Commentary: we don't know what we don't know: co-design and implementation science to advance digital psychological interventions.

Implementation of digital mental health interventions for children and adolescents: A systematic review

BackgroundDigital health interventions have the potential to improve the efficacy and accessibility of mental health services for people with severe mental health problems, but their integration into routine practice is a challenge. The real-world implementation of digital health interventions should be considered alongside digital intervention development. However, little is known about the quality of implementation research in this area, including the extent to which implementation science theories, models and frameworks are used. The aim of this review was to synthesise evidence regarding the application of theories, models and frameworks in research investigating the implementation of digital health interventions in services for people with severe mental health problems. Secondary aims were to consider the contexts within which studies had been undertaken and the degree of service user involvement in this research.MethodsA scoping review method was employed. Electronic databases were systematically searched for published papers in English and reference lists of included studies were hand searched. Included studies used an implementation science theory, model, or framework to understand, guide or evaluate the implementation of digital health interventions in services for people with severe mental health problems.ResultsTwelve eligible studies were identified. Studies were primarily undertaken in community mental health services with staff participants and there was variation in the types of digital interventions that were investigated. Eight different implementation science theories, models, and frameworks were used and were mainly employed to guide qualitative analysis. Most studies were undertaken in the early exploratory stages of implementation projects and there was little evidence regarding factors affecting the longer-term sustainment of digital health interventions in practice. Only one study reported the inclusion of service users in the design of the implementation study.ConclusionsThe use of implementation theories, models, and frameworks in efforts to implement digital health interventions in routine care for people with severe mental health problems is limited. Researchers should consider integrating such approaches throughout the research process and ensure service users are involved in this work. Further research regarding implementation processes, and the reach and sustainment of digital health interventions in routine practice, is required.

Background Depression is a common mood disorder, mainly manifested as persistent low mood, reduced interest, lack of energy and decreased cognitive function, etc. Traditional intervention methods include psychotherapy and drug therapy, but the therapeutic effects vary among individuals, and some patients may experience compliance issues or side effects of the drugs. In recent years, digital psychological intervention has gradually become an important approach for the auxiliary treatment of depression due to its characteristics of safety, repeatability and personalized customization. Animated films possess rich characteristics of color narrative and emotional expression. Through visual stimulation and story scenarios, they can potentially influence the emotions of the audience. However, its specific effect on regulating the emotions of patients with depression remains unclear. For this reason, this study explores the role of digital intervention in animated films in regulating the emotions of patients with depression, with the aim of providing theoretical basis and practical methods for non-pharmacological intervention of depression. Methods The research subjects were 120 inpatients with depression. All patients met the Diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The patients were randomly divided into the experimental group and the control group, with 60 cases in each group. Both groups of patients received conventional drug treatment. On this basis, the experimental group participated in an 8-week digital intervention of animated films, twice a week, for 30 minutes each time. The intervention content includes watching animated film clips and interactive emotional feedback sessions. Before and after the intervention The Hamilton Depression Rating Scale (HDRS) and the Emotion Regulation Questionnaire were adopted respectively. The ERQ and the Mini-Mental State Examination (MMSE) were used to assess the changes in patients' emotional symptoms and cognitive states. Statistical analysis was conducted using paired t-tests and inter-group comparisons. A p value <0.05 was considered statistically significant. Results After digital intervention, the negative emotions of the patients in the experimental group were effectively improved, and the HDRS score decreased from 22.8 ± 5.4 to 14.6 ± 4.2. The ERQ score rose from 3.2 ± 0.8 to 4.5 ± 0.7. The MMSE score increased from 25.1 ± 3.2 to 27.0 ± 2.6. The HDRS score of the patients in the control group only decreased from 23.1 ± 5.6 to 20.9 ± 5.1, and the changes in ERQ and MMSE scores were not significant (p>.05). The results show that digital intervention in animated films is significantly superior to conventional drug treatment in alleviating emotional symptoms and improving cognitive status in patients with depression. Discussion Digital intervention in animated films can effectively alleviate the negative emotions of patients with depression and enhance their emotional regulation ability and cognitive state. Through the combined effect of visual stimulation, color narrative and emotional storytelling, the research provides a safe, operable and repeatable non-pharmaceutical intervention approach for the adjuvant treatment of depression, making up for the limitations of traditional drug treatment in emotion regulation. In the future, personalized animation content and immersive digital intervention can be explored to enhance the emotional regulation effect and clinical application value of patients with depression.

