Engagement in Digital Mental Health Interventions: Can Monetary Incentives Help?

Digital mental health interventions (DMHI) are scalable and cost-effective strategies for increasing access to mental health care; however, dropout rates associated with digital interventions are high, particularly for open-access digital interventions. While some studies have focused on predictors of dropout from digital mental health programs, few studies have focused on engagement features that might improve engagement. In this perspective article, we discuss whether monetary incentives (MI) are one avenue to increasing user engagement in DMHI. We begin by reviewing the literature on the effects of MI for behavior change in health domains (e.g., dietary behaviors, substance use, and medication adherence). Then, drawing on a pilot study we conducted to test the effects of different levels of MI on usage and improvement in subjective well-being among users of a DMHI (Happify), we discuss the potential applications of MI for DMHI, the potential drawbacks of financial incentives in this context, and open questions for future research.

Artificially intelligent chatbots in digital mental health interventions: a review.

INTRODUCTION: Increasing demand for mental health services and the expanding capabilities of artificial intelligence (AI) in recent years has driven the development of digital mental health interventions (DMHIs). To date, AI-based chatbots have been integrated into DMHIs to support diagnostics and screening, symptom management and behavior change, and content delivery. AREAS COVERED: We summarize the current landscape of DMHIs, with a focus on AI-based chatbots. Happify Health's AI chatbot, Anna, serves as a case study for discussion of potential challenges and how these might be addressed, and demonstrates the promise of chatbots as effective, usable, and adoptable within DMHIs. Finally, we discuss ways in which future research can advance the field, addressing topics including perceptions of AI, the impact of individual differences, and implications for privacy and ethics. EXPERT OPINION: Our discussion concludes with a speculative viewpoint on the future of AI in DMHIs, including the use of chatbots, the evolution of AI, dynamic mental health systems, hyper-personalization, and human-like intervention delivery.

The Effects of a Digital Mental Health Intervention in Adults With Cardiovascular Disease Risk Factors: Analysis of Real-World User Data.

BACKGROUND: The American Heart Association has identified poor mental health as a key barrier to healthy behavior change for those with cardiovascular disease (CVD) risk factors such as high blood pressure, high cholesterol, and diabetes. Digital mental health interventions, like those delivered via the internet to computers or smartphones, may provide a scalable solution to improving the mental and physical health of this population. Happify is one such intervention and has demonstrated evidence of efficacy for improving aspects of mental health in both the general population and in users with chronic conditions. OBJECTIVE: The objectives of this analysis of real-world data from Happify users with self-reported CVD risk factors, including high blood pressure and cholesterol, diabetes, and heart disease, were to examine whether these users would report improvements in subjective well-being and anxiety over time (H1) and use of Happify as recommended would be associated with significantly greater improvement in subjective well-being and anxiety over time compared to less-than-recommended usage (H2). METHODS: Data were obtained from existing Happify users who reported the aforementioned CVD risk factors. The sample included 1803 users receiving at least 6 weeks' exposure to Happify (ranging from 42 days to 182 days) who completed at least one activity and two assessments within the app during that time. Subjective well-being was assessed with the Happify Scale, a 9-item measure of positive emotionality and life satisfaction, and anxiety was assessed with the Generalized Anxiety Disorder 2 (GAD-2). To evaluate H1, changes over time in both outcomes were assessed using mixed effects linear regression models, controlling for demographics and usage. For H2, an interaction term was added to the models to assess whether usage as recommended was associated with greater improvement over time. RESULTS: Both hypotheses were supported. For both the Happify scale and GAD-2, the initial multivariable model without an interaction demonstrated an effect for time from baseline, and the addition of the interaction term between time and recommended use was significant as well. CONCLUSIONS: This analysis of real-world data provides preliminary evidence that Happify users with self-reported CVD risk factors including high blood pressure or cholesterol, diabetes, and heart disease experienced improved well-being and anxiety over time and that those who used Happify as recommended experienced greater improvements in these aspects of mental health than those who completed fewer activities. These findings extend previous research, which demonstrated that engagement with Happify as recommended was associated with improved well-being among physically healthy users and in those with chronic conditions, to a new population for whom mental health is especially critical: those at risk of developing CVD.

