Physiological and behavioral effects of interpersonal validation: A multilevel approach to examining a core intervention strategy among self-injuring adolescents and their mothers.

OBJECTIVE: The current study examined how teaching an interpersonal validation-oriented skill from dialectical behavior therapy affects behavioral and biological indices of self-inflicted injury (SII) risk among self-injuring adolescents and their mothers (n = 30 dyads), and typical control mother-daughter dyads (n = 30). METHOD: Behavioral indicators of family functioning (e.g., cohesion, coercion, and invalidation) and a physiological index of emotion dysregulation (respiratory sinus arrhythmia [RSA]) were examined across two conflict tasks (pre- and postskills training). RESULTS: Dyads' subjective affect and observed behavior generally improved when practicing validation. Findings indicate mother-, daughter-, and dyad-level behavior accounted for significant variance in RSA reactivity. CONCLUSIONS: Results demonstrate that teaching a single skill on one occasion can have detectable effects on biosocial functioning, with important implications for the etiology and treatment of SII.

Psychological and Autonomic Correlates of Emotion Dysregulation among Women in Substance Use Disorder Treatment.

BACKGROUND: Emotion regulation is increasingly recognized as important for the prevention and treatment of substance use disorder (SUD). However, there is an identified lack of physiological indexes of emotion dysregulation in SUD treatment studies, critically needed to better understand the link between emotion regulation capacity (measured physiologically) and self-report health outcomes among individuals in SUD treatment. OBJECTIVE: To examine the association between respiratory sinus arrhythmia (RSA) and self-report health outcomes among women in SUD treatment. METHODS: This is a cross-sectional study based on baseline data from 217 women enrolled in a randomized control trial to study a mind-body intervention as an adjunct to SUD treatment. All participants were enrolled in community-based outpatient treatment. Participants were administered questionnaires to examine sample characteristics, mental health symptoms, and interoceptive awareness and mindfulness skills. RSA data was gathered as an index of emotion dysregulation. Descriptive statistics, bivariate correlations, and regression were used in the analyses. RESULTS: Findings highlight the extensive trauma histories, low SES, and the high symptoms of distress in this sample. RSA was only significantly correlated with interoceptive awareness after controlling for age and BMI. Measures of symptomatic distress and mindfulness were not correlated with RSA. Conclusions/Importance: Results provide the first evidence of RSA as an index of interoceptive awareness in this population. The inclusion of biomarkers such as RSA in SUD clinical studies may help identify individuals that are in need of targeted treatments that include interoceptive awareness training focused on improving emotion regulation.

Emotional face recognition in adolescent suicide attempters and adolescents engaging in non-suicidal self-injury.

Little is known about the bio-behavioral mechanisms underlying and differentiating suicide attempts from non-suicidal self-injury (NSSI) in adolescents. Adolescents who attempt suicide or engage in NSSI often report significant interpersonal and social difficulties. Emotional face recognition ability is a fundamental skill required for successful social interactions, and deficits in this ability may provide insight into the unique brain-behavior interactions underlying suicide attempts versus NSSI in adolescents. Therefore, we examined emotional face recognition ability among three mutually exclusive groups: (1) inpatient adolescents who attempted suicide (SA, n = 30); (2) inpatient adolescents engaged in NSSI (NSSI, n = 30); and (3) typically developing controls (TDC, n = 30) without psychiatric illness. Participants included adolescents aged 13-17 years, matched on age, gender and full-scale IQ. Emotional face recognition was evaluated using the diagnostic assessment of nonverbal accuracy (DANVA-2). Compared to TDC youth, adolescents with NSSI made more errors on child fearful and adult sad face recognition while controlling for psychopathology and medication status (ps < 0.05). No differences were found on emotional face recognition between NSSI and SA groups. Secondary analyses showed that compared to inpatients without major depression, those with major depression made fewer errors on adult sad face recognition even when controlling for group status (p < 0.05). Further, compared to inpatients without generalized anxiety, those with generalized anxiety made fewer recognition errors on adult happy faces even when controlling for group status (p < 0.05). Adolescent inpatients engaged in NSSI showed greater deficits in emotional face recognition than TDC, but not inpatient adolescents who attempted suicide. Further results suggest the importance of psychopathology in emotional face recognition. Replication of these preliminary results and examination of the role of context-dependent emotional processing are needed moving forward.

Facial emotion recognition in childhood-onset bipolar I disorder: an evaluation of developmental differences between youths and adults.

OBJECTIVES: Bipolar disorder (BD) is a severe mental illness with high healthcare costs and poor outcomes. Increasing numbers of youths are diagnosed with BD, and many adults with BD report that their symptoms started in childhood, suggesting that BD can be a developmental disorder. Studies advancing our understanding of BD have shown alterations in facial emotion recognition both in children and adults with BD compared to healthy comparison (HC) participants, but none have evaluated the development of these deficits. To address this, we examined the effect of age on facial emotion recognition in a sample that included children and adults with confirmed childhood-onset type-I BD, with the adults having been diagnosed and followed since childhood by the Course and Outcome in Bipolar Youth study. METHODS: Using the Diagnostic Analysis of Non-Verbal Accuracy, we compared facial emotion recognition errors among participants with BD (n = 66; ages 7-26 years) and HC participants (n = 87; ages 7-25 years). Complementary analyses investigated errors for child and adult faces. RESULTS: A significant diagnosis-by-age interaction indicated that younger BD participants performed worse than expected relative to HC participants their own age. The deficits occurred both for child and adult faces and were particularly strong for angry child faces, which were most often mistaken as sad. Our results were not influenced by medications, comorbidities/substance use, or mood state/global functioning. CONCLUSIONS: Younger individuals with BD are worse than their peers at this important social skill. This deficit may be an important developmentally salient treatment target - that is, for cognitive remediation to improve BD youths' emotion recognition abilities.

