mental health application thesis

• Open access
• Published: 02 October 2023

Design and development of a mobile-based self-care application for patients with depression and anxiety disorders

• Khadijeh Moulaei 1 ,
• Kambiz Bahaadinbeigy 2 ,
• Esmat Mashoof 3 &
• Fatemeh Dinari 2  

BMC Medical Informatics and Decision Making volume  23 , Article number:  199 ( 2023 ) Cite this article

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Background and Aim

Depression and anxiety can cause social, behavioral, occupational, and functional impairments if not controlled and managed. Mobile-based self-care applications can play an essential and effective role in controlling and reducing the effects of anxiety disorders and depression. The aim of this study was to design and develop a mobile-based self-care application for patients with depression and anxiety disorders with the goal of enhancing their mental health and overall well-being.

Materials and methods

In this study we designed a mobile-based application for self -management of depression and anxiety disorders. In order to design this application, first the education- informational needs and capabilities were identified through a systematic review. Then, according to 20 patients with depression and anxiety, this education-informational needs and application capabilities were approved. In the next step, the application was designed.

In the first step, 80 education-information needs and capabilities were identified. Finally, in the second step, of 80 education- informational needs and capabilities, 68 needs and capabilities with a mean greater than and equal to 3.75 (75%) were considered in application design. Disease control and management, drug management, nutrition and diet management, recording clinical records, communicating with physicians and other patients, reminding appointments, how to improve lifestyle, quitting smoking and reducing alcohol consumption, educational content, sedation instructions, introducing health care centers for depression and anxiety treatment and recording activities, personal goals and habits in a diary were the most important features of this application.

The designed application can encourage patients with depression and stress to perform self-care processes and access necessary information without searching the Internet.

Peer Review reports

Depressive and anxiety disorders are significant contributors to worldwide disability [ 1 ] affecting up to 25% of general practice patients [ 2 ]. Normally, these disorders may not be as “brain disorders,“ but they do interfere with normal cognitive, emotional, and self-reflective functions [ 3 ]. Brain disorders include any conditions or disabilities that affect the brain [ 4 , 5 ]. These disorders, caused by factors such as disease, genetics, or traumatic damage, encompass a range of conditions, including brain injuries, brain tumors, neurological diseases, as well as mental disorders like depression and anxiety [ 6 , 7 ]. Depression and anxiety due to their nature always cause social, occupational and functional harm [ 8 ]. Studies have shown that if depression and anxiety are not treated, controlled and / or managed, they can lead to poor quality of life [ 9 ], increased risk of suicide [ 10 , 11 ], job loss due to frequent absences [ 12 ], and premature mortality, persistent fatigue, sad and angry mood, decreased self-esteem and ability to perform daily activities, and increased risk of hospitalization [ 13 ]. On the other hand, due to the stigma associated with depressive and anxiety disorders, people are often reluctant to seek consultation and medication, which can hinder their access to effective psychological therapies [ 14 ]. One of the most effective ways to treat, control and / or manage these two disorders is self-care. Self-care as an independent factor can reduce the risk of disease complications [ 15 ].

Self-care processes help patients to control emotions, adhere to treatment, understand the treatment rationale, improve quality of life, reduce stress and anxiety, feel more secure, and increase life satisfaction. Also, these processes will ultimately maintain physical and mental health, reduce mortality, reduce health care costs, increase patient satisfaction and improve patients’ quality of life [ 16 ]. Mobile -based applications can be used as a platform for self-care services [ 17 ]. Mobile applications have become an all-encompassing tool for helping people to manage and control anxiety and depression symptoms [ 18 ], provide quick and easy access to health information, and improve interaction with therapists [ 19 ]. In other words, applications can aid people in managing their health, promoting a healthy lifestyle, and providing accurate information when and where it’s needed. Encouraging findings have been reported regarding the effectiveness of mobile-based applications for addressing depression and anxiety [ 20 ]. Lattie et al. [ 21 ] investigate the role of digital health interventions in improving depression and anxiety among students and concluded that applications are effective as computer, web, and virtual reality-based interventions in improving depression and anxiety. Almodovar et al. [ 22 ] also showed that mobile applications can increase self-confidence in coping skills and improve depressive and anxiety disorders.

