Testing the Feasibility, Acceptability, and Potential Efficacy of an Innovative Digital Mental Health Care Delivery Model Designed to Increase Access to Care: Open Trial of the Digital Clinic.

The need for a new generation of digital mental health tools to support more accessible, effective and equitable care.

There has been a surge in mental health concerns during the COVID-19 pandemic, which has prompted the increased use of digital platforms. However, there is little known about the mental health needs and behaviors of the global population during the pandemic. This study aims to fill this knowledge gap through the analysis of real-world data collected from users of a digital mental health app (Wysa) regarding their engagement patterns and behaviors, as shown by their usage of the service. This study aims to (1) examine the relationship between mental health distress, digital health uptake, and COVID-19 case numbers; (2) evaluate engagement patterns with the app during the study period; and (3) examine the efficacy of the app in improving mental health outcomes for its users during the pandemic. This study used a retrospective observational design. During the COVID-19 pandemic, the app's installations and emotional utterances were measured from March 2020 to October 2021 for the United Kingdom, the United States of America, and India and were mapped against COVID-19 case numbers and their peaks. The engagement of the users from this period (N=4541) with the Wysa app was compared to that of equivalent samples of users from a pre-COVID-19 period (1000 iterations). The efficacy was assessed for users who completed pre-post assessments for symptoms of depression (n=2061) and anxiety (n=1995) on the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) test measures, respectively. Our findings demonstrate a significant positive correlation between the increase in the number of installs of the Wysa mental health app and the peaks of COVID-19 case numbers in the United Kingdom (P=.02) and India (P<.001). Findings indicate that users (N=4541) during the COVID period had a significantly higher engagement than the samples from the pre-COVID period, with a medium to large effect size for 80% of these 1000 iterative samples, as observed on the Mann-Whitney test. The PHQ-9 and GAD-7 pre-post assessments indicated statistically significant improvement with a medium effect size (PHQ-9: P=.57; GAD-7: P=.56). This study demonstrates that emotional distress increased substantially during the pandemic, prompting the increased uptake of an artificial intelligence-led mental health app (Wysa), and also offers evidence that the Wysa app could support its users and its usage could result in a significant reduction in symptoms of anxiety and depression. This study also highlights the importance of contextualizing interventions and suggests that digital health interventions can provide large populations with scalable and evidence-based support for mental health care.

Sexual minority youth, particularly sexual minority youth of color, report elevated mental health challenges and persistent barriers to care. The COVID-19 pandemic exacerbated these disparities and catalyzed a shift toward digital health and digital mental health services. This rapid transition has made it challenging to understand digital exclusion and the digital divide. This cross-sectional study identified the prevalence of digital health and digital mental health service use among US adolescents during the COVID-19 pandemic and examined heterogeneity by sexual orientation, race and ethnicity, and their intersection. Nationally representative data were obtained from the 2021 Adolescent Behaviors and Experiences Survey (N=7705). Weighted distributions of digital health and digital mental health use were calculated, and modified Poisson regression models estimated adjusted prevalence ratios (aPRs) by sexual orientation, race and ethnicity, and their intersection. Across the sample, digital health and digital mental health use were 25.8% and 8.5%, respectively. (All percentages reported are weighted estimates.) Digital mental health use was 5.6% among heterosexual participants and 18.1% among all sexual minority youth. In adjusted models, sexual minority subgroups had higher prevalence of digital mental health use than heterosexual peers (lesbian, gay, and bisexual [LGB]: aPR 2.60; sexually diverse: aPR 2.41; all P≤.05). This pattern held among White, Black or African American, and multiracial LGB participants. Digital mental health use was 10.2% among White participants and ranged from 4.8% to 15% among racially or ethnically minoritized participants. Black or African American, Hispanic or Latino, and Asian or Pacific Islander participants had lower prevalence of digital mental health use than White peers overall (Black or African American: aPR 0.70; Hispanic or Latino: aPR 0.55; Asian or Pacific Islander: aPR 0.48; all P≤.05) and among sexual minority youth (Black or African American: aPR 0.60; Hispanic or Latino: aPR 0.35; Asian or Pacific Islander: aPR 0.23; all P≤.05). Racial and ethnic disparities in digital mental health use were pronounced among LGB (Hispanic or Latino: aPR 0.52; P≤.05) and sexually diverse participants (Black or African American: aPR 0.36; Hispanic or Latino: aPR 0.17; Asian or Pacific Islander: aPR 0.10; all P≤.05), but not heterosexual participants. Digital health use did not differ by sexual orientation. However, Black or African American and Hispanic or Latino participants had lower prevalence of digital health use than White peers (28.8%) overall (Black or African American: aPR 0.76; Hispanic or Latino: aPR 0.78; all P≤.05) and among heterosexual (Black or African American: aPR 0.73; Hispanic or Latino: aPR 0.80; all P≤.05) and sexual minority youth participants (Hispanic or Latino: aPR 0.75). Digital platforms offer promise for expanding access to mental health care among sexual minority youth, but persistent inequities must be addressed. Cocreation with lived-experience experts may be critical to ensure digital services are trusted, inclusive, and accessible for all youth.

