Providing Human Support for the Use of Digital Mental Health Interventions: Systematic Meta-review.

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.

Healthy hearts healthy minds: A randomized trial of online interventions to improve physical activity.

INTRODUCTION: Depressed individuals are more likely to die from cardiovascular disease (CVD) than those without depression. People with CVD have higher rates of depression than those without and have higher mortality rates if they have comorbid depression. While physical activity (PA) improves both, few people engage in enough. We compared self-guided internet-based cognitive behavior therapy (CBT) + Fitbit or mindfulness-based cognitive therapy (MBCT) + Fitbit, with Fitbit only to increase daily steps for participants with depression who have low PA. METHODS: Adult participants (N = 340) were recruited from two online patient-powered research networks and randomized to one of three study interventions for 8 weeks with an additional 8 weeks of follow-up. Using linear mixed effects models, we evaluated the effect of the intervention on average daily steps (NCT03373110). RESULTS: Average daily steps increased 2.8 steps per day in MBCT+Fitbit, 2.9 steps/day in CBT + Fitbit, but decreased 8.2 steps/day in Fitbit Only. These changes were not statistically different between the MBCT+Fitbit and CBT + Fitbit groups, but were different from Fitbit Only across the initial 8-week period. Group differences were not maintained across follow-up. Exploratory analyses identified comorbid anxiety disorders, self-reported PA, and employment status as moderators. DISCUSSION: Changes in daily steps over both 8- and 16-week periods-regardless of intervention group-were minimal. The results emphasize the limits of using self-guided web-based psychotherapy with an activity tracker to increase PA in participants with a history of depression and low PA.

A systematic review of the literature on telepsychiatry for bipolar disorder.

OBJECTIVE: Bipolar (BP) disorder is a highly morbid disorder that is often misdiagnosed or undiagnosed and affects a large number of adults and children. Due to the coronavirus disease 2019 public health emergency stay at home orders, most outpatient mental health care was provided via telepsychiatry, and the many benefits of virtual care ensure that this will continue as an ongoing practice. The main aim of this review was to investigate what is currently known about the use of telepsychiatry services in the diagnosis and treatment of BP disorder across the lifespan. METHOD: A systematic literature review assessing the use of telepsychiatry in BP disorder was conducted in PubMed, PsychINFO, and Medline. RESULTS: Six articles were included in the final review. All included articles assessed populations aged 17 years or older. The literature indicates that BP disorder was addressed in telepsychiatry services at a similar rate as in-person services, reliable diagnoses can be made using remote interviews, satisfaction rates are comparable to in-person services, telepsychiatry services are able to reach and impact patients with BP disorder, are sustainable, and patient outcomes can improve using a telepsychiatry intervention. CONCLUSIONS: Given the morbidity of BP disorder, the research addressing the telepsychiatry diagnosis and treatment of BP disorder is sparse, with only emerging evidence of its reliability, effectiveness, and acceptance. There is no research assessing the safety and efficacy of telepsychiatry in pediatric populations with BP disorder. Given the morbidity associated with BP disorder at any age, further research is needed to determine how to safely and effectively incorporate telepsychiatry into clinical care for BP adult and pediatric patients.

An online intervention for increasing physical activity in individuals with mood disorders at risk for cardiovascular disease: Design considerations.

BACKGROUND: Physical activity can mitigate the risk of cardiovascular diseases, but the presence of mood disorders makes it challenging to follow or develop a regular exercise habit. We conducted an online comparative effectiveness study (Healthy Hearts Healthy Minds) to evaluate whether an online psychosocial intervention adjunctive to an activity monitor (Fitbit) can improve adherence to physical activity among individuals with mood disorders who have or are at-risk for cardiovascular disease (CVD). METHODS: In this paper, we explore design considerations (including both procedural challenges and achievements) of relevance to our study. RESULTS: Challenges of this study included navigating a complex IRB review process, integrating two study platforms, automating study procedures, and optimizing participant engagement. Achievements of this study included building trust with collaborators, leveraging existing online communities, generating daily data reports, and conducting patient-centered research. LIMITATIONS: These design considerations are based on a single online comparative effectiveness study, and other online intervention studies may be presented with other unique challenges that are specific to their study format or aims. Consistent with some of the generalizability challenges facing other online studies, participants in this study were overall highly educated (most had at least a college degree). CONCLUSIONS: We successfully conducted a large-scale virtual online intervention to increase physical activity of participants with comorbid mood and cardiovascular disorders by overcoming substantial operational and technical challenges. We hope that this exploration of design considerations in the context of our online study can inform upcoming online intervention studies.

