.org/2014/9/e209/ %U https://doi.org/10.2196/jmir.3147 %U http://www.ncbi.nlm.nih.gov/pubmed/25249003 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 16 %N 9 %P e206 %T Online and Social Networking Interventions for the Treatment of Depression in Young People: A Systematic Review %A Rice,Simon M %A Goodall,Joanne %A Hetrick,Sarah E %A Parker,Alexandra G %A Gilbertson,Tamsyn %A Amminger,G. Paul %A Davey,Christopher G %A McGorry,Patrick D %A Gleeson,John %A Alvarez-Jimenez,Mario %+ Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, 35 Poplar Rd, Parkville, Melbourne, 3052, Australia, 61 419497599, simon.rice@unimelb.edu.au %K Internet %K depression %K young adult %K adolescent %K social networking %K support groups %K review %D 2014 %7 16.09.2014 %9 Review %J J Med Internet Res %G English %X Background: Major depression accounts for the greatest burden of all diseases globally. The peak onset of depression occurs between adolescence and young adulthood, and for many individuals, depression displays a relapse-remitting and increasingly severe course. Given this, the development of cost-effective, acceptable, and population-focused interventions for depression is critical. A number of online interventions (both prevention and acute phase) have been tested in young people with promising results. As these interventions differ in content, clinician input, and modality, it is important to identify key features (or unhelpful functions) associated with treatment outcomes. Objective: A systematic review of the research literature was undertaken. The review was designed to focus on two aspects of online intervention: (1) standard approaches evaluating online intervention content in randomized controlled designs (Section 1), and (2) second-generation online interventions and services using social networking (eg, social networking sites and online support groups) in any type of research design (Section 2). Methods: Two specific literature searches were undertaken. There was no date range specified. The Section 1 search, which focused on randomized controlled trials, included only young people (12-25 years) and yielded 101 study abstracts, of which 15 met the review inclusion criteria. The Section 2 search, which included all study design types and was not restricted in terms of age, yielded 358 abstracts, of which 22 studies met the inclusion criteria. Information about the studies and their findings were extracted and tabulated for review. Results: The 15 studies identified in Section 1 described 10 trials testing eight different online interventions, all of which were based on a cognitive behavioral framework. All but one of the eight identified studies reported positive results; however, only five of the 15 studies used blinded interviewer administered outcomes with most trials using self-report data. Studies varied significantly in presentation of intervention content, treatment dose, and dropout. Only two studies included moderator or clinician input. Results for Section 2 were less consistent. None of the Section 2 studies reported controlled or randomized designs. With the exception of four studies, all included participants were younger than 25 years of age. Eight of the 16 social networking studies reported positive results for depression-related outcomes. The remaining studies were either mixed or negative. Findings for online support groups tended to be more positive; however, noteworthy risks were identified. Conclusions: Online interventions with a broad cognitive behavioral focus appear to be promising in reducing depression symptomology in young people. Further research is required into the effectiveness of online interventions delivering cognitive behavioral subcomponents, such as problem-solving therapy. Evidence for the use of social networking is less compelling, although limited by a lack of well-designed studies and social networking interventions. A range of future social networking therapeutic opportunities are highlighted. %M 25226790 %R 10.2196/jmir.3304 %U http://www.jmir.org/2014/9/e206/ %U https://doi.org/10.2196/jmir.3304 %U http://www.ncbi.nlm.nih.gov/pubmed/25226790 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 16 %N 9 %P e208 %T Norwegian General Practitioners’ Perspectives on Implementation of a Guided Web-Based Cognitive Behavioral Therapy for Depression: A Qualitative Study %A Wilhelmsen,Maja %A Høifødt,Ragnhild Sørensen %A Kolstrup,Nils %A Waterloo,Knut %A Eisemann,Martin %A Chenhall,Richard %A Risør,Mette Bech %+ Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Breivika, Tromsø, 9037, Norway, 47 99001559, maja.wilhelmsen@uit.no %K mental health %K Internet %K telemedicine %K qualitative research %K primary health care %K cognitive therapy %K depression %D 2014 %7 10.09.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: Previous research suggests that Internet-based cognitive behavioral therapy (ICBT) has a positive effect on symptoms of depression. ICBT appears to be more effective with therapist support, but it is unclear what this support should comprise. General practitioners (GPs) have positive attitudes toward ICBT. However, ICBT is rarely used in regular care in general practice. More research is warranted to integrate the potential of ICBT as part of regular care. Objective: The aim of this study was to explore aspects perceived by GPs to affect the implementation of guided ICBT in daily practice. Understanding their perspectives may contribute to improving the treatment of depression in the context of general practice. Methods: A training package (3-day course) introducing a Norwegian translation of the ICBT program MoodGYM was developed and presented to GPs in Norway. Following training, GPs were asked to include guided ICBT in their regular care of patients with symptoms of depression by providing brief, face-to-face follow-up consultations between modules. We interviewed 11 GPs who had taken the course. Our interview guide comprised open questions that encouraged GPs to frame their responses using examples from their experiences when implementing ICBT. Thematic analysis was chosen to explore patterns across the data. Results: An overall belief that ICBT would benefit both the patients’ health and the GPs’ own work satisfaction prompted the GPs to take the ICBT course. ICBT motivated them to invest time and effort in improving treatment. The