IntroductionDespite promising outcomes, lack of engagement and poor adherence are barriers to treating mental health using digital CBT, particularly in minority groups. After conducting guided focus groups, a current mental health app was adapted to be more inclusive for minorities living with SCD.MethodsPatients between the ages of 16–35 with SCD who reported experiencing anxiety or depression symptoms were eligible for this study. Once enrolled, participants were randomly assigned to receive one of two versions of a mental health app: 1) the current version designed for the general population or 2) the adapted version. Baseline measures for depression, anxiety, pain, and self-efficacy were completed at the start of the study and again at post-intervention (minimum 4 weeks).ResultsCompared to baseline, mean scores for pain decreased an average of 3.29 (p = 0.03) on a 10-point scale, self-efficacy improved 3.86 points (p = 0.007) and depression symptoms decreased 5.75 points (p = 0.016) for the group that received the adapted app. On average, control participants engaged with the app 5.64 times while the participants in the experimental group engaged 8.50 times (p = 0.40). Regardless of group assignment, a positive relationship (r = 0.47) was shown between app engagement and a change in depression symptoms (p = 0.042).DiscussionTarget enrollment for this study sought to enroll 40 participants. However, after difficulties locating qualified participants, enrollment criteria were adjusted to expand the population pool. Regardless of these efforts, the sample size for this study was still smaller than anticipated (n = 21). Additionally, irrespective of group approximately 40% of participants did not engage with the app. However, despite a small sample size and poor engagement, this study 1) demonstrated the feasibility of implementing socially relevant changes into a mental health app and 2) indicated that participants in the intervention group displayed better outcomes and showed trends for greater app interaction.ConclusionThese promising results should encourage future researchers to continue exploring ideal adaptations for implementing digital CBT in minority populations. Future studies should also consider implementing post-intervention surveys to help identify common factors relating to a lack of engagement.Trial registrationThis trial (NCT04587661) was registered on August 12th, 2020.

Research shows that a large proportion of the world’s population has experience with mental health difficulties, and reliable as well as scalable care is urgently needed. Digital mental health seems to be an obvious solution to provide the better delivery of care but also the delivery of better care. With an imagined future of real-time information sharing, improved diagnosis and monitoring of mental health conditions, and remote care, supported by advances in artificial intelligence, many tech companies have emerged over the last three decades to plug the treatment gap and provide services. The evidence base seems compelling: some online treatments have the capability to treat individuals quite successfully. However, the introduction, utilisation, and expansion of digital mental health technologies have not always focused on public health only. Using a surveillance capitalism perspective, this paper approaches the democratisation–privatisation dichotomy in digital mental health with a critical lens. In particular, the paper details how (commercially valuable) mental health data are extracted, “shared”, and claimed as an asset by big tech companies. Reviewing the terms, conditions, and practices of ten popular mental health apps, the paper polemically argues that mental digital health cannot unlock real value for society—better treatment, good quality care, and efficient delivery—if power, politics, and profits remain in the hands of big tech companies. To conclude, the paper draws attention to contemporary discourses that seek to promote democracy and public value for digital mental health apps, technologies, and solutions.

