Electronic Mental Health Research Articles

Boundary objects and technological frames: officer’s’ perceptions and experiences using mental health screeners on the frontline

ABSTRACT Police officers play a key role in determining the result of incidents that involve people in mental health crisis given their role as first responders and gatekeepers to services. In this paper, we ethnographically study one Canadian, mid-size municipal police service’s integration of an electronic mental health screener (MHS). The screener was designed to assist officers in undertaking risk assessment, as well as facilitate collaborative action between police and emergency department staff by providing a tool that uses a shared medical language. Drawing on the theoretical concepts of ‘boundary objects’ and ‘technological frames’, we explore: (1) how the technology worked in practice and, what, if any, perceived impact it had on police decision-making; and, (2) how the technology was perceived to affect information sharing and collaboration among the criminal justice and health systems, and subsequently, the outcome of mental health calls for service. From our analysis, we argue that frontline officers and police administration hold differing, and at times, incongruent technological frames towards MHS. Specifically, we argue that frontline officers do not perceive the screener as providing a shared understanding that facilitates risk assessment, but instead perceive it to be a performance management tool used to track officer decision-making, enable the collection and sharing of health information within the criminal justice system, and demonstrate accountability to police service boards. Further, our analysis illuminates the power of experiential knowledge in resisting technological adoption and organisational reform.

Success Factors for and Barriers to Integration of Electronic Mental Health Screening in Primary Care.

Success Factors for and Barriers to Integration of Electronic Mental Health Screening in Primary Care.

Electronic Mental Health as an Option for Egyptian Psychiatry: Cross-Sectional Study.

BackgroundEgypt is a country of nearly 100 million citizens, and there are less than 1000 registered psychiatrists. The mental health care system is under resourced and nearly inaccessible for the majority of the population. In addition, youth under the age of 25 years represent 50% of Egyptian citizens; however, there are no specific services addressing their unique needs. How can the needs of the largest population in the Middle East be effectively addressed? Is a web-based framework an option for Egyptian psychiatrists to serve the population?ObjectiveThe aims of this study were to better understand the opinions of psychiatrists on the current state of mental health care services in Egypt and their current knowledge on electronic mental health (EMH); assess the attitudes of Egyptian psychiatrists toward web-based interventions and telemedicine for mental health; and identify perceived advantages and barriers of EMH development in Egypt.MethodsA cross-sectional survey was conducted online among 640 Egyptian psychiatrists. It included a total of 36 items within a set of 16 questions asking about EMH literacy, integrating EMH into the mental health care system, and the perceived priorities and barriers of EMH. The sampling was supported by Tanta University, a large academic institution close to Cairo. Statistical analysis was performed using SPSS 25 (IBM Corp). Descriptive statistics, the chi-square test, the independent sample t test, and analysis of variance were applied.ResultsA total of 188 participants responded (response rate of 29.4%), of which 54.2% (102/188) were female and 54.3% (102/188) were between 30 and 45 years old. Less than half of the participants thought that the current health care system was efficient for adults (69/155, 44.4%), and even less thought it was efficient for youth (44/155, 28.3%). Almost all participants agreed that EMH would be beneficial for patient care (147/155, 94.8%) and that integrating EMH into the current health care system would be a good idea (118/155, 76.2%). The highest rated utility of web-based solutions was documentation, followed by psychoeducation and communication with professionals. The main advantages were to improve access to care in rural areas of the country and its convenience.ConclusionsThere is scarcity of mental health resources in Egypt. Egyptian psychiatrists are interested in EMH and believe web-based platforms can become part of the solution for the Egyptian mental health care system.

Factors Influencing College Students' Mental Health Promotion: The Mediating Effect of Online Mental Health Information Seeking.

For college students, mental health is an important factor in ensuring their ability to study and have a normal life. This research focuses on factors affecting the mental health of college students in the information network society. We constructed a theoretical model that influences their online mental health information seeking behavior from internal and external perspectives, and by extension, affects their mental health. Through the data obtained by field research and questionnaire survey on the online mental health information seeking behavior of some college students in Internet health information platforms, a structural equation model is used to test the hypotheses. Results show that the quality of external Internet platforms and the quality of internal electronic health literacy have a significantly positive impact on the online health information searching behavior of college students; electronic health literacy and online mental health information seeking behavior have significantly direct positive effects on college students’ mental health. Further, online health information searching behavior has a significant mediating effect between Internet platform quality, electronic health literacy, and college students’ mental health. The research conclusions have theoretical value and practical significance to study the factors influencing college students’ mental health in the context of information network society.

