Effects of Actissist, a digital health intervention for early psychosis: A randomized clinical trial.

Schizophrenia affects 24 million people worldwide. Digital health interventions drawing on psychological principles have been developed, but their effectiveness remains unclear. This parallel, assessor-blinded, randomized clinical trial aimed to investigate whether a cognitive behaviour therapy-informed digital health intervention (Actissist app) confers added benefit on psychotic symptoms over and above remote symptom monitoring (ClinTouch app). Participants recruited from UK community health services were randomized 1:1 to receive either Actissist plus treatment as usual (TAU) or ClinTouch plus TAU. Eligible participants were adults with schizophrenia-spectrum psychosis within five years of first episode onset meeting a criterion level of positive symptoms severity. The primary outcome was Positive and Negative Syndrome Scale (PANSS) symptoms total score at 12 weeks post-randomization. Intention-to-treat analysis included 172 participants, with 149 participants (86.6 %) providing primary outcome data. Actissist plus TAU was not associated with greater reduction than an active control remote symptom monitoring app (ClinTouch) in PANSS total score at post-randomization. There were no significant effects between groups across secondary measures. There were no serious adverse reactions. Both groups improved on the primary psychotic symptoms measure at primary end-point and on secondary measures over time. The Actissist app is safe but not superior to digital symptom monitoring.

Technology use and attitudes towards digital mental health in people with severe mental health problems: a survey study in China.

Introduction: Digital mental health is a promising solution to support people with severe mental health problems (SMI) in China. However, little is known about the ownership rate of digital technologies and attitudes towards utilising digital health technologies (DHTs) among people with SMI in the Chinese context. The aims of this study were to understand: (i) digital technology ownership and usage rate of people with SMI in China; (ii) attitudes toward DHTs in mental health services; and (iii) how the COVID-19 pandemic has influenced views on digital mental health. Methods: A cross-sectional survey was given to outpatients with SMI using the REDCap platform. To capture a diverse sample of people with SMI, the survey was distributed across psychiatric hospitals, general hospitals with a psychiatric unit, secondary hospitals, and community healthcare centres. Results: In total, 447 survey respondents completed the survey. Relative high ownership rates of digital technologies were found, with smartphone ownership (95.5%) and access to the internet (82.1%) being the highest technologies reported. However, less than half of respondents reported frequent health-related usage of digital technologies, which may be related to the lack of knowledge in using DHTs. Most respondents found DHTs being useful for access to mental health services during the pandemic and were willing to use DHTs after the pandemic. Discussion: Our data suggest that, despite the high ownership rate of digital technologies, training programmes to improve digital health literacy for people with SMI in China are necessary to realise the full potential of digital mental health.

Digital tools to support mental health: a survey study in psychosis.

BACKGROUND: There is a notable a gap between promising research findings and implementation of digital health tools. Understanding and addressing barriers to use is key to widespread implementation. METHODS: A survey was administered to a self-selecting sample in-person (n = 157) or online (n = 58), with questions examining: i) ownership and usage rates of digital devices among people with psychosis; ii) interest in using technology to engage with mental health services; and iii) facilitators of and barriers to using digital tools in a mental healthcare context. RESULTS: Device ownership: Virtually all participants owned a mobile phone (95%) or smartphone (90%), with Android phones slightly more prevalent than iPhones. Only a minority owned a fitness tracker (15%) or smartwatch (13%). Device ownership was significantly lower in unemployed people and those without secondary education. Device cost and paranoid ideation were barriers to ownership. Technology and mental health services: Most participants (88%) said they would willingly try a mental health app. Symptom monitoring apps were most popular, then appointment reminders and medication reminders. Half the sample would prefer an app alongside face-to-face support; the other half preferred remote support or no other mental health support. Facilitators: Participants thought using a mental health app could increase their understanding of psychosis generally, and of their own symptoms. They valued the flexibility of digital tools in enabling access to support anywhere, anytime. Barriers: Prominent barriers to using mental health apps were forgetting, lack of motivation, security concerns, and concerns it would replace face-to-face care. Overall participants reported no substantial effects of technology on their mental health, although a quarter said using a phone worsened paranoid ideation. A third used technology more when psychotic symptoms were higher, whereas a third used it less. Around half used technology more when experiencing low mood. CONCLUSIONS: Our findings suggest rapidly increasing device ownership among people with psychosis, mirroring patterns in the general population. Smartphones appear appropriate for delivering internet-enabled support for psychosis. However, for a sub-group of people with psychosis, the sometimes complex interaction between technology and mental health may act as a barrier to engagement, alongside more prosaic factors such as forgetting.