Mind the Gap: The Relation Between Identity Gaps and Depression Symptoms in Cultural Adaptation.

Personal-enacted identity gaps, defined as the difference between an individual's self-view and the self that one expresses in communication, affect depression levels of international students living in the United States. Thus, identity gaps are an important construct for understanding the relation between identity and health outcomes. The present research examined the relation between personal-enacted identity gaps formed through communication with Americans and depression, extending previous work by considering the roles of acculturative stress and self-construal and providing one of the first tests of the relation between identity gaps and acculturative stress. A sample of 171 undergraduate and graduate international students studying in the United States was recruited to participate in an online study consisting of self-report questionnaires. Results indicated that as hypothesized, higher levels of personal-enacted identity gaps were associated with depression symptoms and that acculturative stress mediates this relation. However, independent self-construal did not moderate the relation between these variables. Testing additional models revealed multiple ways in which these factors could affect each other. Overall, results suggest that personal-enacted identity gaps, acculturative stress, and depression symptoms are important to consider in tandem in order to understand the emotional experiences of the international students and identify who is at risk for poor mental health. Future longitudinal research is needed to further understand the relations amongst these factors.

An evaluation of suicidal risk in bipolar patients with comorbid posttraumatic stress disorder.

BACKGROUND: While bipolar disorder (BD) and posttraumatic stress disorder (PTSD) frequently co-occur and individually have a higher risk of suicide compared to the general population, few studies have examined the impact of comorbid PTSD on suicidal ideation in patients with BD. METHODS: We analyzed baseline data from the Clinical and Health Outcomes Initiative in Comparative Effectiveness for bipolar disorder study (Bipolar CHOICE), a 6-month, pharmacological comparative effectiveness trial of individuals with BD. Bipolar CHOICE enrolled 482 individuals. A hierarchical multiple regression analysis assessed whether comorbid PTSD was associated with increased suicidal ideation as assessed by the Concise Health Risk Tracking Scale (CHRT) total and factor scores, while controlling for common correlates of suicidal ideation in this population such as a current major depressive episode, comorbid anxiety disorders, severity of illness and previous suicide attempts. RESULTS: Consistent with our hypothesis, diagnosis of comorbid PTSD was a significant predictor of the CHRT total score (ß=2.59, p=.03). Comorbid PTSD was also a significant predictor of the CHRT propensity factor (ß=2.32, adjusted p=.04), but was not a significant predictor of the active suicidal thoughts factor. Additionally, all participants with comorbid PTSD (N = 58) endorsed current suicidal ideation (p=.005) and were more likely to have had a previous suicide attempt (p<.001) compared to those without PTSD. LIMITATIONS: Generalizability beyond outpatient settings is limited, mixed affective states were not assessed, and analyses were cross-sectional. CONCLUSIONS: Patients have an increased risk of suicidal ideation when PTSD is comorbid with BD.

Influence of encoding instructions and response bias on cross-cultural differences in specific recognition.

Prior cross-cultural research has reported cultural variations in memory. One study revealed that Americans remembered images with more perceptual detail than East Asians (Millar et al. in Cult Brain 1(2-4):138-157, 2013). However, in a later study, this expected pattern was not replicated, possibly due to differences in encoding instructions (Paige et al. in Cortex 91:250-261, 2017). The present study sought to examine when cultural variation in memory-related decisions occur and the role of instructions. American and East Asian participants viewed images of objects while making a Purchase decision or an Approach decision and later completed a surprise recognition test. Results revealed Americans had higher hit rates for specific memory, regardless of instruction type, and a less stringent response criterion relative to East Asians. Additionally, a pattern emerged where the Approach decision enhanced hit rates for specific memory relative to the Purchase decision only when administered first; this pattern did not differ across cultures. Results suggest encoding instructions do not magnify cross-cultural differences in memory. Ultimately, cross-cultural differences in response bias, rather than memory sensitivity per se, may account for findings of cultural differences in memory specificity.