Sociodemographic factors associated with routine outcome monitoring: a historical cohort study of 28,382 young people accessing child and adolescent mental health services.

Patient-reported outcome measures (PROMs) are important tools to inform patients, clinicians and policy-makers about clinical need and the effectiveness of any given treatment. Consistent PROM use can promote early symptom detection, help identify unexpected treatment responses and improve therapeutic engagement. Very few studies have examined associations between patient characteristics and PROM data collection. We used the electronic mental health records for 28,382 children and young people (aged 4-17years) accessing Child and Adolescent Mental Health Services (CAMHS) across four South London boroughs between the 1st of January 2008 to the 1st of October 2017. We examined the completion rates of the caregiver Strengths and Difficulties Questionnaire (SDQ), a ubiquitous PROM for CAMHS at baseline and 6-month follow-up. SDQs were present for approximately 40% (n=11,212) of the sample at baseline, and from these, only 8% (n=928) had a follow-up SDQ. Patterns of unequal PROM collection by sociodemographic factors were identified: males were more likely (aOR 1.07, 95% CI 1.01-1.13), whilst older age (aOR 0.87, 95% CI 0.87-0.88), Black (aOR 0.79 95% CI 0.74-0.84) and Asian ethnicity (aOR 0.75 95% CI 0.66-0.86) relative to White ethnicity, and residence within the most deprived neighbourhood (aOR 0.87 95% CI 0.80-0.94) were less likely to have a record of baseline SDQ. Similar results were found in the sub-group (n=11,212) with follow-up SDQ collection. Our findings indicate systematic differences in the currently available PROMS data and highlights which groups require increased focus if we are to gain equitable PROM collection. We need to ensure representative PROM collection for all individuals accessing treatment, regardless of ethnic or socioeconomic background; biased data have adverse ramifications for policy and service level decision-making.

Evaluation of Electronic Mental Health Implementation in Northern Territory Services Using the Integrated "Promoting Action on Research Implementation in Health Services" Framework: Qualitative Study.

BackgroundElectronic mental health is a promising strategy to bridge the treatment gap in mental health care. Training workshops have been delivered to service providers working with Aboriginal and Torres Strait Islander people at a primary health care level to raise awareness and knowledge of electronic mental health approaches.ObjectiveThis study aimed to understand service providers’ perspectives and experiences of electronic mental health adoption. More specifically, it aimed to use the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to further identify and understand how different factors facilitate or impede electronic mental health uptake within primary health care settings providing services to Aboriginal and Torres Strait Islander people.MethodsQualitative interviews were conducted with 57 service providers working with Aboriginal and Torres Strait Islander people, who had undergone electronic mental health training workshops.ResultsSeveral factors related to innovation (electronic mental health approach), recipients (service providers as an individual and as a team), and context (local, organizational, and external contexts) were found to influence electronic mental health uptake. Particularly, organizational readiness, in terms of information technology resources and infrastructure, policies, workforce and culture, and processes to mandate electronic mental health use, were found to be significant impediments to electronic mental health utilization. These findings led to the development of a three-phase implementation strategy that aims to enhance electronic mental health adoption by addressing organizational readiness before and post electronic mental health training.ConclusionsThe i-PARIHS provides a useful determinant framework that deepens our understanding of how different factors impede or facilitate electronic mental health adoption in this setting. This insight was used to develop a practical and comprehensive implementation strategy to enhance the utilization of electronic mental health approaches within primary health care settings, involving three phases: pretraining consultations, training workshops, and post-training follow-up support.

