Nonprofessional Peer Support to Improve Mental Health: Randomized Trial of a Scalable Web-Based Peer Counseling Course

Background: Millions of people worldwide are underserved by the mental health care system. Indeed, most mental health problems go untreated, often because of resource constraints (eg, limited provider availability and cost) or lack of interest or faith in professional help. Furthermore, subclinical symptoms and chronic stress in the absence of a mental illness diagnosis often go unaddressed, despite their substantial health impact. Innovative and scalable treatment delivery methods are needed to supplement traditional therapies to fill these gaps in the mental health care system. Objective: This study aims to investigate whether a self-guided web-based course can teach pairs of nonprofessional peers to deliver psychological support to each other. Methods: In this experimental study, a community sample of 30 dyads (60 participants, mostly friends), many of whom presented with mild to moderate psychological distress, were recruited to complete a web-based counseling skills course. Dyads were randomized to either immediate or delayed access to training. Before and after training, dyads were recorded taking turns discussing stressors. Participants’ skills in the helper role were assessed before and after taking the course: the first author and a team of trained research assistants coded recordings for the presence of specific counseling behaviors. When in the client role, participants rated the session on helpfulness in resolving their stressors and supportiveness of their peers. We hypothesized that participants would increase the use of skills taught by the course and decrease the use of skills discouraged by the course, would increase their overall adherence to the guidelines taught in the course, and would perceive posttraining counseling sessions as more helpful and their peers as more supportive. Results: The course had large effects on most helper-role speech behaviors: helpers decreased total speaking time, used more restatements, made fewer efforts to influence the speaker, and decreased self-focused and off-topic utterances (ds=0.8-1.6). When rating the portion of the session in which they served as clients, participants indicated that they made more progress in addressing their stressors during posttraining counseling sessions compared with pretraining sessions (d=1.1), but they did not report substantive changes in feelings of closeness and supportiveness of their peers (d=0.3). Conclusions: The results provide proof of concept that nonprofessionals can learn basic counseling skills from a scalable web-based course. The course serves as a promising model for the development of web-based counseling skills training, which could provide accessible mental health support to some of those underserved by traditional psychotherapy

Stigma toward individuals with mental illness among Indian adolescents: Findings from three secondary schools and a cross-cultural comparison

Despite the importance of understanding public attitudes toward mental illnesses, few studies have examined the views of young people or individuals in non-western settings. We aimed to assess the prevalence of stigma toward individuals with mental illness among youths in India, examine factors associated with stigma, and compare stigma cross-culturally with a sample of American youths. Our sample consisted of 945 Indian secondary school students (49.7% female, Mean age=14.21) from three high schools in Maharashtra, India. Participants completed a social distance scale to assess stigma, as well as measures of depressive symptoms and anxiety symptoms. Stigma toward individuals with mental illness was commonly reported: only 42% of students reported that they were willing to talk with someone with a mental illness, and 41% were willing to be friends with someone with a mental illness. Gender and age were significantly associated with stigma, with males and younger students reporting greater stigma. Participants’ depressive symptoms and anxiety symptoms were not associated with stigma. Furthermore, compared to American adolescents from a different sample who completed the same stigma measure, Indian adolescents reported significantly more stigma (d = 0.55). Overall, this study provides one of the first direct cross-cultural comparisons of stigma among youths and highlights the need for greater awareness about mental illnesses among Indian adolescents. These findings raise concern for the potential consequences of psychiatric labels for youths in non-western settings. Strategies and approaches to combat the harmful effects of stigma are discussed

Race and socioeconomic status as predictors of willingness to use internet-based treatments or face-to-face psychotherapy: A nationally representative study

Background: There is an ongoing debate about whether digital mental health interventions (DMHIs) can reduce racial and socioeconomic inequities in access to mental health care. One key factor in this debate involves the extent to which racial and ethnic minoritized and socioeconomically disadvantaged individuals are willing to use, and pay for, DMHIs. Objective: We examined racial and ethnic as well as socioeconomic differences in participants’ willingness to pay (WTP) for DMHIs vs. one-on-one therapy (1:1 therapy). Methods: We conducted a national survey of people in the United States (N = 423, women: n = 204, age: M = 45.15, SD = 16.19, Non-Hispanic White: n = 293) via Prolific. After reading descriptions of DMHIs and 1:1 therapy, participants rated their willingness to use each treatment for 1) free, 2) for a small fee, 3) as a maximum dollar amount, and 4) as a percentage of their total monthly income. At the end of the study there was a decision task to potentially receive more information about DMHIs and 1:1 therapy. Results: Race and ethnicity were associated with willingness to pay higher amounts of one’s income, as a percent or the dollars, and was also associated with information-seeking for DMHIs in the behavioral task. By and large, race and ethnicity was not associated with willingness to try 1:1 therapy. Greater educational attainment was associated to willingness to try DMHIs for free, the decision to learn more about DMHIs, and willingness to pay for 1:1 therapy. Income was inconsistently associated to willingness to try DMHIs and 1:1 therapy. Conclusions: If they are available for free or at very low costs, DMHIs may reduce inequities by expanding access to mental healthcare for racial and ethnic minoritized individuals and economically disadvantaged groups