most important motivating aspects in MoodGYM were that a program based on cognitive behavioral therapy could add a structured agenda to their consultations and empower depressed patients. Organizational aspects, such as a lack of time and varied practice, inhibited the use of ICBT. Inadequate knowledge, recalling the program, and changing own habits were also challenging. The GPs were ambivalent about whether ICBT had a negative impact on the doctor–patient interaction in the module follow-ups. Generally, GPs made an effort to recommend MoodGYM, but the expected module follow-ups were often not provided to patients and instead the GPs returned to standard treatment. Conclusions: GPs’ feedback in the present study contribute to our understanding of the challenges of changing treatment for depression. Our findings indicated that recommending ICBT could add to the GP’s toolkit. Offering training and highlighting the following aspects may increase recommendation of ICBT by GPs: (1) ICBT is theory-based and credible, (2) ICBT increases the GPs’ work satisfaction by having a tool to offer, and (3) ICBT facilitates empowerment of patients in their own health. In addition, the present study also indicated that complex aspects must be accommodated before module follow-ups can be incorporated into GPs’ treatment of depression. %M 25208886 %R 10.2196/jmir.3556 %U http://www.jmir.org/2014/9/e208/ %U https://doi.org/10.2196/jmir.3556 %U http://www.ncbi.nlm.nih.gov/pubmed/25208886 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 16 %N 7 %P e166 %T Assessing the Applicability of E-Therapies for Depression, Anxiety, and Other Mood Disorders Among Lesbians and Gay Men: Analysis of 24 Web- and Mobile Phone-Based Self-Help Interventions %A Rozbroj,Tomas %A Lyons,Anthony %A Pitts,Marian %A Mitchell,Anne %A Christensen,Helen %+ Australian Research Centre in Sex, Health and Society, Faculty of Health Sciences, La Trobe University, 215, Franklin Street, Melbourne, 3000, Australia, 61 3 9479 8765, t.rozbroj@latrobe.edu.au %K Internet therapy %K e-therapy %K cCBT %K mental health %K gay men %K lesbian %K minority stress %K depression %K anxiety %K review %D 2014 %7 03.07.2014 %9 Review %J J Med Internet Res %G English %X Background: Lesbians and gay men have disproportionately high rates of depression and anxiety, and report lower satisfaction with treatments. In part, this may be because many health care options marginalize them by assuming heterosexuality, or misunderstand and fail to respond to the challenges specifically faced by these groups. E-therapies have particular potential to respond to the mental health needs of lesbians and gay men, but there is little research to determine whether they do so, or how they might be improved. Objective: We sought to examine the applicability of existing mental health e-therapies for lesbians and gay men. Methods: We reviewed 24 Web- and mobile phone-based e-therapies and assessed their performance in eight key areas, including the use of inclusive language and content and whether they addressed mental health stressors for lesbians and gay men, such as experiences of stigma related to their sexual orientation, coming out, and relationship issues that are specific to lesbians and gay men. Results: We found that e-therapies seldom addressed these stressors. Furthermore, 58% (14/24) of therapies contained instances that assumed or suggested the user was heterosexual, with instances especially prevalent among better-evidenced programs. Conclusions: Our findings, and a detailed review protocol presented in this article, may be used as guides for the future development of mental health e-therapies to better accommodate the needs of lesbians and gay men. %M 24996000 %R 10.2196/jmir.3529 %U http://www.jmir.org/2014/7/e166/ %U https://doi.org/10.2196/jmir.3529 %U http://www.ncbi.nlm.nih.gov/pubmed/24996000 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 16 %N 5 %P e130 %T Computer-Delivered and Web-Based Interventions to Improve Depression, Anxiety, and Psychological Well-Being of University Students: A Systematic Review and Meta-Analysis %A Davies,E Bethan %A Morriss,Richard %A Glazebrook,Cris %+ Division of Psychiatry and Applied Psychology, School of Medicine, Institute of Mental Health, The University of Nottingham, Jubilee Campus, Triumph Road, Nottingham, NG7 2TU, United Kingdom, 44 0115 74 84293, mcxebd@nottingham.ac.uk %K systematic review %K meta-analysis %K intervention %K universities %K students %K mental health %K depression %K anxiety %K health promotion %D 2014 %7 16.05.2014 %9 Review %J J Med Internet Res %G English %X Background: Depression and anxiety are common mental health difficulties experienced by university students and can impair academic and social functioning. Students are limited in seeking help from professionals. As university students are highly connected to digital technologies, Web-based and computer-delivered interventions could be used to improve students’ mental health. The effectiveness of these intervention types requires investigation to identify whether these are viable prevention strategies for university students. Objective: The intent of the study was to systematically review and analyze trials of Web-based and computer-delivered interventions to improve depression, anxiety, psychological distress, and stress in university students. Methods: Several databases were searched using keywords relating to higher education students, mental health, and eHealth interventions. The eligibility criteria for studies included in the review were: (1) the study aimed to improve symptoms relating to depression, anxiety, psychological distress, and stress, (2) the study involved computer-delivered or Web-based interventions accessed via computer, laptop, or tablet, (3) the study was a randomized controlled trial, and (4) the study was trialed on higher education students. Trials were reviewed and outcome data analyzed through random effects meta-analyses for each outcome and each type of trial arm comparison. Cochrane Collaboration risk of bias tool was used to assess study quality. Results: A total of 17 trials were identified, in which seven were the same three interventions on separate samples; 14 reported sufficient information for meta-analysis. The majority (n=13) were website-delivered and nine interventions were based on cognitive behavioral