Evaluating the Feasibility of a Multiplayer Role-Playing Game as a Behavioral Health Intervention in Adolescent Patients With Chronic Physical or Mental Conditions: Protocol for a Cohort Study.

BACKGROUND: Numerous studies have revealed that adolescents with chronic physical or mental conditions (CPMCs) are at an increased risk for depression and anxiety, with serious direct and indirect negative effects on treatment adherence, family functioning, and health-related quality of life. As game-based approaches are effective interventions in treating anxiety and depression, we propose to explore the use of a multiplayer role-playing game (RPG) as a potential intervention for social isolation, anxiety, and depression. OBJECTIVE: The objectives of this study were to (1) determine the feasibility of using Masks, a multiplayer RPG, as an intervention for social isolation, anxiety, and depression in adolescents with CPMCs; (2) evaluate the viability of the research process; and (3) gauge participation in and engagement with RPG-based interventions. METHODS: This study is a remote synchronous game-based intervention for adolescents with CPMCs aged 14-19 years. Eligible participants completed a web-based baseline survey to assess anxiety, depression, and social isolation and to identify their gaming habits. After completing the baseline survey, they participated in 5 moderated Masks game sessions. In Masks, players assume the roles of young superheroes; select their character types, superpowers; and perform actions determined by the game's rule system and dice rolls. All game sessions were played using Discord, a communication platform commonly used by gaming communities. Games were led and moderated by game masters (GMs). After each game session, participants completed surveys to assess changes in anxiety, depression, and social isolation, and their attitude toward the game and the user experience. The participants also completed an exit survey after all 5 game sessions (modified version of the Patient Health Questionnaire and the Generalized Anxiety Disorder Questionnaire, and 17 open-ended questions). The GMs rated each game session and reported on gameplay, player behavior, comfort, and engagement levels of the players. RESULTS: As of March 2020, six participants were recruited for the pilot study to participate in moderated web-based game sessions of Masks; 3 completed all game sessions and all required assessments. Although the number of participants was too low to draw generalizable conclusions, self-reported clinical outcomes did seem to indicate a positive change in depression, anxiety, and social isolation symptoms. Qualitative analysis of postgame survey data from participants and GMs indicated high levels of engagement and enjoyment. Furthermore, the participants provided feedback about improved mood and engagement related to weekly participation in Masks. Lastly, responses to the exit survey showed interest in future RPG-related studies. CONCLUSIONS: We established a workflow for gameplay and evaluated a research protocol for evaluating the impact of RPG participation on isolation, anxiety, and depression symptoms in adolescents with CPMCs. Preliminary data collected from the pilot study support the validity of the research protocol and the use of RPG-based interventions in larger clinical studies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/43987.

Middle School Students' Experiences with Cyberbullying and Perspectives Toward Prevention and Bystander Intervention in Schools.

Cyberbullying is a growing problem for middle school students. Bystander interventions that train witnesses to positively intervene can prevent cyberbullying. Through six focus groups, we explored forty-six middle school students' experiences with cyberbullying and opportunities for school-based prevention programs to encourage positive bystander behavior. Focus groups were recorded, transcribed, and analyzed using content analysis. Students viewed cyberbullying as an important problem with significant consequences. They noted hesitancy in reporting to parents and school personnel and felt more comfortable discussing cyberbullying with a near-peer (e.g., older sibling or friend). Students desired combining school-based and online programming with near-peer mentorship. This study suggests need for targeted prevention programs that center middle school students' lived experiences with cyberbullying and their preferences for learning and utilizing positive bystander strategies.

Antiracist Curriculum Implementation for Pediatric Residents.

