Behavioral Therapy for Functional Heartburn: Recommendation Statements.

BACKGROUND & AIMS: Brain-gut behavior therapies (BGBT) are increasingly recognized as effective therapeutic interventions for functional heartburn. However, recommendations regarding candidacy for treatment, initial treatment selection, and navigating treatment non-response have not been established for functional heartburn specifically. The aim of this study was to establish expert-based recommendations for behavioral treatment in patients with functional heartburn. METHODS: The validated RAND/University of California, Los Angeles Appropriateness Method was applied to develop recommendations. A 15-member panel composed of 10 gastrointestinal psychologists and 5 esophageal specialists ranked the appropriateness of a series of statements on a 9-point interval scale over 2 ranking periods. Statements were within the following domains: pre-therapy evaluation, candidacy criteria for BGBT, selection of initial BGBT, role of additional therapy for initial non-response to BGBT, and role of pharmacologic neuromodulation. The primary outcome was appropriateness of each intervention based on the recommendation statements. RESULTS: Recommendations for psychosocial assessment (eg, hypervigilance, symptom-specific anxiety, health-related quality of life), candidacy criteria (eg, motivated for BGBT, acknowledges the role of stress in symptoms), and treatment were established. Gut-directed hypnotherapy or cognitive behavioral therapy were considered appropriate BGBT for functional heartburn. Neuromodulation and/or additional BGBT were considered appropriate in the context of non-response. CONCLUSIONS: Gut-directed hypnotherapy and/or cognitive behavioral therapy are recommended as appropriate behavioral interventions for heartburn symptoms, depending on clinical indication, specific gut-brain targets, and preferred treatment modality (pharmacologic vs non-pharmacologic). Pre-therapy evaluation of psychosocial processes and candidacy for BGBT are important to determine eligibility for referral to psychogastroenterology services.

Food-related quality of life driven by hypervigilance and anxiety around eating in organic gastrointestinal conditions.

BACKGROUND: Food-related quality of life (FRQoL) measures the impact of diet, eating behaviours and food-related anxiety on quality of life. Patients often view food and eating as central to symptom management. This is the first study to examine FRQoL in patients with inflammatory bowel disease, celiac sprue, achalasia and eosinophilic oesophagitis. METHODS: A total of 289 adults aged ≥18 years completed self-report measures evaluating the use of dietary treatment, FRQoL and other psychosocial outcomes. Principal component factor analysis evaluated potential subscales within the Food-Related Quality of Life Scale (FRQoL-29), to date validated only with a total score. Univariate analyses investigated differences in FRQoL based on diagnosis, whereas correlations and hierarchical regression identified relationships between FRQoL and psychosocial outcomes. RESULTS: Factor analysis revealed four subscales within the FRQoL-29, with hypervigilance around eating being the primary driver in total score. Patients reported substantial impacts of FRQoL, with those not using diet therapy scoring significantly higher for FRQoL than those on a diet with and without the support of a registered dietitian (RD). Both social (r = 0.41, p < 0.001) and physical (r = 0.31, p < 0.001) domains of health-related quality of life were higher in patients with greater FRQoL. CONCLUSION: FRQoL is significantly degraded in patients with organic gastrointestinal illness diseases, and hypervigilance around food appears to contribute most to this. Use of dietary treatment and meeting with an RD were associated with lower FRQoL, though it is unclear if patients sought RD assistance before FRQoL declined. Future studies on the relationship between dietary treatment, RD support and FRQoL are warranted.

When Is Patient Behavior Indicative of Avoidant Restrictive Food Intake Disorder (ARFID) Vs Reasonable Response to Digestive Disease?