Effects of a Digital Mental Health Program on Perceived Stress in Adolescents Aged 13-17 Years: Protocol for a Randomized Controlled Trial.

BACKGROUND: Stress is an important transdiagnostic risk factor in adolescence and predicts a host of physical and psychological problems in adolescence and adulthood. Adolescence is also a developmental stage in which people may be more sensitive or reactive to stress. Indeed, research has shown that adolescents report high levels of stress, particularly when enrolled in school. However, adolescents report engaging in few, if any, stress management techniques. Consequently, the development of effective programs to help address adolescent stress is particularly important. To date, most stress management programs for adolescents are delivered within schools, and the evidence for such programs is mixed. Furthermore, most of these programs rely on traditional stress management techniques rather than incorporating methods to address the underlying negative cognitive processes, such as rumination, that may contribute to or exacerbate the effects of perceived stress. OBJECTIVE: The aim of this study is to test the short-term effects of a digital mental health program designed for adolescents aged 13-17 years on perceived stress and rumination. METHODS: This is a randomized controlled trial in which adolescents between the ages of 13 and 17 years, with elevated levels of perceived stress and brooding, will be randomly assigned to complete 8 weeks of a digital mental health program (Happify for Teens) or to a corresponding wait-list control group. The study will take place over 3 months, including the 8-week intervention period and 1-month postintervention follow-up. The primary outcome, perceived stress, along with secondary and exploratory outcomes (ie, brooding, optimism, sleep disturbance, and loneliness) will be assessed via self-report at baseline, 4 weeks, 8 weeks, and 12 weeks to compare changes in these outcomes across conditions. RESULTS: Recruitment is expected to begin in the second quarter of 2021, with a target sample size of 800 participants (400 per condition). Participants will begin the study as they are recruited and will finish in waves, with the first wave of data expected 8 weeks after recruitment begins and the final wave of data expected by the end of the third quarter of 2021. CONCLUSIONS: Although school-based stress management programs for adolescents are common, research suggests that they may be limited in their reach and more effective for school-based stress than other types of stress. This trial will be one of the first attempts to examine the potential benefits of a digital mental health program on adolescents to address stress along with negative cognitive processes such as rumination. If successful, this would help introduce a more scalable alternative to school-based programs that offers adolescents greater privacy while also providing insight into novel ways to target adolescent mental health more generally. TRIAL REGISTRATION: ClinicalTrials.gov NCT04567888; https://clinicaltrials.gov/ct2/show/NCT04567888. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25545.

The Impact of a Digital Intervention (Happify) on Loneliness During COVID-19: Qualitative Focus Group.