therapy (CBT). A total of 1795 participants were randomized and 1480 analyzed. Risk of bias was considered moderate, as many publications did not sufficiently report their methods and seven explicitly conducted completers’ analyses. In comparison to the inactive control, sensitivity meta-analyses supported intervention in improving anxiety (pooled standardized mean difference [SMD] −0.56; 95% CI −0.77 to −0.35, P<.001), depression (pooled SMD −0.43; 95% CI −0.63 to −0.22, P<.001), and stress (pooled SMD −0.73; 95% CI −1.27 to −0.19, P=.008). In comparison to active controls, sensitivity analyses did not support either condition for anxiety (pooled SMD −0.18; 95% CI −0.98 to 0.62, P=.66) or depression (pooled SMD −0.28; 95% CI −0.75 to −0.20, P=.25). In contrast to a comparison intervention, neither condition was supported in sensitivity analyses for anxiety (pooled SMD −0.10; 95% CI −0.39 to 0.18, P=.48) or depression (pooled SMD −0.33; 95% CI −0.43 to 1.09, P=.40). Conclusions: The findings suggest Web-based and computer-delivered interventions can be effective in improving students’ depression, anxiety, and stress outcomes when compared to inactive controls, but some caution is needed when compared to other trial arms and methodological issues were noticeable. Interventions need to be trialed on more heterogeneous student samples and would benefit from user evaluation. Future trials should address methodological considerations to improve reporting of trial quality and address post-intervention skewed data. %M 24836465 %R 10.2196/jmir.3142 %U http://www.jmir.org/2014/5/e130/ %U https://doi.org/10.2196/jmir.3142 %U http://www.ncbi.nlm.nih.gov/pubmed/24836465 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 16 %N 3 %P e92 %T Internet-Based Motivation Program for Women With Eating Disorders: Eating Disorder Pathology and Depressive Mood Predict Dropout %A von Brachel,Ruth %A Hötzel,Katrin %A Hirschfeld,Gerrit %A Rieger,Elizabeth %A Schmidt,Ulrike %A Kosfelder,Joachim %A Hechler,Tanja %A Schulte,Dietmar %A Vocks,Silja %+ Department of Clinical Psychology and Psychotherapy, Osnabrück University, Knollstr 15, Osnabrück, 49069, Germany, 49 541 969 ext 4743, ruth.vonbrachel@rub.de %K attrition %K Web-based treatment %K eHealth, eating disorders %K motivation to change %K anorexia nervosa %K bulimia nervosa %K bootstrapping %K survival analysis %D 2014 %7 31.03.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: One of the main problems of Internet-delivered interventions for a range of disorders is the high dropout rate, yet little is known about the factors associated with this. We recently developed and tested a Web-based 6-session program to enhance motivation to change for women with anorexia nervosa, bulimia nervosa, or related subthreshold eating pathology. Objective: The aim of the present study was to identify predictors of dropout from this Web program. Methods: A total of 179 women took part in the study. We used survival analyses (Cox regression) to investigate the predictive effect of eating disorder pathology (assessed by the Eating Disorders Examination-Questionnaire; EDE-Q), depressive mood (Hopkins Symptom Checklist), motivation to change (University of Rhode Island Change Assessment Scale; URICA), and participants’ age at dropout. To identify predictors, we used the least absolute shrinkage and selection operator (LASSO) method. Results: The dropout rate was 50.8% (91/179) and was equally distributed across the 6 treatment sessions. The LASSO analysis revealed that higher scores on the Shape Concerns subscale of the EDE-Q, a higher frequency of binge eating episodes and vomiting, as well as higher depression scores significantly increased the probability of dropout. However, we did not find any effect of the URICA or age on dropout. Conclusions: Women with more severe eating disorder pathology and depressive mood had a higher likelihood of dropping out from a Web-based motivational enhancement program. Interventions such as ours need to address the specific needs of women with more severe eating disorder pathology and depressive mood and offer them additional support to prevent them from prematurely discontinuing treatment. %M 24686856 %R 10.2196/jmir.3104 %U http://www.jmir.org/2014/3/e92/ %U https://doi.org/10.2196/jmir.3104 %U http://www.ncbi.nlm.nih.gov/pubmed/24686856 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 16 %N 3 %P e90 %T Acceptability of Online Self-Help to People With Depression: Users’ Views of MoodGYM Versus Informational Websites %A Schneider,Justine %A Sarrami Foroushani,Pooria %A Grime,Paul %A Thornicroft,Graham %+ Institute of Mental Health & School of Sociology & Social Policy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom, 44 115 8467307, Justine.Schneider@nottingham.ac.uk %K computers, cognitive therapy %K method acceptability %K depression %K workplace %K qualitative evaluation %D 2014 %7 28.03.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: Little is known about the factors that influence acceptability of and adherence to online psychological interventions. Evidence is needed to guide further development of promising programs. Objective: Our goal was to investigate users’ views of two online approaches to self-help for depression: computerized cognitive behavior therapy (cCBT) and informational websites, in a workplace context. Computerized CBT offers an inexpensive and accessible alternative to face-to-face therapy, and employers have an interest in reducing the working time lost to depression or stress. Yet little is known about how employees, who have actual experience of using online approaches, judge the intervention as a process. Methods: The qualitative data reported here were collected within an online randomized controlled trial whose participants had diagnosable depression. The experimental intervention was a 5-week cCBT program called MoodGYM, and the control condition was five informational websites about mental health. Data were collected via online questionnaires. There was no evidence of the superiority of either in terms of treatment outcomes. In parallel, using brief rating scales and open-ended questions designed for this purpose, we examined the relative acceptability of each approach over time, including perceptions of cCBT compared to seeing a health care professional. Results: At least 60% of participants held online