Digital Mental Health's Unstable Dichotomy-Wellness and Health.

This Viewpoint discusses the unacknowledged risks and harms and unrealized clinical benefits of digital mental wellness and health technologies and offers suggestions for ways to catalyze the next phase of these technologies by focusing on safety, evidence, and engagement.

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

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

Adverse Events Reporting in Digital Interventions Evaluations for Psychosis: A Systematic Literature Search and Individual Level Content Analysis of Adverse Event Reports.

BACKGROUND: Digital health interventions (DHIs) have significant potential to upscale treatment access to people experiencing psychosis but raise questions around patient safety. Adverse event (AE) monitoring is used to identify, record, and manage safety issues in clinical trials, but little is known about the specific content and context contained within extant AE reports. This study aimed to assess current AE reporting in DHIs. STUDY DESIGN: A systematic literature search was conducted by the iCharts network (representing academic, clinical, and experts by experience) to identify trials of DHIs in psychosis. Authors were invited to share AE reports recorded in their trials. A content analysis was conducted on the shared reports. STUDY RESULTS: We identified 593 AE reports from 18 DHI evaluations, yielding 19 codes. Only 29 AEs (4.9% of total) were preidentified by those who shared AEs as being related to the intervention or trial procedures. While overall results support the safety of DHIs, DHIs were linked to mood problems and psychosis exacerbation in a few cases. Additionally, 27% of studies did not report information on relatedness for all or at least some AEs; 9.6% of AE reports were coded as unclear because it could not be determined what had happened to participants. CONCLUSIONS: The results support the safety of DHIs, but AEs must be routinely monitored and evaluated according to best practice. Individual-level analyses of AEs have merit to understand safety in this emerging field. Recommendations for best practice reporting in future studies are provided.

Digital Tools to Facilitate the Detection and Treatment of Bipolar Disorder: Key Developments and Future Directions.

Bipolar disorder (BD) impacts over 40 million people around the world, often manifesting in early adulthood and substantially impacting the quality of life and functioning of individuals. Although early interventions are associated with a better prognosis, the early detection of BD is challenging given the high degree of similarity with other psychiatric conditions, including major depressive disorder, which corroborates the high rates of misdiagnosis. Further, BD has a chronic, relapsing course, and the majority of patients will go on to experience mood relapses despite pharmacological treatment. Digital technologies present promising results to augment early detection of symptoms and enhance BD treatment. In this editorial, we will discuss current findings on the use of digital technologies in the field of BD, while debating the challenges associated with their implementation in clinical practice and the future directions.

Digital Navigator Training to Increase Access to Mental Health Care in Community-Based Organizations.

Providing human support for users of behavioral health technology can help facilitate the necessary engagement and clinical integration of digital tools in mental health care. A team conducted digital navigator training that taught participants how to promote patrons' digital literacy, evaluate and recommend health apps, and interpret smartphone data. The authors trained 80 participants from 21 organizations, demonstrating this training's feasibility, acceptability, and need. Case studies explore the implementation of this training curriculum. As technology's potential in mental health care expands, training can empower digital navigators to ensure that the use of digital tools is informed, equitable, and clinically relevant.

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

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

Exploring current smartphone-based cognitive assessments in schizophrenia and bipolar disorder.

Schizophrenia and bipolar disorder are associated with cognitive deficits that contribute significantly to disability. However, traditional in-lab cognitive assessments are time-consuming and not optimized for remote administration. Recent advancements in smartphone technology enable momentary cognitive assessments in a real-world context. This brief report reviews recent research in momentary cognitive assessments in individuals with schizophrenia and bipolar disorder through reviewing mobile platforms and cognitive assessments studied. A total of 14 experimental articles were reviewed, focusing on cognitive domains including visual working memory, processing speed, executive function, verbal fluency, verbal memory, social cognition, and typing patterns. The review highlights the feasibility of remote cognitive assessment with smartphones, and provides a layout of domains studied in this context, but illustrates a low volume of current research, the need for additional studies, and the potential for innovations like digital phenotyping.

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

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

Integrated Digital Mental Health Care: A Vision for Addressing Population Mental Health Needs.

The unmet need for mental health care continues to rise across the world. This article synthesizes the evidence supporting the components of a hypothetical model of integrated digital mental health care to meet population-wide mental health needs. This proposed model integrates two approaches to broadening timely access to effective care: integrated, primary care-based mental health services and digital mental health tools. The model solves for several of the key challenges historically faced by digital health, through promoting digital literacy and access, the curation of evidence-based digital tools, integration into clinical practice, and electronic medical record integration. This model builds upon momentum toward the integration of mental health services within primary care and aligns with the principles of the Collaborative Care Model. Finally, the authors present the major next steps toward implementation of integrated digital mental health care at scale.