Exploring engagement with the CBT-informed Actissist smartphone application for early psychosis.

BACKGROUND: Individuals with psychosis report favourable attitudes towards psychological interventions delivered via smartphone apps. Evidence for acceptability, safety, feasibility and efficacy is promising but in-depth reporting of app engagement in trials is sparse. AIMS: To examine how people with psychosis engaged with the cognitive behaviour therapy (CBT)-informed Actissist app over a 12-week intervention period, and to examine factors associated with app engagement. METHODS: Secondary data from participants in the intervention arm (n = 24) of a proof-of-concept randomised controlled trial of the Actissist app were analysed. The app prompted participants to engage with app-based CBT-informed material in five domains (voices, socialization, cannabis use, paranoia, perceived criticism) at pseudo-random intervals (three notifications per day, six days per week). Participants could self-initiate use any time. App use was financially incentivised. RESULTS: Participants responded to 47% of app notifications. Most app engagements (87%) were app-initiated rather than self-initiated. Participants engaged most with the voices domain, then paranoia. Age and employment status were significantly associated with overall app engagement. CONCLUSION: Individuals with psychosis engaged well with Actissist, particularly with areas focussing on voice-hearing and paranoia. App-generated reminders successfully prompted app engagement. As financial incentives may have increased app engagement, future studies of non-incentivized engagement in larger samples are needed.

Mental health professionals views and the impact of COVID-19 pandemic on implementing digital mental health in China: A nationwide survey study.

Background: Using digital health technologies (DHTs) to deliver and augment healthcare is an innovative way to solve common challenges that the mental healthcare setting faces. Despite China's rapid development of DHT, a comprehensive understanding of staff views of DHTs is lacking, which limited the evidence to support implementation strategies. In the current study, we aim to: (i) investigate staff attitudes towards digital technology for mental health problems in China; (ii) explore staff's views on the facilitators and barriers regarding uptake and adoption of digital technology in mental health services in China; and (iii) understand how the COVID-19 pandemic has changed staff views on digital mental health. Methods: An online survey was conducted to explore staff attitudes towards implementing DHTs in China. Descriptive statistics were conducted to summarise quantitative data. Free-text data were analysed using qualitative content analysis. Results: 1270 mental health professionals completed the survey. Respondents reported low levels of knowledge of DHTs and moderate levels of accessibility of DHTs in their hospitals. Respondents expressed positive attitudes towards DHTs and demonstrated moderate levels of perceived feasibility and acceptability of implementing DHTs in clinical services. As expected, respondents reported that the COVID-19 pandemic caused significant impacts on their clinical services, and almost all respondents deemed DHTs useful for services provision during the pandemic and were willing to apply such technologies in clinical services after the pandemic. Conclusions: Despite the Chinese mental health staff expressed positive attitudes towards implementing DHTs in clinical practice, most of the staff lacked sufficient knowledge to provide such services. These findings highlight the need to develop implementation strategies such as training programmes and dissemination of research evidence to support the translation of research.

Developing a Theory-Informed Smartphone App for Early Psychosis: Learning Points From a Multidisciplinary Collaboration.

Background: Actissist is a smartphone app designed to deliver an intervention grounded in cognitive behavior therapy for early psychosis. Actissist was developed by a multidisciplinary team of academics, clinicians, experts by experience and software engineers. Actissist has been tested in two trials, the first a proof-of-concept trial where Actissist was safe, acceptable and feasible, the second, a powered randomized controlled trial. Objective: This article describes how our multidisciplinary team designed and developed Actissist. This article describes: (i) how Actissist was informed by initial qualitative interviews and focus groups and an expert reference group; (ii) refinements made to the app based on ongoing user feedback; (iii) successes and challenges encountered; and (iv) learning points and recommendations for involving stakeholders in digital health interventions. Methods: Expert reference group meetings informed the development of Actissist and design of subsequent trials, which included individuals with lived experience of psychosis, clinicians, academics, computer scientists and software engineers. Person-centered stakeholder involvement was promoted using focus groups and qualitative interviews prior to the development of the app, which informed version one of Actissist. Interviews were carried out with participants who had used Actissist. Two further versions of Actissist were developed following additional rounds of testing. Results: Multidisciplinary working throughout the Actissist project led to the development, inclusion and improvement of the app design and content. These changes and features included non-directive and compassionate content, co-designed recovery videos, relaxation exercises, psychoeducation material, ability to "favorite" areas of the app that users found helpful, and goal-setting. Challenges to collaborative working included discrepancies between what stakeholders want and what is technically possible to deliver, resource pressures, trying to deliver desired features within the boundaries of fundamental trial design considerations, and power imbalances associated with multidisciplinary working. Conclusions: The involvement of stakeholders in the design and development and delivery of Actissist has been fundamental to our development approach. Through this collaborative process, we have identified different perspectives and ideas that would have not been generated by the research team alone. Clinical Trial Registrations: Proof-of-concept trial: http://www.isrctn.com/ISRCTN34966555 Fully-powered randomized controlled trial: https://www.isrctn.com/ISRCTN76986679.