BACKGROUND & AIMS: Dietary modification is common in patients with digestive diseases to improve symptoms; however, food avoidance can become problematic. Avoidant Restrictive Food Intake Disorder (ARFID) is characterized as failure to meet one's nutritional needs owing to sensory hypersensitivity, lack of interest in eating, or fear of aversive consequences from eating, and is associated with negative medical and psychosocial outcomes. This study characterizes ARFID behaviors in adults with achalasia, celiac sprue, eosinophilic esophagitis, and inflammatory bowel disease. METHODS: In this cross-sectional study, 289 adults aged 18 and older completed self-report measures evaluating use of dietary treatment, ARFID symptoms, and psychosocial outcomes. Primary analyses investigated the occurrence of ARFID in patients with achalasia, celiac, eosinophilic esophagitis, and inflammatory bowel disease. Secondary analyses explored the associations between ARFID symptoms and clinical and psychosocial outcomes. RESULTS: More than half (53.7%) of the total sample met the diagnostic criteria for ARFID based on the Nine-Item ARFID Screen (NIAS), with 78.4% of patients with achalasia meeting criteria. Patients on a physician-directed diet showed greater fear of gastrointestinal symptoms (P = .025), less interest in food (P = .046), and a higher total NIAS score (P = .045). For patients using dietary therapy, those who had met with a dietitian reported higher NIAS scores (P = .039). Food avoidance/restriction was associated with increased anxiety and depression, and diminished health-related quality of life. CONCLUSIONS: It is likely that ARFID rates, as measured by the NIAS, are inflated in these 4 patient groups. These findings highlight the need for updated assessments of ARFID in patients with complex digestive diseases.

Challenges and Benefits of an Internet-Based Intervention With a Peer Support Component for Older Adults With Depression: Qualitative Analysis of Textual Data.

BACKGROUND: Technological interventions provide many opportunities for improving the health and quality of life of older adults. However, interaction with new technologies can also cause frustration. Although these themes have been explored in extant research, much remains to be learned with regard to how the challenges of aging and technology use and the experiences of participating in a social and learning environment are interrelated. OBJECTIVE: This study aimed to perform a qualitative analysis of data collected from MoodTech, a pilot study of an internet-based intervention with a peer support component for older adults with symptoms of depression, to better understand the participants' experience of using technological interventions, including the challenges and benefits that they experienced over the course of these interventions. METHODS: We employed an inductive qualitative analysis method based on grounded theory methodology and interpretative phenomenological analysis to analyze participant textual data. These textual data were of 3 main types: (1) assignments in which participants challenged their negative thoughts, (2) status updates, and (3) comments in the peer support component of the intervention. RESULTS: We have presented the results through 3 main themes: (1) the challenges of aging as seen through the participants' comments, (2) the difficulties experienced by the participants in using MoodTech, and (3) the benefits they derived from participating. CONCLUSIONS: This paper offers several contributions concerning study participants' experiences with internet-based cognitive behavioral therapy (iCBT) interventions with a peer support component and design considerations for developing complex technological interventions that support the challenges participants experience due to aging and cognitive difficulties. First, technical issues encountered by older adults within the context of the intervention can interact with and exacerbate the insecurities they experience in life, and it is important to consider how intervention components might be designed to mitigate these issues. Second, peer support can be employed as a mechanism to facilitate communication, support, and collaborative problem solving among participants in an intervention. The insights from this paper can inform the design of iCBT interventions for older adults.

Internet-delivered cognitive behavioral therapies for late-life depressive symptoms: a systematic review and meta-analysis.

Background: This study aimed to review and synthesize evidence related to the effectiveness of internet-based cognitive behavioral therapy (iCBT) for reducing depressive symptoms in older adults.Method: The authors conducted a systematic review of intervention studies testing iCBT for symptoms of depression in older adults. An initial search of PubMed, PsychINFO, and Web of Science was undertaken, followed by a manual search of reference lists of the relevant articles. The Cochrane Risk of Bias Tool was used to appraise study quality. The mean effect size for included studies was estimated in a random effects model. Meta-regression was used to examine potential moderators of effect sizes.Results: Nine studies met the inclusion criteria, including 1272 participants averaging 66 years of age. The study design included randomized controlled trials (k = 3), controlled trials without randomization (k = 2), uncontrolled trials (k = 2), and naturalistic evaluation (k = 2). Seven studies tested iCBT with some level of therapist involvement and 2 examined self-guided iCBT. Six studies tested interventions specifically adapted for older adults. The mean within-group effect size was 1.27 (95% CI = 1.09, 1.45) and the mean between-group effect size was 1.18 (95% CI = 0.63, 1.73). Participants' age was negatively associated with within-group effect sizes (b = -0.06, p = .016).Conclusions: iCBT is a promising approach for reducing depressive symptoms among older adults with mild to moderate depressive symptoms. However, studies involving older adults in iCBT trials were limited, had considerable heterogeneity, and were of low quality, calling for more studies with rigorous designs to produce a best-practice guideline.