Psychiatrists' experiences and opinions of generative artificial intelligence in mental healthcare: An online mixed methods survey.

Following the launch of ChatGPT in November 2022, interest in large language model (LLM)-powered chatbots has surged with increasing focus on the clinical potential of these tools. Missing from this discussion, however, are the perspectives of physicians. The current study aimed to explore psychiatrists' experiences and opinions on this new generation of chatbots in mental health care. An online survey including both quantitative and qualitative responses was distributed to a non-probability sample of psychiatrists affiliated with the American Psychiatric Association. Findings revealed 44 % of psychiatrists had used OpenAI's ChatGPT-3.5 and 33 % had used GPT-4.0 "to assist with answering clinical questions." Administrative tasks were cited as a major benefit of these tools: 70 % somewhat agreed/agreed "documentation will be/is more efficient". Three in four psychiatrists (75 %) somewhat agreed/agreed "the majority of their patients will consult these tools before first seeing a doctor". Nine in ten somewhat agreed/agreed that clinicians need more support/training in understanding these tools. Open-ended responses reflected these opinions but respondents also expressed divergent opinions on the value of generative AI in clinical practice, including its impact on the future of the profession.

Current evidence on the efficacy of mental health smartphone apps for symptoms of depression and anxiety. A meta-analysis of 176 randomized controlled trials.

The mental health care available for depression and anxiety has recently undergone a major technological revolution, with growing interest towards the potential of smartphone apps as a scalable tool to treat these conditions. Since the last comprehensive meta-analysis in 2019 established positive yet variable effects of apps on depressive and anxiety symptoms, more than 100 new randomized controlled trials (RCTs) have been carried out. We conducted an updated meta-analysis with the objectives of providing more precise estimates of effects, quantifying generalizability from this evidence base, and understanding whether major app and trial characteristics moderate effect sizes. We included 176 RCTs that aimed to treat depressive or anxiety symptoms. Apps had overall significant although small effects on symptoms of depression (N=33,567, g=0.28, p<0.001; number needed to treat, NNT=11.5) and generalized anxiety (N=22,394, g=0.26, p<0.001, NNT=12.4) as compared to control groups. These effects were robust at different follow-ups and after removing small sample and higher risk of bias trials. There was less variability in outcome scores at post-test in app compared to control conditions (ratio of variance, RoV=-0.14, 95% CI: -0.24 to -0.05 for depressive symptoms; RoV=-0.21, 95% CI: -0.31 to -0.12 for generalized anxiety symptoms). Effect sizes for depression were significantly larger when apps incorporated cognitive behavioral therapy (CBT) features or included chatbot technology. Effect sizes for anxiety were significantly larger when trials had generalized anxiety as a primary target and administered a CBT app or an app with mood monitoring features. We found evidence of moderate effects of apps on social anxiety (g=0.52) and obsessive-compulsive (g=0.51) symptoms, a small effect on post-traumatic stress symptoms (g=0.12), a large effect on acrophobia symptoms (g=0.90), and a non-significant negative effect on panic symptoms (g=-0.12), although these results should be considered with caution, because most trials had high risk of bias and were based on small sample sizes. We conclude that apps have overall small but significant effects on symptoms of depression and generalized anxiety, and that specific features of apps - such as CBT or mood monitoring features and chatbot technology - are associated with larger effect sizes.

Generative Language Models and Open Notes: Exploring the Promise and Limitations.

Patients' online record access (ORA) is growing worldwide. In some countries, including the United States and Sweden, access is advanced with patients obtaining rapid access to their full records on the web including laboratory and test results, lists of prescribed medications, vaccinations, and even the very narrative reports written by clinicians (the latter, commonly referred to as "open notes"). In the United States, patient's ORA is also available in a downloadable form for use with other apps. While survey studies have shown that some patients report many benefits from ORA, there remain challenges with implementation around writing clinical documentation that patients may now read. With ORA, the functionality of the record is evolving; it is no longer only an aide memoire for doctors but also a communication tool for patients. Studies suggest that clinicians are changing how they write documentation, inviting worries about accuracy and completeness. Other concerns include work burdens; while few objective studies have examined the impact of ORA on workload, some research suggests that clinicians are spending more time writing notes and answering queries related to patients' records. Aimed at addressing some of these concerns, clinician and patient education strategies have been proposed. In this viewpoint paper, we explore these approaches and suggest another longer-term strategy: the use of generative artificial intelligence (AI) to support clinicians in documenting narrative summaries that patients will find easier to understand. Applied to narrative clinical documentation, we suggest that such approaches may significantly help preserve the accuracy of notes, strengthen writing clarity and signals of empathy and patient-centered care, and serve as a buffer against documentation work burdens. However, we also consider the current risks associated with existing generative AI. We emphasize that for this innovation to play a key role in ORA, the cocreation of clinical notes will be imperative. We also caution that clinicians will need to be supported in how to work alongside generative AI to optimize its considerable potential.