BACKGROUND: Loneliness is a growing area of concern, attracting attention as a public health concern due to its association with a variety of psychological and physical health problems. However, interventions targeting loneliness are less common than interventions for other mental health problems, such as depression and anxiety, and existing interventions focus primarily on building social skills and increasing opportunities for social interaction despite research suggesting these techniques are not the most effective. Furthermore, although there is an increasing need for scalable and convenient interventions, digital interventions for loneliness are even less common. OBJECTIVE: Using a qualitative approach, we explore how adults (18-64 years of age) who express wanting to be more connected to others experience loneliness and react to a digital mental health intervention targeting loneliness. METHODS: A total of 11 participants were recruited from a pilot randomized controlled trial exploring the impact of a digital mental health intervention, Happify Health, on loneliness among adults aged 18-64 years who indicated wanting to feel more connected to others when signing up for the platform. Participants were invited to participate in a 3-day asynchronous focus group about their experiences with loneliness, with Happify Health, and with social distancing during the COVID-19 pandemic. All 11 participants completed the focus group in May 2020. RESULTS: Participants' responses were coded using thematic analysis, which led to identifying five themes, each with separate subthemes, that could be applied across the 3-day focus group: loneliness, relationships, social distancing, skill acquisition, and coping. Overall, we observed variability across participants in terms of the source of their loneliness, their perceptions of their social connections, and their motivation to reduce feelings of loneliness; however, participants commonly referred to negative self-perceptions as a cause or consequence of loneliness. Participants also varied in the extent to which they felt social distancing increased or decreased feelings of loneliness. In regard to the intervention, participants showed evidence of adopting skills they used to address their loneliness, particularly mindfulness and gratitude, and then using these skills to shift toward more active coping strategies following the intervention, including during the COVID-19 pandemic. CONCLUSIONS: The heterogeneity in participants' experiences with loneliness described during this focus group emphasizes the subjective and complex nature of loneliness. This highlights the importance of developing loneliness interventions that use a variety of strategies, including both direct and indirect strategies for reducing loneliness. However, based on our data, a key component to loneliness interventions is incorporating strategies for addressing underlying negative self-perceptions that stem from, but also contribute to, loneliness. This data also provides preliminary evidence that digital platforms may be an effective tool for disseminating loneliness interventions while providing the added benefit of offering a productive distraction when feeling lonely.

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.

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.

The Effects of a Digital Well-Being Intervention on Patients With Chronic Conditions: Observational Study.

BACKGROUND: Chronic conditions account for 75% of health care costs, and the impact of chronic illness is expected to grow over time. Although subjective well-being predicts better health outcomes, people with chronic conditions tend to report lower well-being. Improving well-being might mitigate costs associated with chronic illness; however, existing interventions can be difficult to access and draw from a single theoretical approach. Happify, a digital well-being intervention program drawing from multiple theoretical traditions to target well-being, has already been established as an efficacious means of improving well-being in both distressed and nondistressed users. OBJECTIVE: This study aimed to compare change in well-being over time after using Happify for users with and without a chronic condition. METHODS: Data were obtained from Happify users, a publicly available digital well-being program accessible via website or mobile phone app. Users work on tracks addressing a specific issue (eg, conquering negative thoughts) composed of games and activities based on positive psychology, cognitive behavioral therapy, and mindfulness principles. The sample included 821 users receiving at least 6 weeks' exposure to Happify (ranging from 42 to 179 days) who met other inclusion criteria. As part of a baseline questionnaire, respondents reported demographic information (age and gender) and whether they had any of the prespecified chronic conditions: arthritis, diabetes, insomnia, multiple sclerosis, chronic pain, psoriasis, eczema, or some other condition (450 reported a chronic condition, whereas 371 did not). Subjective well-being was assessed with the Happify Scale, a 9-item measure of positive emotionality and life satisfaction. To evaluate changes in well-being over time, a mixed effects linear regression model was fit for subjective well-being, controlling for demographics and platform usage. RESULTS: At baseline, users with a chronic condition had significantly lower subjective well-being (mean 38.34, SD 17.40) than users without a chronic condition (mean 43.65, SD 19.13). However, change trajectories for users with or without a chronic condition were not significantly different; both groups experienced equivalent improvements in well-being. We also found an effect for time from baseline (b=0.071; SE=0.010; P<.01) and number of activities completed (b=0.03; SE=0.009; P<.01), and a 2-way interaction between number of activities completed and time from baseline (b=0.0002; SE=0.00006; P<.01), such that completing more activities and doing so over increasingly longer periods produced improved well-being scores. CONCLUSIONS: Data from this study support the conclusion that users with a chronic condition experienced significant improvement over time. Despite reporting lower subjective well-being on the whole, their change trajectory while using Happify was equivalent to those without a chronic condition. Consistent with past research, users who completed more activities over a longer period showed the most improvement. In short, the presence of a chronic condition did not prevent users from showing improved well-being when using Happify.