"They Are Not Hard-to-Reach Clients. We Have Just Got Hard-to-Reach Services." Staff Views of Digital Health Tools in Specialist Mental Health Services.

Background: Digital health products designed to help people with severe mental health problems appear to be feasible, acceptable, and efficacious. The challenge facing the digital mental health field is implementing digital tools in routine service delivery. To date, there has been a paucity of qualitative research exploring staff views of digital health solutions in the context of mental healthcare. Engaging and involving frontline staff in the design and rollout of new technology to improve utilization is imperative for successful uptake and adoption of digital tools. The aim of the current study is to explore frontline staff views regarding the utility and appropriateness of using digital tools in the healthcare pathway for people accessing specialist secondary care mental health services. Method: Qualitative study using framework analysis was used with 48 mental health staff working in early intervention for psychosis services. Six groups comprising 5-10 early intervention service staff members in each group were conducted across the Northwest of England. Robust measures were used to develop a stable framework, including member checking, triangulation, and consensus meetings. Results: Three themes were identified a priori: i) perceived barriers to adopting smartphone apps for early psychosis; ii) acceptability of digital health tools for early psychosis patients; and iii) data security, safety, and risk. Alongside exploring the a priori topics, one theme was generated a posteriori: iv) relationships. Conclusions: Staff working in specialist early intervention for psychosis services found digital tools on the whole acceptable in mental health service provision, but raised a number of concerns that will likely affect implementation of such systems into routine service delivery and practice. Thirteen recommendations are made in this paper as a result of the themes generated in these data. Implementing of digital systems needs to be simple and uncomplicated and improve clinical workflows for staff rather than hinder and increase clinical workflows. Furthermore, organizational support with a clear plan for implementing technological innovations is required for successful adoption of digital systems. Consideration of staff views around digital systems is important if successful adoption and implementation of such systems are to occur. Clinical Trial Registration: http://www.isrctn.com, identifier ISRCTN34966555.

Feasibility of using a smartphone app to assess early signs, basic symptoms and psychotic symptoms over six months: A preliminary report.

BACKGROUND: Psychosis relapses are common, have profound adverse consequences for patients, and are costly to health services. 'Early signs' have been used to predict relapse, in the hope of prevention or mitigation, with moderate sensitivity and specificity. We investigated the feasibility and validity of adding 'basic symptoms' to conventional early signs and monitoring these using a smartphone app. METHODS: Individuals (n = 18) experiencing a relapse within the past year were asked to use a smartphone app ('ExPRESS') weekly for six months to report early signs, basic symptoms and psychotic symptoms. Above-threshold increases in app-reported psychotic symptoms prompted a telephone interview (PANSS positive items) to assess relapse. RESULTS: Participants completed 65% app assessments and 58% telephone interviews. App items showed high concurrent validity with researcher-rated psychotic symptoms and basic symptoms over six months. There was excellent agreement between telephone call and face-to-face assessed psychotic symptoms. The primary relapse definition, based on telephone assessment and casenotes, compared well with a casenote-only definition but had better specificity. Mixed-effects models provided preliminary evidence of concurrent and predictive validity: early signs and basic symptoms were associated with most app-assessed psychotic symptom variables the same week and with a number of psychotic symptoms variables three weeks later; adding basic symptoms to early signs improved model fit in most of these cases. CONCLUSIONS: This is the first study to test a smartphone app for monitoring early signs and basic symptoms as putative relapse predictors. It demonstrates that weekly app-based monitoring is feasible, valid and acceptable over six months.

The digital revolution and its impact on mental health care.