Self-injurious implicit attitudes among adolescent suicide attempters versus those engaged in nonsuicidal self-injury.

BACKGROUND: Suicide is among the most important mental health issues affecting adolescents today despite much research on its detection and prevention. Beyond suicide attempts (SAs), clinicians are increasingly confronted with another, potentially related problem: non-suicidal self-injury (NSSI)-defined as the deliberate destruction of body tissue without intent to die. NSSI may increase risk for making an SA by sevenfold, but many studies examining this link have involved youths engaging in both NSSI and SAs. Thus, there is a need to compare homogeneous groups of adolescents engaged in NSSI-only or SA-only, but not both, to advance what is known about each form of self-harm. The self-injurious implicit association task (SI-IAT) is a particularly important computerized behavioral task to study such adolescents because the SI-IAT provides objective behavioral data about problems for which people may lack insight or be motivated to conceal, such as SAs and NSSI. METHODS: We evaluated implicit associations with cutting and death/suicide using the computerized SI-IAT in three mutually exclusive groups: (1) adolescents who made an SA but had never engaged in NSSI (n = 47); (2) adolescents who engaged in NSSI but had never made an SA (n = 46); and (3) typically developing control (TDC) adolescents without history of psychiatric problems (n = 43). RESULTS: Nonsuicidal self-injury participants had stronger identification with cutting versus no cutting than either SA or TDC participants. Contrary to our hypothesis, NSSI participants had stronger identification with suicide/death versus life than either SA or TDC participants. CONCLUSIONS: Strong implicit attitudes towards suicide/death among adolescents with NSSI without a prior SA suggest that clinicians should not dismiss NSSI as not serious. Further work is required to elucidate the mechanism by which youths engaged in NSSI acquire these stronger identifications and make a first-time SA to develop novel treatment and prevention strategies blocking this transformation, ultimately reducing youth suicide.

Affective processing bias in youth with primary bipolar disorder or primary attention-deficit/hyperactivity disorder.

High rates of comorbidity and overlapping diagnostic criteria between pediatric bipolar disorder (BD) and attention-deficit/hyperactivity disorder (ADHD) contribute to diagnostic and treatment confusion. To advance what is known about both disorders, we compared effect of emotional stimuli on response control in children with primary BD, primary ADHD and typically developing controls (TDC). Participants included 7-17 year olds with either "narrow-phenotype" pediatric BD (n = 25), ADHD (n = 25) or TDC (n = 25). Groups were matched on participant age and FSIQ. The effect of emotional stimuli on response control was assessed using the Cambridge Neuropsychological Test Automated Battery Affective Go/No-Go task (CANTAB AGN). We found a group by target valence interaction on commission errors [F(2,71) = 5.34, p < 0.01, ƞ p (2) = 0.13] whereby ADHD, but not TDC participants, made more errors on negative than positive words [t(24) = -2.58, p < 0.05, r = 0.47]. In contrast, there was a nonsignificant trend for BD participants to make fewer errors on negative versus positive words compared to ADHD and TDC participants. Between-subjects effects showed that ADHD participants made more errors than TDC, but not BD participants. Our main finding advances what is known about the effect of emotional stimuli on response control in children with ADHD. Our results suggesting a positive affective processing bias in children with ADHD compliment emerging literature show that difficulties with emotional processing and regulation may be core features of ADHD. Further, given the observed pattern of results in children with ADHD compared to BD children, our behavioral results suggest the importance of examining differences in the brain-behavior mechanisms involved in affective processing in children with ADHD compared to BD children.

Multidimensional Approach to Exploring Neighborhood Determinants and Symptom Severity Among Individuals With Psychosis.

