The Digital Navigator: Standardizing Human Technology Support in App-Integrated Clinical Care.

Background: Mental health apps offer scalable care, yet clinical adoption is hindered by low user engagement and integration challenges into clinic workflows. Human support staff called digital navigators, trained in mental health technology, could enhance care access and patient adherence and remove workflow burdens from clinicians. While the potential of this role is clear, training staff to become digital navigators and assessing their impact are primary challenges. Methods: We present a detailed manual/framework for implementation of the Digital Navigator within a short-term, cognitive-behavioral therapy-focused hybrid clinic. We analyze patient engagement, satisfaction, and digital phenotyping data quality outcomes. Data from 83 patients, for the period spanning September 2022 to September 2023, included Digital Navigator satisfaction, correlated with demographics, mindLAMP app satisfaction, engagement, and passive data quality. Additionally, average passive data across 33 clinic patients from November 2023 to January 2024 were assessed for missingness. Results: Digital Navigator satisfaction averaged 18.8/20. Satisfaction was not influenced by sex, race, gender, or education. Average passive data quality across 33 clinic patients was 0.82 at the time this article was written. Digital Navigator satisfaction scores had significant positive correlation with both clinic app engagement and perception of that app. Conclusions: Results demonstrate preliminary support and patient endorsement for the Digital Navigator role and positive outcomes around digital engagement and digital phenotyping data quality. Through sharing training resources and standardizing the role, we aim to enable clinicians and researchers to adapt and utilize the Digital Navigator for their own needs.

Racial and Ethnic Differences in Bullying: Review and Implications for Intervention.

Despite increased research on bullying over the past few decades, researchers still have little understanding of how bullying differentially affects racial and ethnic minority and immigrant youth. To facilitate efforts to better evaluate the impact of bullying among racial and ethnic minority youth and improve interventions, we integrated research from multiple disciplines and conducted a systematic search to review relevant cross-cultural research on the prevalence of bullying, risk and protective factors, and differences in behaviors and outcomes associated with bullying in these populations. Studies measuring differences in bullying prevalence by racial and ethnic groups are inconclusive, and discrepancies in findings may be explained by differences in how bullying is measured and the impact of school and social environments. Racial and ethnic minorities and immigrants are disproportionately affected by contextual-level risk factors associated with bullying (e.g., adverse community, home, and school environments), which may moderate the effects of individual-level predictors of bullying victimization or perpetration (e.g., depressive symptoms, empathy, hostility, etc.) on involvement and outcomes. Minority youth may be more likely to perpetrate bullying, and are at much higher risk for poor health and behavioral outcomes as a result of bias-based bullying. At the same time, racial and ethnic minorities and immigrants may be protected against bullying involvement and its negative consequences as a result of strong ethnic identity, positive cultural and family values, and other resilience factors. Considering these findings, we evaluate existing bullying interventions and prevention programs and propose directions for future research.

Social connectedness, stressful life events, and self-injurious thoughts and behaviors among young adults.

OBJECTIVES: Preventing self-injurious thoughts and behaviors (SITBs) is particularly challenging on commuter campuses, given lower social cohesion and higher levels of stress than among traditional college populations. The present study examined the relationship between stressful life events (SLEs) and risk for different forms of SITBs, along with the potential buffering role of social connectedness, in a diverse sample of young adults from a commuter college. METHODS: Participants were 1712 (81% female; 61% racial/ethnic minority; 20% sexual minority) undergraduate and graduate students from a public commuter college in New York City. Participants completed an anonymous survey that inquired about lifetime and recent (past 12months) history of suicidal ideation, suicide attempts, and non-suicidal self-injury (NSSI), along with social connectedness and lifetime history of SLEs. RESULTS: Lower levels of social connectedness and exposure to a higher number of SLEs were associated with engaging in SITBs in the past year, particularly both suicide attempts and non-suicidal self-injury. However, social connectedness did not buffer against the impact of SLEs on SITBs. LIMITATIONS: Data are cross-sectional, limiting conclusions about directionality, and females were overrepresented. CONCLUSIONS: Identifying ways to increase social connectedness on diverse commuter campuses may help decrease risk of SITBs. However, it may not buffer against the impact of SLEs on risk of SITBs. Future studies should examine contextual variables (e.g., type and timing of social support) that may play a role in protecting against SITBs, particularly for those with a history of adversity.