Using digital technology to promote physical health in mental healthcare: A sequential mixed-methods study of clinicians' views.

AIM: Recent years have seen innovation in 'mHealth' tools and health apps for the management/promotion of physical health and fitness across the general population. However, there is limited research on how this could be applied to mental healthcare. Therefore, we examined mental healthcare professionals' current uses and perceived roles of digital lifestyle interventions for promoting healthy lifestyles, physical health and fitness in youth mental healthcare. METHODS: A sequential, mixed-methods design was used, consisting of a quantitative online survey, followed by qualitative in-depth interviews. RESULTS: A total of 127 mental healthcare professionals participated in the online survey. Participants had limited mHealth experience, and the majority agreed that further training would be beneficial. Thirteen mental healthcare professionals were interviewed. Five themes were generated (i) digital technology's ability to enhance the physical healthcare; (ii) Conditions for the acceptability of apps; (iii) Limitations on staff capability and time; (iv) Motivation as the principal barrier; and (v) Practicalities around receiving lifestyle data. Systematic integration of data produced novel insights around: (i) staff involvement and needs; (ii) ideal focus and content of digital lifestyle interventions; and (iii) barriers towards implementation (including mental healthcare professionals own limited experience using digital lifestyle interventions, which aligned with the appeal of formal training). CONCLUSIONS: Overall, digital lifestyle interventions were positively received by mental healthcare professionals, particularly for health behaviour-tracking and mHealth support for exercise and nutrition. Practical suggestions for facilitating their uptake/implementation to improve availability of physical health interventions in mental healthcare are presented.

Social connections as determinants of cognitive health and as targets for social interventions in persons with or at risk of Alzheimer's disease and related disorders: a scoping review.

BACKGROUND: Social connections have a significant impact on health across age groups, including older adults. Loneliness and social isolation are known risk factors for Alzheimer's disease and related dementias (ADRD). Yet, we did not find a review focused on meta-analyses and systematic reviews of studies that had examined associations of social connections with cognitive decline and trials of technology-based and other social interventions to enhance social connections in people with ADRD. STUDY DESIGN: We conducted a scoping review of 11 meta-analyses and systematic reviews of social connections as possible determinants of cognitive decline in older adults with or at risk of developing ADRD. We also examined eight systematic reviews of technology-based and other social interventions in persons with ADRD. STUDY RESULTS: The strongest evidence for an association of social connections with lower risk of cognitive decline was related to social engagement and social activities. There was also evidence linking social network size to cognitive function or cognitive decline, but it was not consistently significant. A number of, though not all, studies reported a significant association of marital status with risk of ADRD. Surprisingly, evidence showing that social support reduces the risk of ADRD was weak. To varying degrees, technology-based and other social interventions designed to reduce loneliness in people with ADRD improved social connections and activities as well as quality of life but had no significant impact on cognition. We discuss strengths and limitations of the studies included. CONCLUSIONS: Social engagement and social activities seem to be the most consistent components of social connections for improving cognitive health among individuals with or at risk for ADRD. Socially focused technology-based and other social interventions aid in improving social activities and connections and deserve more research.

Digital and precision clinical trials: innovations for testing mental health medications, devices, and psychosocial treatments.

Mental health treatment advances - including neuropsychiatric medications and devices, psychotherapies, and cognitive treatments - lag behind other fields of clinical medicine such as cardiovascular care. One reason for this gap is the traditional techniques used in mental health clinical trials, which slow the pace of progress, produce inequities in care, and undermine precision medicine goals. Newer techniques and methodologies, which we term digital and precision trials, offer solutions. These techniques consist of (1) decentralized (i.e., fully-remote) trials which improve the speed and quality of clinical trials and increase equity of access to research, (2) precision measurement which improves success rate and is essential for precision medicine, and (3) digital interventions, which offer increased reach of, and equity of access to, evidence-based treatments. These techniques and their rationales are described in detail, along with challenges and solutions for their utilization. We conclude with a vignette of a depression clinical trial using these techniques.