Understanding Users' Experiences of a Novel Web-Based Cognitive Behavioral Therapy Platform for Depression and Anxiety: Qualitative Interviews From Pilot Trial Participants.

BACKGROUND: Digital mental health interventions (DMHIs) can help bridge the gap between the demand for mental health care and availability of treatment resources. The affordances of DMHIs have been proposed to overcome barriers to care such as accessibility, cost, and stigma. Despite these proposals, most evaluations of the DMHI focus on clinical effectiveness, with less consideration of users' perspectives and experiences. OBJECTIVE: We conducted a pilot randomized controlled trial of "Overcoming Thoughts," a web-based platform that uses cognitive and behavioral principles to address depression and anxiety. The "Overcoming Thoughts" platform included 2 brief interventions-cognitive restructuring and behavioral experimentation. Users accessed either a version that included asynchronous interactions with other users ("crowdsourced" platform) or a completely self-guided version (control condition). We aimed to understand the users' perspectives and experiences by conducting a subset of interviews during the follow-up period of the trial. METHODS: We used purposive sampling to select a subset of trial participants based on group assignment (treatment and control) and symptom improvement (those who improved and those who did not on primary outcomes). We conducted semistructured interviews with 23 participants during the follow-up period that addressed acceptability, usability, and impact. We conducted a thematic analysis of the interviews until saturation was reached. RESULTS: A total of 8 major themes were identified: possible opportunities to expand the platform; improvements in mental health because of using the platform; increased self-reflection skills; platform being more helpful for certain situations or domains; implementation of skills into users' lives, even without direct platform use; increased coping skills because of using the platform; repetitiveness of platform exercises; and use pattern. Although no differences in themes were found among groups based on improvement status (all P values >.05, ranging from .12 to .86), there were 4 themes that differed based on conditions (P values from .01 to .046): helpfulness of self-reflection supported by an exercise summary (greater in control); aiding in slowing thoughts and feeling calmer (greater in control); overcoming patterns of avoidance (greater in control); and repetitiveness of content (greater in the intervention). CONCLUSIONS: We identified the different benefits that users perceived from a novel DMHI and opportunities to improve the platform. Interestingly, we did not note any differences in themes between those who improved and those who did not, but we did find some differences between those who received the control and intervention versions of the platform. Future research should continue to investigate users' experiences with DMHIs to better understand the complex dynamics of their use and outcomes.

Antifragile Behavior Change Through Digital Health Behavior Change Interventions.

Digital health behavior change interventions (DHBCIs) offer users accessible support, yet their promise to improve health behaviors at scale has not been met. One reason for this unmet potential may be a failure to offer users support that is tailored to their personal characteristics and goals. We apply the concept of antifragility to propose how DHBCIs could be better designed to support diverse users' behavior change journeys. We first define antifragility as a feature of an individual's relationship to a particular challenge such that if one is antifragile to a challenge, one is well positioned to benefit from facing that challenge. Second, we introduce antifragile behavior change to describe behavior change processes that leverage person-specific antifragilities to maximize benefits and minimize risk in the behavior change process. While most existing behavior change models focus on improving one's motivation and ability to face challenges, antifragile behavior change complements these models by helping to select challenges that are most likely to produce desired outcomes. Next, we propose three principles by which DHBCIs can help users to develop antifragile behavior change strategies: providing personalized guidance, embracing variance and exploration in choosing behaviors, and prioritizing user agency. Finally, we offer an example of how a DHBCI could be designed to support antifragile behavior change.

Social Interactivity in Live Video Experiences Reduces Loneliness.