To our knowledge, various studies have been done on the design and development of mobile apps to manage and control anxiety and depression. These applications have different capabilities, including patient monitoring, symptom tracking, emotional support, telecounseling, online training, medication reminders, BMI calculator, reporting and meditation management [ 23 , 24 , 25 ]. It should be noted that: none of these applications have all the features introduced in our study and only have some of these characteristics [ 23 , 24 , 25 ], for example, the 7 Cups of Tea application does not provide the possibility of interacting with the health care provider [ 26 ], and the language of these applications is not Farsi. Therefore, Iranian patients with stress and anxiety could not use these applications. Therefore, in the present study, we designed and developed a mobile-based self-care application for patients with depression and anxiety disorders. In this study, we answer the following three questions:

What are the necessary capabilities and educational-informational needs of patients for designing a mobile-based self-care application through a literature review?

What are the capabilities and educational-informational needs of patients for designing a mobile-based self-care application, considering the perspectives and opinions of patients with depression and anxiety?

How is the application designed and what features does it have?

The present study is a developmental-applied study that was conducted in the following three stages.

Stage 1: identify the capabilities and education- information needs of patients to design the application

According to various studies [ 17 , 27 , 28 , 29 , 30 , 31 ], the first step in designing a mobile-based application is to identify information needs and necessary capabilities. These information needs and capabilities can be identified through a literature review [ 17 , 29 , 31 ], holding a panel of experts [ 28 ], focus groups with the end users [ 30 ], or interviewing target users [ 27 ]. In the first step of our study, patients’ information-educational needs and application capabilities were identified by literature review on January 1, 2022, from PubMed, Web of Science and Scopus databases. For this purpose, the following search strategy was used.

(Depression OR anxiety) AND (mobile-Based self-care application OR mobile-based Self-management application).

Inclusion criteria consisted of articles published in English, having access to the full text, and containing relevant information on the required information-educational needs and capabilities for designing the application. Exclusion criteria encompassed articles that did not provide clear information about self-care for anxiety and depression disorders through applications. The study excluded books, book chapters, letters to the editor, and conference abstracts.

Related articles were retrieved from the three introduced databases and entered into Endnote software. Two hundred and fifty-one articles were extracted from three databases: PubMed, Web of Science and Scopus. One hundred and forty-two studies from PubMed, 89 studies from Scopus and 20 study from Web of Science were retrieved. Four duplicate articles were excluded from the study. Then, 98 remaining sources were carefully examined and compared with inclusion and exclusion criteria. Then, the titles, abstracts and keywords of all articles were studied. Finally, 8 articles were included in the study (Fig.  1 ) [ 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 ]. We studied the full text of these articles and extracted the necessary data elements for designing and developing applications. Data collection was carried out using a data extraction form, and its validity was confirmed based on the opinions of two medical informatics and two psychiatric specialists.

Selection of studies based on the PRISMA flowchart

Stage 2: confirm the capabilities and education- informational needs to design the application

At this stage, the data collection tool was a questionnaire designed based on the educational information needs and capabilities identified in the previous stage. The questionnaire consisted of six parts, with the first part focusing on demographic information (4 questions). The second part: education-informational needs and capabilities in six parts: user profile (8 questions), clinical history (9 questions), lifestyle (14 questions), disease management and control (28 questions), sedation instructions (10 questions), and application capabilities (16 questions). Also, for each part of the questionnaire, an open-ended question was mentioned under the heading “Other cases”. The Content Validity Ratio (CVR) was employed to assess the questionnaire’s content validity. Two medical informatics and three psychiatric specialists completed the questionnaire to calculate the CVR. These people had the experience of conducting various researches in the field of anxiety and stress and collaborating in the design of self-care applications. In order to calculate the CVR, the expert panel was instructed to rate each question using a three-point scale: “essential,“ “helpful but not essential,“ and “not essential” [ 17 , 40 ]. Afterward, the CVR was determined utilizing the subsequent formula:

n represents the count of experts choosing the “essential” option, while N represents the total number of experts.

As per Lawshe’s criteria for CVR, when the expert panel consists of five members, the minimum acceptable value for each item is 0.99 [ 40 ]. In this research, the minimum acceptable CVR value for each question, as determined by the experts, was 1.00. Additionally, the overall CVR ratio was computed as 1.00.

Moreover, the reliability of the questionnaire was evaluated by Cronbach’s alpha and was confirmed with a value of 0.902 (Appendix A). Sampling was not performed at this stage, and all patients with depression and anxiety (40 patients) referred to the Hamzeh Medical Center affiliated to Fasa University of Medical Sciences (Fasa city, Iran) from December 2021-December 2022 were included in the study. It should be noted that during this period of time, 510 patients with psychiatric disorders had referred to this center, 40 of them were suffering from depression and anxiety. In order to participate, an invitation was sent to all of these patients. Thirty people accepted the invitation and finally 20 people entered the study according to the inclusion criteria. The inclusion criteria were:

At least 18 years old.