The digital revolution is evolving at an unstoppable pace. Alongside the unprecedented explosion of digital technology facilities and systems, mental health care is under greater pressure than ever before. With its emphasis on big data, computing power, mobile technology, and network information, digital technology is set to transform health care delivery. This article reviews the field of digital health technology assessment and intervention primarily in secondary service mental health care, including the barriers and facilitators to adopting and implementing digitally mediated interventions in service delivery. We consider the impact of digitally mediated communication on human interaction and its potential impact on various mental states such as those linked to mood, anxiety but also well-being. These developments point to a need for both theory- and data-driven approaches to digital health care. We argue that, as developments in digital technology are outpacing the evaluation of rigorous digital health interventions, more advanced methodologies are needed to keep up with the pace of digital technology development. The need for co-production of digital tools with and for people with chronic and mental health difficulties, and implications of digital technology for psychotherapy practice, will be central to this development. PRACTITIONER POINTS: Mental health problems are one of the main causes of global and societal burden and are a growing public health. People with mental health problems around the world have limited, if any, chance of accessing psychological help at all. Technological innovations and solutions are being considered in an attempt to address the size and scale of the mental health crisis worldwide. Digital platforms allow people to self-monitor and self-manage in a way that face-to-face/paper-based methods of assessment have up until now not allowed. We provide examples of digital tools that are being developed and used in the secondary setting and identify a number of challenges in the digital health field that require careful consideration.

Development and Long-Term Acceptability of ExPRESS, a Mobile Phone App to Monitor Basic Symptoms and Early Signs of Psychosis Relapse.

BACKGROUND: Schizophrenia relapses are common, have profound, adverse consequences for patients and are costly to health services. Early signs interventions aim to use warning signs of deterioration to prevent full relapse. Such interventions show promise but could be further developed. This study addresses 2 developments: adding basic symptoms to checklists of conventional early signs and using a mobile phone app ExPRESS to aid early signs monitoring. OBJECTIVE: This study aimed to (1) design a pool of self-report items assessing basic symptoms (Basic Symptoms Checklist, BSC); (2) develop and beta test a mobile phone app (ExPRESS) for monitoring early signs, basic symptoms, and psychotic symptoms; and (3) evaluate the long-term acceptability of ExPRESS via qualitative feedback from participants in a 6-month feasibility study. METHODS: The BSC items and ExPRESS were developed and then adjusted following feedback from beta testers (n=5) with a schizophrenia diagnosis. Individuals (n=18) experiencing a relapse of schizophrenia within the past year were asked to use ExPRESS for 6 months to answer weekly questions about experiences of early signs, basic symptoms, and psychotic symptoms. At the end of follow-up, face-to-face qualitative interviews (n=16; 2 were uncontactable) explored experiences of using ExPRESS. The topic guide sought participants' views on the following a priori themes regarding app acceptability: item content, layout, and wording; app appearance; length and frequency of assessments; worries about app use; how app use fitted with participants' routines; and the app's extra features. Interview transcripts were analyzed using the framework method, which allows examination of both a priori and a posteriori themes, enabling unanticipated aspects of app use experiences to be explored. RESULTS: Participants' mean age was 38 years (range 22-57 years). Responses to a priori topics indicated that long-term use of ExPRESS was acceptable; small changes for future versions of ExPRESS were suggested. A posteriori themes gave further insight into individuals' experiences of using ExPRESS. Some reported finding it more accessible than visits from a clinician, as assessments were more frequent, more anonymous, and did not require the individual to explain their feelings in their own words. Nevertheless, barriers to app use (eg, unfamiliarity with smartphones) were also reported. Despite ExPRESS containing no overtly therapeutic components, some participants found that answering the weekly questions prompted self-reflection, which had therapeutic value for them. CONCLUSIONS: This study suggests that apps are acceptable for long-term symptom monitoring by individuals with a schizophrenia diagnosis across a wide age range. If the potential benefits are understood, patients are generally willing and motivated to use a weekly symptom-monitoring app; most participants in this study were prepared to do so for more than 6 months. TRIAL REGISTRATION: ClinicalTrials.gov NCT03558529; https://clinicaltrials.gov/ct2/show/NCT03558529 (Archived by WebCite at http://www.webcitation.org/70qvtRmZY).

A qualitative exploration of service user views about using digital health interventions for self-management in severe mental health problems.