Objectives: Racism has been recognized as a public health crisis, with calls for greater focus on antiracism in medical training. We sought to evaluate a longitudinal antiracist curriculum among pediatric residents. Methods: In 2020-2021, we delivered seven educational sessions to pediatric trainees in a single residency program. We administered pre-/post-surveys to assess changes in awareness of structural racism, knowledge of health inequities, antiracist clinical skills, and individual/institutional advocacy behaviors. Awareness was measured with 27 Likert-type items spanning five conceptual domains (schools, healthcare, justice system, employment, and housing/transportation). We evaluated knowledge with 18 true/false or multiple-choice questions. Participants indicated comfort with clinical skills using 13 Likert-type items drawn from national toolkits and policy statements. Individual/institutional advocacy behaviors were measured with 14 items from the Antiracism Behavioral Inventory. McNemar or paired Wilcoxon signed-rank tests compared measures before and after implementation. Results: Out of 121 residents, 79 (65%) completed pre-surveys, 47 (39%) completed post-surveys, and 37 (31%) were eligible for matching across responses. 78% of respondents were female and 68% identified as White. We found significant increases in awareness across several conceptual domains (schools: p = 0.03; healthcare: p = 0.004; employment: p = 0.003; housing/transportation: p = 0.02). Mean knowledge score increased after implementation (p = 0.03). Self-reported clinical skills improved significantly (p < 0.001). Individual advocacy behaviors increased (p < 0.001); there were no changes in institutional advocacy. Conclusion: We demonstrate improvements in several educational constructs with a novel antiracist curriculum. Efforts to scale and sustain this work are ongoing, and additional teaching and evaluation methodologies may be incorporated in the future.

Support over Social Media among Socially Isolated Sexual and Gender Minority Youth in Rural U.S. during the COVID-19 Pandemic: Opportunities for Intervention Research.

Sexual and gender minority (SGM) rural adolescents are at risk for higher levels of social isolation, a well-known risk factor for depression and other negative health outcomes. We qualitatively examined how rural SGM youth seek emotional and informational support, which are protective factors for social isolation on social media (SM) regarding their SGM identity, and determined which SM platforms and tools are most effective in providing support. We conducted semistructured online interviews with rural SGM teens who screened positive for social isolation in spring 2020 and used a thematic analysis approach to analyze the data. Sixteen youths participated in interviews. Themes included seeking emotional support through SM groups and communities, seeking emotional support in designated online SGM spaces, using SM feeds for informational support, and disclosing SGM identity differentially across platforms. SM-based interventions could be leveraged to provide emotional and informational support for rural SGM youth across specific SM platforms and consider whether they are providing emotional or information support. Interventions focused on informational support may best be used on content-based platforms. Those designed to combat social isolation and connect marginalized SGM youths to similar others might benefit from community and forum-based platforms.

A Social Media Website (Supporting Our Valued Adolescents) to Support Treatment Uptake for Adolescents With Depression or Anxiety: Pilot Randomized Controlled Trial.

BACKGROUND: Adolescents with depression or anxiety initiate mental health treatment in low numbers. Supporting Our Valued Adolescents (SOVA) is a peer support website intervention for adolescents seen in primary care settings and their parents with the goal of increasing treatment uptake through changing negative health beliefs, enhancing knowledge, offering peer emotional support, and increasing parent-adolescent communication about mental health. OBJECTIVE: This pilot study aimed to refine recruitment and retention strategies, refine document intervention fidelity, and explore changes in study outcomes (the primary outcome being treatment uptake). METHODS: We conducted a 2-group, single-blind, pilot randomized controlled trial in a single adolescent medicine clinic. Participants were aged 12 to 19 years with clinician-identified symptoms of depression or anxiety for which a health care provider recommended treatment. The patient and parent, if interested, were randomized to receive the SOVA websites and enhanced usual care (EUC) compared with EUC alone. Baseline, 6-week, and 3-month measures were collected using a web-based self-report survey and blinded electronic health record review. The main pilot outcomes assessed were the feasibility of recruitment and retention strategies. Implementation outcomes, intervention fidelity, missingness, and adequacy of safety protocols were documented. Descriptive statistics were used to summarize mental health service use and target measures with 2-sample t tests to compare differences between arms. RESULTS: Less than half of the adolescents who were offered patient education material (195/461, 42.2%) were referred by their clinician to the study. Of 146 adolescents meeting the inclusion criteria, 38 completed the baseline survey, qualifying them for randomization, and 25 (66%, 95% CI 51%-81%) completed the 6-week measures. There was limited engagement in the treatment arm, with 45% (5/11) of adolescents who completed 6-week measures reporting accessing SOVA, and most of those who did not access cited forgetting as the reason. Changes were found in target factors at 6 weeks but not in per-protocol analyses. At 12 weeks, 83% (15/18) of adolescents randomized to SOVA received mental health treatment as compared with 50% (10/20) of adolescents randomized to EUC (P=.03). CONCLUSIONS: In this pilot trial of a peer support website intervention for adolescents with depression or anxiety, we found lower-than-expected study enrollment after recruitment. Although generalizability may be enhanced by not requiring parental permission for adolescent participation in the trials of mental health interventions, this may limit study recruitment and retention. We found that implementing education introducing the study into provider workflow was feasible and acceptable, resulting in almost 500 study referrals. Finally, although not the primary outcome, we found a signal for greater uptake of mental health treatment in the arm using the SOVA intervention than in the usual care arm. TRIAL REGISTRATION: ClinicalTrials.gov NCT03318666; https://clinicaltrials.gov/ct2/show/NCT03318666. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/12117.