Having a smart mobile phone literacy.

Declare informed consent to participate in the study.

Do not suffer from acute cognitive and mental disorders except depression and anxiety.

The questionnaire was electronically designed, and its link was sent to patients on January 12, 2022. All questionnaires were completed by January 20. It is worth mentioning that to incentivize participation, each participant received a gift card worth 1,000,000 Iranian Rials for a local grocery store in Fasa city.

The results obtained from the questioner were analyzed by SPSS 23.0. The answers “completely unnecessary”, “unnecessary”, “neutral”, “necessary”, and “completely necessary” with scores from 1 to 5 was given. Also, descriptive statistics (frequency, mean, and standard deviation (SD) were used. In accordance with the opinion of the research team and several psychiatrists, information-educational needs and application capabilities with a mean greater than and equal to 3.75 (75%) were considered to design and develop the application. A cut-off score of 3.75 or higher indicates that only items rated as “necessary”, and “completely necessary” by patients are included in the application design. Other studies [ 17 , 31 , 41 ] related to application design showed that by considering mean greater than and equal to 3.75 (75%) as a cutoff, more important and necessary information-educational needs and capabilities will be selected for application design. As a result, the application will be more efficient and useful.

Stage 3: design and development a prototype of the mobile-based application

At this stage, based on the education-informational needs and capabilities approved in the previous stage, the prototype was designed with the Java programming language in an Android Studio programming environment. SQLite DB was used to design the database. After entering the information and saving it by the patients, the mobile application sends the information to the application database. After the information is saved, they can access stored information, edit it or add new information. Finally, patients can report the information stored in PDF format and send the report to their physicians via social networks or email. During the study, the use of the application was free for patients. Moreover, it should be noted that we did not design a user interface for physicians, and the patient’s communication with physicians will be through social networks and email.

Given the popularity of the Android operating system in Iran, the prototype of this application was specifically designed for Android OS version 4.4 KitKat and higher. Notably, both the application and its database were developed by a Mobile App Design company, ensuring that only the patient can access and share the information stored in the application’s database with their therapist.

Ethical considerations

The code of ethics with the number IR.KMU.REC.1399.025 was obtained from the ethics committee of Kerman University of Medical Sciences on March 18, 2020. Patients’ informed consent was obtained before participating in the study. The participation of physicians and patients in the study was also completely voluntary and it was possible for them to leave the study at any time.

Stage one: identify the education- informational needs and capabilities to design the application

An overview of selected studies is presented in Table  1 . Moreover, Fig.  1 shows the search results and the study selection process.

Table  2 shows the demographic information of patient’s participant in stage two of the study. The majority of participants (60%) were female. Most age groups were 31–40 years old. Also, the majority of participants (80%) were suffering from depression and anxiety.

Findings related to education-informational needs and capabilities required for application design included six categories include: user profiles, clinical records, lifestyle, disease management and control, relaxation instructions, and application capabilities (Table  3 ). The importance of each of these education-informational needs and capabilities is presented in Table  3 . Of 80 education-informational needs and capabilities, 68 education-informational needs and capabilities with a larger mean and equal to 3.75 (75%) were considered for application design.

In the user profile, national code, age, weight, education, address and contact number with a mean of less than 3.75 were not included in the application design. In the lifestyle category, underlying diseases and in the application capabilities category, BMI calculation, lectures, relaxing music and games and intellectual puzzles were excluded from the study and were not considered for designing the application.

According to the results obtained in the needs assessment stage, a mobile-based self-care application for patients with anxiety and stress disorders was designed with the Java programming language in the Android Studio environment. The architecture of this self -care app is shown in Fig.  2 .

The architecture of the designed mobile self-care application

This application has six main sections namely user profiles, clinical records, lifestyle, disease management and control, relaxation instructions, and application capabilities on the main page of the application (Fig.  3 ). By clicking on each of the icons of these sections, a subset of their related features will be displayed. In total, this application has 20 pages for features of each section: user profiles (1 page), clinical records (2 page), lifestyle (3 page), disease management and control (10 page), relaxation instructions (2 page), and application capabilities (2 page). In the following, each of these sections is described.