Background: Loneliness, especially when chronic, can substantially reduce one's quality of life. However, positive social experiences might help to break cycles of loneliness by promoting more prosocial cognitions and behaviors. Internet-mediated live video communication platforms (eg Zoom and Twitch) may offer an engaging and accessible medium to deliver such social experiences to people at scale. Despite these platforms' widespread use, there is a lack of research into how their socially interactive elements affect users' feelings of loneliness and connection. Objective: We aimed to experimentally evaluate whether socially interactivity in live video experience improves loneliness-related outcomes. Materials and Methods: We recruited participants from an online survey recruitment platform and assigned half to participate in a socially interactive live video experience with 6-12 strangers and the other half to a non-interactive control experience that was designed to be identical in every way but not socially interactive. Participants completed several baseline self-report measures of psychosocial wellbeing, participated in the hour-long video experience (an entertaining astronomy lesson), and then completed some baseline measures again. Four weeks later, we followed up with participants to evaluate their change in trait loneliness since baseline. We Pre-registered our hypotheses and analysis plan and provide our data, analysis code, and study materials online. Results: Two hundred and forty-nine participants completed the initial study and met inclusion criteria, 199 of whom also completed the 4-week follow-up. Consistent with our predictions, we found that directly after the more socially interactive experience, participants' feelings of connectedness increased more (p < 0.001), positive affect increased more (p = 0.002), feelings of loneliness decreased more (p < 0.001), social threat decreased more (p = 0.006), and negative affect decreased more (p = 0.003) than they did after the less interactive experience. However, change in trait loneliness between baseline and 4 weeks later did not differ between conditions (p = 0.953). Conclusions: Including socially interactive components in live video experiences can improve loneliness-related psychosocial outcomes for a short time. Future work should explore leveraging these benefits toward longer-term prosociality. Future work can also identify if the effects we observed generalize across different populations and kinds of online experiences.

Irrelevant insights make worldviews ring true.

Our basic beliefs about reality can be impossible to prove and yet we can feel a strong intuitive conviction about them, as exemplified by insights that imbue an idea with immediate certainty. Here we presented participants with worldview beliefs such as "people's core qualities are fixed" and simultaneously elicited an aha moment. In the first experiment (N = 3000, which included a direct replication), participants rated worldview beliefs as truer when they solved anagrams and also experienced aha moments. A second experiment (N = 1564) showed that the worldview statement and the aha moment must be perceived simultaneously for this 'insight misattribution' effect to occur. These results demonstrate that artificially induced aha moments can make worldview beliefs seem truer, possibly because humans partially rely on feelings of insight to appraise an idea's veracity. Feelings of insight are therefore not epiphenomenal and should be investigated for their effects on decisions, beliefs, and delusions.

User Experience, Engagement, and Popularity in Mental Health Apps: Secondary Analysis of App Analytics and Expert App Reviews.

BACKGROUND: User experience and engagement are critical elements of mental health apps' abilities to support users. However, work examining the relationships among user experience, engagement, and popularity has been limited. Understanding how user experience relates to engagement with and popularity of mental health apps can demonstrate the relationship between subjective and objective measures of app use. In turn, this may inform efforts to develop more effective and appealing mental health apps and ensure that they reach wide audiences. OBJECTIVE: We aimed to examine the relationship among subjective measures of user experience, objective measures of popularity, and engagement in mental health apps. METHODS: We conducted a preregistered secondary data analysis in a sample of 56 mental health apps. To measure user experience, we used expert ratings on the Mobile App Rating Scale (MARS) and consumer ratings from the Apple App Store and Google Play. To measure engagement, we acquired estimates of monthly active users (MAU) and user retention. To measure app popularity, we used download count, total app revenue, and MAU again. RESULTS: MARS total score was moderately positively correlated with app-level revenue (Kendall rank [T]=0.30, P=.002), MAU (T=0.39, P<.001), and downloads (T=0.41, P<.001). However, the MARS total score and each of its subscales (Engagement, Functionality, Aesthetics, and Information) showed extremely small correlations with user retention 1, 7, and 30 days after downloading. Furthermore, the total MARS score only correlated with app store rating at T=0.12, which, at P=.20, did not meet our threshold for significance. CONCLUSIONS: More popular mental health apps receive better ratings of user experience than less popular ones. However, user experience does not predict sustained engagement with mental health apps. Thus, mental health app developers and evaluators need to better understand user experience and engagement, as well as to define sustained engagement, what leads to it, and how to create products that achieve it. This understanding might be supported by better collaboration between industry and academic teams to advance a science of engagement.

Social relationship quality, depression and inflammation: A cross-cultural longitudinal study in the United States and Tokyo, Japan.