The inhibitory effect of some pyrazole ligands and their Cu(II) complexes on the growth of Escherichia coli, Klebsiella-Enterobacter spp., and Staphylococcus aureus.

The aim of this study was to evaluate the inhibitory activity of chemistry products against the growth of Escherichia coli, Klebsiella-Enterobacter spp., and Staphylococcus aureus. Pyrazole derivatives (4-bromo-2-(1H-pyrazol-3-yl)phenol, 4-nitro-3-pyrazolecarboxylic acid, N-(benzyloxycarbonyl)-1H-pyrazole-1-carboxamidine), 3-amino-5-hydroxypyrazole, 3,5-pyrazoledicarboxylic acid monohydrate, and selected complexes of Cu(II) with the mentioned pyrazoles as ligands were used as chemistry bioactives for antibacterial activity. The testing method was carried out according to the disc diffusion method. Some compounds have shown inhibitory effects against the growth of E. coli. A small number of compounds have shown inhibitory effects against the growth of Klebsiella-Enterobacter spp. but did not show inhibitory effects on Staphylococcus aureus compared to amoxicillin as a standard.

Predicting Depression in Adolescents Using Mobile and Wearable Sensors: Multimodal Machine Learning-Based Exploratory Study.

BACKGROUND: Depression levels in adolescents have trended upward over the past several years. According to a 2020 survey by the National Survey on Drug Use and Health, 4.1 million US adolescents have experienced at least one major depressive episode. This number constitutes approximately 16% of adolescents aged 12 to 17 years. However, only 32.3% of adolescents received some form of specialized or nonspecialized treatment. Identifying worsening symptoms earlier using mobile and wearable sensors may lead to earlier intervention. Most studies on predicting depression using sensor-based data are geared toward the adult population. Very few studies look into predicting depression in adolescents. OBJECTIVE: The aim of our work was to study passively sensed data from adolescents with depression and investigate the predictive capabilities of 2 machine learning approaches to predict depression scores and change in depression levels in adolescents. This work also provided an in-depth analysis of sensor features that serve as key indicators of change in depressive symptoms and the effect of variation of data samples on model accuracy levels. METHODS: This study included 55 adolescents with symptoms of depression aged 12 to 17 years. Each participant was passively monitored through smartphone sensors and Fitbit wearable devices for 24 weeks. Passive sensors collected call, conversation, location, and heart rate information daily. Following data preprocessing, 67% (37/55) of the participants in the aggregated data set were analyzed. Weekly Patient Health Questionnaire-9 surveys answered by participants served as the ground truth. We applied regression-based approaches to predict the Patient Health Questionnaire-9 depression score and change in depression severity. These approaches were consolidated using universal and personalized modeling strategies. The universal strategies consisted of Leave One Participant Out and Leave Week X Out. The personalized strategy models were based on Accumulated Weeks and Leave One Week One User Instance Out. Linear and nonlinear machine learning algorithms were trained to model the data. RESULTS: We observed that personalized approaches performed better on adolescent depression prediction compared with universal approaches. The best models were able to predict depression score and weekly change in depression level with root mean squared errors of 2.83 and 3.21, respectively, following the Accumulated Weeks personalized modeling strategy. Our feature importance investigation showed that the contribution of screen-, call-, and location-based features influenced optimal models and were predictive of adolescent depression. CONCLUSIONS: This study provides insight into the feasibility of using passively sensed data for predicting adolescent depression. We demonstrated prediction capabilities in terms of depression score and change in depression level. The prediction results revealed that personalized models performed better on adolescents than universal approaches. Feature importance provided a better understanding of depression and sensor data. Our findings can help in the development of advanced adolescent depression predictions.

Stakeholder perspectives on digital behavioral health applications targeting adolescent depression and suicidality: Policymaker, provider, and community insights.