In the user profile section, the patient can register after entering the application and by entering a username and password enter the application.

In the clinical history category, the patients can save various information about blood group, family history of mental disorder and type of disorder, duration of the disorder, history of suicide, history of hospitalization, time of first hospitalization, number of hospitalizations and history of smoking and alcohol consumption on their mobile phone and send them to his/her doctor as a pdf file (Fig.  4 ).

In the lifestyle category, educational information in the form of videos and texts related to exercise, sleep, proper nutrition, proper weight, smoking and alcohol, stress and anxiety management, healthy bad habits, how to overcome wrong beliefs, how to overcome failures, personal health, physical activity, mind and body strengthening, healthy sex, social support and healthy relationships are provided.

In the disease management and control category, the complications caused by depression and anxiety can be controlled and managed. As an example, part of this application is intended for quitting smoking and alcohol. The patient can enter the days he does not smoke or drink alcohol in the application. Also, enter the cost of cigarettes and alcohol consumed per day and number of cigarettes smoked daily in the application. Then, by clicking on “calculate”, the app tells the patient how much money you have saved by not buying cigarettes so far, as well as how many days you have been clean and how many cigarettes you have not smoked so far. Seeing statistics can give patients positive energy and make it easier to quit smoking or drinking (Fig.  5 ). Moreover, in order to get rid of addiction and drugs, patients can send their current history to their therapists on a daily basis through social networks in the form of text, audio, video or PDF files. Then, the therapists will provide them with the necessary guidance and recommendations.

In the category of relaxation instructions, different methods of relaxing the patient through slow and regular breathing, muscle strengthening, prayer, music therapy, aromatherapy, mental imagery, mindfulness, meditation, walking with mindfulness or yoga and repetition of soothing words is taught. These trainings were provided to the patient in the form of text, videos and voice.

It should be noted that the educational material featured in our application, which includes topics such as lifestyle guidance, relaxation instructions, and disease management and control, was meticulously curated from the websites of the Iranian Psychological Association ( https://iranpa.org/ ) and Iranian Psychiatrist Association ( http://www.psychiatrist.ir/main/ ). To ensure the accuracy and alignment of this content with recommended best practices in treatment, a rigorous review process was undertaken. Specifically, the content underwent evaluation and approval by two experienced psychiatrists who possess expertise in the field of mental health and have a deep understanding of evidence-based treatment approaches. This collaborative effort between medical professionals and our development team aimed to ensure that the educational content within our application adheres to the highest standards of quality and reliability, ultimately providing users with valuable and trustworthy information to support their mental health and well-being.

In the capabilities category, addresses and phone numbers of medical centers in Fars province (Iran) were introduced to patients to receive counseling services. Patients could contact these centers to get an appointment or go to these centers in person according to the addresses provided. In the field of drug management, nutrition and diet management, patients could set a diet plan for themselves. For example, in the drug management section, patients could enter the drug name, dosage, drug allergies, and drug use date. According to the time and date of use, the necessary reminders were given to the patient (Fig.  6 ). In the notebook section, patients can write down information about their mental health, relationships, mood or feelings. Also, record her/his activities, personal goals or habits.

In the section of communication with doctors, consultants and other patients, a group was formed on WhatsApp and Telegram, patients could talk to doctors and consultants and other patients and share their experiences in this groups. Also, they could ask their questions. In the section of appointment reminder, patients could enter the time and date of appointment, doctor’s name and office address. Like other applications, patients can customize reminders based on physicians’ recommendations. For example, the patient needs to be advised by the doctor to take a medicine every day at 8 am, the patient can take his medicine on time by set a reminder for every day at 8 am. Based on the recorded time and date, reminders are provided to the patient automatically. It should be noted that reminders can act as guidance or messages to help facilitate behavior change and increase adherence to medication or treatment and patient attendance at appointments [ 49 ]. Moreover, reminders can reduce the need to memorize, reduce the number of missed drug doses, reduce treatment interruptions, avoid forgetting to take medications, and perform laboratory tests on time [ 49 , 50 ].

In the application settings, the user can change settings such as font and size, font color and themes.

It should be noted that after registering information in the application, patients can report them in PDF format and send them to their therapists via email or social networks. Patients could also talk to their therapist through social networks. Figure  7 shows an example of conversations between the patient and the therapist.