A Review of Popular Smartphone Apps for Depression and Anxiety: Assessing the Inclusion of Evidence-Based Content

Smartphone applications for the treatment of depression and anxiety have acquired millions of users, yet little is known about whether they include evidence-based therapeutic content. We examined the extent to which popular mental health applications (MH apps) for depression and anxiety contain treatment elements found in empirically supported psychotherapy protocols (i.e., “common elements”). Of the 27 MH apps reviewed, 23 included at least one common element, with a median of three elements. Psychoeducation (in 52% of apps), relaxation (44%), meditation (41%), mindfulness (37%), and assessment (37%) were the most frequent elements, whereas several elements (e.g., problem solving) were not found in any apps. We also identified gaps between app content and empirically supported treatments. Cognitive restructuring was more common in depression protocols than in depression apps (75% of protocols vs. 31% of apps), as was problem solving (34% vs. 0%). For anxiety, exposure (85%, 12%), cognitive restructuring (60%, 12%), and problem solving (25%, 0%) were more common in protocols than apps. Overall, our findings highlight empirically supported treatment elements that are poorly represented in current MH apps. The absence of several core treatment elements underscores the need for future research, including randomized trials testing the effectiveness of popular MH apps

Is there an app for that? A review of popular mental health and wellness apps

Smartphone apps for mental health and wellness (MH apps) reach millions of people and have the potential to reduce the public health burden of common mental health problems. Thousands of MH apps are currently available, but real-world consumers generally gravitate toward a very small number of them. Given their widespread use, and the lack of empirical data on their effects, understanding the content within MH apps is an important public health priority. An overview of the content within these apps could be an important resource for users, clinicians, researchers, and experts in digital health. Here, we offer summaries of the content within highly popular MH apps. Our aim is not to provide comprehensive coverage of the MH app space. Rather, we sought to describe a small number of highly popular MH apps in three common categories: meditation and mindfulness, journaling and self-monitoring, and AI chatbots. We downloaded the two most popular apps in each of these categories (respectively: Calm, Headspace; Reflectly, Daylio; Replika, Wysa). These six apps accounted for 83% of monthly active users of MH apps. For each app, we summarize information in four domains: intervention content, features that may contribute to engagement, the app’s target audience, and differences between the app’s free version and its premium version. In the years ahead, rigorous evaluations of highly popular MH apps will be needed. Until then, we hope that this overview will help readers stay up-to-date on the content within some of the most widely used digital mental health interventions

Efficacy and Conflicts of Interest in Randomized Controlled Trials Evaluating Headspace and Calm Apps: Systematic Review

BackgroundAlthough there are thousands of mental health apps, 2 apps, Headspace and Calm, claim a large percentage of the marketplace. These two mindfulness and meditation apps have reached tens of millions of active users. To guide consumers, clinicians, and researchers, we performed a systematic review of randomized controlled trials (RCTs) of Headspace and Calm. ObjectiveOur study aimed to evaluate intervention efficacy, risk of bias, and conflicts of interest (COIs) in the evidence base for Headspace and Calm, the two most popular mental health apps at the time of our search. MethodsTo identify studies, we searched academic databases (Google Scholar, MEDLINE, and PsycINFO) and the websites of Headspace and Calm in May 2021 for RCTs of Headspace and Calm testing efficacy via original data collection, published in English in peer-reviewed journals. For each study, we coded (1) study characteristics (eg, participants, sample size, and outcome measures), (2) intervention characteristics (eg, free vs paid version of the app and intended frequency of app usage), (3) all study outcomes, (4) Cochrane risk of bias variables, and (5) COI variables (eg, presence or absence of a preregistration and the presence or absence of a COI statement involving the company). ResultsWe identified 14 RCTs of Headspace and 1 RCT of Calm. Overall, 93% (13/14) of RCTs of Headspace and 100% (1/1) of RCTs of Calm recruited participants from a nonclinical population. Studies commonly measured mindfulness, well-being, stress, depressive symptoms, and anxiety symptoms. Headspace use improved depression in 75% of studies that evaluated it as an outcome. Findings were mixed for mindfulness, well-being, stress, and anxiety, but at least 40% of studies showed improvement for each of these outcomes. Studies were generally underpowered to detect “small” or “medium” effect sizes. Furthermore, 50% (7/14) of RCTs of Headspace and 0% (0/1) of RCTs of Calm reported a COI that involved Headspace or Calm (the companies). The most common COI was the app company providing premium app access for free for participants, and notably, 14% (2/14) of RCTs of Headspace reported Headspace employee involvement in study design, execution, and data analysis. Only 36% (5/14) of RCTs of Headspace were preregistered, and the 1 RCT of Calm was not preregistered. ConclusionsThe empirical research on Headspace appears promising, whereas there is an absence of randomized trials on Calm. Limitations of this study include an inability to compare Headspace and Calm owing to the dearth of RCTs studying Calm and the reliance on author reports to evaluate COIs. When determining whether or not mental health apps are of high quality, identification of high-quality apps and evaluation of their effectiveness and investigators’ COIs should be ensured