Background: With adolescent depression and suicidality increasing, technology-based interventions may help address mental health needs. The Enhancing Treatment and Utilization for Depression and Emergent Suicidality (ETUDES) Center supports development of technology interventions to help primary care providers target these problems. To successfully develop and integrate such interventions into primary care, iterative engagement of stakeholders is necessary. This paper outlines our stakeholder engagement process, a qualitative analysis of feedback and outcomes, and how feedback was incorporated to develop Center interventions. Methods: Stakeholder panels represented key end-users of ETUDES Center interventions (adolescents, young adults, parents, and healthcare providers) and their advocates at the organizational/policy level. Meetings were held throughout intervention development and at annual retreats. Detailed meeting notes were collected and summarized by the stakeholder engagement team in real time, after which action items were generated and reviewed by the full research team. Using a content analysis approach, all stakeholder feedback summaries were coded using a prespecified codebook organized by recurring topics. Codes were organized under the Consolidated Framework for Implementation Research (CFIR). Anonymous stakeholder feedback surveys assessed relevance of topics, meeting effectiveness, and stakeholder involvement. Results: Stakeholder meetings provided feedback on topics such as representation, language, access to care, and stigma. Relevant feedback and recommendations were incorporated into subsequent iterations of the interventions and their implementation. Mean stakeholder ratings of meeting proceedings on a 0-3 Likert scale ranged from 1.70 (SD = 0.10) for participation to 2.43 (SD = 0.08) for effectiveness in addressing meeting agenda. Conclusions: The iterative engagement approach yielded practical feedback from stakeholders about ETUDES Center interventions. The team organized feedback to identify barriers and facilitators to using Center interventions and to generate action items, which were transposed onto components of an implementation strategy, supplemented by the CFIR-ERIC Implementation Strategy Matching Tool. Stakeholder feedback will direct the future development of an integrated intervention and guide further stakeholder engagement in developing technologies for adolescent mental health.Plain Language Summary: Depression and suicide in teens have been on the rise for the past several years. Primary care may be an ideal place to address these concerns because most teens have a primary care provider (PCP) who can offer a confidential place for both teens and their caregivers. Our Center develops technology-based interventions to help PCPs address teen depression and suicidality. Multiple barriers may hinder PCPs in addressing teen depression and suicidality. This paper describes how we engaged multiple types of stakeholders-or individuals with an interest in adolescent mental health-to ask for their feedback over a series of meetings, to help us improve the fit of our interventions to this population. Stakeholders included providers, community members like parents and mental health advocates, youth, and policymakers. We learned what was most important to them-including concerns about equitable access (e.g., providing broadband internet to families who do not have it so they can still participate) and legal risks or failures for the technology to identify suicidality. In this paper, we describe our process for not only recruiting and engaging stakeholders but also for planning action based on their feedback. Similar processes could be used by other researchers and clinical organizations seeking to incorporate technology into mental health interventions.

"You have people here to help you, people like me." A Qualitative Analysis of a Blogging Intervention for Adolescents and Young Adults with Depression or Anxiety.

Blogging in the lay community has been shown to be a popular means of expression for all ages exhibiting mental illness symptoms. With the recent rise of mental illness rates among adolescents, blogging in a space specifically designated to discuss mental health topics for adolescents could potentially be beneficial for this demographic. In order to reveal whether or not blogging has positive effects on adolescents and young adults, we created a moderated, anonymous eHealth intervention for those in this demographic experiencing depression and/or anxiety symptoms. This intervention, called Supporting Our Valued Adolescents (SOVA), allows a safe place for participants ages 14-26 (inclusive) to read, write, and comment on blog posts regarding various mental health topics. In this paper, we analyze 40 SOVA blog posts and their corresponding comments written by 18 participants over a six-month period to see if actively engaging on the website was beneficial for their mental health. These posts and comments were analyzed on their degree of self-disclosure, regulatory and interpersonal support, acknowledgement of others, and reader feedback. We found that the content analyzed implied that blogging had a positive effect on participants using this online intervention.

Perceived Facilitators of and Barriers to Implementation of a Decision Support Tool for Adolescent Depression and Suicidality Screening: Focus Group and Interview Study.