Home page of depression and anxiety self-care application

Recording of medical and clinical records

Quitting drinking and smoking

Drug management

An example of a conversation between a patient and a therapist

In order to better understand the capabilities of the designed application, we designed a use-case diagram for patients and physicians. The application allows patients to: (1) log into the system, (2) Create a profile, (3) record their clinical history, (4) View tutorials with self-care instructions, (5) Using the app’s capabilities to manage and control the disease, (6) reporting on recorded clinical information, (7) sending reports to physicians through social networks or email, and (8) paying for the visit (Fig.  8 ). All patient data is stored in the application database. Moreover, the application allows physicians to: (1) receive reports sent by the patient, and (2) provide treatment recommendations or make an appointment (Fig.  8 ).

Use Case diagram for patient and physician

In this study, a mobile-based self-care application was designed and developed for patients with depression and anxiety disorders. The designed application allows the patient to register and enter through a username and password and record their clinical history in PDF format and send it to the doctor. Also, this app can help to improve patients’ lifestyles by providing educational information on reducing and controlling anxiety and depression in the form of videos, text and voice. Moreover, management of medications dose and time of use, the ability to record activities, personal goals and habits in a diary, the introduction of depression and anxiety treatment centers, communication with other patients and doctors were other features of this application. Wasil R et al. [ 51 ] reviewed applications were designed for depressive and anxiety disorders in a review study. The most common features used in these applications included educational and self-assessment services to patients, how to gain calm, concentration and meditation. Also, in our study, educational services were provided to improve self-care processes and how to achieve relaxation, concentration and meditation. Instructions for concentration and relaxation let person to get rid of internal and external factors that bother him/her. These instructions can help people to return to a normal state and perform daily routine activities in the present [ 52 ] and reduce stress and anxiety in people with depressive and anxiety disorders [ 53 , 54 , 55 ].

Fuller-Tyszkiewicz et al. [ 56 ] also designed a self-monitoring application with name BlueWatch to improve the well-being of adults with depressive symptoms. This app is organized based on the principles of Cognitive Behavioral Therapy (CBT) in six modules of psychological education about depression and an introduction to CBT, behavioral activation, cognitive reconstruction, problem-solving skills, assertiveness, and treatment methods to prevent Recurrence of disease. Blue Watch features also included short audio education activities, daily practice and self-monitoring functions (using daily mood recordings), short welcome video, training with the app and dashboard (to store patient activities and texts). The present study provides daily exercises in the form of relaxation instructions in the designed application. Patients by performing daily exercises such as calm and regular breathing, muscle strengthening, prayer, music therapy, aromatherapy, mental imagery, mindfulness, meditation, walking with mindfulness or yoga, repeating soothing words help themselves to reduce stress and anxiety.

Management of smoking, shisha, alcohol and drugs was another feature of the application designed in our study. Deady et al. [ 57 ] also were considered a section for managing of smoking, hookahs, alcohol, and drugs in their application, along with other information-educational needs and capabilities such as training programs (prevention of exacerbation of effects of anxiety and depression disorders, overcoming stress and negative thoughts, how to get away from relationships and stressful environments) relaxation instruction, sleep management, physical activity and exercise, and daily programming. Other studies [ 58 , 59 , 60 ] have shown that there is a direct link between depression and anxiety and smoking. They can increase the severity of anxiety and depression in these patients over the time. So, in self-care applications for these patients, it is better to allocate a section for smoking, shisha, alcohol management.

Patient management of medications was another feature of the application designed in the present study. This feature can help patients to enter the name of the drug, dosage, drug allergies and drug use date. In order to take the medicine, the necessary warnings were given to the patient according to the time and date of use. Philip Kaare Løventoft et al. [ 61 ] designed an application called life management to support patients with depression. This application has various capabilities for user registration, measuring the patient’s depression based on the WHO Major Depression Inventory (MDI) questionnaire, Mood, appetite and sleep registration, calendar and event types, location tracking and mapping (providing data on patient movement patterns for Predicting phases of depression) and routine management (to help users with daily tasks such as getting out of bed, taking a shower, and daily programming). Also, it had capabilities to record a list of drugs that could be edited by the user, reminding the use of drugs in the Medication management section.

In evaluating a mobile application, there are always problems, advantages and disadvantages, which will be analyzed in the following. Furthermore, Wei and et al. [ 62 ], underscored the significance of an interactive process that didn’t bewilder users or require numerous iterations for comprehension, as such hurdles hindered their sustained engagement with the application. For example, offering clear explanations of how the mHealth intervention operated, including guidance on what steps to take next, encouraged ongoing usage.