Importance: The impact of cumulative exposure to neighborhood factors on psychosis, depression, and anxiety symptom severity prior to specialized services for psychosis is unknown. Objective: To identify latent neighborhood profiles based on unique combinations of social, economic, and environmental factors, and validate profiles by examining differences in symptom severity among individuals with first episode psychosis (FEP). Design, Setting, and Participants: This cohort study used neighborhood demographic data and health outcome data for US individuals with FEP receiving services between January 2017 and August 2022. Eligible participants were between ages 14 and 40 years and enrolled in a state-level coordinated specialty care network. A 2-step approach was used to characterize neighborhood profiles using census-tract data and link profiles to mental health outcomes. Data were analyzed March 2023 through October 2023. Exposures: Economic and social determinants of health; housing conditions; land use; urbanization; walkability; access to transportation, outdoor space, groceries, and health care; health outcomes; and environmental exposure. Main Outcomes and Measures: Outcomes were Community Assessment of Psychic Experiences 15-item, Patient Health Questionnaire 9-item, and Generalized Anxiety Disorder 7-item scale. Results: The total sample included 225 individuals aged 14 to 36 years (mean [SD] age, 20.7 [4.0] years; 152 men [69.1%]; 9 American Indian or Alaska Native [4.2%], 13 Asian or Pacific Islander [6.0%], 19 Black [8.9%], 118 White [55.1%]; 55 Hispanic ethnicity [26.2%]). Of the 3 distinct profiles identified, nearly half of participants (112 residents [49.8%]) lived in urban high-risk neighborhoods, 56 (24.9%) in urban low-risk neighborhoods, and 57 (25.3%) in rural neighborhoods. After controlling for individual characteristics, compared with individuals residing in rural neighborhoods, individuals residing in urban high-risk (mean estimate [SE], 0.17 [0.07]; P = .01) and urban low-risk neighborhoods (mean estimate [SE], 0.25 [0.12]; P = .04) presented with more severe psychotic symptoms. Individuals in urban high-risk neighborhoods reported more severe depression (mean estimate [SE], 1.97 [0.79]; P = .01) and anxiety (mean estimate [SE], 1.12 [0.53]; P = .04) than those in rural neighborhoods. Conclusions and Relevance: This study found that in a cohort of individuals with FEP, baseline psychosis, depression, and anxiety symptom severity differed by distinct multidimensional neighborhood profiles that were associated with where individuals reside. Exploring the cumulative effect of neighborhood factors improves our understanding of social, economic, and environmental impacts on symptoms and psychosis risk which could potentially impact treatment outcomes.

The Indirect Effects of a Mindfulness Mobile App on Productivity Through Changes in Sleep Among Retail Employees: Secondary Analysis.

BACKGROUND: Chronic sleep disturbance is prevalent among United States employees and associated with costly productivity impairment. Mindfulness interventions improve sleep (ie, insomnia and daytime sleepiness) and productivity outcomes, and mobile apps provide scalable means of intervention delivery. However, few studies have examined the effects of mindfulness mobile apps on employees, and no research to date has tested the role of sleep improvement as a potential mechanism of action for productivity outcomes. OBJECTIVE: This study examined the effects of Calm, a consumer-based mindfulness app, and sleep coaching, on productivity impairment among retail employees through the indirect effects of changes in insomnia and daytime sleepiness. METHODS: This study was a secondary analysis of data from a randomized controlled trial (N=1029) comparing the use of Calm (n=585, 56.9%) to a waitlist control (n=444, 43.2%) for 8 weeks among employees of a large retail employer in the United States. A subset of individuals with elevated insomnia symptoms also had access to brief sleep coaching with Calm (n=101, 9.8%). Insomnia symptom severity, daytime sleepiness, and productivity impairment (ie, absenteeism, presenteeism, overall productivity impairment, and non-work activity impairment) were assessed at baseline and weeks 2, 4, 6, and 8. Indirect effects were evaluated with latent growth curve modeling to test whether the Calm intervention (Calm group vs waitlist control) was effective in reducing work productivity impairment through changes in sleep disturbance. RESULTS: No significant main effects of Calm intervention on productivity impairment were detected for any outcome at α level of .05, with the exception of non-work activity impairment models, in which Calm intervention reduced non-work activity impairment over time (P=.01 and P=.02 for insomnia and sleepiness models, respectively). Significant indirect effects of insomnia were detected for presenteeism (P=.002), overall work productivity (P=.01), and non-work activity impairment (P=.002); Calm intervention produced significantly greater reductions in insomnia symptoms (relative to waitlist control), and decreases in insomnia were associated with decreases in work productivity impairment. There was no significant indirect effect of change in insomnia on changes in absenteeism (P=.20). Furthermore, we detected no significant indirect effects of daytime sleepiness on productivity impairment. CONCLUSIONS: We found that Calm (plus sleep coaching for a small subset of individuals) had beneficial effects on employee sleep, and these benefits on sleep were related to indirect effects on productivity impairment (ie, presenteeism, overall work productivity impairment, and non-work activity impairment). There were no overall main effects of Calm intervention on productivity impairment; however, insomnia appears to be a mechanism associated with benefits for employee productivity. This is one of the first studies to suggest that sleep benefits of a mindfulness mobile app may also indirectly relate to benefits for workplace productivity. TRIAL REGISTRATION: ClinicalTrials.gov NCT05120310; https://clinicaltrials.gov/ct2/show/NCT05120310.

A Mobile App for Stress Management in Middle-Aged Men and Women (Calm): Feasibility Randomized Controlled Trial.

