Towards adaptive technology in routine mental health care.

This paper summarizes the information technology-related research findings after 5 years with the INTROducing Mental health through Adaptive Technology project. The aim was to improve mental healthcare by introducing new technologies for adaptive interventions in mental healthcare through interdisciplinary research and development. We focus on the challenges related to internet-delivered psychological treatments, emphasising artificial intelligence, human-computer interaction, and software engineering. We present the main research findings, the developed artefacts, and lessons learned from the project before outlining directions for future research. The main findings from this project are encapsulated in a reference architecture that is used for establishing an infrastructure for adaptive internet-delivered psychological treatment systems in clinical contexts. The infrastructure is developed by introducing an interdisciplinary design and development process inspired by domain-driven design, user-centred design, and the person based approach for intervention design. The process aligns the software development with the intervention design and illustrates their mutual dependencies. Finally, we present software artefacts produced within the project and discuss how they are related to the proposed reference architecture. Our results indicate that the proposed development process, the reference architecture and the produced software can be practical means of designing adaptive mental health care treatments in correspondence with the patients' needs and preferences. In summary, we have created the initial version of an information technology infrastructure to support the development and deployment of Internet-delivered mental health interventions with inherent support for data sharing, data analysis, reusability of treatment content, and adaptation of intervention based on user needs and preferences.

Internet-Delivered Self-help for Adults With ADHD (MyADHD): Usability Study.

BACKGROUND: Although effective pharmacological treatment exists, many adults with attention-deficit/hyperactivity disorder (ADHD) prefer a nonpharmacological option for managing their symptoms. Internet-delivered self-help interventions have the potential to address this unmet supportive care need reported by adults with ADHD, at relatively low costs. However, if the intervention does not offer optimal functions, content, and layout, it could decrease adherence and engagement and potentially compromise the effectiveness of such interventions. Thus, there is a need for examining the usability and factors that enhance and impair the usability of internet-delivered self-help interventions. OBJECTIVE: This study evaluates the usability of an internet-delivered self-help intervention for adults with ADHD (MyADHD). The main goals were to (1) collect qualitative and quantitative data on usability and (2) identify usability problems. METHODS: Individual think-aloud interviews and staged usability testing (N=5) were conducted to evaluate the usability of the MyADHD intervention in terms of function, content, and design. MyADHD end users provided iterative feedback to maximize engagement and usability. They performed tasks involved in operating the intervention and provided "think-aloud" commentary and postsession usability ratings. The interviews were recorded, transcribed verbatim, and analyzed. RESULTS: Participants were satisfied with the overall usability of the program. The average perceived usability score out of 100 was 70 for the first round of testing and improved to 77.5 after applying modifications, with a mean score of 75.5 (SD 5.9) for all rounds of usability testing. The analysis of the interviews revealed 3 central themes: functionality, content, and layout. CONCLUSIONS: Optimizing the usability of internet-delivered self-guided interventions is a critical step in the design and development process. The usability testing in this study provided valuable information from users' perspectives on the content and platform of the intervention. Analysis revealed the need for intervention enhancement with regard to design, functionality, and content from the perspective of potential end users. Overall, participants saw value in the MyADHD intervention and were confident that they could use it for the self-management of symptoms and expressed the desire to use the entire intervention when it becomes available. Through this development process, we produced an intervention that is likely to be used successfully and is ready for deployment in a randomized controlled trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT04511169; https://clinicaltrials.gov/ct2/show/NCT04511169.

Predictors of Treatment Response to an Internet-Delivered Intervention Targeting Residual Cognitive Symptoms After Major Depressive Disorder.

Objective: Residual cognitive symptoms after depression are common and associated with reduced daily life functioning and an increased risk of depression relapse. There is a lack of knowledge on treatments targeting residual cognitive symptoms after major depressive disorder (MDD), including the factors associated with treatment response. The aim of the current study is to explore factors of treatment response to a guided internet-delivered intervention for former depressed adults experiencing residual cognitive symptoms. Method: Forty-three former depressed adults with residual cognitive symptoms were included. Linear mixed model analyses were used to investigate the impact of pre-treatment demographic-, illness, and symptom variables, and therapy process variables, such as credibility, expectancy, and user behavior, on reduction in residual cognitive symptoms from pre-treatment to 6-month follow-up. Results: Having had MDD for a year or less predicted more reductions in residual cognitive symptoms from pre- to 6-month follow-up. Higher levels of perceived treatment credibility and expectancy evaluated in the early course of treatment did also predict a positive treatment response. No demographic-, symptom-variables, previous number of episodes with MDD, and user behavior were associated with change in residual cognitive symptoms. Conclusion: This study suggests that individuals with shorter duration of previous depressions might have larger reductions in residual cognitive symptoms at 6-month follow-up compared to those with a longer duration of depression. Treatment credibility and expectancy also predicted treatment response and effort should also be made to ensure interventions credibility. Results should be interpreted with caution due to the study having a low sample size. Further investigation of predictors should be conducted in a full scale randomized controlled trial.

Developing an internet-delivered intervention targeting residual cognitive symptoms after major depressive disorder: a person-based approach.