The unwillingness of patients [ 63 , 64 ] to cooperate in the evaluation process is one of the major issues with evaluating mobile applications. Patients’ lack of knowledge and awareness of the advantages and uses of these applications, as well as a lack of sufficient evidence regarding the effectiveness of anxiety and stress applications, may also contribute to their unwillingness to cooperate. Therefore, ways to encourage patient cooperation should be offered. One of these solutions is to give patients adequate information about the utility and efficacy of the application. The application’s adoption and use, as well as collaboration, can all be enhanced by this solution. Additionally, inviting patients from different races, ethnicities, genders, ages, and education statuses to a meeting of the research team to discuss this application and its advantages can be helpful [ 65 ]. If patients are made aware that self-care tools may aid in illness management and control. Then, it will be simpler for patients to embrace these apps since they would think that by following self-care the applications, their recovery will be substantially accelerated [ 64 , 66 , 67 ]. The team can highlight the advantages of an anxiety and depression self-care app, like better health information access‌ [ 68 ], lower medical errors and treatment costs, improved coordination among healthcare providers, and reduced patient travel [ 69 ]. They can also inform patients that the app offers greater flexibility, enabling them to spend less time at treatment centers and more time on daily tasks [ 70 ].

Privacy concerns during patient evaluations are another issue that has been identified in prior research [ 71 , 72 , 73 ]. Designers of applications should strive to keep patient information private. Therefore, each patient must have a unique username and password for self-care applications. In addition, the research team should provide sufficient assurance to the patients that the information they enter will remain confidential while using the application. The ease of use of self-care applications is another patient concern [ 74 , 75 ]. This issue can be resolved by providing patients with the necessary training in the form of multiple training sessions, as well as by preparing educational files in the form of video and text regarding the use of the application for patients and doctors [ 24 ].

Another issue in mobile application evaluation is the availability of various evaluation tools (questionnaires such as mobile app rating scale (MARS) and system usability scale (SUS), heuristic evaluation, think aloud, etc.) and the lack of flexibility of these tools. For instance, Zhou et al. [ 76 ], argued that the SUS questionnaire, when applied to aspects unique to mobile apps, fails to yield the specific information required for evaluating mobile applications effectively, highlighting the need for tailored evaluation tools in the mobile app domain. To solve this issue, the primary objective of each research’s evaluation should be identified, and then the right tool should be chosen. The tool selected for evaluation should focus on various dimensions related to evaluation quality, readability and cultural sensitivity of content, usability and features of health applications [ 77 ]. Another drawback of application evaluation studies is the length of time needed to complete the evaluation. A mobile application may initially appeal to the patient and the therapist in a way that yields a positive initial evaluation result, but over time, the outcome changes. As a result, it is preferable to evaluate over time. It should be noted that imbalances in access to online health care systems that are a reflection of well-known socioeconomic disparities in access to online services. The same factor makes using mobile devices for remote service delivery to rely on patients who have more facilities and skills and may unjustly burden those who are less able with treatment using newer technologies [ 78 ]. One of the difficulties that evaluators encounter when assessing applications for anxiety and stress management programs is this disparity. In this case, researchers may decide to exclude study participants who lack smart phones, internet access, adequate bandwidth, a sufficient level of literacy, or the desire to take part in the study.

App evaluation can also have benefits. Different aspects of an application are examined in different ways during evaluations. For instance, the following three factors are taken into account and scrutinized during the usability evaluation: (1) Having greater usability, (2) more user satisfaction (meets the user’s expectations), and (3) easier learning (the operation can be learned very quickly by observation). Or, ten indicators are highlighted in Nielsen’s assessment: (1) display Visibility of system status, (2) consistency and standards, (3) user control and freedom, (4) error prevention, (5) recognition rather than recall, 6) flexibility and efficiency of use, (7) flexibility and efficiency of use, (8) aesthetic and minimalist design, (9) honesty in expressing mistakes and providing solutions - assisting users in identifying, analyzing, and resolving errors; and (10) assistance and documentation [ 79 , 80 ]. The design team will identify and address any issues with these dimensions after evaluating the application. A user-friendly application will subsequently be created for users. However, once all the issues are resolved, the patients’ continued use of the application will increase. Patients will be less satisfied and use these applications less if an application is not usable or does not have the necessary quality for the patient’s goals [ 81 ]. According to some studies [ 82 , 83 ], users will be dissatisfied with the application if there are potential delays in their response to the application, a lack of optimal speed for the information and content it contains, difficulty in learning and comprehending its features. So, the amount of use of the application with them decreases day by day.