Aim This meta-analysis aimed to compare the efficacy of in-person and digital mental health interventions in addressing Postpartum Depression. Methods Following PRISMA guidelines, the protocol for this meta-analysis was registered at the Open Science Framework (Retrieved from osf.io/wy3s4). This meta analysis included Randomized Controlled Trials (RCTs) conducted between 2013 and 2023. A comprehensive literature search identified 35 eligible RCTs from various electronic databases. Inclusion criteria focused on pregnant women over 18 years old, encompassing antenatal depression and up to two years postpartum. Diagnostic interviews or Edinburgh Postnatal Depression Scale (EPDS) were used to establish PPD. Digital interventions included telephonic, app-based, or internet-based approaches, while in-person interventions involved face-to-face sessions. Results The meta-analysis revealed a moderate overall effect size of −0.69, indicating that psychological interventions are effective for PPD. Digital interventions (g = −0.86) exhibited a higher mean effect size than in-person interventions (g = −0.55). Both types of interventions displayed substantial heterogeneity (digital: I2 = 99%, in-person: I2 = 92%), suggesting variability in intervention content, delivery methods, and participant characteristics. Conclusion Digital mental health interventions show promise in addressing PPD symptoms, with a potentially greater effect size compared to in-person interventions. However, the high heterogeneity observed in both modalities underscores the need for further research to identify key drivers of success and tailor interventions to diverse populations. Additionally, the choice between digital and in-person interventions should consider individual needs and preferences. Ongoing research should further investigate and optimise intervention modalities to better serve pregnant women at risk of PPD.

Scientific literature from the last two decades indicates that, when it comes to mental health, technology is presented either as panacea or anathema. This is partly because researchers, too frequently, have planted themselves either in the field of digital mental health interventions (variably called “telepsychiatry”, “digital therapeutics”, “computerized therapy”, etc.), or in that of the problems arising from technology, with little cross-fertilization between the two. Yet, a closer look at the two fields reveals unifying themes that underpin both the advantages and dangers of technology in mental health. This article discusses five such themes. First, the breakneck pace of technology evolution keeps digital mental health interventions updated and creates more potentially problematic activities, leaving researchers perennially behind, so new technologies become outdated by the time they are studied. Second, the freedom of creating and using technologies in a regulatory vacuum has led to proliferation and choice, but also to a Wild-West online environment. Third, technology is an open window to access information, but also to compromise privacy, with serious implications for online psychology and digital mental health interventions. Fourth, weak bonds characterize online interactions, including those between therapists and patients, contributing to high attrition from digital interventions. Finally, economic analyses of technology-enabled care may show good value for money, but often fail to capture the true costs of technology, a fact that is mirrored in other online activities. The article ends with a call for collaborations between two interrelated fields that have been—till now—mutually insular.

This study aims to determine the efficacy of digital psychological interventions for specific psychological outcomes, including depression, anxiety, stress, insomnia, fatigue, and quality of life in patients with cardiovascular disease. Randomized controlled trials evaluating digital psychological interventions for adult cardiovascular diseases patients were systematically searched in PubMed, Embase, CINAHL, Cochrane Library, Web of Science, CNKI, Wan Fang, and VIP up to July 2025. Primary outcomes were depression and anxiety, while secondary outcomes included stress, insomnia, fatigue, and quality of life. The consistency model was used to conduct a network meta-analysis. Thirty-six RCTs involving 5,486 participants were included. Digital psychological interventions significantly improved psychological outcomes compared with controls. Telemedical interventional monitoring was most effective for reducing depression (SUCRA=84.1%), while cognitive behavioural therapy ranked highest for anxiety (SUCRA=84.7%) and stress (SUCRA=98.7%). Health education showed the greatest benefit for quality of life (SUCRA=99.6%). Evidence for insomnia and fatigue was limited but suggested potential benefits of digital interventions. Based on the analysis in this study, telemedicine intervention monitoring shows the most promise to alleviate depressive symptoms, cognitive behavioral therapy shows potential in reducing anxiety and stress, and health education was associated with the most significant improvements in quality of life. Our findings suggest that integrating personalized digital interventions into cardiac rehabilitation programs may be promising, while also highlighting the need for further research into long-term efficacy and multimodal intervention approaches. PROSPERO: CRD420251110636.