A multi-faceted approach to characterizing user behavior and experience in a digital mental health intervention.

Digital interventions offer great promise for supporting health-related behavior change. However, there is much that we have yet to learn about how people respond to them. In this study, we present a novel mixed-methods approach to analysis of the complex and rich data that digital interventions collect. We perform secondary analysis of IntelliCare, an intervention in which participants are able to try 14 different mental health apps over the course of eight weeks. The goal of our analysis is to characterize users' app use behavior and experiences, and is rooted in theoretical conceptualizations of engagement as both usage and user experience. In the first aim, we employ cluster analysis to identify subgroups of participants that share similarities in terms of the frequency of their usage of particular apps, and then employ other engagement measures to compare the clusters. We identified four clusters with different app usage patterns: Low Usage, High Usage, Daily Feats Users, and Day to Day users. Each cluster was distinguished by its overall frequency of app use, or the main app that participants used. In the second aim, we developed a computer-assisted text analysis and visualization method - message highlighting - to facilitate comparison of the clusters. Last, we performed a qualitative analysis using participant messages to better understand the mechanisms of change and usability of salient apps from the cluster analysis. Our novel approach, integrating text and visual analytics with more traditional qualitative analysis techniques, can be used to generate insights concerning the behavior and experience of users in digital health contexts, for subsequent personalization and to identify areas for improvement of intervention technologies.

Comparison of the Effects of Coaching and Receipt of App Recommendations on Depression, Anxiety, and Engagement in the IntelliCare Platform: Factorial Randomized Controlled Trial.

BACKGROUND: IntelliCare is a modular platform that includes 12 simple apps targeting specific psychological strategies for common mental health problems. OBJECTIVE: This study aimed to examine the effect of 2 methods of maintaining engagement with the IntelliCare platform, coaching, and receipt of weekly recommendations to try different apps on depression, anxiety, and app use. METHODS: A total of 301 participants with depression or anxiety were randomized to 1 of 4 treatments lasting 8 weeks and were followed for 6 months posttreatment. The trial used a 2X2 factorial design (coached vs self-guided treatment and weekly app recommendations vs no recommendations) to compare engagement metrics. RESULTS: The median time to last use of any app during treatment was 56 days (interquartile range 54-57), with 253 participants (84.0%, 253/301) continuing to use the apps over a median of 92 days posttreatment. Receipt of weekly recommendations resulted in a significantly higher number of app use sessions during treatment (overall median=216; P=.04) but only marginal effects for time to last use (P=.06) and number of app downloads (P=.08). Coaching resulted in significantly more app downloads (P<.001), but there were no significant effects for time to last download or number of app sessions (P=.36) or time to last download (P=.08). Participants showed significant reductions in the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) across all treatment arms (P s<.001). Coached treatment led to larger GAD-7 reductions than those observed for self-guided treatment (P=.03), but the effects for the PHQ-9 did not reach significance (P=.06). Significant interaction was observed between receiving recommendations and time for the PHQ-9 (P=.04), but there were no significant effects for GAD-7 (P=.58). CONCLUSIONS: IntelliCare produced strong engagement with apps across all treatment arms. Coaching was associated with stronger anxiety outcomes, and receipt of recommendations enhanced depression outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02801877; https://clinicaltrials.gov/ct2/show/NCT02801877.

