As interest in and use of telehealth during the COVID-19 global pandemic increase, the potential of digital health to increase access and quality of mental health is becoming clear. Although the ...world today must "flatten the curve" of spread of the virus, we argue that now is the time to "accelerate and bend the curve" on digital health. Increased investments in digital health today will yield unprecedented access to high-quality mental health care. Focusing on personal experiences and projects from our diverse authorship team, we share selected examples of digital health innovations while acknowledging that no single piece can discuss all the impressive global efforts past and present. Exploring the success of telehealth during the present crisis and how technologies like apps can soon play a larger role, we discuss the need for workforce training, high-quality evidence, and digital equity among other factors critical for bending the curve further.
The mental health consequences of the coronavirus disease (COVID-19) pandemic, community-wide interventions, and social media use during a pandemic are unclear. The first and most draconian ...interventions have been implemented in Wuhan, China, and these countermeasures have been increasingly deployed by countries around the world.
The aim of this study was to examine risk factors, including the use of social media, for probable anxiety and depression in the community and among health professionals in the epicenter, Wuhan, China.
We conducted an online survey via WeChat, the most widely used social media platform in China, which was administered to 1577 community-based adults and 214 health professionals in Wuhan. Probable anxiety and probable depression were assessed by the validated Generalized Anxiety Disorder-2 (cutoff ≥3) and Patient Health Questionnaire-2 (cutoff ≥3), respectively. A multivariable logistic regression analysis was used to examine factors associated with probable anxiety and probable depression.
Of the 1577 community-based adults, about one-fifth of respondents reported probable anxiety (n=376, 23.84%, 95% CI 21.8-26.0) and probable depression (n=303, 19.21%, 95% CI 17.3-21.2). Similarly, of the 214 health professionals, about one-fifth of surveyed health professionals reported probable anxiety (n=47, 22.0%, 95% CI 16.6-28.1) or probable depression (n=41, 19.2%, 95% CI 14.1-25.1). Around one-third of community-based adults and health professionals spent ≥2 hours daily on COVID-19 news via social media. Close contact with individuals with COVID-19 and spending ≥2 hours daily on COVID-19 news via social media were associated with probable anxiety and depression in community-based adults. Social support was associated with less probable anxiety and depression in both health professionals and community-based adults.
The internet could be harnessed for telemedicine and restoring daily routines, yet caution is warranted toward spending excessive time searching for COVID-19 news on social media given the infodemic and emotional contagion through online social networks. Online platforms may be used to monitor the toll of the pandemic on mental health.
There is little research on the application of gamification to mental health and well-being. Furthermore, usage of gamification-related terminology is inconsistent. Current applications of ...gamification for health and well-being have also been critiqued for adopting a behaviorist approach that relies on positive reinforcement and extrinsic motivators.
This study aimed to analyze current applications of gamification for mental health and well-being by answering 3 research questions (RQs). RQ1: which gamification elements are most commonly applied to apps and technologies for improving mental health and well-being? RQ2: which mental health and well-being domains are most commonly targeted by these gamified apps and technologies? RQ3: what reasons do researchers give for applying gamification to these apps and technologies? A systematic review of the literature was conducted to answer these questions.
We searched ACM Digital Library, CINAHL, Cochrane Library, EMBASE, IEEE Explore, JMIR, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science for qualifying papers published between the years 2013 and 2018. To answer RQ1 and RQ2, papers were coded for gamification elements and mental health and well-being domains according to existing taxonomies in the game studies and medical literature. During the coding process, it was necessary to adapt our coding frame and revise these taxonomies. Thematic analysis was conducted to answer RQ3.
The search and screening process identified 70 qualifying papers that collectively reported on 50 apps and technologies. The most commonly observed gamification elements were levels or progress feedback, points or scoring, rewards or prizes, narrative or theme, personalization, and customization; the least commonly observed elements were artificial assistance, unlockable content, social cooperation, exploratory or open-world approach, artificial challenge, and randomness. The most commonly observed mental health and well-being domains were anxiety disorders and well-being, whereas the least commonly observed domains were conduct disorder and bipolar disorders. Researchers' justification for applying gamification to improving mental health and well-being was coded in 59% (41/70) of the papers and was broadly divided into 2 themes: (1) promoting engagement and (2) enhancing an intervention's intended effects.