BackgroundWith the increasing adoption of high-speed internet and mobile technologies by older adults, digital health is a promising modality to enhance clinical care for people with knee osteoarthritis (KOA), including those with knee replacement (KR).ObjectiveThis study aimed to summarize the current use, cost-effectiveness, and patient and clinician perspectives of digital health for intervention delivery in KOA and KR.MethodsIn this narrative review, search terms such as mobile health, smartphone, mobile application, mobile technology, ehealth, text message, internet, knee osteoarthritis, total knee arthroplasty, and knee replacement were used in the PubMed and Embase databases between October 2018 and February 2021. The search was limited to original articles published in the English language within the past 10 years. In total, 91 studies were included.ResultsDigital health technologies such as websites, mobile apps, telephone calls, SMS text messaging, social media, videoconferencing, and custom multi-technology systems have been used to deliver interventions in KOA and KR populations. Overall, there was significant heterogeneity in the types and applications of digital health used in these populations. Digital patient education improved disease-related knowledge, especially when used as an adjunct to traditional methods of patient education for both KOA and KR. Digital health that incorporated person-specific motivational messages, biofeedback, or patient monitoring was more successful at improving physical activity than self-directed digital interventions for both KOA and KR. Many digital exercise interventions were found to be as effective as in-person physical therapy for people with KOA. Many digital exercise interventions for KR incorporated both in-person and web-based treatments (blended format), communication with clinicians, and multi-technology systems and were successful in improving knee range of motion and self-reported symptoms and reducing the length of hospital stays. All digital interventions that incorporated cognitive behavioral therapy or similar psychological interventions showed significant improvements in knee pain, function, and psychological health when compared with no treatment or traditional treatments for both KOA and KR. Although limited in number, studies have indicated that digital health may be cost-effective for these populations, especially when travel costs are considered. Finally, although patients with KOA and KR and clinicians had positive views on digital health, concerns related to privacy and security and concerns related to logistics and training were raised by patients and clinicians, respectively.ConclusionsFor people with KOA and KR, many studies found digital health to be as effective as traditional treatments for patient education, physical activity, and exercise interventions. All digital interventions that incorporated cognitive behavioral therapy or similar psychological treatments were reported to result in significant improvements in patients with KOA and KR when compared with no treatment or traditional treatments. Overall, technologies that were blended and incorporated communication with clinicians, as well as biofeedback or patient monitoring, showed favorable outcomes.

Digital health interventions have potential to enhance rehabilitation services by increasing accessibility, affordability and scalability. However, implementation of digital interventions in rehabilitation is poorly understood. This scoping review aims to map current strategies, research designs, frameworks, outcomes and determinants used to support and evaluate the implementation of digital interventions in rehabilitation. Comprehensive searches from inception until October 2022 of MEDLINE, CINAHL, PsycINFO, PEDro, SpeechBITE, NeuroBITE, REHABDATA, WHO International Clinical Trial Registry and the Cochrane Library. Two reviewers screened studies against the eligibility criteria. Implementation science taxonomies and methods, including Powell et al.'s compilation of implementation strategies, were used to guide analysis and synthesis of findings. The search retrieved 13,833 papers and 23 studies were included. Only 4 studies were randomised controlled trials and 9 studies (39%) were feasibility studies. Thirty-seven discrete implementation strategies were reported across studies. Strategies related to training and educating clinicians (91%), providing interactive assistance (61%), and developing stakeholder interrelationships (43%) were most frequently reported. Few studies adequately described implementation strategies and methods for selecting strategies. Almost all studies measured implementation outcomes and determinants; most commonly, acceptability, compatibility and dose delivered of digital interventions. The rigour of implementation methods in the field is currently poor. Digital interventions require carefully planned and tailored implementation to facilitate successful adoption into rehabilitation practice. To keep pace with rapidly advancing technology, future rehabilitation research should prioritise using implementation science methods to explore and evaluate implementation while testing effectiveness of digital interventions.