BACKGROUND: Middle-aged adults (40-65 years) report higher stress levels than most other age groups. There is a need to determine the feasibility of using a meditation app to reduce stress and improve stress-related outcomes in middle-aged adults with a focus on men, as previous meditation app-based studies have reported a low proportion of or even no male participants. OBJECTIVE: This study aims to (1) determine the feasibility (ie, acceptability and demand with a focus on men) of a consumer-based meditation app (Calm), to reduce stress among middle-aged adults reporting elevated stress levels, and (2) explore the preliminary effects of Calm on perceived stress, psychological outcomes (anxiety, depressive symptoms, mindfulness, and general coping), health behaviors (physical activity and eating habits), and COVID-19 perceptions. METHODS: This feasibility randomized controlled trial evaluated an app-based meditation intervention in middle-aged adults (N=83) with elevated stress levels (ie, Perceived Stress Scale score ≥15) and limited or no previous experience with meditation. Participants were randomized to the intervention group (Calm app) or a control (educational podcasts; POD) group. Participants completed self-report assessments at baseline and postintervention (week 4). Feasibility was measured as acceptability and demand using Bowen framework. Feasibility and COVID-19 perceptions data were examined using descriptive statistics, and preliminary effects were evaluated using repeated measures analysis of variance. RESULTS: Participants were satisfied with Calm (27/28, 96%) and found it appropriate or useful (26/28, 93%). Most reported they would likely continue using the Calm app (18/28, 64%). More Calm users reported satisfaction, appropriateness or usefulness, and intent to continue app use than POD users. Calm users (n=33) completed a mean of 20 (SD 31.1) minutes of meditation on the days they meditated and 103 (SD 109.1) minutes of meditation per week. The average adherence rate to the prescribed meditation was 71% among Calm app users, compared to 62% among POD users. Recruitment rate of men was 35% (29/83). Of those randomized to Calm, 55% (15/29) were men, and retention among them was higher (14/15, 93%) than that among women (12/20, 60%). No significant within or between group differences were observed. CONCLUSIONS: A 4-week, app-based mindfulness meditation intervention (Calm) may be feasible for middle-aged adults and a useful stress-management tool. Calm users expressed satisfaction with the app and felt it was appropriate and useful. Significant improvements in perceived stress and psychological outcomes or stress-related health behaviors were not observed. Even though men spent less time in meditation than women did and completed fewer weekly sessions, they were more likely to adhere to the prescription. Further research is needed for improving stress and stress-related outcomes among middle-aged adults with emphasis on the effects of mindfulness meditation apps for men. TRIAL REGISTRATION: ClinicalTrials.gov NCT04272138; https://clinicaltrials.gov/ct2/show/NCT04272138.

Pregnant women's use of a consumer-based meditation mobile app: A descriptive study.

Objective: The objectives of this study were to explore the satisfaction of pregnant or recently pregnant women with the existing Calm app content (i.e. non-pregnancy) and preferences and recommendations for the types of pregnancy-specific content that would be helpful to pregnant women. Methods: This study was a national cross-sectional survey of subscribers to a meditation mobile app (i.e. Calm). Eligible participants were currently pregnant or recently pregnant (within the past 12 months) and used Calm during their pregnancy. Participants were asked about their Calm usage and perceived benefits of Calm during pregnancy, and interest in pregnancy-specific content. Descriptive statistics were used to characterize the sample. Results: Participants (N = 111) were on average 34 years old (SD = 5.4) and half of the sample was currently pregnant (N = 55). The most common reasons for using the Calm app during pregnancy was for sleep problems (29%; n = 31) or anxiety (27%; n = 29). Women reported Calm was most helpful for improving sleep (32%; n = 32), anxiety (25%; n = 25), and stress (21%; n = 21). Nearly all women wanted pregnancy-specific meditation content within the app (98%; n = 98) and expressed interest in topics including pregnancy-related anxiety (68%; n = 67), postpartum (50%; n = 49), pregnancy-related sleep problems (41%; n = 40), and labor and delivery (38%; n = 37). Conclusion: Women who used the Calm app during pregnancy found it helpful for improving sleep, anxiety, and stress but desire pregnancy-specific content. Future meditation mobile app studies should utilize pregnancy-specific content and test the feasibility and efficacy of sleep and mental health in pregnant women.

Meditation Mobile App Developed for Patients With and Survivors of Cancer: Feasibility Randomized Controlled Trial.

BACKGROUND: To address the unmet need for a commercial cancer-specific meditation app, we leveraged a long-standing partnership with a consumer-based app (ie, Calm) to develop the first commercial meditation app prototype adapted specifically for the needs of patients with cancer. Input was obtained at both the individual user and clinic levels (ie, patients with and survivors of cancer and health care providers). OBJECTIVE: This study aimed to determine the feasibility of a cancer-specific meditation app prototype. METHODS: Patients with and survivors of cancer who were recruited and enrolled in the feasibility randomized controlled trial were asked to use the prototype app daily (≥70 minutes per week) for 4 weeks. Participants completed web-based weekly questionnaires and a final poststudy questionnaire and were asked to participate in an optional web-based poststudy interview. The questionnaires and interviews covered the following feasibility categories: acceptability, demand, practicality, and adaptation. RESULTS: A total of 36 patients with and survivors of cancer completed the baseline questionnaire, 18 completed the final questionnaire, and 6 completed the optional interviews. Weekly and poststudy questionnaires indicated high overall enjoyment, ease of use, and satisfaction with the app content, aesthetics, and graphics. The objective use data indicated that the average total app use rate was 73.39 (SD 7.12) minutes per week. Interviews (N=6) revealed positive and mixed responses to the app prototype and informative differences related to preferences for narrators, emotional content, and meditation teaching but an overall appreciation for the variety of options. CONCLUSIONS: The most likely candidates for moving from cancer-specific meditation apps to dissemination are through partnering with the industry, in which name recognition and market distribution are already established (even showing a base of users from the targeted population with cancer). This study established the feasibility of a cancer-specific mobile meditation app prototype for patients with and survivors of cancer, using a commercially available app. The quantitative and qualitative data demonstrated the acceptability, demand, practicality, and adaptation of the prototype. Improvements suggested by the participants will be considered in the final app design before testing the efficacy of the app in a future study. TRIAL REGISTRATION: Clinicaltrials.gov NCT05459168; https://clinicaltrials.gov/ct2/show/record/NCT05459168.