Frequency of Clinicians’ Assessments for Access to Lethal Means in Persons at Risk for Suicide

Objective We measured the frequency of clinicians’ assessments for access to lethal means, including firearms and medications in patients at risk of suicide from electronic medical and mental health records in outpatient and emergency settings. Methods We included adult patients who reported suicide ideation on the PHQ-9 depression screener in behavioral health and primary care outpatient settings of a large integrated health system in the U.S. and those with suicidal behavior treated in the emergency department. Two separate natural language processing queries were developed on medical record text documentation: (1) assessment for access to firearms (8,994 patients), (2) assessment for access to medications (4,939 patients). Results Only 35% of patients had documentation of firearm or medication assessment in the month following treatment for suicidal behavior in the emergency setting. Among those reporting suicidal ideation in outpatient setting, 31% had documentation of firearm assessment and 23% for medication assessment. The accuracy of the estimates was very good for firearm assessment (F1 = 89%) and medication assessment in the outpatient setting (F1 = 91%) and fair for medication assessment in the emergency setting (F1 = 70%) due to more varied documentation styles. Conclusions Lethal means assessment following report of suicidal ideation or behavior is low in a nonacademic health care setting. Until health systems implement more structured documentation to measure lethal means assessment, such as discrete data field, NLP methods may be used to conduct research and surveillance of this important prevention practice in real-world settings.

Drafting the Aboriginal and Islander Mental Health Initiative for Youth (AIMhi-Y) App: Results of a formative mixed methods study

BackgroundCulturally responsive, strengths-based early-intervention mental health treatment programs are considered most appropriate to influence the high rates of psychological distress and suicide experienced by Aboriginal and Torres Strait Islander youth. Few early intervention services effectively bridge the socio-cultural and geographic challenges of providing sufficient and culturally relevant services in rural and remote Australia. Mental Health apps provide an opportunity to bridge current gaps in service access if co-designed with Aboriginal and Torres Strait Islander youth to meet their needs. AimsThis paper reports the results of the formative stage of the AIMhi-Y App development process which engaged Aboriginal and Torres Strait Islander youth in the co-design of the new culturally informed AIMhi-Y App. MethodsUsing a participatory design research approach, a series of co-design workshops were held across three sites with five groups of young people. Workshops explored concepts, understanding, language, acceptability of electronic mental health tools (e-mental health) and identified important characteristics of the presented applications and websites, chosen for relevance to this group. An additional peer supported online survey explored use of technology, help seeking and e-mental health design elements which contribute to acceptability. ResultsForty-five, Aboriginal and Torres Strait Islander youth, aged 10–18 years, from three sites in the Northern Territory (NT) were involved in the workshops (n = 29). Although experiencing psychological distress, participants faced barriers to help seeking. Apps were perceived as a potential solution to overcome barriers by increasing mental health literacy, providing anonymity if desired, and linking young people with further help. Preferred app characteristics included a strength-based approach, mental health information, relatable content and a fun, appealing, easy to use interface which encouraged app progression. Findings informed the new AIMhi-Y App draft, which is a strengths-based early intervention wellbeing app for Aboriginal and Torres Strait Islander youth. ConclusionsResearch findings highlight the need, feasibility and potential of these types of tools, from the perspective of Aboriginal and Torres Strait Islander youth.

Electronic Mental Health Screening in a Pediatric Heart Failure and Transplant Clinic

Mental health disorders have deleterious effects on outcomes in adult heart failure. Mental health is not systematically investigated or screened in pediatric heart failure and transplantation patients. Our institution implemented universal mental health screening for all patients age 11 or older in our pediatric heart failure and transplant clinic. 17 items are answered on a tablet while the patient awaits cardiac testing. Validated mental health screening tools are utilized: the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder scale (GAD-7). Scores for both scales range from 0-4 = no symptoms, 5-9 = mild symptoms, 10-14 = moderate symptoms, >15 = severe symptoms. Scores are immediately available in the electronic health record. The presence of suicidal ideation, severe depression and/or anxiety leads to notification of the psychologist for further intervention. 94 patients have been screened to date. Median age was 16.25 years (IQR 14.7-18.4). Median PHQ-9 score was 2 (IQR 0-6) and 2 (IQR 0-5.3) for GAD-7. Four patients (4.3%) reported severe depression, 8 (8.5%) moderate depression, 15 (16%) mild, 67 (71.3%) reported no depressive symptoms. Seven patients reported suicidal ideation (7.5%). Six patients (6.4%) reported severe anxiety, 8 (8.5%) moderate anxiety, 14 (14.9%) mild anxiety and 66 (70.2%) reported no anxiety. There were no differences in mental health scores between heart failure and transplant patients (Table 1). Eighteen new behavioral health interventions were implemented due to screening. Electronic mental health screening can successfully be employed in pediatric heart failure and transplant clinics. A significant portion have moderate to severe anxiety (14.9%) or moderate to severe depression (12.8%). Mental health screening has led to many behavioral health interventions in this population. Our initial experience supports the use of mental health screening in a pediatric heart failure and transplant clinic.