BACKGROUND: Depression is an illness with biological, psychological, and social underpinnings, which may include the interplay of inflammation, psychological traits, stress, social relationships, and cultural background. AIMS: This work examines the prospective associations between social relationship quality and depressive symptoms, and between social relationship quality and inflammatory outcomes in two distinct cultures. METHODS: Data were obtained from two longitudinal, prospective cohort studies: Midlife in the United States (MIDUS), and Midlife Development in Japan (MIDJA) between 2004 and 2010. One thousand three hundred and twenty-seven community-based adults were included in analyses, 1,054 from the United States and 273 from Tokyo, Japan. Depressive symptoms (measured by the CES-D Depression Scale) and inflammation (measured by blood sample concentrations of the inflammatory biomarkers interleukin-6 and C-reactive protein) were the outcomes. Social relationship quality was the predictor. Culture, trait independence and interdependence, and psychosocial stressors were examined as moderators of the link between social relationship quality and depressive symptoms. RESULTS: Higher social relationship quality was associated with lower depressive symptoms in the United States (ß = -6.15, p < .001), but not in Japan (ß = -1.25, p = .390). Social relationship quality had no association with inflammation. Psychosocial stressors moderated the link between social relationship quality and depressive symptoms in both the United States (ß = -0.39, p = .001) and Tokyo (ß = -0.55, p = .001), such that social relationship quality acted as a buffer against depressive symptoms as psychosocial stress increased. CONCLUSION: Improving the perceived quality of social relationships appears to be a stronger target for depression interventions in the United States than in Tokyo, Japan.

Impact of the COVID-19 Pandemic on Online Obsessive-Compulsive Disorder Support Community Members: Survey Study.

BACKGROUND: People with obsessive-compulsive disorder (OCD) have faced unique challenges during the COVID-19 pandemic. Research from the first two months of the pandemic suggests that a small proportion of people with OCD experienced worsening in their OCD symptoms since the pandemic began, whereas the rest experienced either no change or an improvement in their symptoms. However, as society-level factors relating to the pandemic have evolved, the effects of the pandemic on people with OCD have likely changed as well, in complex and population-specific ways. Therefore, this study contributes to a growing body of knowledge on the impact of the COVID-19 pandemic on people and demonstrates how differences across studies might emerge when studying specific populations at specific timepoints. OBJECTIVE: This study aimed to assess how members of online OCD support communities felt the COVID-19 pandemic had affected their OCD symptoms, around 3 months after the pandemic began. METHODS: We recruited participants from online OCD support communities for our brief survey. Participants indicated how much they felt their OCD symptoms had changed since the pandemic began and how much they felt that having OCD was making it harder to deal with the pandemic. RESULTS: We collected survey data from June through August 2020 and received a total of 196 responses, some of which were partial responses. Among the nonmissing data, 65.9% (108/164) of the participants were from the United States and 90.5% (152/168) had been subjected to a stay-at-home order. In all, 92.9% (182/196) of the participants said they experienced worsening of their OCD symptoms since the pandemic began, although the extent to which their symptoms worsened differed across dimensions of OCD; notably, symmetry and completeness symptoms were less likely to have worsened than others. Moreover, 95.5% (171/179) of the participants felt that having OCD made it difficult to deal with the pandemic. CONCLUSIONS: Our study of online OCD support community members found a much higher rate of OCD symptom worsening than did other studies on people with OCD conducted during the current COVID-19 pandemic. Factors such as quarantine length, location, overlapping society-level challenges, and differing measurement and sampling choices may help to explain this difference across studies.

The dark side of Eureka: Artificially induced Aha moments make facts feel true.

Some ideas that we have feel mundane, but others are imbued with a sense of profundity. We propose that Aha! moments make an idea feel more true or valuable in order to aid quick and efficient decision-making, akin to a heuristic. To demonstrate where the heuristic may incur errors, we hypothesized that facts would appear more true if they were artificially accompanied by an Aha! moment elicited using an anagram task. In a preregistered experiment, we found that participants (n=300) provided higher truth ratings for statements accompanied by solved anagrams even if the facts were false, and the effect was particularly pronounced when participants reported an Aha! experience (d = .629). Recent work suggests that feelings of insight usually accompany correct ideas. However, here we show that feelings of insight can be overgeneralized and bias how true an idea or fact appears, simply if it occurs in the temporal 'neighbourhood' of an Aha! moment. We raise the possibility that feelings of insight, epiphanies, and Aha! moments have a dark side, and discuss some circumstances where they may even inspire false beliefs and delusions, with potential clinical importance.