A Practical Do-It-Yourself Recruitment Framework for Concurrent eHealth Clinical Trials: Identification of Efficient and Cost-Effective Methods for Decision Making (Part 2).

BACKGROUND: The ability to successfully recruit participants for electronic health (eHealth) clinical trials is largely dependent on the use of efficient and effective recruitment strategies. Determining which types of recruitment strategies to use presents a challenge for many researchers. OBJECTIVE: The aim of this study was to present an analysis of the time-efficiency and cost-effectiveness of recruitment strategies for eHealth clinical trials, and it describes a framework for cost-effective trial recruitment. METHODS: Participants were recruited for one of 5 eHealth trials of interventions for common mental health conditions. A multipronged recruitment approach was used, including digital (eg, social media and Craigslist), research registry-based, print (eg, flyers and posters on public transportation), clinic-based (eg, a general internal medicine clinic within an academic medical center and a large nonprofit health care organization), a market research recruitment firm, and traditional media strategies (eg, newspaper and television coverage in response to press releases). The time costs and fees for each recruitment method were calculated, and the participant yield on recruitment costs was calculated by dividing the number of enrolled participants by the total cost for each method. RESULTS: A total of 777 participants were enrolled across all trials. Digital recruitment strategies yielded the largest number of participants across the 5 clinical trials and represented 34.0% (264/777) of the total enrolled participants. Registry-based recruitment strategies were in second place by enrolling 28.0% (217/777) of the total enrolled participants across trials. Research registry-based recruitment had a relatively high conversion rate from potential participants who contacted our center for being screened to be enrolled, and it was also the most cost-effective for enrolling participants in this set of clinical trials with a total cost per person enrolled at US $8.99. CONCLUSIONS: On the basis of these results, a framework is proposed for participant recruitment. To make decisions on initiating and maintaining different types of recruitment strategies, the resources available and requirements of the research study (or studies) need to be carefully examined.

Harnessing Peer Support in an Online Intervention for Older Adults with Depression.

OBJECTIVE: This pilot study evaluated the feasibility and efficacy of two methods of delivering a cognitive behaviorally informed Internet intervention for depression for adults 65 years and older. METHODS: Forty-seven participants were enrolled and assigned to receive one of two versions of the Internet intervention, either delivered individually (III) or with peer support (II+PS), or to a wait list control group (WLC). Primary outcomes included change in depressive symptoms from baseline to post-intervention (week 8), site use, self-reported usability, and coach time. Secondary outcomes included measures of social support and isolation and anxiety. RESULTS: Follow-up data were provided by 85.1% (40 of 47) of enrolled participants. There were significant differences in depression change across groups (F(2,37) = 3.81, p = 0.03). Greater reductions in depressive symptoms were found for the III (p = 0.02) and II+PS (p = 0.03) compared with WLC, and significantly less coach time was required in the II+PS (p = 0.003). CONCLUSIONS: These results highlight the potential of cognitive-behaviorally informed Internet interventions for older adults with depression, and indicate that peer-supported programs are both acceptable and equivalent to individually delivered Internet interventions. Including peer support may be a viable and potentially more cost-effective option for disseminating online treatments for depression for older adults.

IntelliCare: An Eclectic, Skills-Based App Suite for the Treatment of Depression and Anxiety.