Testing the Pragmatic Effectiveness of a Consumer-Based Mindfulness Mobile App in the Workplace: Randomized Controlled Trial.

BACKGROUND: Mental health and sleep problems are prevalent in the workforce, corresponding to costly impairment in productivity and increased health care use. Digital mindfulness interventions are efficacious in improving sleep and mental health in the workplace; however, evidence supporting their pragmatic utility, potential for improving productivity, and ability to reduce employer costs is limited. OBJECTIVE: This pragmatic, cluster randomized controlled trial aimed to evaluate the experimental effects of implementing a commercially available mindfulness app-Calm-in employees of a large, multisite employer in the United States. Outcomes included mental health (depression, anxiety, and stress), sleep (insomnia and daytime sleepiness), resilience, productivity impairment (absenteeism, presenteeism, overall work impairment, and non-work activity impairment), and health care use (medical visit frequency). METHODS: Employees were randomized at the work site to receive either the Calm app intervention or waitlist control. Participants in the Calm intervention group were instructed to use the Calm app for 10 minutes per day for 8 weeks; individuals with elevated baseline insomnia symptoms could opt-in to 6 weeks of sleep coaching. All outcomes were assessed every 2 weeks, with the exception of medical visits (weeks 4 and 8 only). Effects of the Calm intervention on outcomes were evaluated via mixed effects modeling, controlling for relevant baseline characteristics, with fixed effects of the intervention on outcomes assessed at weeks 2, 4, 6, and 8. Models were analyzed via complete-case and intent-to-treat analyses. RESULTS: A total of 1029 employees enrolled (n=585 in the Calm intervention group, including 101 who opted-in to sleep coaching, and n=444 in waitlist control). Of them, 192 (n=88 for the Calm intervention group and n=104 for waitlist) completed all 5 assessments. In the complete-case analysis at week 8, employees at sites randomized to the Calm intervention group experienced significant improvements in depression (P=.02), anxiety (P=.01), stress (P<.001), insomnia (P<.001), sleepiness (P<.001), resilience (P=.02), presenteeism (P=.01), overall work impairment (P=.004), and nonwork impairment (P<.001), and reduced medical care visit frequency (P<.001) and productivity impairment costs (P=.01), relative to the waitlist control. In the intent-to-treat analysis at week 8, significant benefits of the intervention were observed for depression (P=.046), anxiety (P=.01), insomnia (P<.001), sleepiness (P<.001), nonwork impairment (P=.04), and medical visit frequency (P<.001). CONCLUSIONS: The results suggest that the Calm app is an effective workplace intervention for improving mental health, sleep, resilience, and productivity and for reducing medical visits and costs owing to work impairment. Future studies should identify optimal implementation strategies that maximize employee uptake and large-scale implementation success across diverse, geographically dispersed employers. TRIAL REGISTRATION: ClinicalTrials.gov NCT05120310; https://clinicaltrials.gov/ct2/show/NCT05120310.

Evaluation of Mood Check-in Feature for Participation in Meditation Mobile App Users: Retrospective Longitudinal Analysis.

BACKGROUND: Mindfulness meditation smartphone apps may improve mental health but lack evidence-based behavioral strategies to encourage their regular use for attaining mental health benefits. In October 2019, the Calm mindfulness meditation app introduced a mood check-in feature, but its effects on participation in meditation have yet to be tested. OBJECTIVE: The objective of this study was to investigate how a mood check-in feature impacts meditation behavior in Calm app subscribers. METHODS: This was a retrospective longitudinal analysis of mobile app usage data from a random sample of first-time subscribers to the Calm app (n=2600) who joined in summer 2018 or summer 2019. The mood check-in feature allows users to rate their mood using an emoji after completing a meditation session and displays a monthly calendar of their past mood check-ins. Regression analyses were used to compare the rate of change in meditation behavior before and after the introduction of mood check-ins and to estimate how usage of mood check-ins was associated with individuals' future meditation behavior (ie, intent-to-treat effects). Additional regression models examined the heterogenous effect of mood check-ins between subscribers who were active or inactive users prior to the introduction to mood check-ins (ie, above or below the median number of weeks with any meditation within their cohort). In order to confirm the specific associations between mood check-ins and meditation engagement, we modeled the direct relationship between the use of mood check-ins in previous weeks and subsequent meditation behavior (ie, treatment on the treated effects). RESULTS: During the first 9 months of their subscription, the 2019 cohort completed an average of 0.482 more sessions per week (95% CI 0.309 to 0.655) than the 2018 cohort; however, across both cohorts, average weekly meditation declined (-0.033 sessions per week, 95% CI -0.035 to -0.031). Controlled for trends in meditation before mood check-ins and aggregate differences between the 2018 and 2019 samples, the time trend in the number of weekly meditation sessions increased by 0.045 sessions among the 2019 cohort after the introduction of mood check-ins (95% CI 0.039 to 0.052). This increase in meditation was most pronounced among the inactive subscribers (0.063 sessions, 95% CI 0.052 to 0.074). When controlled for past-week meditation, use of mood check-ins during the previous week was positively associated with the likelihood of meditating the following week (odds ratio 1.132, 95% CI 1.059 to 1.211); however, these associations were not sustained beyond 1 week. CONCLUSIONS: Using mood check-ins increases meditation participation in Calm app subscribers and may be especially beneficial for inactive subscribers. Mobile apps should consider incorporating mood check-ins to help better engage a wider range of users in app-based meditation, but more research is warranted.