BACKGROUND: Screening Wizard (SW) is a technology-based decision support tool aimed at guiding primary care providers (PCPs) to respond to depression and suicidality screens in adolescents. Separate screens assess adolescents' and parents' reports on mental health symptoms, treatment preferences, and potential treatment barriers. A detailed summary is provided to PCPs, also identifying adolescent-parent discrepancies. The goal of SW is to enhance decision-making to increase the utilization of evidence-based treatments. OBJECTIVE: This qualitative study aims to describe multi-stakeholder perspectives of adolescents, parents, and providers to understand the potential barriers to the implementation of SW. METHODS: We interviewed 11 parents and 11 adolescents and conducted two focus groups with 18 health care providers (PCPs, nurses, therapists, and staff) across 2 pediatric practices. Participants described previous experiences with screening for depression and were shown a mock-up of SW and asked for feedback. Interviews and focus groups were transcribed verbatim, and codebooks were inductively developed based on content. Transcripts were double coded, and disagreements were adjudicated to full agreement. Completed coding was used to produce thematic analyses of the interviews and focus groups. RESULTS: We identified five main themes across the interviews and focus groups: parents, adolescents, and pediatric PCPs agree that depression screening should occur in pediatric primary care; there is concern that accurate self-disclosure does not always occur during depression screening; SW is viewed as a tool that could facilitate depression screening and that might encourage more honesty in screening responses; parents, adolescents, and providers do not want SW to replace mental health discussions with providers; and providers want to maintain autonomy in treatment decisions. CONCLUSIONS: We identified that providers, parents, and adolescents are all concerned with current screening practices, mainly regarding inaccurate self-disclosure. They recognized value in SW as a computerized tool that may elicit more honest responses and identify adolescent-parent discrepancies. Surprisingly, providers did not want the SW report to include treatment recommendations, and all groups did not want the SW report to replace conversations with the PCP about depression. Although SW was originally developed as a treatment decision algorithm, this qualitative study has led us to remove this component, and instead, SW focuses on aspects identified as most useful by all groups. We hope that this initial qualitative work will improve the future implementation of SW.

Experience of Peer Bloggers Using a Social Media Website for Adolescents With Depression or Anxiety: Proof-of-Concept Study.

BACKGROUND: Supporting Our Valued Adolescents (SOVA) is a moderated and anonymous social media website intervention. SOVA ambassadors are adolescents and young adults (AYA) asked to write monthly blog posts and comments on others' posts on topics surrounding mental health. OBJECTIVE: This study aims to understand the feasibility and acceptability of peer blogging for a moderated mental health intervention website and explore whether bloggers-AYA who self-report symptoms of depression and anxiety-experience potential benefits. METHODS: AYA aged 14 to 26 years with a self-reported history of depression or anxiety were recruited to the SOVA Peer Ambassador Program. Participants were asked to write one blog post a month and comment at least four times a month on other blog posts, for which they were compensated for up to US $15 monthly. Outcome variables measured at baseline and 3 months after intervention included website usability and feasibility, depressive symptoms, anxiety symptoms, mental health treatment history, cybercoping, personal blogging style, self-esteem, loneliness, mental health stigma, social support, and positive youth development characteristics. Open-ended questions were asked about their blogging acceptability and usability. RESULTS: Of 66 AYA showing interest and completing onboarding, 71% (47/66) wrote at least one blog post, with an average of 3 posts per person. A sample of 51% (34/66) of participants completed a 3-month survey for the full analysis. Almost all 34 participants were satisfied with the experience of blogging (32/34, 94%) and rated the website usability as good (80.1, SD 14.9). At 3 months, self-esteem scores increased by 2.1, with a small-medium effect size (P=.01; Cohen d=0.45), and youth competence and confidence increased by 0.7 (P=.002) and 1.3 (P=.002), with medium effect sizes (Cohen d=0.62 and 0.60), respectively. CONCLUSIONS: A blogging intervention for AYA with a history of depression or anxiety was feasible with regular and active engagement and shows evidence in a one-sample design for positive changes in strength-based assets-self-esteem, competence, and confidence-which map onto resilience.

Social Media Use and Monitoring for Adolescents With Depression and Implications for the COVID-19 Pandemic: Qualitative Study of Parent and Child Perspectives.