BACKGROUND: The development of digital health interventions (DHIs) for severe mental health problems is fast-paced. Researchers are beginning to consult service users to inform DHIs; however, much of this involvement has been limited to feedback on specific interventions post-DHI development. This study had two aims: 1. explore service user views towards DHIs for severe mental health problems; and 2. make recommendations for specific content within DHIs based on service user needs and suggestions. METHODS: Qualitative interviews with eighteen people with severe mental health problems focussed on two domains: 1) views about DHIs for severe mental health problems; and 2) ideas for future DHI content and design features. Data were analysed thematically. RESULTS: Participants responses were captured in five key themes: 1) DHIs could be empowering tools that instigate reflection and change; 2) society is already divided; DHIs will further increase this divide; 3) considerations must be made about who has access to DHI data and how this data may be used; 4) DHIs should not be delivered without other support options; and 5) DHIs should provide a positive, fun, practical and interactive method for self-management. CONCLUSIONS: Participants found DHIs acceptable due to the empowering nature of self-management and ability to take ownership of their own healthcare needs. However, concerns included the potential for digital exclusion, privacy and confidentiality and fears about DHIs being used to replace other mental health services. Service users want tools to help them self-manage their mental health, but also provide positive and recovery-focussed content that can be used in conjunction with other support options.

Early Psychosis Service User Views on Digital Technology: Qualitative Analysis.

BACKGROUND: Digital technology has the potential to improve outcomes for people with psychosis. However, to date, research has largely ignored service user views on digital health interventions (DHIs). OBJECTIVE: The objective of our study was to explore early psychosis service users' subjective views on DHIs. METHODS: Framework analysis was undertaken with data obtained from 21 semistructured interviews with people registered with early intervention for psychosis services. Robust measures were used to develop a stable framework, including member checking, triangulation, independent verification of themes, and consensus meetings. RESULTS: The following 4 themes were established a priori: acceptability of technology in psychosis and mental health; technology increasing access to and augmenting mental health support; barriers to adopting DHIs; and concerns about management of data protection, privacy, risk, and security of information. The following 2 themes were generated a posteriori: blending DHIs with face-to-face treatment and empowerment, control, and choice. DHIs were also viewed as potentially destigmatizing, overcoming barriers faced in traditional service settings, facilitating communication, and empowering service users to take active control of their health care. CONCLUSIONS: In the first study of its kind, early psychosis service users' were largely positive about the potential use of DHIs supporting and managing mental health. Overall, service users felt that DHIs were a progressive, modern, and relevant platform for health care delivery. Concerns were expressed around privacy and data security and practical barriers inherent within DHIs, all of which require further attention. Future research should explore whether findings transfer to other service user groups, other technology delivery formats, and across a range of treatment modalities.

Use of the Internet and Mobile Phones for Self-Management of Severe Mental Health Problems: Qualitative Study of Staff Views.

BACKGROUND: Researchers are currently investigating the feasibility, acceptability, and efficacy of digital health interventions for people who experience severe mental health problems such as psychosis and bipolar disorder. Although the acceptability of digital health interventions for severe mental health problems appears to be relatively high and some people report successfully using the Internet and mobile phones to manage their mental health, the attitudes of mental health care staff toward such approaches have yet to be considered. OBJECTIVE: The aim of this study was to explore mental health care staff experiences of clients with severe mental health problems engaging with the Internet and mobile phones to self-manage their mental health and their views toward these behaviors. The study also sought to examine the opinions expressed by mental health care staff toward digital health interventions for severe mental health problems to identify potential facilitators and barriers to implementation. METHODS: Four focus groups were conducted with 20 staff working in mental health care services in the North West of the England using a topic guide. Focus groups involved 12 staff working in secondary care psychological services (7 participants in focus group 1 and 5 participants in focus group 4), 4 staff working in a rehabilitation unit (focus group 2), and 4 staff working in a community mental health team (focus group 3). Focus groups were transcribed verbatim, and transcripts were analyzed thematically to identify key themes that emerged from the data. RESULTS: Four overarching themes, two with associated subthemes, were identified: (1) staff have conflicting views about the pros and cons of using Web-based resources and digital health interventions to manage mental health; (2) digital health interventions could increase access to mental health support options for severe mental health problems but may perpetuate the digital divide; (3) digital health interventions' impact on staff roles and responsibilities; and (4) digital health interventions should be used to enhance, not replace, face-to-face support. CONCLUSIONS: This study is the first, to our knowledge, to qualitatively explore the experiences and attitudes of mental health care staff toward individuals with severe mental health problems using the Internet, mobile phones, and digital health interventions to self-manage their mental health. Understanding the positive and negative experiences and views shared by staff toward both current and potential digital health intervention use has enabled the identification of several considerations for implementation. Additionally, the findings suggest mental health care staff need clear guidance and training in relation to their responsibilities in recommending reputable and secure websites, forums, and digital health interventions and in how to manage professional boundaries on the Internet. Overall, the study highlights that digital health interventions could be well received by staff working in mental health services but importantly, such management options must be presented to frontline staff as an avenue to enhance care and extend choice, rather than as a method to reduce costs.