Success Factors for and Barriers to Integration of Electronic Mental Health Screening in Primary Care.

Currently, only a third of primary care providers screen for substance use, which is a growing epidemic. This quality improvement study aimed to improve the screening process by integrating the Drug Abuse Screening Test without information systems support into the electronic health record to increase completed screenings and provider interventions for positive screenings in adult patients at an urban primary care clinic. Electronic drug abuse screening should include a prescreen followed by the Drug Abuse Screening Test, interprofessional approach, comprehensive education, and utilization of generic tools to create new screening forms. Staff participated in a new drug abuse screening process, and chart audits and staff interviews were conducted. There was a 9% increase in completed screenings by medical assistants with electronic versus paper screening (30% vs 21%, respectively; P < .001). There was a 33.4% increase in provider intervention for positive screenings with electronic versus paper screening (55% vs 21%, respectively; P = .1081). Primary care providers can play an increased role in drug abuse treatment by using available technology to overcome barriers to screening independent of information systems support. By adopting the new electronic screening documentation process, this clinic was able to increase its screening outcomes.

Exploring Mental Health Professionals' Perspectives of Text-Based Online Counseling Effectiveness With Young People: Mixed Methods Pilot Study.

BackgroundPopulation-based studies show that the risk of mental ill health is highest among young people aged 10 to 24 years, who are also the least likely to seek professional treatment because of a number of barriers. Electronic mental (e-mental) health services have been advocated as a method for decreasing these barriers for young people, among which text-based online counseling (TBOC) is a primary intervention used at many youth-oriented services. Although TBOC has shown promising results, its outcome variance is greater in comparison with other electronic interventions and adult user groups.ObjectiveThis pilot study aimed to explore and confirm e-mental health professional’s perspectives about various domains and themes related to young service users’ (YSUs) motivations for accessing TBOC services and factors related to higher and lower effectiveness on these modalities.MethodsParticipants were 9 e-mental health professionals who were interviewed individually and in focus groups using a semistructured interview. Thematic analysis of qualitative themes from interview transcripts was examined across the areas of YSU motivations for access and factors that increase and decrease TBOC effectiveness.ResultsA total of 4 domains and various subthemes were confirmed and identified to be related to YSUs’ characteristics, motivations for accessing TBOC, and moderators of service effectiveness: user characteristics (ie, prior negative help-seeking experience, mental health syndrome, limited social support, and perceived social difficulties), selection factors (ie, safety, avoidance motivation, accessibility, and expectation), and factors perceived to increase effectiveness (ie, general therapeutic benefits, positive service-modality factors, and persisting with counseling despite substantial benefit) and decrease effectiveness (ie, negative service-modality factors).ConclusionsParticipants perceived YSUs to have polarized expectations of TBOC effectiveness and be motivated by service accessibility and safety, in response to several help-seeking concerns. Factors increasing TBOC effectiveness were using text-based communication, the online counselor’s interpersonal skills and use of self-management and crisis-support strategies, and working with less complex presenting problems or facilitating access to more intensive support. Factors decreasing TBOC effectiveness were working with more complex problems owing to challenges with assessment, the slow pace of text communication, lack of nonverbal conversational cues, and environmental and connectivity issues. Other factors were using ineffective techniques (eg, poor goal setting, focusing, and postcounseling direction) that produced only short-term outcomes, poor timeliness in responding to service requests, rupture in rapport from managing service boundaries, and low YSU readiness and motivation.

Technological State of the Art of Electronic Mental Health Interventions for Major Depressive Disorder: Systematic Literature Review.