BACKGROUND: Although youth report many positive experiences with social media (SM) use in their daily lives, adolescents with depression are more vulnerable to the risks of SM use than adolescents without depression. Parents protect adolescents with depression from the risks of SM use by monitoring their child's SM activity; however, this comes into conflict with the adolescent's need for autonomy in their web-based communication. The implications of SM use and monitoring for adolescents with depression and their parents are of particular relevance to the COVID-19 pandemic, as rates of SM use have increased in response to physical distancing measures. OBJECTIVE: This study aims to explore parent and child perspectives regarding the use and function of SM in the daily lives of adolescents with depression and parents' perceptions of and experience with monitoring their child's SM use. METHODS: We conducted qualitative interviews with adolescents with depression (n=23) and one parent of each adolescent (n=23) between July 2013 and September 2014. The adolescents were patients seeking treatment for depression in Pittsburgh, Pennsylvania. Data analysis included dyadic analysis of the adolescents' and parents' perspectives and qualitative descriptions of individual parent interviews to explore their experiences with SM use and monitoring. The construct of parental knowledge and factors hypothesized to contribute to parental knowledge, including adolescent disclosure, parental solicitation, and parental control, were used to guide the codebook and dyadic data analysis. RESULTS: Dyadic analyses showed that parents and their children disagreed on the use and function of SM in the daily lives of adolescents with depression, with adolescents viewing SM as a forum for honest expression of their emotions, whereas parents felt that their children's posts were inconsequential and interfered with the adolescents' lives. Furthermore, parents reported using a wide range of strategies to gain knowledge of their child's SM use to monitor their safety on SM, including direct solicitation and indirect solicitation, such as keeping the child's passwords, asking friends or siblings about their child's SM use, and restricting SM behavior and access to devices. CONCLUSIONS: Clinicians should support adolescents with depression and their parents in finding common ground for an effective and acceptable monitoring approach. Resources are provided for clinicians navigating conversations about SM use and monitoring with adolescents with depression and their parents during the COVID-19 pandemic.

Digital Approaches to Remote Pediatric Health Care Delivery During the COVID-19 Pandemic: Existing Evidence and a Call for Further Research.

The global spread of the coronavirus disease (COVID-19) outbreak poses a public health threat and has affected people worldwide in various unprecedented ways, both personally and professionally. There is no question that the current global COVID-19 crisis, now more than ever, is underscoring the importance of leveraging digital approaches to optimize pediatric health care delivery in the era of this pandemic. In this perspective piece, we highlight some of the available digital approaches that have been and can continue to be used to streamline remote pediatric patient care in the era of the COVID-19 pandemic, including but not limited to telemedicine. JMIR Pediatrics and Parenting is currently publishing a COVID-19 special theme issue in which investigators can share their interim and final research data related to digital approaches to remote pediatric health care delivery in different settings. The COVID-19 pandemic has rapidly transformed health care systems worldwide, with significant variations and innovations in adaptation. There has been rapid expansion of the leveraging and optimization of digital approaches to health care delivery, particularly integrated telemedicine and virtual health. Digital approaches have played and will play major roles as invaluable and reliable resources to overcome restrictions and challenges imposed during the COVID-19 pandemic and to increase access to effective, accessible, and consumer-friendly care for more patients and families. However, a number of challenges remain to be addressed, and further research is needed. Optimizing digital approaches to health care delivery and integrating them into the public health response will be an ongoing process during the current COVID-19 outbreak and during other possible future pandemics. Regulatory changes are essential to support the safe and wide adoption of these approaches. Involving all relevant stakeholders in addressing current and future challenges as well as logistical, technological, and financial barriers will be key for success. Future studies should consider evaluating the following research areas related to telemedicine and other digital approaches: cost-effectiveness and return on investment; impact on quality of care; balance in use and number of visits needed for the management of both acute illness and chronic health conditions; system readiness for further adoption in other settings, such as inpatient services, subspecialist consultations, and rural areas; ongoing user-centered evaluations, with feedback from patients, families, and health care providers; strategies to optimize health equity and address disparities in access to care related to race and ethnicity, socioeconomic status, immigration status, and rural communities; privacy and security concerns for protected health information with Health Insurance Portability and Accountability Act (HIPAA)-secured programs; confidentiality issues for some specific populations, especially adolescents and those in need of mental health services; early detection of exposure to violence and child neglect; and integration of training into undergraduate and graduate medical education and subspecialty fellowships. Addressing these research areas is essential to understanding the benefits, sustainability, safety, and optimization strategies of telemedicine and other digital approaches as key parts of modern health care delivery. These efforts will inform long-term adoption of these approaches with expanded dissemination and implementation efforts.

Technology Use for Adolescent Health and Wellness.