Promoting graduate student mental health during COVID-19: Acceptability, feasibility, and perceived utility of an online single-session intervention

The COVID-19 outbreak has simultaneously increased the need for mental health services and decreased their availability. Brief online self-help interventions that can be completed in a single session could be especially helpful in improving access to care during the crisis. However, little is known about the uptake, acceptability, and perceived utility of these interventions outside of clinical trials in which participants are compensated. Here, we describe the development, deployment, acceptability ratings, and pre-post effects of a single-session intervention, the Common Elements Toolbox (COMET), adapted for the COVID-19 crisis to support graduate and professional students. Participants (n = 263), who were not compensated, were randomly assigned to two of three modules: behavioral activation, cognitive restructuring, and gratitude. Over one week, 263 individuals began and 189 individuals (72%) completed the intervention. Participants reported that the intervention modules were acceptable (93% endorsing), helpful (88%), engaging (86%), applicable to their lives (87%), and could help them manage COVID-related challenges (88%). Participants reported pre- to post-program improvements in secondary control (i.e., the belief that one can control their reactions to objective events; dav=0.36, dz=0.50, p<0.001) and in the perceived negative impact of the COVID-19 crisis on their quality of life (dav=0.22, dz=0.25, p<0.001). On average, differences in their perceived ability to handle lifestyle changes resulting from the pandemic were positive, but small and at the level of a nonsignificant trend (dav=0.13, dz=0.14, p=0.066). Our results highlight the acceptability and utility of an online intervention for supporting individuals through the COVID-19 crisis

Shamiri Templeton Comparative Effectiveness Trial

This project page is used to store data, preprints, code, protocols, and other publicly available project materials for the Templeton World Charity Foundation-funded 2021 five-group RCT of Shamiri and its component intervention

Online single-session interventions for Kenyan adolescents: study protocol for a comparative effectiveness randomised controlled trial

Background Mental health problems are the leading cause of disability among adolescents worldwide, yet access to treatment is limited. Brief digital interventions have been shown to improve youth mental health, but little is known about which digital interventions are most effective.Aims To evaluate the effectiveness of two digital single-session interventions (Shamiri-Digital and Digital-CBT (cognitive-behavioural therapy)) among Kenyan adolescents.Methods We will perform a school-based comparative effectiveness randomised controlled trial. Approximately 926 Kenyan adolescents will be randomly assigned to one of three conditions: Shamiri-Digital (focused on gratitude, growth mindsets and values), Digital-CBT (focused on behavioural activation, cognitive restructuring and problem solving) or a study-skills control condition (focused on note-taking and essay writing skills). The primary outcomes include depressive symptoms (measured by the Patient Health Questionnaire-8), anxiety symptoms (Generalized Anxiety Disorder Screener-7) and subjective well-being (Short Warwick-Edinburgh Mental Well-being Scale). The secondary outcomes include acceptability, appropriateness, primary control and secondary control. Acceptability and appropriateness will be measured immediately post-intervention; other outcomes will be measured 2 weeks, 4 weeks and 12 weeks post-intervention.Results We hypothesise that adolescents assigned to Shamiri-Digital and adolescents assigned to Digital-CBT will experience greater improvements (assessed via hierarchical linear models) than those assigned to the control group. We will also compare Shamiri-Digital with Digital-CBT, although we do not have a preplanned hypothesis.Conclusions Our findings will help us evaluate two digital single-session interventions with different theoretical foundations. If effective, such interventions could be disseminated to reduce the public health burden of common mental health problems.Trial registration number PACTR202011691886690