Associations Between Rural or Urban Status, Health Outcomes and Behaviors, and COVID-19 Perceptions Among Meditation App Users: Longitudinal Survey Study.

BACKGROUND: Rural and urban differences in health outcomes and behaviors have been well-documented, with significant rural health disparities frequently highlighted. Mobile health (mHealth) apps, such as meditation apps, are a novel method for improving health and behaviors. These apps may be a critical health promotion strategy during the COVID-19 pandemic and could potentially be used to address rural health disparities. However, limited research has assessed whether meditation app health outcomes are associated with rural and urban residence, and it is unclear whether disparities in health and behaviors between rural and urban populations would persist among meditation app users. OBJECTIVE: We aimed to explore associations between rural or urban status, psychological outcomes, and physical activity among users of a mobile meditation app. We further aimed to explore associations between rural or urban status and perceived effects of COVID-19 on stress, mental health, and physical activity, and to explore changes in these outcomes in rural versus urban app users over time. METHODS: This study was a secondary analysis of a national survey conducted among subscribers to the meditation app Calm. Eligible participants completed online baseline surveys from April to June 2020, and follow-up surveys from June to September 2020, assessing demographics, psychological outcomes, physical activity, and perceived effects of COVID-19 on stress, mental health, and physical activity. RESULTS: Participants (N=8392) were mostly female (7041/8392, 83.9%), non-Hispanic (7855/8392, 93.6%), and White (7704/8392, 91.8%); had high socioeconomic status (income ≥US $100,000: 4389/8392, 52.3%; bachelor's degree or higher: 7251/8392, 86.4%); and resided in a metropolitan area core (rural-urban commuting area code 1: 7192/8392, 85.7%). Rural or urban status was not associated with baseline stress, depression, anxiety, pre-COVID-19 and current physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Repeated-measures models showed overall decreases in depression, anxiety, and perceived effects of COVID-19 on physical activity from baseline to follow-up, and no significant changes in stress or perceived effects of COVID-19 on stress and mental health over time. Models also showed no significant main effects of rural or urban status, COVID-19 statewide prevalence at baseline, or change in COVID-19 statewide prevalence. CONCLUSIONS: We did not find associations between rural or urban status and psychological outcomes (ie, stress, depression, and anxiety), physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Rural or urban status does not appear to drive differences in outcomes among meditation app users, and the use of mHealth apps should continue to be explored as a health promotion strategy in both rural and urban populations. Furthermore, our results did not show negative cumulative effects of COVID-19 on psychological outcomes and physical activity among app users in our sample, the majority of whom were urban, White, female, and of high socioeconomic status. Further research is needed to investigate meditation app use as a health promotion strategy in rural and urban populations.

The Effect of Meditation and Physical Activity on the Mental Health Impact of COVID-19-Related Stress and Attention to News Among Mobile App Users in the United States: Cross-sectional Survey.

BACKGROUND: The COVID-19 pandemic has been declared an international public health emergency, and it may have long-lasting effects on people's mental health. There is a need to identify effective health behaviors to mitigate the negative mental health impact of COVID-19. OBJECTIVE: The objectives of this study were to (1) examine the regional differences in mental health and COVID-19-related worry, attention to news, and stress, in light of the state-level prevalence of COVID-19 cases; (2) estimate the associations between mental health and COVID-19-related worry, attention to news, and stress and health behavior engagement (ie, physical activity, mindfulness meditation); and (3) explore the mediating effect of health behavior engagement on the associations between mental health and COVID-19-related worry, attention to news, and stress. METHODS: A cross-sectional survey was distributed to a sample of US adult paying subscribers to the Calm app (data were collected from April 22 to June 3, 2020). The survey assessed COVID-19-related worry, attention to news, and stress; health behavior engagement; and mental health (ie, perceived stress, posttraumatic stress disorder, and anxiety and depression). Statistical analyses were performed using R software. Differences in COVID-19-related worry, attention to news, and stress and mental health by location were assessed using t tests and chi-square tests. Logistic and ordinary least squares models were used to regress mental health and health behavior on COVID-19-related worry, attention to news, and stress; moreover, causal mediation analysis was used to estimate the significance of the mediation effects. RESULTS: The median age of the respondents (N=8392) was 47 years (SD 13.8). Participants in the Mid-Atlantic region (New Jersey, New York, and Pennsylvania) reported higher levels of stress, more severe depression symptoms, greater worry about COVID-19, paying more attention to COVID-19-related news, and more stress related to social distancing recommendations than participants living in other regions. The association between worry about COVID-19 and perceived stress was significantly mediated by changes in physical activity (P<.001), strength of meditation habit (P<.001), and stopping meditation (P=.046). The association between worry about COVID-19 and posttraumatic stress disorder symptoms was significantly mediated by changes in physical activity (P<.001) and strength of meditation habit (P<.001). CONCLUSIONS: Our findings describe the mental health impact of COVID-19 and outline how continued participation in health behaviors such as physical activity and mindfulness meditation reduce worsening of mental health due to the COVID-19 pandemic. These data have important implications for public health agencies and health organizations to promote the maintenance of health habits to reduce the residual mental health burden of the COVID-19 pandemic.