As avid users of technology, adolescents are a key demographic to engage when designing and developing technology applications for health. There are multiple opportunities for improving adolescent health, from promoting preventive behaviors to providing guidance for adolescents with chronic illness in supporting treatment adherence and transition to adult health care systems. This article will provide a brief overview of current technologies and then highlight new technologies being used specifically for adolescent health, such as artificial intelligence, virtual and augmented reality, and machine learning. Because there is paucity of evidence in this field, we will make recommendations for future research.

Prescribing Technology to Increase Uptake of Depression Treatment in Primary Care: A Pre-implementation Focus Group Study of SOVA (Supporting Our Valued Adolescents).

Supporting Our Valued Adolescents (SOVA) is a web-based technology intervention designed to increase depression and anxiety treatment uptake by adolescents in the context of an anonymous peer community with an accompanying website for parents. With a goal of informing the design of a hybrid effectiveness-implementation randomized controlled trial, we conducted a pre-implementation study in two primary care practices to guide implementation strategy development. We conducted focus groups with primary care providers (PCPs) at three different timepoints with PCPs (14 total) from two community practices. A baseline survey was administered using Evidence-Based Practice Attitude Scale (EBPAS) and Physician Belief Scale (PBS). Subsequently, during each focus group, PCPs listened to a relevant presentation after which a facilitated discussion was audio recorded and transcribed. After timepoint 1, a codebook based on Consolidated Framework for Intervention Research (CFIR) and qualitative description were used to summarize findings and inform implementation strategies that were then adapted based on PCP feedback from timepoint 2. PCPs were provided with resources to implement SOVA over 5 months and then a third focus group was conducted to gather their feedback. Based on EBPAS and PBS, PCPs are willing to try new evidence-based practices and have positive feelings about taking care of psychosocial problems with some concerns about increased burden. During focus groups, PCPs expressed SOVA has a relative advantage and intuitive appeal, especially due to its potential to overcome stigma and reach adolescents and parents who may not want to talk about mental health concerns with their PCP. PCPs informed various implementation strategies (e.g., advertising to reach a wider audience than the target population; physical patient reminders). During timepoint 3, however, they shared they had a difficult time utilizing these despite their intention. PCPs requested use of champions and others to nudge them and priming of families with advertising, so that the PCP would not be required to initiate recommendation of the intervention, but only offer their strong endorsement when prompted. The process of conducting a pre-implementation study in primary care settings may assist with piloting potential implementation strategies and understanding barriers to their use.Trial registration NCT03318666.

Role of Moderators on Engagement of Adolescents With Depression or Anxiety in a Social Media Intervention: Content Analysis of Web-Based Interactions.

BACKGROUND: The Supporting Our Valued Adolescents (SOVA) intervention aims to use a moderated social media website to encourage peer discussion about negative health beliefs, which may prevent treatment uptake. Web moderators with a background in behavioral health are used to facilitate peer conversation to promote a sense of community, provide social support, and ensure safety. OBJECTIVE: Although moderation is a core component of this intervention, little is known on best practices for moderators to ensure safety while encouraging engagement. This study sought to describe interactions between moderators and peer users and understand moderator experiences through individual interviews. METHODS: Adolescents and young adults aged 14 to 26 years with depression or anxiety history were recruited for a usability study of the SOVA intervention. During this study, 14 moderators were trained to regularly review comments to blog posts for safety, facilitate conversation, and correct misinformation. A total of 110 blog posts and their associated comments were extracted and coded using a codebook based on items from the supportive accountability model and a peer social support analysis. Closing interviews with 12 moderators assessing their experience of moderating were conducted, recorded, and transcribed. Blog post text and comments as well as transcripts of moderator interviews were assessed using a thematic analysis approach, and blog posts were examined for trends in content of moderator comments comparing blog posts with differences in comment contributor order. RESULTS: There were no safety concerns during the study, and moderators only intervened to remove identifiable information. Web moderators exhibited elements of supportive accountability (such as being perceived as experts and using verbal rewards as well as offering informational and emotional support). When the moderators provided the last comment under a blog post, thereby potentially ending contribution by users, they were at times found to be commenting about their own experiences. Moderators interviewed after completing their role expressed challenges in engaging users. A cohort of moderators who received more extensive training on supportive accountability and peer social support felt their ability to engage users improved because of the training. CONCLUSIONS: Moderators of a Web-based support site for adolescents with depression or anxiety were able to ensure safety while promoting user engagement. Moderators can elicit user engagement by offering gratitude and encouragement to users, asking users follow-up questions, and limiting their own opinions and experiences when responding to comments.