therapy to be at least as acceptable as seeing a professional about mental health issues, and they were more likely to retain this opinion over time if they used the interactive program, MoodGYM, rather than informational websites alone. Barriers to cCBT use fell into four categories: intrinsic, intrapersonal problems; extrinsic technical problems; generic issues mostly pertaining to perceptions of cCBT; and specific issues about the intervention or control condition. These indicate strategies for improving engagement. Conclusions: As first-aid for mild to moderate mental health problems, evidence-based computerized approaches have broad acceptability. This could be increased by attending to the barriers noted here and by proactively managing users’ expectations at individual and organizational levels. The findings have implications for occupational health providers and others addressing the needs of working-age adults with depression. They also raise methodological issues for online research. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 24529487; http://www.controlled-trials.com/ISRCTN24529487 (Archived by Webcite at http://www.webcitation.org/6O8cCL4mh). %M 24681717 %R 10.2196/jmir.2871 %U http://www.jmir.org/2014/3/e90/ %U https://doi.org/10.2196/jmir.2871 %U http://www.ncbi.nlm.nih.gov/pubmed/24681717 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 3 %N 1 %P e6 %T Evaluating a Brief, Internet-Based Intervention for Co-Occurring Depression and Problematic Alcohol Use in Young People: Protocol for a Randomized Controlled Trial %A Deady,Mark %A Teesson,Maree %A Kay-Lambkin,Frances %A Mills,Katherine L %+ National Drug and Alcohol Research Centre, University of New South Wales (UNSW), 22-32 King Street, Randwick NSW 2031, Sydney, 2052, Australia, 61 293850320, m.deady@unsw.edu.au %K depression %K alcohol %K young people %K Internet-based %K comorbidity %D 2014 %7 27.02.2014 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression and alcohol misuse represent two of the major causes of disease burden in young adults. These conditions frequently co-occur and this co-occurrence is associated with increased risks and poorer outcomes than either disorder in isolation. Integrated treatments have been shown to be effective, however, there remains a significant gap between those in need of treatment and those receiving it, particularly in young people. The increased availability of Internet-based programs to complement health care presents a unique opportunity in the treatment of these conditions. Objective: The objective of our study was to evaluate whether a brief, Internet-based, self-help intervention (the DEAL [DEpression-ALcohol] Project) can be effective in treating co-occurring depression and problematic alcohol use in young people (18-25 years old). Methods: The evaluation will take the form of a randomized controlled trial (RCT), comparing the DEAL Project with an attention-control condition (HealthWatch). The RCT will consist of a four-week intervention phase and a 24-week follow-up. It will be entirely Internet-based and open Australia-wide to young people 18 to 25 years old. The primary outcomes will be change in depression symptoms and alcohol use at 5, 12, and 24 weeks post baseline. Secondary outcomes include change in general functioning and quality of life, anxiety/stress symptomatology, and a number of other depression/alcohol related outcomes. Process analysis will also measure engagement across the conditions. Results: This study is currently ongoing with preliminary results expected in late 2014. Conclusions: This study, to our knowledge, will be the first RCT of a Internet-based treatment for comorbid depression and problematic alcohol use in any age group. If successful, the program represents a novel and innovative approach to addressing the significant harms associated with these conditions and will be an invaluable resource to those not receiving help elsewhere. Trial Registration: Australian New Zealand Clinical Trials Registry; ACTRN12613000033741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363461 (Archived by WebCite at http://www.webcitation.org/6Mrg9VFX4). %M 24583824 %R 10.2196/resprot.3192 %U http://www.researchprotocols.org/2014/1/e6/ %U https://doi.org/10.2196/resprot.3192 %U http://www.ncbi.nlm.nih.gov/pubmed/24583824 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 16 %N 2 %P e67 %T Routine Real-Time Cost-Effectiveness Monitoring of a Web-Based Depression Intervention: A Risk-Sharing Proposal %A Naveršnik,Klemen %A Mrhar,Aleš %+ Prototype Analytics, Sandoz Development Center, Lek Pharmaceuticals, SDC, Verovškova 57, Ljubljana, SI-1000, Slovenia, 386 1 5803459, klemen.naversnik@sandoz.com %K depression %K medical economics %K value-based purchasing %D 2014 %7 27.02.2014 %9 Viewpoint %J J Med Internet Res %G English %X Background: A new health care technology must be cost-effective in order to be adopted. If evidence regarding cost-effectiveness is uncertain, then the decision maker faces two choices: (1) adopt the technology and run the risk that it is less effective in actual practice, or (2) reject the technology and risk that potential health is forgone. A new depression eHealth service was found to be cost-effective in a previously published study. The results, however, were unreliable because it was based on a pilot clinical trial. A conservative decision maker would normally require stronger evidence for the intervention to be implemented. Objective: Our objective was to evaluate how to facilitate service implementation by shifting the burden of risk due to uncertainty to the service provider and ensure that the intervention remains cost-effective during routine use. Methods: We propose a risk-sharing scheme, where the service cost depends on the actual effectiveness of the service in real-life setting. Routine efficacy data can be used as the input to the cost-effectiveness model, which employs a mapping function to translate a depression specific score into quality-adjusted life-years. The latter is the denominator in the cost-effectiveness ratio calculation, required by the health care decision maker. The output of the model is a “value graph”, showing intervention value as a function of its observed (future) efficacy, using the €30,000 per quality-adjusted life-year (QALY) threshold. Results: We found that the eHealth service