#WhyWeTweetMH: Understanding Why People Use Twitter to Discuss Mental Health Problems.

BACKGROUND: Use of the social media website Twitter is highly prevalent and has led to a plethora of Web-based social and health-related data available for use by researchers. As such, researchers are increasingly using data from social media to retrieve and analyze mental health-related content. However, there is limited evidence regarding why people use this emerging platform to discuss mental health problems in the first place. OBJECTIVES: The aim of this study was to explore the reasons why individuals discuss mental health on the social media website Twitter. The study was the first of its kind to implement a study-specific hashtag for research; therefore, we also examined how feasible it was to circulate and analyze a study-specific hashtag for mental health research. METHODS: Text mining methods using the Twitter Streaming Application Programming Interface (API) and Twitter Search API were used to collect and organize tweets from the hashtag #WhyWeTweetMH, circulated between September 2015 and November 2015. Tweets were analyzed thematically to understand the key reasons for discussing mental health using the Twitter platform. RESULTS: Four overarching themes were derived from the 132 tweets collected: (1) sense of community; (2) raising awareness and combatting stigma; (3) safe space for expression; and (4) coping and empowerment. In addition, 11 associated subthemes were also identified. CONCLUSIONS: The themes derived from the content of the tweets highlight the perceived therapeutic benefits of Twitter through the provision of support and information and the potential for self-management strategies. The ability to use Twitter to combat stigma and raise awareness of mental health problems indicates the societal benefits that can be facilitated via the platform. The number of tweets and themes identified demonstrates the feasibility of implementing study-specific hashtags to explore research questions in the field of mental health and can be used as a basis for other health-related research.

Acceptability of Interventions Delivered Online and Through Mobile Phones for People Who Experience Severe Mental Health Problems: A Systematic Review.

BACKGROUND: Psychological interventions are recommended for people with severe mental health problems (SMI). However, barriers exist in the provision of these services and access is limited. Therefore, researchers are beginning to develop and deliver interventions online and via mobile phones. Previous research has indicated that interventions delivered in this format are acceptable for people with SMI. However, a comprehensive systematic review is needed to investigate the acceptability of online and mobile phone-delivered interventions for SMI in depth. OBJECTIVE: This systematic review aimed to 1) identify the hypothetical acceptability (acceptability prior to or without the delivery of an intervention) and actual acceptability (acceptability where an intervention was delivered) of online and mobile phone-delivered interventions for SMI, 2) investigate the impact of factors such as demographic and clinical characteristics on acceptability, and 3) identify common participant views in qualitative studies that pinpoint factors influencing acceptability. METHODS: We conducted a systematic search of the databases PubMed, Embase, PsycINFO, CINAHL, and Web of Science in April 2015, which yielded a total of 8017 search results, with 49 studies meeting the full inclusion criteria. Studies were included if they measured acceptability through participant views, module completion rates, or intervention use. Studies delivering interventions were included if the delivery method was online or via mobile phones. RESULTS: The hypothetical acceptability of online and mobile phone-delivered interventions for SMI was relatively low, while actual acceptability tended to be high. Hypothetical acceptability was higher for interventions delivered via text messages than by emails. The majority of studies that assessed the impact of demographic characteristics on acceptability reported no significant relationships between the two. Additionally, actual acceptability was higher when participants were provided remote online support. Common qualitative factors relating to acceptability were safety and privacy concerns, the importance of an engaging and appealing delivery format, the inclusion of peer support, computer and mobile phone literacy, technical issues, and concerns about the impact of psychological state on intervention use. CONCLUSIONS: This systematic review provides an in-depth focus on the acceptability of online and mobile phone-delivered interventions for SMI and identified the need for further research in this area. Based on the results from this review, we recommend that researchers measure both hypothetical and actual acceptability to identify whether initial perceptions of online and mobile phone-delivered interventions change after access. In addition, more focus is needed on the potential impact of demographic and clinical characteristics on acceptability. The review also identified issues with module completion rates and intervention use as measures of acceptability. We therefore advise researchers to obtain qualitative reports of acceptability throughout each phase of intervention development and testing. Further implications and opportunities for future research are discussed.