BACKGROUND: Digital mental health tools have tended to use psychoeducational strategies based on treatment orientations developed and validated outside of digital health. These features do not map well to the brief but frequent ways that people use mobile phones and mobile phone apps today. To address these challenges, we developed a suite of apps for depression and anxiety called IntelliCare, each developed with a focused goal and interactional style. IntelliCare apps prioritize interactive skills training over education and are designed for frequent but short interactions. OBJECTIVE: The overall objective of this study was to pilot a coach-assisted version of IntelliCare and evaluate its use and efficacy at reducing symptoms of depression and anxiety. METHODS: Participants, recruited through a health care system, Web-based and community advertising, and clinical research registries, were included in this single-arm trial if they had elevated symptoms of depression or anxiety. Participants had access to the 14 IntelliCare apps from Google Play and received 8 weeks of coaching on the use of IntelliCare. Coaching included an initial phone call plus 2 or more texts per week over the 8 weeks, with some participants receiving an additional brief phone call. Primary outcomes included the Patient Health Questionnaire-9 (PHQ-9) for depression and the Generalized Anxiety Disorder-7 (GAD-7) for anxiety. Participants were compensated up to US $90 for completing all assessments; compensation was not for app use or treatment engagement. RESULTS: Of the 99 participants who initiated treatment, 90.1% (90/99) completed 8 weeks. Participants showed substantial reductions in the PHQ-9 and GAD-7 (P<.001). Participants used the apps an average of 195.4 (SD 141) times over the 8 weeks. The average length of use was 1.1 (SD 2.1) minutes, and 95% of participants downloaded 5 or more of the IntelliCare apps. CONCLUSIONS: This study supports the IntelliCare framework of providing a suite of skills-focused apps that can be used frequently and briefly to reduce symptoms of depression and anxiety. The IntelliCare system is elemental, allowing individual apps to be used or not used based on their effectiveness and utility, and it is eclectic, viewing treatment strategies as elements that can be applied as needed rather than adhering to a singular, overarching, theoretical model. TRIAL REGISTRATION: Clinicaltrials.gov NCT02176226; http://clinicaltrials.gov/ct2/show/NCT02176226 (Archived by WebCite at http://www.webcitation/6mQZuBGk1).

Hospitalization Experiences and Post-traumatic Stress in Inflammatory Bowel Disease: Opportunities for Change.

INTRODUCTION: Medical trauma related to IBD (IBD-PTS) affects approximately 25% of patients and is associated with poor outcomes. Prior studies identify common hospitalization experiences as potentially traumatic but have not measured risk relationships for the development of IBD-PTS. We aim to investigate what aspects of hospitalizations may increase the chance of medical trauma and IBD-PTS development. METHODS: Adult patients with IBD enrolled in the IBD Partners database were recruited. Study specific questionnaires included PTSD checklist, 5th edition (PCL-5), patient experience questionnaire, and items about the patient's most stressful hospitalization and nonhospital sources of medical trauma. Established criteria for the PCL-5 identified significant IBD-PTS symptoms (re-experiencing, avoidance, mood change, hyperarousal, global diagnosis). Select disease and treatment information was obtained from the main IBD Partners dataset. Univariate and multivariate statistics evaluated the relationships between hospitalization data and IBD-PTS. RESULTS: There were 639 participants with at least 1 hospitalization for IBD included. Approximately two-thirds had Crohn's disease; most were White, non-Hispanic, female, middle-aged, and reported their IBD as being in remission. Forty percent of patients stated a hospitalization was a source of IBD-PTS. Frequent anxiety while hospitalized increased the odds of IBD-PTS 2 to 4 times; similar relationships existed for pain/pain control. Higher quality communication, information, and listening skills reduced the odds of IBD-PTS, albeit marginally. CONCLUSIONS: Patients with IBD consistently cite hospitalizations as potential sources of medical trauma. Poorly managed anxiety and pain demonstrate the greatest chance for IBD-PTS development. Gender and racial/ethnic differences emerged for these risks. Positive interactions with the medical team may help mitigate in-hospital IBD-PTS development.

This study finds IBD patients with the poorest hospital experiences and those with poor pain and anxiety control are at the highest risk of developing post-traumatic stress disorder symptoms due to medical trauma. Medical staff behavior is an important consideration.

A randomized noninferiority trial evaluating remotely-delivered stepped care for depression using internet cognitive behavioral therapy (CBT) and telephone CBT.

