Predicting response to a smartphone-based cognitive-behavioral therapy for body dysmorphic disorder.

BACKGROUND: Body dysmorphic disorder (BDD) is a severe, chronic disorder if untreated. Smartphone cognitive behavioral therapy (CBT) for BDD is efficacious and can reduce key treatment barriers (e.g., lack of clinicians, cost, stigma). While promising, little is known about who is more or less likely to benefit from this approach. METHODS: This is a secondary data analysis of a randomized, waitlist-controlled trial of smartphone CBT for BDD. Participants (N = 80) were recruited nationally and randomized to receive a 12-week, coach-guided CBT for BDD app, either immediately or after a 12-week waitlist. The main outcome for this analysis was BDD severity (BDD-YBOCS) over time (baseline, week 6, week 12) during the active app use phase in each randomized group (n = 74). Secondary outcomes included treatment response (≥30 % reduction in BDD-YBOCS) and remission (total BDD-YBOCS ≤16) at end-of-treatment. RESULTS: Immediate (vs. delayed) CBT predicted better outcomes (symptom improvement), as did gender identity (symptom improvement), higher baseline treatment credibility and expectancy (response, remission), lower baseline BDD severity (remission), and sexual minority status (vs. heterosexual; response, remission). LIMITATIONS: Limitations include the relatively small sample, drop-out rate of 22 %, and limited gender and racial-ethnic diversity. CONCLUSIONS: These results highlight a potential advantage of smartphone CBT in historically marginalized populations, and the importance of efforts to hasten treatment access, bolster confidence in the treatment at treatment onset, and develop stratified care models to optimize treatment allocation and efficacy.

Testing a Behavioral Activation Gaming App for Depression During Pregnancy: Multimethod Pilot Study.

BACKGROUND: Depression during pregnancy is increasingly recognized as a worldwide public health problem. If untreated, there can be detrimental outcomes for the mother and child. Anxiety is also often comorbid with depression. Although effective treatments exist, most women do not receive treatment. Technology is a mechanism to increase access to and engagement in mental health services. OBJECTIVE: The Guardians is a mobile app, grounded in behavioral activation principles, which seeks to leverage mobile game mechanics and in-game rewards to encourage user engagement. This study seeks to assess app satisfaction and engagement and to explore changes in clinical symptoms of depression and anxiety among a sample of pregnant women with elevated depressive symptoms. METHODS: This multimethod pilot test consisted of a single-arm, proof-of-concept trial to examine the feasibility and acceptability of The Guardians among a pregnant sample with depression (N=18). Participation included two web-based study visits: (1) a baseline assessment to collect demographic and obstetric information and to assess clinical symptoms and (2) an exit interview to administer follow-up measures and explore user experience. Participants completed biweekly questionnaires (ie, Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7) during the trial to assess depression and anxiety symptom severity. App satisfaction was measured using 2 self-report scales (ie, Mobile Application Rating Scale and Player Experience of Needs Satisfaction scale). Engagement with The Guardians was captured using game interaction metric data. We used backward-eliminated mixed effects longitudinal models to examine the effects of app engagement and satisfaction and length of time in the study on symptoms of depression and anxiety. Content analysis was conducted on qualitative data from exit interviews. RESULTS: The 15-day and 30-day overall app retention rates were 26.6% and 15.1%, respectively. Mixed effects models found significant negative main effects of week in study (ß=-.35; t61=-3.05; P=.003), number of activities completed (ß=-.12; t61=-2.05; P=.04), days played (ß=-.12; t58=-2.9; P=.005), and satisfaction, according to the Mobile Application Rating Scale (ß=-3.05; t45=-2.19; P=.03) on depressive symptoms. We have reported about similar analyses for anxiety. There is preliminary evidence suggesting harder activities are associated with greater mood improvement than easier activities. Qualitative content analysis resulted in feedback falling under the following themes: activities, app design, engagement, fit of the app with lifestyle, perceived impact of the app on mood, and suggestions for app modifications. CONCLUSIONS: Preliminary results from this multimethod study of The Guardians indicate feasibility and acceptability among pregnant women with depression. Retention and engagement levels were more than double those of previous public mental health apps, and use of the app was associated with significant decrease in depressive symptom scores over the 10-week trial. The Guardians shows promise as an effective and scalable digital intervention to support women experiencing depression.

Framing maternal morbidity: WHO scoping exercise.

BACKGROUND: Maternal morbidity estimations are not based on well-documented methodologies and thus have limited validity for informing efforts to address the issue and improve maternal health. To fill this gap, maternal morbidity needs to be clearly defined, driving the development of tools and indicators to measure and monitor maternal health. This article describes the scoping exercise conducted by the World Health Organization's Department of Reproductive of Health and Research (WHO/RHR), as an essential first step in this process. METHODS: A literature review was conducted to identify the range of definitions and conditions included in various studies of maternal morbidity with a special focus on the similarities and discrepancies of the definitions used across the studies. Furthermore a questionnaire was developed which included sections on key areas identified during the review and was sent out electronically to 130 international experts in the field of maternal health. RESULTS: Maternal morbidities have been categorized in a variety of ways based on the causes, types of complications, and/or timeline. Issues regarding the time frame, severity, identification and classification and demographics were identified as key areas in the literature that require further investigation to achieve consensus on a maternal morbidity definition. Fifty-five (N = 55) individuals responded with completed questionnaires. Respondents' views on the time frame for the postpartum period varied from 6 weeks to beyond one year postpartum, it was noted that time frame depended on the type of complication. The majority of respondents said maternal morbidity should comprise a continuum of severity, whereas the identification of the cases should use a mixed criteria employing multiple methods. CONCLUSIONS: Significant discrepancy in literature and expert opinion exists concerning elements of a maternal morbidity definition. There is a clear need for a concrete definition that would allow for consistent measurement and monitoring of maternal morbidity across settings and time.