Can a meditation app help my sleep? A cross-sectional survey of Calm users.

Use of mindfulness mobile apps has become popular, however, there is little information about subscribers' perceptions of app content and its impact on sleep and mental health. The purpose of this study was to survey subscribers to Calm, a popular mindfulness meditation app, to explore perceived improvements in sleep and mental health, evaluate what components of the app were associated with improvements in sleep and mental health, and determine whether improvements differed based on sleep quality. Calm subscribers who had used a sleep-related component in the last 90 days completed a Web-based investigator-developed survey and the Pittsburgh Sleep Quality Index. The survey included questions about using Calm for sleep, sleep disturbances, mental health diagnoses (i.e., anxiety, depression, PTSD) and perceived impacts of the app. Participants reported on the extent to which they felt that using Calm had improved their sleep and mental health. Most participants reported sleep disturbance, and almost half reported a mental health diagnosis. The majority of participants reported that using Calm helped them fall asleep, stay asleep, and get restful sleep. All sleep components were associated with perceived improvements in sleep disturbance. Severity of sleep disturbance moderated relationships between using Calm components and reporting improved sleep. Among subscribers with mental health diagnoses, most reported that Calm helped improve symptoms. Perceived improvement in anxiety and depression was associated with using Calm's meditation components but not Sleep Stories or music/soundscapes. Severity of sleep disturbance did not moderate relationships between using Calm components and reporting mental health improvements. Given the accessibility of app-based meditation, research is needed to evaluate the efficacy of meditation apps to improve sleep disturbance. While some sleep content may be helpful for sleep, more research is needed to test what specific content affects mental health.

Testing a mindfulness meditation mobile app for the treatment of sleep-related symptoms in adults with sleep disturbance: A randomized controlled trial.

The objective of this randomized controlled trial was to test whether a commercially available, mindfulness meditation mobile app, (i.e., Calm app), was effective in reducing fatigue (primary outcome), pre-sleep arousal, and daytime sleepiness (secondary outcomes) in adults with sleep disturbance (Insomnia Severity Index Score >10) as compared to a wait-list control group. Associations between the use of the Calm app (i.e., adherence to the intervention) and changes in sleep quality was also explored in the intervention group only. Adults with sleep disturbance were recruited (N = 640). Eligible and consenting participants (N = 263) were randomly assigned to the intervention (n = 124) or a wait-list control (n = 139) group. Intervention participants were asked to meditate using the Calm app ≥10 minutes/day for eight weeks. Fatigue, daytime sleepiness, and pre-sleep arousal were assessed at baseline, mid- (4-weeks) and post-intervention (8-weeks) in both groups, whereas sleep quality was evaluated only in the intervention group. Findings from intent-to-treat analyses suggest the use of the Calm app for eight weeks significantly decreased daytime fatigue (p = .018) as well as daytime sleepiness (p = .003) and cognitive (p = .005) and somatic (p < .001) pre-sleep arousal as compared to the wait-list control group. Within the intervention group, use of the Calm app was associated with improvements in sleep quality (p < .001). This randomized controlled trial demonstrates that the Calm app can be used to treat fatigue, daytime sleepiness, and pre-sleep arousal in adults with sleep disturbance. Given that the Calm app is affordable and widely accessible, these data have implications for community level dissemination of a mobile app to improve sleep-related symptoms associated with sleep disturbance. Trial registration: ClinicalTrials.gov NCT04045275.

A mindfulness meditation mobile app improves depression and anxiety in adults with sleep disturbance: Analysis from a randomized controlled trial.

OBJECTIVE: The objective of this study was to 1) determine the effects of a meditation app on depression and anxiety in adults with sleep disturbance, and 2) explore the potential mediating effects of fatigue, daytime sleepiness, and pre-sleep arousal on the relationship between use of the meditation app and changes in depression and anxiety. METHODS: Participants were 239 adults with elevated insomnia symptoms (i.e., scores ≥ 10 on the Insomnia Severity Index) and limited or no previous experience with meditation. Depression, anxiety, fatigue, daytime sleepiness, and pre-sleep arousal were assessed at baseline, four weeks, and eight weeks. Repeated-measures ANCOVAs assessed intervention effects on depression and anxiety. Mediation models were estimated using the PROCESS macro. RESULTS: Participants in the meditation group had more improvement in depression and anxiety symptoms during the intervention period than did those in the control group. Changes in somatic and cognitive pre-sleep arousal at mid-intervention fully mediated effects on depression and partially mediated effects on anxiety. There were no significant indirect effects of fatigue and daytime-sleepiness on changes in mental health. CONCLUSIONS: A meditation app may improve depression and anxiety in adults with sleep disturbance, with effects being driven by improvements in pre-sleep arousal. Future studies should consider targeting pre-sleep arousal to improve mental health in this population.