This trial examined whether a stepped care program for depression, which initiated treatment with internet cognitive behavioral therapy, including telephone and messaging support, and stepped up non-responders to telephone-administered cognitive behavioral therapy (tCBT), was noninferior, less costly to deliver, and as acceptable to patients compared to tCBT alone. Adults with a diagnosis of major depressive episode (MDE) were randomized to receive up to 20 weeks of stepped care or tCBT. Stepped care (n = 134) was noninferior to tCBT (n = 136) with an end-of-treatment effect size of d = 0.03 and a 6-month post-treatment effect size of d = -0.07 [90% CI 0.29 to 0.14]. Therapist time in stepped care was 5.26 (SD = 3.08) hours versus 10.16 (SD 4.01) for tCBT (p < 0.0001), with a delivery cost difference of $-364.32 [95% CI $-423.68 to $-304.96]. There was no significant difference in pre-treatment preferences (p = 0.10) or treatment dropout (39 in stepped care; 27 in tCBT; p = 0.14). tCBT patients were significantly more satisfied than stepped care patients with the treatment they received (p < 0.0001). These findings indicate that stepped care was less costly to deliver, but no less effective than tCBT. There was no significant difference in treatment preference or completion, however satisfaction with treatment was higher in tCBT than stepped care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01906476.

Depression prevalence and treatment among older home health services users in the United States.

OBJECTIVE: The purpose of this study is to provide a nationally representative estimate of the rates of depression and depression treatment, and to explore factors associated with receipt of depression treatment, among older home health services users. METHODS: Older home health services users (n = 1666) were selected from 2008 to 2013 Medical Expenditure Panel Survey. Depression was measured by the Patient Health Questionnaire-2. Depression treatment included antidepressants use and receipt of mental health counseling or psychotherapy. Logistic regression was used to examine the association of individual characteristics and receipt of depression treatment. RESULTS: Current depression affected 23% of older home health services users. Less than 40% of those who screened positive for depression reported receiving depression treatment. Among those who received treatment, virtually all (99.8%) reported receiving antidepressants and only 9.5% reported receiving psychotherapy. Among older home health services users with current depression, older age and non-Hispanic black race were associated with lower odds of receiving depression treatment whereas having cognitive impairment was positively associated with receiving depression treatment. CONCLUSION: Depression affects a substantial proportion of older home health services users and is undertreated. Home health services settings may be important platforms to improve depression care among older adults. Future research is needed to develop optimal strategies for integrating depression assessment and treatment in home health services settings.

Teens Engaged in Collaborative Health: The Feasibility and Acceptability of an Online Skill-Building Intervention for Adolescents at Risk for Depression.

BACKGROUND: There is an ongoing need for effective and accessible preventive interventions for adolescent depression and substance abuse. This paper reports on a field trial of an online indicated preventive intervention, ProjectTECH, which is based on cognitive-behavioral therapy (CBT) techniques. The study aims to gather information about the feasibility and acceptability of this program. Secondary aims of this study were to examine the impact of the program on depression symptoms, perceived stress, positive affect, and substance use and to compare differences between groups that were led by a peer versus those that were led by a licensed clinician. METHODS: High school students (n = 39) were recruited primarily through social media advertisements, and assigned to four groups of 8-12 individuals to collaboratively participate in an 8 week peer network-based online preventive intervention which were led by a trained peer guide or a licensed clinician. Participants were provided with didactic lessons, CBT-based mood management tools, and peer networking features, and completed quantitative and qualitative feedback at baseline, midpoint, end of intervention, and 1 month follow up. RESULTS: The program attracted and retained users primarily from social media and was used frequently by many of the participants (system login M = 25.62, SD = 16.58). Participants rated the program as usable, and offered several suggestions for improving the program, including allowing for further personalization by the individual user, and including more prompts to engage with the social network. From baseline to end of intervention, significant decreases were observed in depressive symptoms and perceived stress (p's < .05). Significant increases in positive affect were observed from baseline to midpoint (p < .05) and no changes were observed in substance use, although the rate of substance use was low in this sample. While this study had low power to detect group differences, no consistent differences were observed between participants in a peer-led group and those in a clinician-led group. CONCLUSIONS: Results of this study indicates that ProjectTECH, an indicated preventive intervention for high school-aged adolescents, demonstrates both feasibility, acceptability, and short-term, longitudinal psychological benefits for participants. Future iterations of the program may benefit from close attention to user interface design and the continued use of trained peer support guides.