Background and Aim Population ageing coupled with a rise in chronic illness is placing a greater demand on our healthcare system. This demand on healthcare has led to a greater need for older adults with chronic health conditions to actively engage in personal behaviour change to manage their conditions and improve their quality of life. The Human Computer Interaction (HCI) Community has a growing body of research pertaining to the ways that Behavioural Change Techniques (BCTs) have been integrated into digital applications and intervention systems.1 However, the limitations as to how these interventions have been evaluated has led to the existing research having little impact.2 3 This study will explore the design strategies and theories that currently exist about implementing digital BCTs. Methods The population of interest in this research is older adults with congestive heart failure (CHF). Four studies will be conducted to address the research objectives. Each study will provide specific requirements data, including qualitative, quantitative and digital health data which will inform the functionality and interactivity of the overall digital intervention which will be evaluated in a longitudinal crossover trial. This will enable a comprehensive mapping between existing theory and the practical implementation of any application. Conclusion It is hoped that with close attention to health professionals’, carers’ and older adults’ feedback, the behavioural traits that need to be changed can be identified. By assessing the user’s preferences to interfaces, it should be possible to map features of the application to a behavioural response. This will be a step towards understanding ‘why’ specific design techniques work regarding digital interventions. References P. Klasnja, S. Consolvo, and W. Pratt. How to evaluate technologies for health behaviour change in HCI research. In Proceedings of the 2011 annual conference on Human factors in computing systems - CHI 11, page 3063, New York, New York, USA,2011. ACM Press. ISBN 9781450302289. P. Klasnja, E. B. Hekler, E. V. Korinek, J. Harlow, and S. R. Mishra. Toward Usable Evidence. In Proceedings of the 2017 CHI Conference on Human Factors in Computing Systems - CHI 17, pages 30713082, New York, New York, USA, 2017. ACM Press. ISBN9781450346559. S. Michie, M. M. van Stralen, and R. West. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6(1):42, dec 2011. ISSN 1748-5908. This Project is supported by the European Union’s INTERREG VA program, managed by the Special EU Programs Body(SEUPB).

The promotion of well-being and mental health through the web-based psychological interventions have been investigated in several studies. Recent researches evidenced the efficacy of web-based and app interventions for psychological issues; that appeared more relevant in observational studies comparing treatment-no treatment effects. The evidence based approach for those interventions need to be better investigated for verifying the efficacy of web-based approach. Objective of the present study was to draw the research scenario for digital psychological interventions by evidence-based approach, focusing on efficacy assessment on interventions protocols and typology of interventions. A bibliographic search was conducted on MEDLINE by PubMed and Web of Science database (march 2021), applying the keywords: "mental health"; "internet"; "treatment"; "mental disorder"; "web-based treatment"; "psychotherapy". The bibliographic search gets n.70 scientific papers through scientific register (PubMed, Web of Science). After removed duplicates, n.62 articles was included in the present study. 11 studies were excluded by unsatisfied inclusion criteria. Results showed the psychological web-based interventions are useful for psychological well-being and for mental health prevention; more, they consent the identification of psychological distress and subclinical disorders: the digital interventions can make better the psychotherapeutical path and quality of life, improving the adherence and addressing new perspective. Overall, the psychological web-based interventions could be represent an impo rtant sign for equality in mental health reducing the obstacles (as well geographical, social, economic features) for psychotherapy.