BackgroundDigital mental health apps are rapidly becoming a common source of accessible support across the world, but their effectiveness is often influenced by limited helpfulness and engagement.ObjectiveThis study’s primary objective was to analyze feedback content to understand users’ experiences with engaging with a digital mental health app. As a secondary objective, an exploratory analysis captured the types of mental health app users.MethodsThis study utilized a user-led approach to understanding factors for engagement and helpfulness in digital mental health by analyzing feedback (n=7929) reported on Google Play Store about Wysa, a mental health app (1-year period). The analysis of keywords in the user feedback categorized and evaluated the reported user experience into the core domains of acceptability, usability, usefulness, and integration. The study also captured key deficits and strengths of the app and explored salient characteristics of the types of users who benefit from accessible digital mental health support.ResultsThe analysis of user feedback found the app to be overwhelmingly positively reviewed (6700/7929, 84.50% 5-star rating). The themes of engaging exercises, interactive interface, and artificial intelligence (AI) conversational ability indicated the acceptability of the app, while the nonjudgmentality and ease of conversation highlighted its usability. The app’s usefulness was portrayed by themes such as improvement in mental health, convenient access, and cognitive restructuring exercises. Themes of privacy and confidentiality underscored users’ preference for the integrated aspects of the app. Further analysis revealed 4 predominant types of individuals who shared app feedback on the store.ConclusionsUsers reported therapeutic elements of a comfortable, safe, and supportive environment through using the digital mental health app. Digital mental health apps may expand mental health access to those unable to access traditional forms of mental health support and treatments.

The intersection of mental health and digital technology has become a critical focus in the realm of public health. This paper provides a concise overview of the current trends and responses within this evolving landscape. The widespread integration of digital technology into daily life has both positive and negative implications for mental health. On one hand, digital platforms offer innovative tools for mental health support, including virtual therapy, mental health apps, and online communities. These resources enhance accessibility and reduce barriers to seeking help. Conversely, concerns have arisen regarding the adverse impact of excessive digital screen time, social media use, and cyberbullying on mental well-being. The paper explores the prevalence of digital mental health interventions, emphasizing the need for evidence-based practices and regulatory frameworks to ensure their efficacy and user safety. Additionally, it addresses the growing recognition of the digital divide and disparities in access to mental health resources, emphasizing the importance of inclusivity in digital mental health initiatives. Responses to these challenges involve collaborative efforts among mental health professionals, technology developers, policymakers, and public health practitioners. The paper highlights the importance of research in understanding the nuanced relationship between digital technology and mental health, informing the development of targeted interventions. Furthermore, it emphasizes the need for comprehensive public health strategies that prioritize digital literacy, mental health education, and the promotion of positive online behaviors. The paper underscores the multifaceted nature of the relationship between mental health and digital technology, calling for a holistic and collaborative approach to address the evolving challenges and opportunities in this dynamic landscape.&#x0D; Keywords: Mental health, Digital technologies, Public health, Trends, Review.

