AI-Led Mental Health Support (Wysa) for Health Care Workers During COVID-19: Service Evaluation.

BACKGROUND: The impact that the COVID-19 pandemic has had on health care workers' mental health, in particular, cannot be ignored. Not only did the pandemic exacerbate mental health challenges through elevated stress, anxiety, risk of infection, and social isolation, but regulations to minimize infection additionally hindered the conduct of traditional in-person mental health care. OBJECTIVE: This study explores the feasibility of using Wysa, an artificial intelligence-led mental health app, among health care workers. METHODS: A national tertiary health care cluster in Singapore piloted the use of Wysa among its own health care workers to support the management of their mental well-being during the pandemic (July 2020-June 2022). The adoption of this digital mental health intervention circumvented the limitations of in-person contact and enabled large-scale access to evidence-based care. Rates and patterns of user engagement were evaluated. RESULTS: Overall, the opportunity to use Wysa was well-received. Out of the 527 staff who were onboarded in the app, 80.1% (422/527) completed a minimum of 2 sessions. On average, users completed 10.9 sessions over 3.80 weeks. The interventions most used were for sleep and anxiety, with a strong repeat-use rate. In this sample, 46.2% (73/158) of health care workers reported symptoms of anxiety (Generalized Anxiety Disorder Assessment-7 [GAD-7]), and 15.2% (24/158) were likely to have symptoms of depression (Patient Health Questionnaire-2 [PHQ-2]). CONCLUSIONS: Based on the present findings, Wysa appears to strongly engage those with none to moderate symptoms of anxiety. This evaluation demonstrates the viability of implementing Wysa as a standard practice among this sample of health care workers, which may support the use of similar digital interventions across other communities.

Digital health in fragile states in the Middle East and North Africa (MENA) region: A scoping review of the literature.

INTRODUCTION: Conflict, fragility and political violence, that are taking place in many countries in the Middle East and North Africa (MENA) region have devastating effects on health. Digital health technologies can contribute to enhancing the quality, accessibility and availability of health care services in fragile and conflict-affected states of the MENA region. To inform future research, investments and policy processes, this scoping review aims to map out the evidence on digital health in fragile states in the MENA region. METHOD: We conducted a scoping review following the Joanna Briggs Institute (JBI) guidelines. We conducted descriptive analysis of the general characteristics of the included papers and thematic analysis of the key findings of included studies categorized by targeted primary users of different digital health intervention. RESULTS: Out of the 10,724 articles identified, we included 93 studies. The included studies mainly focused on digital health interventions targeting healthcare providers, clients and data services, while few studies focused on health systems or organizations managers. Most of the included studies were observational studies (49%). We identified no systematic reviews. Most of the studies were conducted in Lebanon (32%) followed by Afghanistan (13%) and Palestine (12%). The first authors were mainly affiliated with institutions from countries outside the MENA region (57%), mainly United Kingdom and United States. Digital health interventions provided a platform for training, supervision, and consultation for health care providers, continuing education for medical students, and disease self-management. The review also highlighted some implementation considerations for the adoption of digital health such as computer literacy, weak technological infrastructure, and privacy concerns. CONCLUSION: This review showed that digital health technologies can provide promising solutions in addressing health needs in fragile and conflict-affected states. However, rigorous evaluation of digital technologies in fragile settings and humanitarian crises are needed to inform their design and deployment.

Understanding Digital Mental Health Needs and Usage With an Artificial Intelligence-Led Mental Health App (Wysa) During the COVID-19 Pandemic: Retrospective Analysis.

BACKGROUND: 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. OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Evaluating a Digital Mental Health Intervention (Wysa) for Workers' Compensation Claimants: Pilot Feasibility Study.

OBJECTIVE: This study examines the feasibility and acceptability of an AI-led digital mental health intervention in a Workers' Compensation (WC) program, Wysa for Return to Work. METHODS: Self-reported demographic data and responses to psychosocial screening questions were analyzed alongside participants' app usage through which four key outcomes were measured: recruitment rate, onboarding rate, retention, and engagement. RESULTS: The data demonstrated a high need for psychosocial interventions among injured workers, especially women, young adults, and those with high severity injuries. Those with more psychosocial risk factors had a higher rate of onboarding, retention, and engagement, and those with severe injuries had higher retention. CONCLUSIONS: Our study concluded that Wysa for Return to Work, the AI-led digital mental health intervention that delivers a recovery program using a digital conversational agent, is feasible and acceptable for a return-to-work population.