The high incidence of new cases of anxiety disorders highlights the need for scalable preventive interventions, which can be achieved through information and communication technologies. To our knowledge, no meta-analysis has been conducted to evaluate purely digital preventive interventions for anxiety in all types of populations. The aim of this study was to assess the effectiveness of digital interventions for the prevention of anxiety disorders. Systematic searches were conducted in six electronic databases (PubMed, PsycINFO, EMBASE, Web of Science, OpenGrey, and CENTRAL) from inception to December 12, 2024. Inclusion criteria for the studies were as follows: (1) randomized controlled trials (RCTs), (2) psychological or psychoeducational digital interventions to prevent anxiety, and (3) all types of populations without anxiety at baseline of the study. A total of 15 studies (19 comparisons; 6093 participants) were included in the systematic review. One study was identified as an outlier and was therefore excluded from the meta-analysis. The pooled analysis showed a small effect in favor of preventive interventions among non-anxious and varied populations (standardized mean difference = −0.32, 95% confidence interval: −0.44 to −0.20; p < 0.001). Sensitivity analyses supported the robustness of this finding. We found no evidence of publication bias. Heterogeneity was high, however, a meta-regression that included one variable (country, the Netherlands) explained 100% of the variance. All RCTs, except two, had a high risk of bias, and the quality of the evidence, according to Grading of Recommendations Assessment, Development, and Evaluation, was very low. There is a need to develop and evaluate new digital preventive interventions with a rigorous methodology.

BackgroundHealth and social care staff are at high risk of experiencing adverse mental health (MH) outcomes during the COVID-19 pandemic. Hence, there is a need to prioritize and identify ways to effectively support their psychological well-being (PWB). Compared to traditional psychological interventions, digital psychological interventions are cost-effective treatment options that allow for large-scale dissemination and transcend social distancing, overcome rurality, and minimize clinician time.ObjectiveThis study reports MH outcomes of a Consolidated Standards of Reporting Trials (CONSORT)-compliant parallel-arm pilot randomized controlled trial (RCT) examining the potential usefulness of an existing and a novel digital psychological intervention aimed at supporting psychological health among National Health Service (NHS) staff working through the COVID-19 pandemic.MethodsNHS Highland (NHSH) frontline staff volunteers (N=169) were randomly assigned to the newly developed NHSH Staff Wellbeing Project (NHSWBP), an established digital intervention (My Possible Self [MPS]), or a waitlist (WL) group for 4 weeks. Attempts were made to blind participants to which digital intervention they were allocated. The interventions were fully automated, without any human input or guidance. We measured 5 self-reported psychological outcomes over 3 time points: before (baseline), in the middle of (after 2 weeks), and after treatment (4 weeks). The primary outcomes were anxiety (7-item General Anxiety Disorder), depression (Patient Health Questionnaire), and mental well-being (Warwick-Edinburgh Mental Well-being Scale). The secondary outcomes included mental toughness (Mental Toughness Index) and gratitude (Gratitude Questionnaire-6).ResultsRetention rates mid- and postintervention were 77% (n=130) and 63.3% (n=107), respectively. Postintervention, small differences were noted between the WL and the 2 treatment groups on anxiety (vs MPS: Cohen d=0.07, 95% CI –0.20 to 0.33; vs NHSWBP: Cohen d=0.06, 95% CI –0.19 to 0.31), depression (vs MPS: Cohen d=0.37, 95% CI 0.07-0.66; vs NHSWBP: Cohen d=0.18, 95% CI –0.11 to 0.46), and mental well-being (vs MPS: Cohen d=–0.04, 95% CI –0.62 to –0.08; vs NHSWBP: Cohen d=–0.15, 95% CI –0.41 to 0.10). A similar pattern of between-group differences was found for the secondary outcomes. The NHSWBP group generally had larger within-group effects than the other groups and displayed a greater rate of change compared to the other groups on all outcomes, except for gratitude, where the rate of change was greatest for the MPS group.ConclusionsOur analyses provided encouraging results for the use of brief digital psychological interventions in improving PWB among health and social care workers. Future multisite RCTs, with power to reliably detect differences, are needed to determine the efficacy of contextualized interventions relative to existing digital treatments.Trial RegistrationISRCTN Registry (ISRCTN) ISRCTN18107122; https://www.isrctn.com/ISRCTN18107122

Overcoming challenges in adherence and engagement digital interventions: The development of the ALGEApp for chronic pain management