However, by assessing applications, it is possible to learn how well they work to enhance self-care practices, self-management, self-efficacy, control over a disease, and disease recovery [ 84 , 85 , 86 , 87 ]. Patients may utilize an application continually if it is efficient in the dimensions that were presented. Organizations and hospitals may also encourage people to utilize these resources. Patients who make use of these effective tools will reduce the number of people who visit medical facilities physically, preventing overcrowding. Additionally, patients will spend less time traveling to treatment facilities and pay lower treatment costs [ 17 ]. On the other hand, studies on app evaluation that publish their findings can assist other app designers and developers in creating the best possible apps. For instance, a city or village’s culture may not support the use of a particular color in the design of an application. When creating their applications, designers are not permitted to use this color. On the other hand, these people can spend less time and money designing and developing an application after seeing the results of these studies. One of the additional benefits of evaluation is that it raises patients’ knowledge and awareness of applications of self-care in the field of health [ 88 , 89 , 90 ]. Patients can then easily learn how to use the applications and become familiar with the various features that a self-care application should have. The evaluation of applications also increases the likelihood that patients will develop loyalty and a sense of community [ 90 ]. The patient will feel more accountable for enhancing the application’s quality when he participates in its evaluation and will offer the research team the necessary feedback.

Evaluations may have disadvantages in addition to their benefits. The expenses incurred to motivate individuals to participate in the evaluation process are the first disadvantages of evaluation. For instance, patients typically decline offers of free participation in studies. So, researchers must pay them the required fees to take part in the study. On the other hand, researchers may need to buy tools to record the evaluation process in order to evaluate an application according to the type of evaluation method, such as video cameras, microphones and headsets, audio recording tools, evaluation analysis software, etc. [ 91 ]. On the other hand, it takes a lot of time to complete evaluation process. In order to assess an application’s long-term effectiveness, users occasionally need to use it for days and hours. As a result, both the research team and the patients will find it boring.

Sometimes, in some evaluation methods, the evaluation of an application for users does not produce satisfactory and good results [ 82 , 83 ]. Because of this, users of this application might become discouraged and stop using it altogether. These situations can occasionally arise from a lack of time for an evaluation or from selecting an improper evaluation technique. Therefore, care must be taken in selecting the method and length of the evaluation in accordance with the purpose of the designed application. It should be noted that one of the disadvantages of self-care applications is that they are constantly being evaluated because of updates. These ongoing assessments could be very expensive for designers and the people who develop them.

Limitations

In the needs assessment stage in order to confirm the capabilities and educational-informational needs necessary for designing the application, we included only 20 patients in the study. Moreover, Patients’ education-informational needs and application capabilities required to design the application were identified only in accordance with the opinions of patients referred to Hamzeh in Fasa speciality and sub-speciality clinics and were not used viewpoint of psychologists and psychiatrists. It is suggested to include more patients in the needs assessment stage in future studies, and also to use the opinions of psychologists and psychiatrists. Also, in this study, the usability of the designed application were not evaluated and its effects on improving and reducing anxiety and stress were not considered. In another study, the usability and effects of app on improving and reducing anxiety and stress will investigated. Through a Randomized Controlled Trials (RCT) study, the effects of the app on improving and reducing anxiety and stress can be investigated.

In the present study, a mobile-based self-care application for patient with depression and anxiety disorders was designed and developed. The designed application provides mechanisms to collect and store patients’ information and send them to physicians. In addition, patients can actively and dynamically participate in self-care processes with the continuous use of this application, and access to required information without search in the Internet. Also, this app has great potential for situations where patients cannot see their doctor in person, such as during the COVID-19 pandemic.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Hospital Information System

Electronic Progress Note

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This study was supported by the Student Research Committee of Kerman University of Medical Sciences. The funder had no role in study design, data collection, and analysis.

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Moulaei, K., Bahaadinbeigy, K., Mashoof, E. et al. Design and development of a mobile-based self-care application for patients with depression and anxiety disorders. BMC Med Inform Decis Mak 23 , 199 (2023). https://doi.org/10.1186/s12911-023-02308-y

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SYSTEMATIC REVIEW article

Effectiveness of mobile app-based psychological interventions for college students: a systematic review of the literature.