Parents' Perceptions of Their Children's Engagement in a Consumer-Based Meditation Mobile App: Cross-Sectional Survey Study.

BACKGROUND: In the United States, nearly half (48%) of school-aged children experience sleep disturbance that results in less than the recommended sleep duration, which may negatively impact mental health and behavior. Mindfulness interventions may improve sleep and mental health in youth. However, there are gaps in the literature regarding how children (2-12 years) and adolescents (13-17 years) practice mindfulness and the extent to which they benefit from these practices. OBJECTIVE: The purpose of this study was to determine parents' perceptions of their children's engagement with a consumer-based mindfulness meditation app and the extent to which they believe their children have benefitted from using the app, particularly with regard to sleep. METHODS: This study is a secondary analysis of a cross-sectional survey in adult subscribers (N=11,108) to the mindfulness meditation mobile app Calm. Participants who indicated that they had a child or children younger than 18 years (2944/11,108) who used the Calm app were asked additional questions related to their perceptions of their children's engagement with Calm. Descriptive statistics were used to assess children's app engagement, and chi-square tests and binary logistic regression models were used to assess differences in children's usage based on gender and age. RESULTS: Among the survey respondents, approximately half of the parents (1537/2944, 52.21%) reported that their children used Calm. Children used Calm mostly for (1) sleep (1168/1537, 75.99%), (2) stress (491/1537, 31.95%), (3) depression or anxiety (430/1537, 27.98%), and (4) improvement of overall health (215/1537,13.99%). Older children were more likely to begin using Calm to reduce stress, depression, or anxiety, whereas younger children were more likely begin using Calm to improve sleep. Most children used Calm when lying down to go to bed (1113/1529, 72.79%). Children were most likely to use sleep stories at night (1144/1207, 94.78%), followed by music and soundscapes (749/1114, 67.24%), meditations (736/1120, 65.71%), and breathing exercises (610/1092, 55.86%). Nearly all parents believed that using sleep stories was helpful for their children's sleep (1090/1128, 96.63%), and the majority of parents felt that the other components were also helpful for their children's sleep (music and soundscapes [570/728, 78.30%], meditations [445/696, 63.94%], and breathing exercises [610/1092, 55.86%]). CONCLUSIONS: To our knowledge, this is the first study to explore parents' perceptions of how their children or adolescents use a popular consumer-based mindfulness mobile app (ie, Calm). As the majority of children use the app for sleep, mindfulness meditation mobile apps should consider incorporating age-appropriate sleep content to meet the needs of this audience. More research is needed to confirm the feasibility and effectiveness of mindfulness meditation apps for improving sleep and mental health in children and adolescents.

Cancer Patients' and Survivors' Perceptions of the Calm App: Cross-Sectional Descriptive Study.

BACKGROUND: There is a need for tools to decrease cancer patients' and survivors' long-term symptom burden. Complementary strategies, such as meditation, can accompany pharmacologic therapy to improve symptoms. Although support programs with targeted content have wider reach, higher adherence, and greater impact, there are no consumer-based meditation apps designed specifically for cancer. OBJECTIVE: This study aimed to gather information to advise the development of a cancer-specific meditation app in a small convenience sample of cancer patients and survivors who currently use the Calm app. METHODS: Adult cancer patients and survivors who are Calm users (N=82) were recruited through the Daily Calm Facebook page. Participants completed a Web-based survey related to Calm app use and satisfaction, interest in and ideas for a cancer-specific Calm app, and demographic characteristics. Open-ended responses were inductively coded. RESULTS: Participants were aged between 18 and 72 years (mean 48.60 years, SD 15.20), mostly female (77/82, 94%), white (65/79, 82%), and non-Hispanic (70/75, 93%), and reported using Calm at least 5 times per week (49/82, 60%). Although rates of satisfaction with current Calm components were high (65/82, 79%; and 51/81, 63%), only 49% (40/82) of participants used guided meditations that they felt specifically helped with their cancer-related symptoms and survivorship, and 40% (33/82) would prefer more cancer-related content, with guided meditations for cancer-specific anxieties (eg, fear of recurrence; n=15) and coping with strong emotions (n=12) being the most common suggestions. A majority of participants (51/82, 62%) reported that they would be interested in becoming a member of a Calm cancer community (eg, in-app discussion boards: 41/46, 89%; and social media communities: 35/42, 83%). Almost half of the participants (37/82, 45%) reported that they would benefit from features that tracked symptoms in concurrence with app usage, but respondents were divided on whether this information should be shared with health care providers through the app (49/82, 60% would share). CONCLUSIONS: Responses suggest ways in which the current Calm app could be adapted to better fit cancer patients' and survivors' needs and preferences, including adding more cancer-specific content, increasing the amount of content focusing on coping with strong emotions, developing communities for Calm users who are cancer patients and survivors, and including features that track cancer-related symptoms. Given differences in opinions about which features were desirable or would be useful, there is a clear need for future cancer-specific apps to be customizable (eg, ability to turn different features on or off). Although future research should address these topics in larger, more diverse samples, these data will serve as a starting point for the development of cancer-specific meditation app and provide a framework for evaluating their effects.