Our findings suggest that the current application of gamification to apps and technologies for improving mental health and well-being does not align with the trend of positive reinforcement critiqued in the greater health and well-being literature. We also observed overlap between the most commonly used gamification techniques and existing behavior change frameworks. Results also suggest that the application of gamification is not driven by health behavior change theory, and that many researchers may treat gamification as a black box without consideration for its underlying mechanisms. We call for the inclusion of more comprehensive and explicit descriptions of how gamification is applied and the standardization of applied games terminology within and across fields.
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.
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.
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).
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 (F
= 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.
Conversational agents appear to be a feasible, engaging, and effective way to deliver CBT.
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.
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.
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.
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.
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.
International Standard Randomized Controlled Trial Number: ISRCTN61214172; https://doi.org/10.1186/ISRCTN61214172.
A growing gap has emerged between people with mental illness and health care professionals, which in recent years has been successfully closed through the adoption of peer support services (PSSs). ...Peer support in mental health has been variously defined in the literature and is simply known as the help and support that people with lived experience of mental illness or a learning disability can give to one another. Although PSSs date back to several centuries, it is only in the last few decades that these services have formally evolved, grown, and become an integral part of the health care system. Debates around peer support in mental health have been raised frequently in the literature. Although many authors have emphasized the utmost importance of incorporating peer support into the health care system to instill hope; to improve engagement, quality of life, self-confidence, and integrity; and to reduce the burden on the health care system, other studies suggest that there are neutral effects from integrating PSSs into health care systems, with a probable waste of resources.
In this general review, we aimed to examine the literature, exploring the evolution, growth, types, function, generating tools, evaluation, challenges, and the effect of PSSs in the field of mental health and addiction. In addition, we aimed to describe PSSs in different, nonexhaustive contexts, as shown in the literature, that aims to draw attention to the proposed values of PSSs in such fields.
The review was conducted through a general search of the literature on MEDLINE, Google Scholar, EMBASE, Scopus, Chemical Abstracts, and PsycINFO. Search terms included peer support, peer support in mental health, social support, peer, family support, and integrated care.
There is abundant literature defining and describing PSSs in different contexts as well as tracking their origins. Two main transformational concepts have been described, namely, intentional peer support and transformation from patients to peer support providers. The effects of PSSs are extensive and integrated into different fields, such as forensic PSSs, addiction, and mental health, and in different age groups and mental health condition severity. Satisfaction of and challenges to PSS integration have been clearly dependent on a number of factors and consequently impact the future prospect of this workforce.
There is an internationally growing trend to adopt PSSs within addiction and mental health services, and despite the ongoing challenges, large sections of the current literature support the inclusion of peer support workers in the mental health care workforce. The feasibility and maintenance of a robust PSS in health care would only be possible through collaborative efforts and ongoing support and engagement from all health care practitioners, managers, and other stakeholders.
The number of mental health apps (MHapps) developed and now available to smartphone users has increased in recent years. MHapps and other technology-based solutions have the potential to play an ...important part in the future of mental health care; however, there is no single guide for the development of evidence-based MHapps. Many currently available MHapps lack features that would greatly improve their functionality, or include features that are not optimized. Furthermore, MHapp developers rarely conduct or publish trial-based experimental validation of their apps. Indeed, a previous systematic review revealed a complete lack of trial-based evidence for many of the hundreds of MHapps available.
To guide future MHapp development, a set of clear, practical, evidence-based recommendations is presented for MHapp developers to create better, more rigorous apps.
A literature review was conducted, scrutinizing research across diverse fields, including mental health interventions, preventative health, mobile health, and mobile app design.
Sixteen recommendations were formulated. Evidence for each recommendation is discussed, and guidance on how these recommendations might be integrated into the overall design of an MHapp is offered. Each recommendation is rated on the basis of the strength of associated evidence. It is important to design an MHapp using a behavioral plan and interactive framework that encourages the user to engage with the app; thus, it may not be possible to incorporate all 16 recommendations into a single MHapp.
Randomized controlled trials are required to validate future MHapps and the principles upon which they are designed, and to further investigate the recommendations presented in this review. Effective MHapps are required to help prevent mental health problems and to ease the burden on health systems.
Social networking sites (SNSs) have become a pervasive part of modern culture, which may also affect mental health.
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.
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.
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.
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.