BackgroundConsumer-facing digital health interventions provide a promising avenue to bridge gaps in mental health care delivery. To evaluate these interventions, understanding how the target population uses a solution is critical to the overall validity and reliability of the evaluation. As a result, usage data (analytics) can provide a proxy for evaluating the engagement of a solution. However, there is paucity of guidance on how usage data or analytics should be used to assess and evaluate digital mental health interventions.ObjectiveThis review aimed to examine how usage data are collected and analyzed in evaluations of mental health mobile apps for transition-aged youth (15-29 years).MethodsA scoping review was conducted using the Arksey and O’Malley framework. A systematic search was conducted on 5 journal databases using keywords related to usage and engagement, mental health apps, and evaluation. A total of 1784 papers from 2008 to 2019 were identified and screened to ensure that they included analytics and evaluated a mental health app for transition-aged youth. After full-text screening, 49 papers were included in the analysis.ResultsOf the 49 papers included in the analysis, 40 unique digital mental health innovations were evaluated, and about 80% (39/49) of the papers were published over the past 6 years. About 80% involved a randomized controlled trial and evaluated apps with information delivery features. There were heterogeneous findings in the concept that analytics was ascribed to, with the top 3 being engagement, adherence, and acceptability. There was also a significant spread in the number of metrics collected by each study, with 35% (17/49) of the papers collecting only 1 metric and 29% (14/49) collecting 4 or more analytic metrics. The number of modules completed, the session duration, and the number of log ins were the most common usage metrics collected.ConclusionsThis review of current literature identified significant variability and heterogeneity in using analytics to evaluate digital mental health interventions for transition-aged youth. The large proportion of publications from the last 6 years suggests that user analytics is increasingly being integrated into the evaluation of these apps. Numerous gaps related to selecting appropriate and relevant metrics and defining successful or high levels of engagement have been identified for future exploration. Although long-term use or adoption is an important precursor to realizing the expected benefits of an app, few studies have examined this issue. Researchers would benefit from clarification and guidance on how to measure and analyze app usage in terms of evaluating digital mental health interventions for transition-aged youth. Given the established role of adoption in the success of health information technologies, understanding how to abstract and analyze user adoption for consumer digital mental health apps is also an emerging priority.

ObjectivesThe impact of the COVID-19 pandemic on population mental health has highlighted the potential for digital mental health to support the needs of those requiring care. This study sought to understand the digital mental health experiences and priorities of Canadians affected by mental health conditions (i.e. seekers, patients, and care partners).MethodsA national cross-sectional electronic survey of Canadians was administered through a market research firm's survey panel. Seekers, patients, and care partners were asked about their digital mental health experiences (e.g. uptake, barriers to access) and priorities. Survey responses were summarized using descriptive statistics.ResultsOverall, 1003 participants completed the survey. 70.2% of participants routinely use digital mental health supports to support themselves or those they care for; however, only 28.6% of participants are satisfied with the available digital mental health supports. Most participants (73.3%) have encountered some barriers when accessing digital mental health supports. Awareness of digital mental health supports was a top barrier identified by participants. The top digital mental health priorities consisted of digital mental health curation, navigation, and a digital mental health passport.ConclusionsMost participants use digital mental health supports for themselves or others, however, many are unaware of digital mental health supports available. Efforts to improve navigating access to digital and in-person mental health services are seen as a top priority, highlighting the need to enable seekers, patients, and care partners to find the appropriate support and make decisions on how to best improve their mental health.

Digital mental health is often touted as a solution to issues of access to mental health care. However, there has been little research done to understand the accessibility of digital mental health, especially for those with disabilities. In this piece, we define accessibility as it relates to mental health apps, describe the current state of accessibility in the digital world broadly and in mental health apps more specifically, outline why accessibility matters in mental health apps, and identify future steps to better incorporate accessibility into research and development of mental health apps.

BackgroundIncreasing rates of mental health diagnoses in college students signal the need for new opportunities to support the mental health of this population. With many mental health apps being efficacious, they may be a promising resource for college campuses to provide support to their students. However, it is important to understand why (or why not) students might want to use apps and their desired features.ObjectiveInformation on students’ interest in mental health apps may inform which apps are to be provided and how campuses can support their use. This study aimed to understand the interest and hesitation in app use and the relationship between mental health needs, as defined by depression, anxiety, and positive mental health, and app use.MethodsThe web-based Healthy Minds Study collected information on mental health needs, perceptions, and service use across colleges and universities. We used a sample of 989 participants who completed the survey between 2018 and 2020 and an elective module on digital mental health. We analyzed the elective module responses using a mixed methods approach, including both descriptive and inferential statistics, along with thematic coding for open text responses.ResultsThe Results from this study revealed that anxiety (b=−0.07; P<.001), but not depression (b=0.03; P=.12) and positive mental health (b=−0.02; P=.17), was a significant predictor of app adoption. Prominent qualitative findings indicated that the most desired app features included tips and advice, access to resources and information, and on-demand support that involves interaction throughout the day. The participants also suggested an overall desire for human interaction to be integrated into an app. As predicted, hesitancy was encountered, and the qualitative results suggested that there was a lack of interest in the adoption of mental health app and preference.ConclusionsThe findings from this study underscore that simply providing digital mental health apps as tools may be insufficient to support their use in college campuses. Although many students were open to using a mental health app, hesitation and uncertainty were common in the participant responses. Working with colleges and universities to increase digital literacy and provide resources that allow students to gauge when app use is appropriate may be helpful when implementing mental health apps as resources in college campuses.