BackgroundElectronic mental (e-mental) health care for depression aims to overcome barriers to and limitations of face-to-face treatment. Owing to the high and growing demand for mental health care, a large number of such information and communication technology systems have been developed in recent years. Consequently, a diverse system landscape formed.ObjectiveThis literature review aims to give an overview of this landscape of e-mental health systems for the prevention and treatment of major depressive disorder, focusing on three main research questions: (1) What types of systems exist? (2) How technologically advanced are these systems? (3) How has the system landscape evolved between 2000 and 2017?MethodsPublications eligible for inclusion described e-mental health software for the prevention or treatment of major depressive disorder. Additionally, the software had to have been evaluated with end users and developed since 2000. After screening, 270 records remained for inclusion. We constructed a taxonomy concerning software systems, their functions, how technologized these were in their realization, and how systems were evaluated, and then, we extracted this information from the included records. We define here as functions any component of the system that delivers either treatment or adherence support to the user. For this coding process, an elaborate classification hierarchy for functions was developed yielding a total of 133 systems with 2163 functions. The systems and their functions were analyzed quantitatively, with a focus on technological realization.ResultsThere are various types of systems. However, most are delivered on the World Wide Web (76%), and most implement cognitive behavioral therapy techniques (85%). In terms of content, systems contain twice as many treatment functions as adherence support functions, on average. Furthermore, autonomous systems, those not including human guidance, are equally as technologized and have one-third less functions than guided ones. Therefore, lack of guidance is neither compensated with additional functions nor compensated by technologizing functions to a greater degree. Although several high-tech solutions could be found, the average system falls between a purely informational system and one that allows for data entry but without automatically processing these data. Moreover, no clear increase in the technological capabilities of systems showed in the field, between 2000 and 2017, despite a marked growth in system quantity. Finally, more sophisticated systems were evaluated less often in comparative trials than less sophisticated ones (OR 0.59).ConclusionsThe findings indicate that when developers create systems, there is a greater focus on implementing therapeutic treatment than adherence support. Although the field is very active, as evidenced by the growing number of systems developed per year, the technological possibilities explored are limited. In addition to allowing developers to compare their system with others, we anticipate that this review will help researchers identify opportunities in the field.

A systematic review of electronic mental health interventions for Indigenous youth: Results and recommendations

Electronic health interventions involve health services delivered using the Internet and related communication technologies. These services can be particularly relevant for Indigenous populations who often have differential access to health-care services compared to general populations, especially within rural and remote areas. As the popularity of electronic health interventions grows, there is an increased need for evidence-based recommendations for the effective use of these technologies. The current study is a systematic review of peer-reviewed and available grey literature with the aim of understanding outcomes of electronic health interventions for mental health concerns among Indigenous people. Studies used electronic health technologies for substance use treatment or prevention, suicide prevention, parenting supports, goal setting and behaviour change and consultation services. Various technological platforms were used across interventions, with both novel and adapted intervention development. Most studies provided qualitative results, with fewer studies focusing on quantitative outcomes. Some preliminary results from the engagement of Indigenous individuals with electronic health services has been demonstrated, but further research is needed to confirm these results. Identified barriers and facilitators are identified from the reviewed literature. Recommendations for future development of electronic health interventions for Indigenous youth are provided.

Exploring User-Related Drivers of the Early Acceptance of Certified Digital Stress Prevention Programs in Germany.

Electronic mental health services represent innovative instruments to increase the dissemination of stress programs in primary prevention. However, little is known about facilitators of their uptake. This study aimed to explore determinants of the acceptance of centrally certified digital stress coping programs and preferences for service delivery modes among adult members of German statutory health insurances. Participants completed a multi-construct 45-item questionnaire covering acceptance of digital stress prevention (behavioral use intention) and potential predictors we assessed using hierarchical regression analysis—(1) socio-demographic variables and time spent online, (2) openness to experience, (3) perceived stress, and (4) attitudes toward e-mental health. Preferences in terms of the willingness to use online, face-to-face and blended programs were analyzed using paired t-tests. Participants (N = 171, 66% female, 18-69 years) reported a moderate acceptance of digital stress management (M = 2.76, SD = 1.16, range: 1-5). We identified younger age (ß = -0.16, P = .009), openness to experience (ß = 0.17, P = .003), and positive attitudes (ß = 0.61, P < .001) as predictors of acceptance (R2 = .50, P < .001). Face-to-face was preferred over online (d = 0.40) and blended (d = 0.33), and blended over stand-alone online delivery mode (d = 0.19; all P < .001). Our findings indicate that promoting favorable attitudes toward digital stress prevention through tailored information may be a starting point to facilitate their adoption.

Using Cluster Analysis to Explore Engagement and e-Attainment as Emergent Behavior in Electronic Mental Health.