A smartphone is a promising tool for daily cardiovascular measurement and mental stress monitoring. A smartphone camera-based photoplethysmography (PPG) and a low-cost thermal camera can be used to ...create cheap, convenient, and mobile monitoring systems. However, to ensure reliable monitoring results, a person must remain still for several minutes while a measurement is being taken. This is cumbersome and makes its use in real-life situations impractical.
We proposed a system that combines PPG and thermography with the aim of improving cardiovascular signal quality and detecting stress responses quickly.
Using a smartphone camera with a low-cost thermal camera added on, we built a novel system that continuously and reliably measures 2 different types of cardiovascular events: (1) blood volume pulse and (2) vasoconstriction/dilation-induced temperature changes of the nose tip. 17 participants, involved in stress-inducing mental workload tasks, measured their physiological responses to stressors over a short time period (20 seconds) immediately after each task. Participants reported their perceived stress levels on a 10-cm visual analog scale. For the instant stress inference task, we built novel low-level feature sets representing cardiovascular variability. We then used the automatic feature learning capability of artificial neural networks to improve the mapping between the extracted features and the self-reported ratings. We compared our proposed method with existing hand-engineered features-based machine learning methods.
First, we found that the measured PPG signals presented high quality cardiac cyclic information (mean pSQI: 0.755; SD 0.068). We also found that the measured thermal changes of the nose tip presented high-quality breathing cyclic information and filtering helped extract vasoconstriction/dilation-induced patterns with fewer respiratory effects (mean pSQI: from 0.714 to 0.157). Second, we found low correlations between the self-reported stress scores and the existing metrics of the cardiovascular signals (ie, heart rate variability and thermal directionality) from short measurements, suggesting they were not very dependent upon one another. Third, we tested the performance of the instant perceived stress inference method. The proposed method achieved significantly higher accuracies than existing precrafted features-based methods. In addition, the 17-fold leave-one-subject-out cross-validation results showed that combining both modalities produced higher accuracy than using PPG or thermal imaging only (PPG+Thermal: 78.33%; PPG: 68.53%; Thermal: 58.82%). The multimodal results are comparable to the state-of-the-art stress recognition methods that require long-term measurements. Finally, we explored effects of different data labeling strategies on the sensitivity of our inference methods. Our results showed the need for separation of and normalization between individual data.
The results demonstrate the feasibility of using smartphone-based imaging for instant stress detection. Given that this approach does not need long-term measurements requiring attention and reduced mobility, we believe it is more suitable for mobile mental health care solutions in the wild.
Internet interventions have been proposed to improve the accessibility and use of evidence-based psychological treatments. However, little is known about attitudes toward such treatments, which can ...be an important barrier to their use.
This study aimed to (1) determine attitudes toward guided internet interventions, (2) assess its acceptability compared with other internet-based formats, and (3) explore predictors of acceptance.
A convenience-sample Web-based survey (N=646) assessed attitudes toward guided internet therapies (ie, perceived usefulness and helpfulness, and advantage relative to face-to-face therapy), preferences for delivery modes (ie, e-preference: guided internet interventions, unguided internet interventions, or videoconferencing psychotherapy), and potential predictors of attitudes and preferences: sociodemographics, help-seeking-related variables, attachment style, and perceived stress.
Although most participants perceived internet interventions as useful or helpful (426/646, 65.9%), a few indicated their advantage relative to face-to-face therapy (56/646, 8.7%). Most participants preferred guided internet interventions (252/646, 39.0%) over videoconferencing psychotherapy (147/646, 22.8%), unguided internet interventions (124/646, 19.2%), and not using internet interventions (121/646, 18.8%; missing data: 1/646, 0.2%). Attachment avoidance and stress were related to e-preference (all P<.05). Moreover, preference for therapist-guided internet interventions was higher for individuals who were aware of internet-based treatment (χ
=12.8; P=.046).
Participants assessed therapist-guided internet interventions as helpful, but not equivalent to face-to-face therapies. The vast majority (523/646, 81.0%) of the participants were potentially willing to use internet-based approaches. In lieu of providing patients with only one specific low-intensity treatment, implementation concepts should offer several options, including guided internet interventions, but not limited to them. Conversely, our results also indicate that efforts should focus on increasing public knowledge about internet interventions, including information about their effectiveness, to promote acceptance and uptake.
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