should improve the patient’s outcome by at least 11.9 points on the Beck Depression Inventory scale in order for the cost-effectiveness ratio to remain below the €30,000/QALY threshold. The value of a single point improvement was found to be between €200 and €700, depending on depression severity at treatment start. Value of the eHealth service, based on the current efficacy estimates, is €1900, which is significantly above its estimated cost (€200). Conclusions: The eHealth depression service is particularly suited to routine monitoring, since data can be gathered through the Internet within the service communication channels. This enables real-time cost-effectiveness evaluation and allows a value-based price to be established. We propose a novel pricing scheme where the price is set to a point in the interval between cost and value, which provides an economic surplus to both the payer and the provider. Such a business model will assure that a portion of the surplus is retained by the payer and not completely appropriated by the private provider. If the eHealth service were to turn out less effective than originally anticipated, then the price would be lowered in order to achieve the cost-effectiveness threshold and this risk of financial loss would be borne by the provider. %M 24583773 %R 10.2196/jmir.2592 %U http://www.jmir.org/2014/2/e67/ %U https://doi.org/10.2196/jmir.2592 %U http://www.ncbi.nlm.nih.gov/pubmed/24583773 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e3 %T Views of Young People in Rural Australia on SPARX, a Fantasy World Developed for New Zealand Youth With Depression %A Cheek,Colleen %A Bridgman,Heather %A Fleming,Theresa %A Cummings,Elizabeth %A Ellis,Leonie %A Lucassen,Mathijs FG %A Shepherd,Matthew %A Skinner,Timothy %+ Rural Clinical School, University of Tasmania, Private Bag 3513, Burnie, 7320, Australia, 61 364305922, Colleen.Cheek@utas.edu.au %K mental health %K stigma %K computer games %K youth %K rural health, computerized CBT %D 2014 %7 18.02.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: A randomized control trial demonstrated that a computerized cognitive behavioral therapy (cCBT) program (Smart, Positive, Active, Realistic, X-factor thoughts [SPARX]) was an appealing and efficacious treatment for depression for adolescents in New Zealand. Little is known about the acceptability of computerized therapy programs for rural Australians and the suitability of computerized programs developed in one cultural context when used in another country. Issues such as accents and local differences in health care access might mean adjustments to programs are required. Objective: This study sought to explore the acceptability of SPARX by youth in rural Australia and to explore whether and how young people would wish to access such a program. Methods: Focus groups and semistructured interviews were conducted with 16 young people attending two youth-focused community services in a small, rural Tasmanian town. An inductive data-driven approach was used to identify themes using the interview transcripts as the primary data source. Interpretation was supported by demographic data, observer notes, and content analysis. Results: Participants reported that young people want help for mental health issues but they have an even stronger need for controlling how they access services. In particular, they considered protecting their privacy in their small community to be paramount. Participants thought computerized therapy was a promising way to increase access to treatment for youth in rural and remote areas if offered with or without therapist support and via settings other than school. The design features of SPARX that were perceived to be useful, included the narrative structure of the program, the use of different characters, the personalization of an avatar, “socialization” with the Guide character, optional journaling, and the use of encouraging feedback. Participants did not consider (New Zealand) accents off-putting. Young people believed the SPARX program would appeal to those who play computer games generally, but may be less appealing for those who do not. Conclusions: The findings suggest that computerized therapy offered in ways that support privacy and choice can improve access to treatment for rural youth. Foreign accents and style may not be off-putting to teenage users when the program uses a playful fantasy genre, as it is consistent with their expectation of fantasy worlds, and it is in a medium with which they already have a level of competence. Rather, issues of engaging design and confidential access appeared to be more important. These findings suggest a proven tool once formally assessed at a local level can be adopted cross-nationally. %M 25659116 %R 10.2196/games.3183 %U http://games.jmir.org/2014/1/e3/ %U https://doi.org/10.2196/games.3183 %U http://www.ncbi.nlm.nih.gov/pubmed/25659116 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 3 %N 1 %P e8 %T A Web-Based Supportive Intervention for Families Living With Depression: Content Analysis and Formative Evaluation %A Stjernswärd,Sigrid %A Hansson,Lars %+ Department of Health Sciences, Lund University, Box 157, Lund, , Sweden, 46 46 2221904, sigrid.stjernsward@med.lu.se %K family caregivers %K depression %K online social networks %K social support %D 2014 %7 14.02.2014 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Relatives of people with a mental illness who live together can experience additional burdens that may require support. A Web-based tool including a psychoeducation module, a diary, and a password-protected forum was developed to support relatives of a person with depression. Objective: The objective of our study was to explore participants’ use of the Web-based tool, with focus on the forum, and to assess its potential health and psychosocial benefits. Methods: Twenty-five people participated in this explorative open trial. Self-rating instruments assessing caregiver burden, stigma, and the tool’s usability were analyzed with Carer QoL7-D, DISC-12, and a system usability scale. A summary measure of subjective burden was assessed with CarerQoL-VAS. The forum posts were studied using content analysis. Results: The majority reported fulfillment from their caregiving tasks (84%, 21/25), and had relational problems (76%, 19/25), their own mental health problems (72%, 18/25), support (72%, 