Effect of Brief Biofeedback via a Smartphone App on Stress Recovery: Randomized Experimental Study.

BACKGROUND: Smartphones are often vilified for negatively influencing well-being and contributing to stress. However, these devices may, in fact, be useful in times of stress and, in particular, aid in stress recovery. Mobile apps that deliver evidence-based techniques for stress reduction, such as heart rate variability biofeedback (HRVB) training, hold promise as convenient, accessible, and effective stress-reducing tools. Numerous mobile health apps that may potentially aid in stress recovery are available, but very few have demonstrated that they can influence health-related physiological stress parameters (eg, salivary biomarkers of stress). The ability to recover swiftly from stress and reduce physiological arousal is particularly important for long-term health, and thus, it is imperative that evidence is provided to demonstrate the effectiveness of stress-reducing mobile health apps in this context. OBJECTIVE: The purpose of this research was to investigate the physiological and psychological effects of using a smartphone app for HRVB training following a stressful experience. The efficacy of the gamified Breather component of the Happify mobile health app was examined in an experimental setting. METHODS: In this study, participants (N=140) underwent a laboratory stressor and were randomly assigned to recover in one of three ways: with no phone present, with a phone present, with the HRBV game. Those in the no phone condition had no access to their phone. Those in the phone present condition had their phone but did not use it. Those in the HRVB game condition used the serious game Breather on the Happify app. Stress recovery was assessed via repeated measures of salivary alpha amylase, cortisol, and self-reported acute stress (on a 1-100 scale). RESULTS: Participants in the HRVB game condition had significantly lower levels of salivary alpha amylase during recovery than participants in the other conditions (F2,133=3.78, P=.03). There were no significant differences among the conditions during recovery for salivary cortisol levels or self-reported stress. CONCLUSIONS: These results show that engaging in a brief HRVB training session on a smartphone reduces levels of salivary alpha amylase following a stressful experience, providing preliminary evidence for the effectiveness of Breather in improving physiological stress recovery. Given the known ties between stress recovery and future well-being, this study provides a possible mechanism by which gamified biofeedback apps may lead to better health.

Understanding Long-Term Trajectories in Web-Based Happiness Interventions: Secondary Analysis From Two Web-Based Randomized Trials.

BACKGROUND: A critical issue in understanding the benefits of Web-based interventions is the lack of information on the sustainability of those benefits. Sustainability in studies is often determined using group-level analyses that might obscure our understanding of who actually sustains change. Person-centric methods might provide a deeper knowledge of whether benefits are sustained and who tends to sustain those benefits. OBJECTIVE: The aim of this study was to conduct a person-centric analysis of longitudinal outcomes, examining well-being in participants over the first 3 months following a Web-based happiness intervention. We predicted we would find distinct trajectories in people's pattern of response over time. We also sought to identify what aspects of the intervention and the individual predicted an individual's well-being trajectory. METHODS: Data were gathered from 2 large studies of Web-based happiness interventions: one in which participants were randomly assigned to 1 of 14 possible 1-week activities (N=912) and another wherein participants were randomly assigned to complete 0, 2, 4, or 6 weeks of activities (N=1318). We performed a variation of K-means cluster analysis on trajectories of life satisfaction (LS) and affect balance (AB). After clusters were identified, we used exploratory analyses of variance and logistic regression models to analyze groups and compare predictors of group membership. RESULTS: Cluster analysis produced similar cluster solutions for each sample. In both cases, participant trajectories in LS and AB fell into 1 of 4 distinct groups. These groups were as follows: those with high and static levels of happiness (n=118, or 42.8%, in Sample 1; n=306, or 52.8%, in Sample 2), those who experienced a lasting improvement (n=74, or 26.8% in Sample 1; n=104, or 18.0%, in Sample 2), those who experienced a temporary improvement but returned to baseline (n=37, or 13.4%, in Sample 1; n=82, or 14.2%, in Sample 2), and those with other trajectories (n=47, or 17.0%, in Sample 1; n=87, or 15.0% in Sample 2). The prevalence of depression symptoms predicted membership in 1 of the latter 3 groups. Higher usage and greater adherence predicted sustained rather than temporary benefits. CONCLUSIONS: We revealed a few common patterns of change among those completing Web-based happiness interventions. A noteworthy finding was that many individuals began quite happy and maintained those levels. We failed to identify evidence that the benefit of any particular activity or group of activities was more sustainable than any others. We did find, however, that the distressed portion of participants was more likely to achieve a lasting benefit if they continued to practice, and adhere to, their assigned Web-based happiness intervention.