Positive future-oriented fantasies and depressive symptoms: Indirect relationship through brooding.

Although a positive future outlook is generally associated with psychological well-being, indulging in positive fantasies about the future has been found to exacerbate negative mood-related outcomes such as depressive symptoms. We examined rumination as a cognitive mechanism in this relationship, using an objectively coded measure of future-oriented fantasies, among 261 young adults assessed twice. Engaging in a positive fantasy about the future was associated with the brooding subtype of rumination but not with reflection at baseline. There was an indirect relationship between fantasies at baseline and depressive symptoms at six-week follow-up through brooding at average and high levels of fantasy positivity when fantasizing was consistent or increased over time but not when it decreased. Engaging in fantasies was indirectly associated with perceived difficulty anticipating likely positive future outcomes through brooding. These findings extend previous research on positive fantasies by suggesting brooding as a mechanism to explain when they are maladaptive.

The impact of mindfulness apps on psychological processes of change: a systematic review.

Mindfulness-based interventions (MBIs) have demonstrated therapeutic efficacy for various psychological conditions, and smartphone apps that facilitate mindfulness practice can enhance the reach and impact of MBIs. The goal of this review was to summarize the published evidence on the impact of mindfulness apps on the psychological processes known to mediate transdiagnostic symptom reduction after mindfulness practice. A literature search from January 1, 1993, to August 7, 2023 was conducted on three databases, and 28 randomized controlled trials involving 5963 adults were included. Across these 28 studies, 67 outcome comparisons were made between a mindfulness app group and a control group. Between-group effects tended to favor the mindfulness app group over the control group in three psychological process domains: repetitive negative thinking, attention regulation, and decentering/defusion. Findings were mixed in other domains (i.e., awareness, nonreactivity, non-judgment, positive affect, and acceptance). The range of populations examined, methodological concerns across studies, and problems with sustained app engagement likely contributed to mixed findings. However, effect sizes tended to be moderate to large when effects were found, and gains tended to persist at follow-up assessments two to six months later. More research is needed to better understand the impact of these apps on psychological processes of change. Clinicians interested in integrating apps into care should consider app-related factors beyond evidence of a clinical foundation and use app databases to identify suitable apps for their patients, as highlighted at the end of this review.

Social determinants of mental health in major depressive disorder: Umbrella review of 26 meta-analyses and systematic reviews.

There is a growing recognition of the impact of social determinants of mental health (SDoMHs) on people with, or at risk of, developing serious mental illnesses. Yet it is not known how associations of individual SDoMHs with risk for major depressive disorder (MDD) vary and roughly compare with one another. Following PRISMA guidelines, this umbrella review included 26 meta-analyses and systematic reviews that reported odds ratios, effect sizes, and/or pooled prevalence rates of MDD in samples with versus without specified SDoMHs. Childhood emotional, physical, or sexual abuse and neglect; intimate partner violence in females; and food insecurity were significantly associated with increased risk of MDD, with medium effect sizes. Natural disasters, terrorist acts, and military combat during deployment had small-size adverse effects, and homelessness, incarceration, and migration were associated with significantly elevated prevalence of MDD. Conversely, higher levels of parental care were significantly associated with reduced risk of MDD with medium effect sizes. Evidence supports the use of certain interventions at the individual and community level that can reduce the impact of these factors and promote health, although much more research is warranted in this area along with meaningful healthcare and societal policies to accomplish this goal.

Content and Process of Adolescent Suicide Ideation: Implications for Risk Assessment.