BackgroundIn most e-mental health (eMH) research to date, adherence is defined according to a trial protocol. However, adherence to a study protocol may not completely capture a key aspect of why participants engage with eMH tools, namely, to achieve personal mental health goals. As a consequence, trial attrition reported as non-adherence or dropout may reflect e-attainment, the discontinuation of eMH engagement after personal goals have been met. Clarifying engagement patterns, such as e-attainment, and how these align with mental health trajectories, may help optimize eMH design and implementation science.ObjectiveThis study aimed to use clustering techniques to identify real-world engagement profiles in a community of eMH users and examine if such engagement profiles are associated with different mental health outcomes. The novelty of this approach was our attempt to identify actual user engagement behaviors, as opposed to employing engagement benchmarks derived from a trial protocol. The potential of this approach is to link naturalistic behaviors to beneficial mental health outcomes, which would be especially informative when designing eMH programs for the general public.MethodsBetween May 2013 and June 2018, Australian adults (N=43,631) signed up to myCompass, a self-guided eMH program designed to help alleviate mild to moderate symptoms of depression, anxiety, and stress. Recorded usage data included number of logins, frequency of mood tracking, number of started and completed learning activities, and number of tracking reminders set. A subset of users (n=168) completed optional self-assessment mental health questionnaires (Patient Health Questionnaire-9 item, PHQ-9; Generalized Anxiety Disorder Questionnaire-7 item, GAD-7) at registration and at 28 and 56 days after sign-up. Another subset of users (n=861) completed the PHQ-9 and GAD-7 at registration and at 28 days.ResultsTwo-step cluster analyses revealed 3 distinct usage patterns across both subsamples: moderates, trackers, and super users, signifying differences both in the frequency of use as well as differences in preferences for program functionalities. For both subsamples, repeated measures analysis of variances showed significant decreases over time in PHQ-9 and GAD-7 scores. Time-by-cluster interactions, however, did not yield statistical significance in both subsamples, indicating that clusters did not predict symptom reduction over time. Interestingly, users who completed the self-assessment questionnaires twice had slightly but significantly lower depression and anxiety levels at sign-up compared with users who completed the questionnaires a third time at 56 days.ConclusionsFindings suggested that although users engaged with myCompass in different but measurable ways, those different usage patterns evoked equivalent mental health benefits. Furthermore, the randomized controlled trial paradigm may unintentionally limit the scope of eMH engagement research by mislabeling early mental health goal achievers as dropouts. More detailed and naturalistic approaches to study engagement with eMH technologies may improve program design and, ultimately, program effectiveness.

Association of physical health multimorbidity with mortality in people with schizophrenia spectrum disorders: Using a novel semantic search system that captures physical diseases in electronic patient records

ObjectiveSingle physical comorbidities have been associated with the premature mortality in people with schizophrenia-spectrum disorders (SSD). We investigated the association of physical multimorbidity (≥two physical health conditions) with mortality in people with SSD. MethodsA retrospective cohort study between 2013 and 2017. All people with a diagnosis of SSD (ICD-10: F20–F29), who had contact with secondary mental healthcare within South London during 2011–2012 were included. A novel semantic search system captured conditions from electronic mental health records, and all-cause mortality were retrieved. Hazard ratios (HRs) and population attributable fractions (PAFs) were calculated for associations between physical multimorbidity and all-cause mortality. ResultsAmong the 9775 people with SSD (mean (SD) age, 45.9 (15.4); males, 59.3%), 6262 (64%) had physical multimorbidity, and 880 (9%) died during the 5-year follow-up. The top three physical multimorbidity combinations with highest mortality were cardiovascular-respiratory (HR: 2.23; 95% CI, 1.49–3.32), respiratory-skin (HR: 2.06; 95% CI, 1.31–3.24), and respiratory-digestive (HR: 1.88; 95% CI, 1.14–3.11), when adjusted for age, gender, and all other physical disease systems. Combinations of physical diseases with highest PAFs were cardiovascular-respiratory (PAF: 35.7%), neurologic-respiratory (PAF: 32.7%), as well as respiratory-skin (PAF: 29.8%). ConclusionsApproximately 2/3 of patients with SSD had physical multimorbidity and the risk of mortality in these patients was further increased compared to those with none or single physical conditions. These findings suggest that in order to reduce the physical health burden and subsequent mortality in people with SSD, proactive coordinated prevention and management efforts are required and should extend beyond the current focus on single physical comorbidities.