Correction: Seeing the "Big" Picture: Big Data Methods for Exploring Relationships Between Usage, Language, and Outcome in Internet Intervention Data.

[This corrects the article DOI: 10.2196/jmir.5725.].

Seeing the "Big" Picture: Big Data Methods for Exploring Relationships Between Usage, Language, and Outcome in Internet Intervention Data.

BACKGROUND: Assessing the efficacy of Internet interventions that are already in the market introduces both challenges and opportunities. While vast, often unprecedented amounts of data may be available (hundreds of thousands, and sometimes millions of participants with high dimensions of assessed variables), the data are observational in nature, are partly unstructured (eg, free text, images, sensor data), do not include a natural control group to be used for comparison, and typically exhibit high attrition rates. New approaches are therefore needed to use these existing data and derive new insights that can augment traditional smaller-group randomized controlled trials. OBJECTIVE: Our objective was to demonstrate how emerging big data approaches can help explore questions about the effectiveness and process of an Internet well-being intervention. METHODS: We drew data from the user base of a well-being website and app called Happify. To explore effectiveness, multilevel models focusing on within-person variation explored whether greater usage predicted higher well-being in a sample of 152,747 users. In addition, to explore the underlying processes that accompany improvement, we analyzed language for 10,818 users who had a sufficient volume of free-text response and timespan of platform usage. A topic model constructed from this free text provided language-based correlates of individual user improvement in outcome measures, providing insights into the beneficial underlying processes experienced by users. RESULTS: On a measure of positive emotion, the average user improved 1.38 points per week (SE 0.01, t122,455=113.60, P<.001, 95% CI 1.36-1.41), about an 11% increase over 8 weeks. Within a given individual user, more usage predicted more positive emotion and less usage predicted less positive emotion (estimate 0.09, SE 0.01, t6047=9.15, P=.001, 95% CI .07-.12). This estimate predicted that a given user would report positive emotion 1.26 points (or 1.26%) higher after a 2-week period when they used Happify daily than during a week when they didn't use it at all. Among highly engaged users, 200 automatically clustered topics showed a significant (corrected P<.001) effect on change in well-being over time, illustrating which topics may be more beneficial than others when engaging with the interventions. In particular, topics that are related to addressing negative thoughts and feelings were correlated with improvement over time. CONCLUSIONS: Using observational analyses on naturalistic big data, we can explore the relationship between usage and well-being among people using an Internet well-being intervention and provide new insights into the underlying mechanisms that accompany it. By leveraging big data to power these new types of analyses, we can explore the workings of an intervention from new angles, and harness the insights that surface to feed back into the intervention and improve it further in the future.

Impact of Psychoeducational Content Delivered Online to a Positive Psychology Aware Community.

Happiness-increasing interventions demonstrate significant variation in outcomes, suggesting that the people who use them might be as important as the interventions themselves to determine efficacy. In light of this, instructive interventions might not be necessary to increase happiness given a population with knowledge of happiness-increasing strategies. We recruited 270 participants with knowledge of positive psychology to receive six weeks of online psychoeducation. We explored participants' use of the website, reported use of happiness strategies, and changes in well-being. Those who spent more time on the website reported smaller changes in well-being than those who spent less time on the website. Conversely, those who reported employing more happiness strategies reported greater increases in well-being than those who used fewer strategies. This shows that for those already familiar with positive psychology, information, rather than instruction, might increase well-being. This has implications for studies evaluating the efficacy of happiness-increasing interventions more broadly.