This study examined differences in the content and process of suicide ideation between adolescents presenting with recent suicide ideation or a suicide attempt in clinical settings. Across two combined study samples, adolescents (N = 229; 79% female; 73% Hispanic/Latine), ages 12-19, presenting with a recent suicide attempt, recent suicide ideation with a past suicide attempt history, or recent suicide ideation with no past suicide attempt history were interviewed in detail about the process and content of their suicide ideation. The group with suicide ideation and a past suicide attempt more often reported that their recent ideation lasted greater than 4 h compared to those with suicide ideation but no past suicide attempt history. The suicide attempt group more often considered ingestion as their first method of attempt, compared to the other two suicide ideation groups, and less often considered "other" methods (e.g., jumping from a height or onto train/traffic, hanging). Wish to die was lower in the ideation-only group, compared to both other groups. Separate analyses from Study 2 suggested that the majority of adolescents' suicide ideation contained imagery; however, a higher proportion of adolescents with suicide ideation and a past suicide attempt reported imagery in their ideation than those with ideation but no past attempt. Understanding what adolescents think about when they consider suicide and how they think about it may be informative about risk of a suicide attempt.

Skills to Enhance Positivity in adolescents at risk for suicide: Protocol for a randomized controlled trial.

BACKGROUND: Suicide and suicidal behavior during adolescence have been steadily increasing over the past two decades. The preponderance of interventions focuses on crisis intervention, underlying psychiatric disorders, regulating negative affect, and reducing cognitive distortions. However, low positive affectivity may be a mechanism that contributes to adolescent suicidal ideation and behaviors independent of other risk factors. Skills to Enhance Positivity (STEP) is an acceptance-based intervention, designed to increase attention to, and awareness of, positive affect and positive experiences. Results from a pilot RCT demonstrated engagement of the target (positive affect) and a decrease in clinical outcomes (suicidal events; i.e., either a suicide attempt or an emergency intervention for an acute suicidal crisis), providing support to test the clinical effectiveness of STEP in a larger clinical trial with clinical staff implementing the intervention. OBJECTIVE: To test the effectiveness of STEP, compared to Enhanced Treatment as Usual (ETAU), in reducing suicidal events and ideation in adolescents admitted to inpatient psychiatric care due to suicide risk. We hypothesize that those randomized to STEP, compared to ETAU, will have lower rates of suicide events, active suicidal ideation (SI), and depressed mood over the 6-month follow-up period. We hypothesize that those randomized to STEP, compared to ETAU, will demonstrate greater improvement in the hypothesized mechanisms of attention to positive affect stimuli and gratitude and satisfaction with life. METHODS: Participants will be randomized to either STEP or ETAU. STEP consists of four in-person sessions focused on psychoeducation regarding positive and negative affect, mindfulness meditation, gratitude, and savoring. Mood monitoring prompts and skill reminders will be sent via text messaging daily for the first month post-discharge and every other day for the following two months. The ETAU condition will receive text-delivered reminders to use a safety plan provided at discharge from the hospital and healthy habits messages, matched in frequency to the STEP group. This trial was registered on 6 August 2021 (ClinicalTrials.gov NCT04994873). RESULTS: The STEP protocol was approved by the National Institute of Mental Health (NIMH) Data and Safety Monitoring Board on March 4, 2022. The RCT is currently in progress. DISCUSSION: The STEP protocol is an innovative, adjunctive treatment that has the potential to have positive effects on adolescent suicidal ideation and attempts beyond that found for standard treatment alone.

Early Life Trauma, Suicide Ideation, and Suicide Attempts: The Role of Rumination and Impulsivity.

Suicide is the second leading cause of death for young adults in the United States. One of the many risk factors for suicide includes exposure to early life trauma. The present study examined whether rumination and impulsivity play a role in the relationship between early life trauma and increased risk for suicidal behavior (i.e., suicide ideation and suicide attempts) among 426 young adults. Early life trauma was associated with brooding, reflective rumination, and impulsivity in the form of negative urgency. Current or recent suicide ideators self-reported greater early life trauma, ruminative thinking, and impulsivity than non-ideators and non-attempters. Further, a multinomial logistic regression found that early life trauma, reflection, lack of premeditation, and lack of perseverance were associated with higher odds of reporting suicide ideation in the previous 6 months. We also found indirect relationships between early life trauma and suicide ideation through brooding or reflection and lack of perseverance in serial mediation analyses. These findings suggest that early life trauma may increase risk of suicide ideation to the degree that it leads to ruminative thinking and lack of follow-through with difficult tasks. How early life trauma might increase risk for ruminative thinking, impulsivity, and subsequent suicidal behavior is discussed.