Acceptance and Expectations of Medical Experts, Students, and Patients Toward Electronic Mental Health Apps: Cross-Sectional Quantitative and Qualitative Survey Study.

BackgroundThe acceptability of electronic mental (e-mental) health apps has already been studied. However, the attitudes of medical experts, students, and patients taking into account their knowledge of and previous experiences with e-mental health apps have not been investigated.ObjectiveThe aim of this study was to explore the attitudes, expectations, and concerns of medical experts, including physicians, psychotherapists and nursing staff, students of medicine or psychology, and patients toward e-mental health apps when considering their knowledge of and former experiences with e-mental health apps.MethodsThis cross-sectional quantitative and qualitative survey was based on a self-developed questionnaire. A total of 269 participants were included (104 experts, 80 students, and 85 patients), and 124 eligible participants answered a paper version and 145 answered an identical online version of the questionnaire. The measures focused on existing knowledge of and experiences with e-mental health apps, followed by a question on whether electronic health development was generally accepted or disliked. Further, we asked about the expectations for an ideal e-mental health app and possible concerns felt by the participants. All items were either presented on a 5-point Likert scale or as multiple-choice questions. Additionally, 4 items were presented as open text fields.ResultsAlthough 33.7% (35/104) of the experts, 15.0% (12/80) of the students, and 41.2% (35/85) of the patients knew at least one e-mental health app, few had already tried one (9/104 experts [8.7%], 1/80 students [1.3%], 22/85 patients [25.9%]). There were more advocates than skeptics in each group (advocates: 71/104 experts [68.3%], 50/80 students [62.5%], 46/85 patients [54.1%]; skeptics: 31/104 experts [29.8%], 20/80 students [25.0%], 26/85 patients [30.6%]). The experts, in particular, believed, that e-mental health apps will gain importance in the future (mean 1.08, SD 0.68; 95% CI 0.94-1.21). When asked about potential risks, all groups reported slight concerns regarding data security (mean 0.85, SD 1.09; 95% CI 0.72-0.98). Patient age was associated with several attitudes toward e-mental health apps (future expectations: r=–0.31, P=.005; total risk score: r=0.22, P=.05). Attitudes toward e-mental health apps correlated negatively with the professional experience of the experts (rs(94)=–0.23, P=.03).ConclusionsAs opposed to patients, medical experts and students lack knowledge of and experience with e-mental health apps. If present, the experiences were assessed positively. However, experts show a more open-minded attitude with less fear of risks. Although some risks were perceived regarding data security, the attitudes and expectations of all groups were rather positive. Older patients and medical experts with long professional experience tend to express more skepticism.Trial RegistrationGerman Clinical Trials Register DRKS00013095; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00013095

Diagnostic trajectories in child and adolescent mental health services: exploring the prevalence and patterns of diagnostic adjustments in an electronic mental health case register

Community-based epidemiological studies show transitions between psychiatric disorders are common during child development. However, little research has explored the prevalence or patterns of the diagnostic adjustments that occur in child and adolescent mental health services (CAMHS). Understanding diagnostic trajectories is necessary to inform theory development in developmental psychopathology and clinical judgements regarding risk and prognosis. In this study, data from CAMHS clinical records were extracted from a British mental health case register (N = 12,543). Analysis calculated the proportion of children whose clinical records showed a longitudinal diagnostic adjustment (i.e. addition of a subsequent diagnosis of a different diagnostic class, at > 30 days’ distance from their first diagnosis). Regression analyses investigated typical diagnostic sequences and their relationships with socio-demographic variables, service use and standardised measures of mental health. Analysis found that 19.3% of CAMHS attendees had undergone a longitudinal diagnostic adjustment. Ethnicity, diagnostic class and symptom profiles significantly influenced the likelihood of a diagnostic adjustment. Affective and anxiety/stress-related disorders longitudinally predicted each other, as did hyperkinetic and conduct disorders, and hyperkinetic and pervasive developmental disorders. Results suggest that approximately one in five young service users have their original psychiatric diagnosis revised or supplemented during their time in CAMHS. By revealing the most common diagnostic sequences, this study enables policy makers to anticipate future service needs and clinicians to make informed projections about their patients’ likely trajectories. Further research is required to understand how young people experience diagnostic adjustments and their psychological and pragmatic implications.