A Social Media Website (Supporting Our Valued Adolescents) to Support Treatment Uptake for Adolescents With Depression and/or Anxiety and Their Parents: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: Few adolescents who experience depression or anxiety connect to mental health treatment. Supporting Our Valued Adolescents (SOVA) is a stakeholder-informed technology intervention that consists of 2 blog-format websites-one for adolescents and another for parents. SOVA is designed to intervene on targets, which may increase the mental health treatment uptake when adolescents with depression or anxiety are identified in primary care settings. OBJECTIVE: This study aims to describe the protocol for a pilot randomized controlled trial designed to refine recruitment and retention strategies, document intervention fidelity and implementation outcomes, and assess changes in health beliefs and knowledge, emotional or informational support, and parent-adolescent communication quality in adolescents and their parents. METHODS: Adolescents identified with symptoms of depression or anxiety, for which a health care provider recommends treatment, and their parents will be recruited from clinics where adolescents are seen for primary care. Adolescent-parent dyads will be randomized at 1:1 to both receive the SOVA websites and enhanced usual care or enhanced usual care alone. Baseline measures and 6-week and 3-month outcomes will be collected by Web-based self-report surveys and electronic health record review. The main pilot outcome is the 6-week study retention rate. Analyses will also assess changes in health beliefs and knowledge, emotional support, and parent-adolescent communication in both adolescents and their parents. RESULTS: The project was funded in 2017. Recruitment commenced in April 2018 and enrollment is ongoing, with completion anticipated at the end of 2019 with subsequent plans for data analysis and publication submission in early 2020. CONCLUSIONS: The findings of this research will inform the design of a multisite hybrid effectiveness-implementation randomized controlled trial examining the effectiveness and optimal implementation strategies for using SOVA in community primary care settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT03318666; https://clinicaltrials.gov/ct2/show/NCT03318666. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/12117.

Screening for Fabry disease and Hereditary ATTR amyloidosis in idiopathic small-fiber and mixed neuropathy.

INTRODUCTION: In this study we assessed the value of genetic screening for Fabry disease (FD) and hereditary ATTR amyloidosis in patients with idiopathic small-fiber neuropathy (SFN) or mixed neuropathy in a clinical setting. METHODS: This was a Nordic multicenter study with 9 participating centers. Patients with idiopathic SFN or mixed neuropathy were included. Genetic sequencing of the TTR and GLA genes was performed. RESULTS: There were 172 patients enrolled in the study. Genetic screening was performed in 155 patients. No pathogenic mutations in the TTR gene were found. A single patient had a possible pathogenic variant, R118C, in the GLA gene, but clinical investigation showed no firm signs of FD. DISCUSSION: Screening for hereditary ATTR amyloidosis and FD in patients with idiopathic SFN or mixed neuropathy without any additional disease-specific symptoms or clinical characteristics in a Nordic population appears to be of little value in a clinical setting. Muscle Nerve 59:354-357, 2019.

An Electronic Referral and Social Work Protocol to Improve Access to Mental Health Services.

BACKGROUND AND OBJECTIVES: The prevalence of mental health problems among adolescents in the United States is a major public health concern. However, the uptake of mental health treatment is low. Integrating behavioral health into primary care is 1 research-informed strategy to increase engagement in treatment. Facilitators of and barriers to implementation of integrated behavioral health in a pediatric primary care setting are not well delineated. METHODS: We examined the effectiveness of 2 mental health quality improvement strategies: an electronic referral and a social work follow-up protocol. We analyzed the following measures: uptake rate of first mental health appointments, overall use of mental health appointments, and first and overall mental health appointment show rate. RESULTS: Overall use rate improved after implementation of electronic referral, with 13 consecutive points above the median. First appointment show rates improved with a special cause run occurring after adding social work students to the mental health quality improvement team. First appointment show rate improved from a monthly average of 51% (November 2014 to March 2016) to 78% (April 2016 to December 2016). Use rate improved initially with increased efforts in assisting patients with scheduling; show rate improved more slowly after an emphasis on scheduling patients exhibiting treatment readiness. CONCLUSIONS: Findings suggest that a number of facilitators can increase the effective use of mental health services in an integrated adolescent clinical setting. These include an electronic referral through a shared electronic health record, multidisciplinary collaboration, and care management by social workers equipped with a variety of clinical and care coordination skills.