Adherence and Engagement With a Cognitive Behavioral Therapy-Based Conversational Agent (Wysa for Chronic Pain) Among Adults With Chronic Pain: Survival Analysis.

BACKGROUND: Digital applications are commonly used to support mental health and well-being. However, successfully retaining and engaging users to complete digital interventions is challenging, and comorbidities such as chronic pain further reduce user engagement. Digital conversational agents (CAs) may improve user engagement by applying engagement principles that have been implemented within in-person care settings. OBJECTIVE: To evaluate user retention and engagement with an artificial intelligence-led digital mental health app (Wysa for Chronic Pain) that is customized for individuals managing mental health symptoms and coexisting chronic pain. METHODS: In this ancillary survival analysis of a clinical trial, participants included 51 adults who presented to a tertiary care center for chronic musculoskeletal pain, who endorsed coexisting symptoms of depression or anxiety (Patient-Reported Outcomes Measurement Information System score of ≥55 for depression or anxiety), and initiated onboarding to an 8-week subscription of Wysa for Chronic Pain. The study outcomes were user retention, defined as revisiting the app each week and on the last day of engagement, and user engagement, defined by the number of sessions the user completed. RESULTS: Users engaged in a cumulative mean of 33.3 sessions during the 8-week study period. The survival analysis depicted a median user retention period (i.e., time to complete disengagement) of 51 days, with the usage of a morning check-in feature having a significant relationship with a longer retention period (P=.001). CONCLUSIONS: Our findings suggest that user retention and engagement with a CBT-based CA built for users with chronic pain is higher than standard industry metrics. These results have clear implications for addressing issues of suboptimal engagement of digital health interventions and improving access to care for chronic pain. Future work should use these findings to inform the design of evidence-based interventions for individuals with chronic pain and to enhance user retention and engagement of digital health interventions more broadly. TRIAL REGISTRATION: ClinicalTrials.gov NCT04640090; https://clinicaltrials.gov/ct2/show/NCT04640090.

Evaluating the Therapeutic Alliance With a Free-Text CBT Conversational Agent (Wysa): A Mixed-Methods Study.

The present study aims to examine whether users perceive a therapeutic alliance with an AI conversational agent (Wysa) and observe changes in the t'herapeutic alliance over a brief time period. A sample of users who screened positively on the PHQ-4 for anxiety or depression symptoms (N = 1,205) of the digital mental health application (app) Wysa were administered the WAI-SR within 5 days of installing the app and gave a second assessment on the same measure after 3 days (N = 226). The anonymised transcripts of user's conversations with Wysa were also examined through content analysis for unprompted elements of bonding between the user and Wysa (N = 950). Within 5 days of initial app use, the mean WAI-SR score was 3.64 (SD 0.81) and the mean bond subscale score was 3.98 (SD 0.94). Three days later, the mean WAI-SR score increased to 3.75 (SD 0.80) and the mean bond subscale score increased to 4.05 (SD 0.91). There was no significant difference in the alliance scores between Assessment 1 and Assessment 2.These mean bond subscale scores were found to be comparable to the scores obtained in recent literature on traditional, outpatient-individual CBT, internet CBT and group CBT. Content analysis of the transcripts of user conversations with the CA (Wysa) also revealed elements of bonding such as gratitude, self-disclosed impact, and personification. The user's therapeutic alliance scores improved over time and were comparable to ratings from previous studies on alliance in human-delivered face-to-face psychotherapy with clinical populations. This study provides critical support for the utilization of digital mental health services, based on the evidence of the establishment of an alliance.

Understanding People With Chronic Pain Who Use a Cognitive Behavioral Therapy-Based Artificial Intelligence Mental Health App (Wysa): Mixed Methods Retrospective Observational Study.