Design and evaluation of a peer network to support adherence to a web-based intervention for adolescents.

BACKGROUND: Depression during adolescence is common but can be prevented. Behavioral intervention technologies (BITs) designed to prevent depression in adolescence, especially standalone web-based interventions, have shown mixed outcomes, likely due to poor intervention adherence. BIT research involving adults has shown that the presence of coaches or peers promotes intervention use. Developmentally, adolescence is a time when peer-based social relationships take precedence. This study examines whether peer-networked support may promote adherence to BITs in this age group. OBJECTIVE: Adopting the framework of the Supportive Accountability model, which defines the types of human support and interactions required to maintain engagement and persistence with BITs, this paper presents a feasibility study of a peer-networked online intervention for depression prevention among adolescents. We described the development of the peer network, the evaluation of participant use of the peer networking features, and qualitative user feedback to inform continued BIT development. METHOD: Two groups of adolescents (N = 13) participated in 10-week programs of the peer networked based online intervention. Adolescents had access to didactic lessons, CBT based mood management tools, and peer networking features. The peer networking features are integrated into the site by making use expectations explicit, allow network members to monitor the activities of others, and to supportively hold each other accountable for meeting use expectations. The study collected qualitative feedback from participants as well as usage of site features and tools. RESULTS: Participants logged in an average of 12.8 sessions over an average of 10.4 unique days during the 10-week program. On average, 66% of all use sessions occurred within the first 3 weeks of use. The number of "exchange comments", that is, comments posted that were part of an exchange between two or more participants, was significantly positively correlated with mean time spent on site (r = 0.62, p = 0.032), use of the Activity Tracker (r = 0.70, p = 0.012) and Didactic Lesson (r = 0.73, p = 0.007). Qualitative interviews revealed that adolescents generally liked and were motivated by the peer networking features during the first weeks of the intervention when general site use by group members was high. However, the decrease of site use by group members during the subsequent weeks negatively affected participants' desire to log on or engage with group members. CONCLUSIONS: This pilot study highlights the potential that a BIT designed to harness the connection among a peer network, thereby promoting supportive accountability, may improve adolescent adherence to BITs for depression prevention.

Uptake and Usage of IntelliCare: A Publicly Available Suite of Mental Health and Well-Being Apps.

BACKGROUND: Treatments for depression and anxiety have several behavioral and psychological targets and rely on varied strategies. Digital mental health treatments often employ feature-rich approaches addressing several targets and strategies. These treatments, often optimized for desktop computer use, are at odds with the ways people use smartphone applications. Smartphone use tends to focus on singular functions with easy navigation to desired tools. The IntelliCare suite of apps was developed to address the discrepancy between need for diverse behavioral strategies and constraints imposed by typical app use. Each app focuses on one strategy for a limited subset of clinical aims all pertinent to depression and anxiety. This study presents the uptake and usage of apps from the IntelliCare suite following an open deployment on a large app marketplace. METHODS: Thirteen lightweight apps, including 12 interactive apps and one Hub app that coordinates use across those interactive apps, were developed and made free to download on the Google Play store. De-identified app usage data from the first year of IntelliCare suite deployment were analyzed for this study. RESULTS: In the first year of public availability, 5,210 individuals downloaded one or more of the IntelliCare apps, for a total of 10,131 downloads. Nearly a third of these individuals (31.8%) downloaded more than one of these apps. The modal number of launches for each of the apps was 1, however the mean number of app launches per app ranged from 3.10 to 16.98, reflecting considerable variability in the use of each app. CONCLUSIONS: The use rate of the IntelliCare suite of apps is higher than public deployments of other comparable digital resources. Our findings suggest that people will use multiple apps and provides support for the concept of app suites as a useful strategy for providing diverse behavioral strategies.