18/25), and difficulties coordinating daily activities with caregiving (56%, 14/25). Most (72%, 18/25) reported having been able to use their inner strength to cope with stigma and discrimination, 64% (16/25) had concealed or hidden the person’s condition, and 40% (10/25) reported having been avoided or shunned by people who knew about the illness. Forty-eight percent (12/25) reported unfair treatment from family; 40% (10/25) in marriage or divorce and 36% (9/25) from mental health staff. Almost one-third (28%, 7/25) reported having stopped themselves from having a close personal relationship. Participants’ subjective assessment of the tool’s usability resulted in a mean of 61.5 (range, 22.5-90; possible total value 0-100; >70=good). Ten people participated in the forum; content analysis resulted in five categories describing relatives’ situations: balancing the caregiver’s role and relationship to the patient; their own lives and need for support; resources and patient advocacy; a looming shadow on leisure, social, and professional life; and interaction and social support. Conclusions: Further studies are needed to explore optimal ways of using Web-based tools to address support for relatives of a person with mental illness. Professional feedback may enhance the use and value of online communities. %M 24550185 %R 10.2196/resprot.3051 %U http://www.researchprotocols.org/2014/1/e8/ %U https://doi.org/10.2196/resprot.3051 %U http://www.ncbi.nlm.nih.gov/pubmed/24550185 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 16 %N 1 %P e27 %T Understanding the Usage of Content in a Mental Health Intervention for Depression: An Analysis of Log Data %A Van Gemert-Pijnen,Julia EWC %A Kelders,Saskia M %A Bohlmeijer,Ernst T %+ University of Twente, Department of Psychology, Health and Technology, Drienerlolaan 5, Enschede, 7522 NB, Netherlands, 31 534896050, j.vangemert-pijnen@utwente.nl %K mental health %K depression %K Web-based intervention %K acceptance commitment therapy %D 2014 %7 31.01.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based interventions for the early treatment of depressive symptoms can be considered effective in reducing mental complaints. However, there is a limited understanding of which elements in an intervention contribute to effectiveness. For efficiency and effectiveness of interventions, insight is needed into the use of content and persuasive features. Objective: The aims of this study were (1) to illustrate how log data can be used to understand the uptake of the content of a Web-based intervention that is based on the acceptance and commitment therapy (ACT) and (2) to discover how log data can be of value for improving the incorporation of content in Web-based interventions. Methods: Data from 206 participants (out of the 239) who started the first nine lessons of the Web-based intervention, Living to the Full, were used for a secondary analysis of a subset of the log data of the parent study about adherence to the intervention. The log files used in this study were per lesson: login, start mindfulness, download mindfulness, view success story, view feedback message, start multimedia, turn on text-message coach, turn off text-message coach, and view text message. Differences in usage between lessons were explored with repeated measures ANOVAs (analysis of variance). Differences between groups were explored with one-way ANOVAs. To explore the possible predictive value of the login per lesson quartiles on the outcome measures, four linear regressions were used with login quartiles as predictor and with the outcome measures (Center for Epidemiologic Studies—Depression [CES-D] and the Hospital Anxiety and Depression Scale—Anxiety [HADS-A] on post-intervention and follow-up) as dependent variables. Results: A significant decrease in logins and in the use of content and persuasive features over time was observed. The usage of features varied significantly during the treatment process. The usage of persuasive features increased during the third part of the ACT (commitment to value-based living), which might indicate that at that stage motivational support was relevant. Higher logins over time (9 weeks) corresponded with a higher usage of features (in most cases significant); when predicting depressive symptoms at post-intervention, the linear regression yielded a significant model with login quartile as a significant predictor (explained variance is 2.7%). Conclusions: A better integration of content and persuasive features in the design of the intervention and a better intra-usability of features within the system are needed to identify which combination of features works best for whom. Pattern recognition can be used to tailor the intervention based on usage patterns from the earlier lessons and to support the uptake of content essential for therapy. An adaptable interface for a modular composition of therapy features supposes a dynamic approach for Web-based treatment; not a predefined path for all, but a flexible way to go through all features that have to be used. %M 24486914 %R 10.2196/jmir.2991 %U http://www.jmir.org/2014/1/e27/ %U https://doi.org/10.2196/jmir.2991 %U http://www.ncbi.nlm.nih.gov/pubmed/24486914 %0 Journal Article %@ 1929-073X %I JMIR Publications Inc. %V 3 %N 1 %P e2 %T Designing Consumer Health Technologies for the Treatment of Patients With Depression: A Health Practitioner's Perspective %A White,Ginger %A Caine,Kelly %A Connelly,Kay %A Selove,Rebecca %A Doub,Tom %+ School of Informatics and Computing, Indiana University, 919 E 10th Street, Bloomington, IN, , United States, 1 812 855 0739, Connelly@indiana.edu %K depression %K health care providers %K technology %K user-computer interface %D 2014 %7 10.01.2014 %9 Original Paper %J Interact J Med Res %G English %X Background: The consumer health technologies used by patients on a daily basis can be effectively leveraged to assist them in the treatment of depression. However, because treatment for depression is a collaborative endeavor, it is important to understand health practitioners’ perspectives on the benefits, drawbacks, and design of such technologies. Objective: The objective of this research was to understand how patients and health practitioners can effectively and successfully influence the design of consumer health treatment technologies for treating patients with depression. Methods: A group