BACKGROUND: Digital health interventions can bridge barriers in access to treatment among individuals with chronic pain. OBJECTIVE: This study aimed to evaluate the perceived needs, engagement, and effectiveness of the mental health app Wysa with regard to mental health outcomes among real-world users who reported chronic pain and engaged with the app for support. METHODS: Real-world data from users (N=2194) who reported chronic pain and associated health conditions in their conversations with the mental health app were examined using a mixed methods retrospective observational study. An inductive thematic analysis was used to analyze the conversational data of users with chronic pain to assess perceived needs, along with comparative macro-analyses of conversational flows to capture engagement within the app. Additionally, the scores from a subset of users who completed a set of pre-post assessment questionnaires, namely Patient Health Questionnaire-9 (PHQ-9) (n=69) and Generalized Anxiety Disorder Assessment-7 (GAD-7) (n=57), were examined to evaluate the effectiveness of Wysa in providing support for mental health concerns among those managing chronic pain. RESULTS: The themes emerging from the conversations of users with chronic pain included health concerns, socioeconomic concerns, and pain management concerns. Findings from the quantitative analysis indicated that users with chronic pain showed significantly greater app engagement (P<.001) than users without chronic pain, with a large effect size (Vargha and Delaney A=0.76-0.80). Furthermore, users with pre-post assessments during the study period were found to have significant improvements in group means for both PHQ-9 and GAD-7 symptom scores, with a medium effect size (Cohen d=0.60-0.61). CONCLUSIONS: The findings indicate that users look for tools that can help them address their concerns related to mental health, pain management, and sleep issues. The study findings also indicate the breadth of the needs of users with chronic pain and the lack of support structures, and suggest that Wysa can provide effective support to bridge the gap.

Delivery of a Mental Health Intervention for Chronic Pain Through an Artificial Intelligence-Enabled App (Wysa): Protocol for a Prospective Pilot Study.

BACKGROUND: Patients with chronic pain often experience coexisting, long-term and debilitating mental health comorbidities such as depression and anxiety. Artificial intelligence-supported cognitive behavioral therapy (AI-CBT) interventions could offer cost-effective, accessible, and potentially effective resources to address this problem. However, there is not enough research conducted about the efficacy of AI-CBT interventions for chronic pain. OBJECTIVE: This prospective cohort study aims to examine the efficacy and use of an AI-CBT intervention for chronic pain (Wysa for Chronic Pain app, Wysa Inc) using a conversational agent (with no human intervention). To the best of our knowledge, this is the first such study for chronic pain using a fully-automated, free-text-based conversational agent. METHODS: Participants with self-reported chronic pain (n=500) will be recruited online on a rolling basis from April 2022 through posts on US-based internet communities within this prospective cohort. Informed consent is received from participants within the app, and the Wysa for Chronic Pain intervention is delivered remotely for 8 weeks. Outcome measures including a numeric pain rating scale and Patient-Reported Outcomes Measurement Information System-Pain Interference, Generalized Anxiety Disorder-7, and Patient Health Questionnaire-9 questionnaires administered to test the effectiveness of the intervention on reducing levels of pain interference, depression, and anxiety. The therapeutic alliance created with the conversational agent will be assessed through the Working Alliance Inventory-Short Revised instrument. Retention and use statistics will be observed for adherence and engagement. RESULTS: The study will open for recruitment in April 2022, and data collection is expected to be completed by August 2022. The results for the primary outcomes are expected to be published by late 2022. CONCLUSIONS: Mental health conversational agents driven by artificial intelligence could be effective in helping patients with chronic pain learn to self-manage their pain and common comorbidities like depression and anxiety. The Wysa for Chronic Pain app is one such digital intervention that can potentially serve as a solution to the problems of affordability and scalability associated with interventions that include a human therapist. This prospective study examines the efficacy of the app as a treatment solution for chronic pain. It aims to inform future practices and digital mental health interventions for individuals with chronic pain. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/36910.

Evaluating User Feedback for an Artificial Intelligence-Enabled, Cognitive Behavioral Therapy-Based Mental Health App (Wysa): Qualitative Thematic Analysis.

BACKGROUND: Digital 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. OBJECTIVE: This 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. METHODS: This 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. RESULTS: The 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. CONCLUSIONS: Users 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.

A systematic approach to equity assessment for digital health interventions: case example of mobile personal health records.