BACKGROUND: Cognitive difficulties are rarely addressed after the treatment of major depressive disorder (MDD). New scalable treatments are needed. To ensure relevance and engagement of novel interventions, there is a need to understand the perspectives of the users. AIM: Explore former depressed adults needs and perspectives during the planning and development of a novel internet-delivered intervention targeting residual cognitive symptoms after MDD. METHOD: The planning phase included exploratory qualitative interviews with former depressed adults (n = 16). In the development phase, a prototype including psychoeducation, attention training and compensatory strategies was tested in think-aloud interviews with former depressed adults (n = 7) and psychologists (n = 4). Data were analysed thematically. RESULTS: Analysis of exploratory interviews identified four themes. Experiences of residual cognitive symptoms consisted of two sub-themes (Everyday life is more demanding; Concerns about cognitive difficulties). Coping with residual cognitive symptoms had two sub-themes (Compensatory strategies; Acceptance). Needs from an intervention consisted of two-subthemes (Need for information; Therapist support). Barriers for engagement consisted of three sub-themes (Being overwhelmed; Not being motivated; Frequent registration). Analysis of think-aloud interviews was organized into three themes: Positive perceptions of content; Concerns regarding content; Perceptions of Layout, Visuals and Navigation. CONCLUSION: The intervention may address concerns and consequences of cognitive difficulties by including psychoeducation, compensatory strategies and elements to increase acceptance and motivation, provided in manageable proportions.

Adaptive Elements in Internet-Delivered Psychological Treatment Systems: Systematic Review.

BACKGROUND: Internet-delivered psychological treatments (IDPTs) are built on evidence-based psychological treatment models, such as cognitive behavioral therapy, and are adjusted for internet use. The use of internet technologies has the potential to increase access to evidence-based mental health services for a larger proportion of the population with the use of fewer resources. However, despite extensive evidence that internet interventions can be effective in the treatment of mental health disorders, user adherence to such internet intervention is suboptimal. OBJECTIVE: This review aimed to (1) inspect and identify the adaptive elements of IDPT for mental health disorders, (2) examine how system adaptation influences the efficacy of IDPT on mental health treatments, (3) identify the information architecture, adaptive dimensions, and strategies for implementing these interventions for mental illness, and (4) use the findings to create a conceptual framework that provides better user adherence and adaptiveness in IDPT for mental health issues. METHODS: The review followed the guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The research databases Medline (PubMed), ACM Digital Library, PsycINFO, CINAHL, and Cochrane were searched for studies dating from January 2000 to January 2020. Based on predetermined selection criteria, data from eligible studies were analyzed. RESULTS: A total of 3341 studies were initially identified based on the inclusion criteria. Following a review of the title, abstract, and full text, 31 studies that fulfilled the inclusion criteria were selected, most of which described attempts to tailor interventions for mental health disorders. The most common adaptive elements were feedback messages to patients from therapists and intervention content. However, how these elements contribute to the efficacy of IDPT in mental health were not reported. The most common information architecture used by studies was tunnel-based, although a number of studies did not report the choice of information architecture used. Rule-based strategies were the most common adaptive strategies used by these studies. All of the studies were broadly grouped into two adaptive dimensions based on user preferences or using performance measures, such as psychometric tests. CONCLUSIONS: Several studies suggest that adaptive IDPT has the potential to enhance intervention outcomes and increase user adherence. There is a lack of studies reporting design elements, adaptive elements, and adaptive strategies in IDPT systems. Hence, focused research on adaptive IDPT systems and clinical trials to assess their effectiveness are needed.

Usability Evaluations of Mobile Mental Health Technologies: Systematic Review.

BACKGROUND: Many mobile health (mHealth) apps for mental health have been made available in recent years. Although there is reason to be optimistic about their effect on improving health and increasing access to care, there is a call for more knowledge concerning how mHealth apps are used in practice. OBJECTIVE: This study aimed to review the literature on how usability is being addressed and measured in mHealth interventions for mental health problems. METHODS: We conducted a systematic literature review through a search for peer-reviewed studies published between 2001 and 2018 in the following electronic databases: EMBASE, CINAHL, PsycINFO, PubMed, and Web of Science. Two reviewers independently assessed all abstracts against the inclusion and exclusion criteria, following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. RESULTS: A total of 299 studies were initially identified based on the inclusion keywords. Following a review of the title, abstract, and full text, 42 studies were found that fulfilled the criteria, most of which evaluated usability with patients (n=29) and health care providers (n=11) as opposed to healthy users (n=8) and were directed at a wide variety of mental health problems (n=24). Half of the studies set out to evaluate usability (n=21), and the remainder focused on feasibility (n=10) or acceptability (n=10). Regarding the maturity of the evaluated systems, most were either prototypes or previously tested versions of the technology, and the studies included few accounts of sketching and participatory design processes. The most common reason referred to for developing mobile mental health apps was the availability of mobile devices to users, their popularity, and how people in general became accustomed to using them for various purposes. CONCLUSIONS: This study provides a detailed account of how evidence of usability of mHealth apps is gathered in the form of usability evaluations from the perspective of computer science and human-computer interaction, including how users feature in the evaluation, how the study objectives and outcomes are stated, which research methods and techniques are used, and what the notion of mobility features is for mHealth apps. Most studies described their methods as trials, gathered data from a small sample size, and carried out a summative evaluation using a single questionnaire, which indicates that usability evaluation was not the main focus. As many studies described using an adapted version of a standard usability questionnaire, there may be a need for developing a standardized mHealth usability questionnaire.