INTRODUCTION:Despite promising outcomes, lack of engagement and poor adherence are barriers to treating mental health using digital CBT, particularly in minority groups. After conducting guided focus groups, a current mental health app was adapted to be more inclusive for minorities living with SCD.METHODS:Patients between the ages of 16–35 with SCD who reported experiencing anxiety or depression symptoms were eligible for this study. Once enrolled, participants were randomly assigned to receive one of two versions of a mental health app 1) the current version designed for the general population and 2) the adapted version. Baseline measures for depression, anxiety, pain and self-efficacy were completed at the start of the study and again at postintervention (minimum 4 weeks).RESULTS:Compared to baseline, pain (p = 0.03), self-efficacy (p = 0.007) and depression symptoms (p = 0.016) improved for the group that received the adapted app. Regardless of group assignment, a positive relationship (r = 0.47) was shown between app engagement and a change in depression symptoms (p = 0.042).DISCUSSION:Target enrollment for this study sought to enroll 40 participants. However, after difficulties locating qualified participants, enrollment criteria were adjusted to expand the population pool. Regardless of these efforts, the sample size for this study was still smaller than anticipated (n = 21). Additionally, irrespective of group approximately 40% of participants did not engage with the app. However, despite a small sample size and poor engagement, participants in the intervention group displayed better outcomes and showed trends for greater app interaction.CONCLUSION:These promising results should encourage future researchers to continue exploring ideal adaptations for implementing digital CBT in minority populations. Future studies should also consider implementing post-intervention surveys to help identify common factors relating to a lack of engagement.

BackgroundThere is currently an increased interest in and acceptance of technology-enabled mental health care. To adequately harness this opportunity, it is critical that the design and development of digital mental health technologies be informed by the needs and preferences of end users. Despite young people and clinicians being the predominant users of such technologies, few studies have examined their perspectives on different digital mental health technologies.ObjectiveThis study aims to understand the technologies that young people have access to and use in their everyday lives and what applications of these technologies they are interested in to support their mental health. The study also explores the technologies that youth mental health clinicians currently use within their practice and what applications of these technologies they are interested in to support their clients’ mental health.MethodsYouth mental health service users (aged 12-25 years) from both primary and specialist services, young people from the general population (aged 16-25 years), and youth mental health clinicians completed a web-based survey exploring technology ownership, use of, and interest levels in using different digital interventions to support their mental health or that of their clients.ResultsA total of 588 young people and 73 youth mental health clinicians completed the survey. Smartphone ownership or private access among young people within mental health services and the general population was universal (611/617, 99%), with high levels of access to computers and social media. Youth technology use was frequent, with 63.3% (387/611) using smartphones several times an hour. Clinicians reported using smartphones (61/76, 80%) and video chat (69/76, 91%) commonly in clinical practice and found them to be helpful. Approximately 50% (296/609) of the young people used mental health apps, which was significantly less than the clinicians (χ23=28.8, n=670; P<.001). Similarly, clinicians were significantly more interested in using technology for mental health support than young people (H3=55.90; P<.001), with 100% (73/73) of clinicians being at least slightly interested in technology to support mental health compared with 88% (520/591) of young people. Follow-up tests revealed no difference in interest between young people from the general population, primary mental health services, and specialist mental health services (all P>.23). Young people were most interested in web-based self-help, mobile self-help, and blended therapy.ConclusionsTechnology access is pervasive among young people within and outside of youth mental health services; clinicians are already using technology to support clinical care, and there is widespread interest in digital mental health technologies among these groups of end users. These findings provide important insights into the perspectives of young people and clinicians regarding the value of digital mental health interventions in supporting youth mental health.