of 10 health practitioners participated in individual semistructured contextual interviews at their offices. Health practitioners rated an a priori identified list of depression indicators using a 7-point Likert scale and generated a list of depression indicators. Finally, health practitioners were asked to rate the perceived usefulness of an a priori identified list of depression treatment technologies using a 7-point Likert scale. Results: Of the 10 health practitioners interviewed, 5 (50%) were mental health practitioners, 3 (30%) nurses, and 2 (20%) general practitioners. A total of 29 unique depression indicators were generated by the health practitioners. These indicators were grouped into 5 high-level categories that were identified by the research team and 2 clinical experts: (1) daily and social functioning, (2) medication, (3) nutrition and physical activity, (4) demographics and environment, and (5) suicidal thoughts. These indicators represent opportunities for designing technologies to support health practitioners who treat patients with depression. The interviews revealed nuances of the different health practitioners’ clinical practices and also barriers to using technology to guide the treatment of depression. These barriers included (1) technology that did not fit within the current practice or work infrastructure, (2) technology that would not benefit the current treatment process, (3) patients forgetting to use the technology, and (4) patients not being able to afford the technology. Conclusions: In order to be successful in the treatment of depression, consumer health treatment technologies must address health practitioners’ technology concerns early on in the design phase, account for the various types of health practitioners, treatment methods, and clinical practices, and also strive to seamlessly integrate traditional and nontraditional depression indicators within various health practitioners’ clinical practices. %M 24413087 %R 10.2196/ijmr.2368 %U http://www.i-jmr.org/2014/1/e2/ %U https://doi.org/10.2196/ijmr.2368 %U http://www.ncbi.nlm.nih.gov/pubmed/24413087 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 16 %N 1 %P e6 %T Keywords to Recruit Spanish- and English-Speaking Participants: Evidence From an Online Postpartum Depression Randomized Controlled Trial %A Barrera,Alinne Z %A Kelman,Alex R %A Muñoz,Ricardo F %+ Palo Alto University, 1791 Arastradero Road, Palo Alto, CA, 94304, United States, 1 650 433 3854, abarrera@paloaltou.edu %K Internet intervention %K prevention %K depression, postpartum %K research subject recruitment %K women %K Spanish speaking %D 2014 %7 09.01.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: One of the advantages of Internet-based research is the ability to efficiently recruit large, diverse samples of international participants. Currently, there is a dearth of information on the behind-the-scenes process to setting up successful online recruitment tools. Objective: The objective of the study was to examine the comparative impact of Spanish- and English-language keywords for a Google AdWords campaign to recruit pregnant women to an Internet intervention and to describe the characteristics of those who enrolled in the trial. Methods: Spanish- and English-language Google AdWords campaigns were created to advertise and recruit pregnant women to a Web-based randomized controlled trial for the prevention of postpartum depression, the Mothers and Babies/Mamás y Bebés Internet Project. Search engine users who clicked on the ads in response to keyword queries (eg, pregnancy, depression and pregnancy) were directed to the fully automated study website. Data on the performance of keywords associated with each Google ad reflect Web user queries from February 2009 to June 2012. Demographic information, self-reported depression symptom scores, major depressive episode status, and Internet use data were collected from enrolled participants before randomization in the intervention study. Results: The Google ads received high exposure (12,983,196 impressions) and interest (176,295 clicks) from a global sample of Web users; 6745 pregnant women consented to participate and 2575 completed enrollment in the intervention study. Keywords that were descriptive of pregnancy and distress or pregnancy and health resulted in higher consent and enrollment rates (ie, high-performing ads). In both languages, broad keywords (eg, pregnancy) had the highest exposure, more consented participants, and greatest cost per consent (up to US $25.77 per consent). The online ads recruited a predominantly Spanish-speaking sample from Latin America of Mestizo racial identity. The English-speaking sample was also diverse with most participants residing in regions of Asia and Africa. Spanish-speaking participants were significantly more likely to be of Latino ethnic background, not married, completed fewer years of formal education, and were more likely to have accessed the Internet for depression information (P<.001). Conclusions: The Internet is an effective method for reaching an international sample of pregnant women interested in online interventions to manage changes in their mood during the perinatal period. To increase efficiency, Internet advertisements need to be monitored and tailored to reflect the target population’s conceptualization of health issues being studied. Trial Registration: ClinicalTrials.gov NCT00816725; http://clinicaltrials.gov/show/NCT00816725 (Archived by WebCite at http://www.webcitation.org/6LumonjZP). %M 24407163 %R 10.2196/jmir.2999 %U http://www.jmir.org/2014/1/e6/ %U https://doi.org/10.2196/jmir.2999 %U http://www.ncbi.nlm.nih.gov/pubmed/24407163 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 10 %P e229 %T Telephone Versus Internet Administration of Self-Report Measures of Social Anxiety, Depressive Symptoms, and Insomnia: Psychometric Evaluation of a Method to Reduce the Impact of Missing Data %A Hedman,Erik %A Ljótsson,Brjánn %A Blom,Kerstin %A El Alaoui,Samir %A Kraepelien,Martin %A Rück,Christian %A Andersson,Gerhard %A Svanborg,Cecilia %A Lindefors,Nils %A Kaldo,Viktor %+ Osher Center for Integrative Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Retzius väg 8, Stockholm, 171 77, Sweden, 46 08 524 800 00, kire.hedman@ki.se %K Internet %K telephone %K self-report measures %K missing data %K method validation %D 2013 %7 18.10.