Despite the increasing number of digital health interventions in low- and middle-income countries and other low-resource settings, little attention has been paid to systematically evaluating impacts of these interventions on health equity. In this article, we present a systematic approach for assessing equity impacts of digital health interventions modeled after the Health Equity Impact Assessment of the Ontario Ministry of Health and Long-Term Care. The assessment approach has 4 steps that address (1) scope, (2) potential equity impacts, (3) mitigation, (4) monitoring, and (5) dissemination strategies. The approach examines impacts on vulnerable and marginalized populations and considers various social determinants of health. Equity principles outlined by Whitehead and Dahlgren are used to ensure systematic considerations of all potential equity impacts. The digital health evaluation approach that is presented is applied to a case example of mobile personal health record application in Kenya.

Digital health, gender and health equity: invisible imperatives.

A growing body of evidence shows the use of digital technologies in health-referred to as eHealth, mHealth or 'digital health'-is improving and saving lives in low- and middle-income countries. Despite this prevalent and persistent narrative, very few studies examine its effects on health equity, gender and power dynamics. This journal supplement addresses these invisible imperatives by going beyond traditional measures of coverage, efficacy and cost-effectiveness associated with digital health interventions, to unpack different experiences of health workers and beneficiaries. The collection of papers presents findings from a cohort of implementation research projects in Africa, Asia, Latin America and the Middle East, and two commentaries offer observations from learning-oriented evaluative activities across the entire cohort. The story emerging from this cohort is comprised of three themes: (i) digital health can positively influence health equity; (ii) gender and power analyses are essential; and (iii) digital health can be used to strengthen upward and downward accountability. These findings, at the individual project level and at the level of the cohort, provide encouraging recommendations on how to approach the design, implementation and evaluation of digital health interventions to address the Sustainable Development Goals agenda of leaving no one behind.

Behavioral and neurochemical effects induced by pyrethroid-based mosquito repellent exposure in rat offsprings during prenatal and early postnatal period.

Synthetic pyrethroids, besides their use in agriculture, are prevalently used in our houses as mosquito repellent (MR) in the form of aerosol, mats, coils and liquid vaporizers. Inhalation of fumes of the MR/liquid vaporizers may get entry into the brain by breaching the developing blood-brain barrier, hence deleterious to developing nervous system and can lead to long-term functional deficits. In the present study the consequence of MR exposure has further been investigated at various stages of development, evaluating free radical mediated effect pertinent to neurobehavioral and neurochemical functioning. Rat pups were exposed to pyrethroid-based MR (allethrin 3.6% w/v, 8 h/day through inhalation) during prenatal (GD1-20), postnatal (PND1-30) and perinatal (GD1-PND30) period of development and assessments were made on PND31. We observed significant oxidative stress, where an increase in lipid peroxidation and a decrease in antioxidants, glutathione, superoxide dismutase and catalase in various brain areas (cerebellum, corpus striatum, frontal cortex and hippocampus) were evident at all the exposure schedules. The hippocampus was the most affected region and further exhibited altered cholinergic functioning in the form of significant decrease in cholinergic (muscarinic) receptor binding (prenatal 32%, postnatal 35%, perinatal 38%) and inhibition in acetylcholinesterase activity (prenatal 20%, postnatal 31% and perinatal 33%). The neurochemical changes were found to accompany decrease in learning and memory performance in exposed rats, the function governed by hippocampus. The result suggests that pyrethroid-based MR inhalation during early developmental period may have adverse effect on developing nervous system causing cholinergic dysfunction leading to learning and memory deficit.

Species variation in pesticide-induced blood-brain barrier dysfunction.

Neurological disorders following acute or chronic exposure to pesticides have been reported in a number of human cases. However, the mechanism(s) by which pesticides produce central nervous system dysfunction is not clear. The objective of the present study was to examine the functional status of blood-brain barrier (BBB) in rats and mice exposed to selected pesticides of different chemical groups. Adult male albino rats and mice were exposed (1/10 of LD50) daily to dichlorvos (organophosphate), lindane (organochlorine) and carbofuran (carbamate) through oral intubation for 3 days. The status of BBB was evaluated by determining brain sodium fluorescein dye uptake and brain uptake index (BUI) in relation to serum dye level. The brain dye uptake and BUI in pesticide-exposed rats did not differ significantly in comparison to that of controls. However, brain dye uptake and BUI were increased significantly in mice exposed to dichlorvos (85%, 40%), lindane (79%, 26%) and carbofuran (129%, 61%). The results of this study show that mouse BBB system is more sensitive to pesticide-induced breach as compared to that of rat. These variations may have a role in determining the outcome of pesticide neurotoxicity in different species.