The literature is consensual regarding the academic community exhibiting higher levels of mental disorder prevalence than the general population. The potential of digital mental health apps for improving access to resources to cope with these issues is ample. However, studies have yet to be performed in Portugal on individuals' attitudes and perceptions toward digital mental health applications or their preferences and decision drivers on obtaining mental health care, self-assessment, or treatment. This study aims to understand the determinants of digital mental health applications use in the Portuguese academic community of Porto, along with potential adoption barriers and enablers. A cross-sectional, web-based survey was delivered via dynamic email to the University of Porto's academic community. Data collection occurred between September 20 and October 20, 2022. We used structural equation modeling to build three models, replicating a peer-reviewed and published study and producing a newly full mediation model shaped by the collected data. We tested the relationships between use of digital mental health apps and perceived stress, perceived need to seek help for mental health, perceived stigma, past use of mental health services, privacy concerns, and social influence. Of the 539 participants, 169 (31.4%) reported having used digital mental health apps. Perceived stress and a latent variable, comprising perceptions of mental health problems and coping strategies, were positively associated with mental health app use, while privacy concerns regarding one's information being accessible to others were negatively associated. Perceived stigma, need to seek help, and close relationships did not have a statistically significant direct effect. These findings can inform product and policy development of new, better-targeted digital mental health app interventions, with implications for researchers and academia, industry, and policymakers. Our study concludes that, to maximize adherence to these apps, they should have low to no financial charges, demonstrate evidence of their helpfulness and focus on the timely delivery of care. We also conclude that to foster digital mental health app use, there is a need to improve mental health literacy, namely regarding self-awareness of one's conditions, acceptable stress levels, and overall behavior towards mental health. RR2-10.2196/41040.

IntroductionVarious regulatory bodies have published ethical principles, codes, and/or guidelines for mental health practice globally. Although such guidelines may lend themselves equally relevant, there seems a paucity of directives specific to digital platforms such as apps utilizing AI-assisted chatbots, etc. in providing aid for mental health concerns. Exploring data-driven ethical principles for all stakeholders including the practitioners/facilitators, potential consumers, and developers of such platforms is crucial given the rapid expansion of digitized mental health support. A novel approach is proposed undertaking gap-analysis by identifying the themes of ethical concerns from practitioners’ and consumers’ perspectives.MethodThematic analysis of literature on ethics in both conventional psychotherapy and digital mental health interventions was conducted to develop a comprehensive thematic framework of ethical principles for digitized mental health care. Based on these foundational themes, a content-valid 30-item research measure was developed to administer on samples of potential consumers as well as practitioners/trainees. In order to reduce the items to meaningful components of ethical considerations, rooted in the participants’ responses, separate principal components analyses were conducted on this primary data from consumers and practitioners, respectively.ResultsPrincipal components analysis on consumers’ data revealed a single component solution, i.e., the consumers perceived a variety of ethical concerns in a unidimensional manner, suggesting that more awareness is needed for them to make better and more informed choices about their mental health care. Principal components analysis on practitioners/trainees’ data found two meaningful components. In other words, practitioners/trainees on the other hand emphasized two aspects of ethical concerns: the competency, design, accountability of a mental health app, and the rights and security that it needs to provide for its consumers.DiscussionCurrent research aimed to bridge the gap in literature with a data-driven, empirical approach to formulate ethical regulations for digitized mental health services, specifically the mental health apps. Findings from the study are proposed to benefit the developers of digital mental health apps, and organizations offering such services in ensuring ethical standards as well as effectively communicating them to the potential consumers.