Assessing the efficacy and effectiveness of a Positive Psychology-based self-help book / Evaluación de la eficacia y la efectividad de un libro de autoyuda basado en Psicología Positiva

The current article discusses the potential utility of self-help books as a means of disseminating positive psychological interventions, and presents data comparing a positive psychology-based self-help book with a cognitive-behavioral self-help book and a self-monitoring control condition. We studied college freshmen (N=58), and argue that this population is a particularly appropriate target for well-being intervention. Outcome measures included both indices of efficacy (depressive symptoms and life satisfaction) and effectiveness (e.g. the extent to which participants found their assigned activities to be meaningful). The two book groups outperformed the control and were equivalently efficacious at reducing depressive symptoms; on life satisfaction, positive self-help outperformed cognitive-behavioral, but only at 6-month follow-up. Positive self-help was also superior to cognitive-behavioral self-help on indices of effectiveness. Possibilities for future directions are discussed, with an emphasis on the realities of practical dissemination to both college students, and to the general public.

El presente artículo analiza la utilidad potencial de los libros de auto-ayuda como medio de difusión de las intervenciones psicológicas positivas, y presenta datos comparando libro de autoayuda basado en psicología positiva, un libro de autoayuda cognitivo-conductual, y una condición de control de auto-monitorización. Participaron estudiantes universitarios de primer año (N = 58), y defendemos que esta población es un objetivo particularmente apropiado para intervenciones centradas en el bienestar. Las medidas de resultado incluyeron tanto índices de eficacia (síntomas depresivos y satisfacción con la vida) como de efectividad (por ejemplo, el grado en el que los participantes juzgaron que sus actividades asignadas tenían sentido). Los dos grupos de libros superaron al grupo control y fueron igualmente eficaces en la reducción de los síntomas. Respecto a la satisfacción vital, el grupo de autoayuda positiva superó al cognitivo-conductual, pero sólo a los 6 meses de seguimiento. La intervención positiva de auto-ayuda también fue superior a la cognitivo-conductual en los índices de efectividad. Se discuten las posibilidades de futuras direcciones, enfatizando las realidades de la difusión práctica tanto en estudiantes universitarios como al público en general.

Disseminating self-help: positive psychology exercises in an online trial.

BACKGROUND: The recent growth of positive psychology has led to a proliferation in exercises to increase positive thoughts, behaviors, and emotions. Preliminary evidence suggests that these exercises hold promise as an approach for reducing depressive symptoms. These exercises are typically researched in isolation as single exercises. The current study examined the acceptability of several multi-exercise packages using online dissemination. OBJECTIVE: The purpose of this study was to investigate methods of dissemination that could increase the acceptability and effectiveness of positive psychology exercises. To achieve this goal, we compared the use of positive psychology exercises when delivered in packages of 2, 4, or 6 exercises. METHODS: Self-help-seeking participants enrolled in this study by visiting an online research portal. Consenting participants were randomly assigned to receive 2, 4, or 6 positive psychology exercises (or assessments only) over a 6-week period. These exercises drew from the content of group positive psychotherapy. Participants visited an automated website that distributed exercise instructions, provided email reminders, and contained the baseline and follow-up assessments. Following each exercise, participants rated their enjoyment of the exercise, answered how often they had used each technique, and completed outcome measures. RESULTS: In total, 1364 individuals consented to participate. Attrition rates across the 2-, 4-, and 6-exercise conditions were similar at 55.5% (181/326), 55.8% (203/364), and 52.7% (168/319) respectively but were significantly greater than the attrition rate of 42.5% (151/355) for the control condition (χ(2)(3) = 16.40, P < .001). Participants in the 6-exercise condition were significant more likely than participants in the 4-exercise condition to use both the third (F(1,312) = 5.61, P = .02) and fourth (F(1,313 )= 6.03, P = .02) exercises. For 5 of the 6 exercises, enjoyment was related to continued use of the exercise at 6-week follow-up (r's = .12 to .39). All conditions produced significant reductions in depressive symptoms (F(1,656) = 94.71, P < .001); however, a significant condition by time interaction (F(3,656) = 4.77, P = .003) indicated that this reduction was larger in the groups that received 2 or 4 exercises compared with the 6-exercise or control condition. CONCLUSION: Increasing the number of exercises presented to participants increased the use of the techniques and did not increase dropout. Participants may be more likely to use these skills when presented with a variety of options. Increasing the number of exercises delivered to participants produced a curvilinear relationship with those in the 2- and 4-exercise conditions reporting larger decreases in depressive symptoms than participants in the 6-exercise or control conditions. Although research generally offers a single exercise to test isolate effects, this study supports that studying variability in dissemination can produce important findings.