Patients with inflammatory rheumatic diseases (IRDs) frequently experience psychological distress; however, access to psychological support remains limited. To investigate the effectiveness of a digital psychological intervention for individuals with IRDs. Participants aged 18 years or older were recruited across Germany between February 22 and June 4, 2024, if they had been diagnosed with rheumatoid arthritis, psoriatic arthritis, or systemic lupus erythematosus and reported psychological distress and reduced quality of life. Participants were randomized to either a self-guided digital psychological intervention or a treatment-as-usual control condition. The primary outcomes were change in psychological distress (German version of the Hospital Anxiety and Depression Scale) and quality of life (Assessment of Quality of Life-8 Dimensions) from baseline to 3 months. Secondary outcomes included changes in self-efficacy, health literacy, perceived stress, functional impairment, depression, and anxiety. A total of 102 participants (mean [SD] age, 47.2 [12.9] years; 92 [90.2%] female) were randomized to an intervention group (n = 52) or a control group (n = 50). The intervention group showed a significantly greater reduction in psychological distress at the 3-month follow-up (least-squares mean [SE] difference, -3.60 [1.07]; 95% CI, -5.73 to -1.47; P < .001; Cohen d = -0.71) and a greater improvement of quality of life (least-squares mean [SE] difference, 0.04 [0.02]; 95% CI, 0.00-0.09; P = .047; Cohen d = 0.49). A significantly greater number of participants in the intervention group experienced a clinically meaningful improvement in psychological distress (29 [59.2%] vs 17 [34.0%]; P = .02) and quality of life (27 [55.1%] vs 16 [32.0%]; P = .03) compared with the control group. Secondary outcomes measures showed a similar pattern of improvement, except for functional impairment. No adverse events related to the intervention were reported. This pilot randomized clinical trial supports the effectiveness and safety of a digital psychological intervention in individuals with IRDs. These findings suggest that such digital interventions could be a valuable, scalable approach to addressing mental health needs in rheumatology. German Clinical Trials Register (DRKS) identifier: DRKS00032862.

BackgroundEngagement predicts benefits from self-managed treatments. However, engagement is an important concern in digital interventions, with over 50% of patients being nonadherent to interventions in chronic conditions such as chronic pain. Little is known about the individual characteristics that contribute to engagement with a digital self-management treatment.ObjectiveThis study tested the mediating role of treatment perceptions (difficulty and helpfulness) in the association between individual baseline characteristics (treatment expectancies and readiness to change) and treatment engagement (online and offline) with a digital psychological intervention for adolescents with chronic pain.MethodsA secondary data analysis of a single-arm trial of Web-based Management of Adolescent Pain, a self-guided internet intervention developed for the management of chronic pain in adolescents, was conducted. Survey data were collected at baseline (T1), midtreatment (ie, 4 weeks after the treatment started; T2), and post treatment (T3). Online engagement was assessed using back-end information on the number of days adolescents accessed the treatment website, while the offline engagement was assessed with the reported frequency of use of skills (ie, pain management strategies) learned at the end of the treatment. Four parallel multiple mediator linear regression models, using ordinary least square regression incorporating the variables were tested.ResultsIn total, 85 adolescents with chronic pain (12-17 years old, 77% female) participated. Several mediation models were significant in predicting online engagement. A significant indirect effect was found for the path expectancies–helpfulness–online engagement (effect 0.125; SE 0.098; 95% CI 0.013-0.389) and for the path precontemplation–helpfulness–online engagement (effect −1.027; SE 0.650; 95% CI −2.518 to −0.054). Fourteen percent of the variance of online engagement was explained by the model including expectancies as a predictor (F3=3.521; P<.05), whereas 15% was explained by the model where readiness to change was the predictor (F3=3.934; P<.05). Offline engagement was partially explained in the model including readiness to change as the predictor but with marginal significance (F3=2.719; R2=0.111; P=.05).ConclusionsTreatment perception, specifically, perceived helpfulness, was a mediator of the pathway between both treatment expectancies and readiness to change and online engagement with a digital psychological intervention for chronic pain. Assessing these variables at baseline and midtreatment may help to determine the risk of nonadherence. Further work is needed to confirm these mediation pathways in larger samples.Trial RegistrationClinicalTrials.gov NCT04043962; https://clinicaltrials.gov/ct2/show/NCT04043962