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet-administered self-report measures of social anxiety, depressive symptoms, and sleep difficulties are widely used in clinical trials and in clinical routine care, but data loss is a common problem that could render skewed estimates of symptom levels and treatment effects. One way of reducing the negative impact of missing data could be to use telephone administration of self-report measures as a means to complete the data missing from the online data collection. Objective: The aim of the study was to compare the convergence of telephone and Internet administration of self-report measures of social anxiety, depressive symptoms, and sleep difficulties. Methods: The Liebowitz Social Anxiety Scale-Self-Report (LSAS-SR), Montgomery-Åsberg Depression Rating Scale-Self-Rated (MADRS-S), and the Insomnia Severity Index (ISI) were administered over the telephone and via the Internet to a clinical sample (N=82) of psychiatric patients at a clinic specializing in Internet-delivered treatment. Shortened versions of the LSAS-SR and the ISI were used when administered via telephone. Results: As predicted, the results showed that the estimates produced by the two administration formats were highly correlated (r=.82-.91; P<.001) and internal consistencies were high in both administration formats (telephone: Cronbach alpha=.76-.86 and Internet: Cronbach alpha=.79-.93). The correlation coefficients were similar across questionnaires and the shorter versions of the questionnaires used in the telephone administration of the LSAS-SR and ISI performed in general equally well compared to when the full scale was used, as was the case with the MADRS-S. Conclusions: Telephone administration of self-report questionnaires is a valid method that can be used to reduce data loss in routine psychiatric practice as well as in clinical trials, thereby contributing to more accurate symptom estimates. %M 24140566 %R 10.2196/jmir.2818 %U http://www.jmir.org/2013/10/e229/ %U https://doi.org/10.2196/jmir.2818 %U http://www.ncbi.nlm.nih.gov/pubmed/24140566 %0 Journal Article %@ 1947-2579 %I JMIR Publications %V 5 %N 1 %P e4454 %T Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review %D 2013 %7 ..2013 %9 %J Online J Public Health Inform %G English %X Veterans accessing Veterans Affairs (VA) health care have more characteristics associated with suicide risk compared with the general U.S. population. Telephone triage is a national telephone-based system used to assess Veterans with acute medical or mental health complaints. We used a biosurveillance application to characterize Veterans who call telephone triage because of suicidal ideation or depression. >2,000 Veterans called during January-June 2012. Suicide prevention training should be prioritized for operators working during off-hours and weekends. Standard notification of clinical staff regarding calls to prevent loss to follow-up and investigation into increased call burden in identified geographic areas is recommended. %R 10.5210/ojphi.v5i1.4454 %U %U https://doi.org/10.5210/ojphi.v5i1.4454 %0 Journal Article %@ 1438-8871 %I Gunther Eysenbach %V 14 %N 3 %P e86 %T Effectiveness of an Online Group Course for Depression in Adolescents and Young Adults: A Randomized Trial %A van der Zanden,Rianne %A Kramer,Jeannet %A Gerrits,Rob %A Cuijpers,Pim %+ Centre of Mental Health of Youth and Adolescents, Trimbos Institute, Da Costakade 45, Utrecht, 3500 AS Utrecht, Netherlands, 31 030 2971100, rzanden@trimbos.nl %K eHealth, health promotion %K depressive symptoms %K anxiety %K adolescents %K Internet %K randomized controlled trial %D 2012 %7 07.06.2012 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is a serious mental health problem, whose first onset is usually in adolescence. Online treatment may offer a solution for the current undertreatment of depression in youth. For adults with depressive symptoms, the effectiveness of Internet-based cognitive behavioral therapy has been demonstrated. This study is one of the first randomized controlled trials to investigate the effectiveness online depression treatment for young people with depressive complaints and the first to focus on an online group course. Objective: To evaluate and discuss the effectiveness of a guided Web-based group course called Grip op Je Dip (Master Your Mood [MYM]), designed for young people aged 16 to 25 years with depressive symptoms, in comparison with a wait-listed control group. Methods: We randomly assigned 244 young people with depressive symptoms to the online MYM course or to a waiting-list control condition. The primary outcome measure was treatment outcome after 3 months on the Center for Epidemiologic Studies Depression Scale. Secondary outcomes were anxiety (measured by the Hospital Anxiety and Depression Scale) and mastery (Mastery Scale). We studied the maintenance of effects in the MYM group 6 months after baseline. Missing data were imputed. Results: The MYM group (n = 121) showed significantly greater improvement in depressive symptoms at 3 months than the control group (n = 123) (t187 = 6.62, P < .001), with a large between-group effect size of d = 0.94 (95% confidence interval [CI] 0.64–1.23). The MYM group also showed greater improvement in anxiety (t187 = 3.80, P < .001, d = 0.49, 95% CI 0.24–0.75) and mastery (t187 = 3.36, P = .001, d = 0.44, 95% CI 0.19–0.70). At 12 weeks, 56% (68/121) of the participants in the MYM group and 20% (24/123) in the control group showed reliable and clinically significant change. This between-group difference was significant (χ21 = 35.0, P < .001) and yielded a number needed to treat of 2.7. Improvements in the MYM group were maintained at 6 months. A limitation is the infeasibility of comparing the 6-month outcomes of the MYM and control groups, as the controls had access to MYM after 3 months. Conclusions: The online group course MYM was effective in reducing depressive symptoms and anxiety and in increasing mastery in young people. These effects persisted in the MYM group at 6 months. Trial Registration: Nederlands Trial Register: NTR1694; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1694 (Archived by WebCite at http://www.webcitation.org/683SBoeGV) %M 22677437 %R 10.2196/jmir.2033 %U http://www.jmir.org/2012/3/e86/ %U https://doi.org/10.2196/jmir.2033 %U http://www.ncbi.nlm.nih.gov/pubmed/22677437