Pursuing happiness in everyday life: the characteristics and behaviors of online happiness seekers.

Although the last decade has witnessed mounting research on the development and evaluation of positive interventions, investigators still know little about the target population of such interventions: happiness seekers. The present research asked three questions about happiness seekers: (1) What are their general characteristics?, (2) What do they purposefully do to become happier?, and (3) How do they make use of self-help resources? In Study 1, we identified two distinct clusters of online happiness seekers. In Study 2, we asked happiness seekers to report on their use of 14 types of happiness-seeking behaviors. In Study 3, we tracked happiness seekers' usage of an iPhone application that offered access to eight different happiness-increasing activities, and assessed their resulting happiness and mood improvements. Together, these studies provide a preliminary portrait of happiness seekers' characteristics and naturalistic behaviors.

Positive psychotherapy.

Positive psychotherapy (PPT) contrasts with standard interventions for depression by increasing positive emotion, engagement, and meaning rather than directly targeting depressive symptoms. The authors have tested the effects of these interventions in a variety of settings. In informal student and clinical settings, people not uncommonly reported them to be "life-changing." Delivered on the Web, positive psychology exercises relieved depressive symptoms for at least 6 months compared with placebo interventions, the effects of which lasted less than a week. In severe depression, the effects of these Web exercises were particularly striking. This address reports two preliminary studies: In the first, PPT delivered to groups significantly decreased levels of mild-to-moderate depression through 1-year follow-up. In the second, PPT delivered to individuals produced higher remission rates than did treatment as usual and treatment as usual plus medication among outpatients with major depressive disorder. Together, these studies suggest that treatments for depression may usefully be supplemented by exercises that explicitly increase positive emotion, engagement, and meaning. ((c) 2006 APA, all rights reserved).

A balanced psychology and a full life.

Psychology since World War II has been largely devoted to repairing weakness and understanding suffering. Towards that end, we have made considerable gains. We have a classification of mental illness that allows international collaboration, and through this collaboration we have developed effective psychotherapeutic or pharmacological treatments for 14 major mental disorders. However, while building a strong science and practice of treating mental illness, we largely forgot about everyday well-being. Is the absence of mental illness and suffering sufficient to let individuals and communities flourish? Were all disabling conditions to disappear, what would make life worth living? Those committed to a science of positive psychology can draw on the effective research methods developed to understand and treat mental illness. Results from a new randomized, placebo-controlled study demonstrate that people are happier and less depressed three months after completing exercises targeting positive emotion. The ultimate goal of positive psychology is to make people happier by understanding and building positive emotion, gratification and meaning. Towards this end, we must supplement what we know about treating illness and repairing damage with knowledge about nurturing well-being in individuals and communities.