Adverse life experiences and triggers for self-harm in young people aged 12–26 years in inner south London: a retrospective observational study

BackgroundThe prevalence of self-harm among children and young people in the UK is increasing, with few accessing formal support. Drivers of self-harm remain poorly understood, and evidence-based opportunities to intervene are scarce. We aimed to identify factors associated with self-harm in young people to inform local action. MethodsIn this retrospective, observational study, we identified 196 residents of the south London Borough of Lambeth, aged 12–26 years, presenting to two emergency departments for injuries related to self-harm in the 2015–16 financial year (April 1, 2015, to March 31, 2016). A pragmatic sample size of 100 was selected via computer randomisation for further analysis. Electronic mental health records were retrospectively analysed using a data collection protocol that was validated with researchers before data collection. Demographics and psychiatric history were obtained from pre-coded databases linking electronic mental health records and Hospital Episode Statistics data on emergency department attendance for self-harm. Presentation details and social risk factors were derived from assessment of case notes pertaining to the 2 weeks after first presentation; we noted any risk factors that had been positively recorded. Data relating to the individual's first presentation within the study period were used; subsequent attendances were not included in the sample. We analysed the data using descriptive statistics. Ethical approval for data access and linkage was granted by the Oxford Research Ethics Committee C (18/SC/0372), Clinical Records Interactive Search system Oversight Committee (project numbers 14–026 and 19–004), and the National Health Service (NHS) Health Research Authority Confidentiality Advisory Group (reference ECC 3–04(f)/2011). This study received approval as an audit project through Southwark Operational Directorate in the South London and Maudsley Foundation NHS Trust. Findings48 (48%) of the 100 selected participants had documented experience of psychological trauma, including exposure to violence. 18 (18%) lived in unstable accommodation, and 20 (20%) were known to social services. Difficulties at home (16 [16%]) and stress relating to housing, school, or financial pressures (13 [13%]) were common documented triggers for the self-harm episode at presentation. Peer influence was rarely noted, although 27 (27%) had recorded experience of bullying. InterpretationAdverse life experiences were prevalent and align with wider population prevalence estimates. Common triggers for self-harm relate to home and school environment and wider socioeconomic stressors, supporting the link between wider determinants of health and self-harm, and contributing to the case for public health action. Risk factors and triggers identified provide potential areas for additional targeted support to prevent development or escalation of self-harm behaviours. FundingUK National Institute for Health Research Biomedical Research Centre at South London and Maudsley NHS Foundation Trust, and King's College London.

Analysis of the Recomposition of Norms and Representations in the Field of Psychiatry and Mental Health in the Age of Electronic Mental Health: Qualitative Study.

BackgroundFor the World Health Organization, electronic health (eHealth) is seen as an effective way to improve therapeutic practices and disease prevention in health. Digital tools lead to major changes in the field of mental medicine, but specific analyses are required to understand and accompany these changes.ObjectiveOur objective was to highlight the positions of the different stakeholders of the mental health care system on eHealth services and tools, as well as to establish professional and user group profiles of these positions and the uses of these services.MethodsIn order to acquire the opinions and expectations of different categories of people, we carried out a qualitative study based on 10 focus groups (n=70, from 3-12 people per group) composed of: general practitioners, psychiatrists, psychologists, social workers, occupational therapists, nurses, caregivers, mental health services users, user representatives, and the general public. The analyses of focus group discussions were performed independently by four investigators through a common analysis grid. The constant comparative method was adopted within this framework.ResultsThe interviewees expressed different problems that new technologies engender in the field of mental health. What was previously strictly under the jurisdiction of physicians now tends to be fragmented and distributed over different groups and locations. New technologies reposition care in the field of domestic, rather than therapeutic, activities, and thus the conception of care as an autonomous activity in the subject’s life is questioned. The ideal of social autonomy through technology is part of the new logic of health democracy and empowerment, which is linked to a strong, contemporary aspiration to perform. Participants emphasized that there was the potential risk of a decrease in autonomy for the digitally engaged patient, while personal empowerment could become a set of obligations.ConclusionsThis qualitative research highlights the heterogeneity of opinions among the groups and within each group. It suggests that opinions on electronic mental health devices are still far from being stabilized, and that a change management process should be set up to both regulate the development and facilitate the use of these tools.