• 1 Department of Education and Psychology, University of Aveiro, Aveiro, Portugal
• 2 Department of Psychology and Education, Portucalense Institute for Human Development (INPP), Universidade Portucalense, Porto, Portugal

Serious mental health disorders are increasing among college students and university counseling services are often overburdened. Mobile applications for mental health have been growing exponentially in the last decade and they are emerging in university settings as a promising tool to promote and intervene in college students' mental health. Additionally, considering the recent covid-19 pandemic, mHealth interventions, due to its nature and possibilities, may play an important role in these institutions. Our main objectives are to explore mhealth interventions in universities, regarding its conceptual framework, acceptability and efficacy outcomes and understand its impact and contributions to address treatment delivery and psychological difficulties resulting from covid-19 pandemic. The literature search was conducted in scientific databases, namely, Web of Science, Pubmed, and Scopus. A search in app stores was not conducted, thus regarding commercially available apps, only those found in our database search were included in our review. We selected studies with mobile applications addressing psychological interventions for college students. A total of 2,158 participants were included in the 8 selected studies and most interventions were delivered through mobile apps only and based in cognitive behavioral therapy. Results suggested that college students accept and adhere to these interventions and preliminary evidence of efficacy was demonstrated in different disorders, such as stress, anxiety, depression and risky behaviors such as alcohol and tobacco abuse and sexual knowledge. We conclude that universities, particularly college counseling services, may benefit from mhealth interventions, not only to address college students' mental health but to decrease some of its difficulties related to lack of human resources. Specifically in covid-19 pandemic context, these interventions may contribute significantly by promoting and delivering psychological interventions at a safe distance.

Introduction

Over the last decade numerous mental health mobile applications have been developed and made available for users ( Bakker et al., 2016 ). Smartphones demonstrate numerous advantages such as great computing capacity, mobility, and more rapid and efficient access to information by using mobile applications ( Donker et al., 2013 ). The enthusiasm of smartphones for healthcare initiatives led to the emergence of a novel field called mHealth ( Ben-Zeev et al., 2014 ) defined as the use of mobile technologies to deliver or support psychological or mental health interventions and includes mobile devices such as smartphones, tablets, Personal Digital Assistants, and wearable devices ( Clough and Casey, 2015b ; Alyami et al., 2017 ). In clinical settings, mHealth may enhance face-to-face treatments, increase patient engagement in therapy sessions and adherence to therapy principles; provide better use of clinician time and resources and improve treatment outcome and risk of relapse ( Clough and Casey, 2015b ). Several studies have shown that mental health apps and cognitive behavioral therapy (CBT)-based apps are efficacious ( Rathbone et al., 2017 ; Linardon et al., 2019 ). However, despite clinical potential, interest and early supporting evidence, one factor that seems to limit mental health apps is low engagement or poor adherence to the intervention ( Torous et al., 2018 ).

One of the areas were mental health apps can have a significant impact is in universities. College years are a sensitive period to the onset of several mental health disorders ( Kessler et al., 2007 ) and many studies have reported a significant rise in serious mental health illness among college students ( Hunt and Eisenberg, 2010 ; Storrie et al., 2010 ; Auerbach et al., 2018 ). Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD) were identified as the most common disorders found in college students ( Auerbach et al., 2018 ). University counseling services constitute a valuable resource to support college student mental health and wellness ( Spooner, 2000 ) and a challenge that seems to be common across several counseling services is the growing student demand for these services and the limited resources to face these demands ( Johnson and Kalkbrenner, 2017 ; Shaw et al., 2017 ; Auerbach et al., 2018 ; Lee and Jung, 2018 ). College students are also large consumers of technology and communicate frequently online ( Shaw et al., 2017 ). A study by Wilansky et al. (2016) referred that mobile applications may increase youth adherence to Cognitive Behavioral Therapy (CBT) and improve treatment outcomes. Research suggests that mHealth is already being used to increase students' awareness and to deliver health-related interventions with increasing popularity; preliminary findings indicate that students are open and willing to use these interventions ( Johnson and Kalkbrenner, 2017 ).

Mobile technologies for mental health assume an important role considering our current reality of pandemics resulting from covid-19 infectious disease. Covid-19 is an infectious disease cause by a coronavirus that rapidly expanded worldwide, and some of the protective measures include physical distancing, wearing a mask, avoiding crowds and close contact, and regularly cleaning your hands ( World Health Organization, 2020 ). College students, alongside with children and health workers, are one of the most exposed groups to develop post-traumatic stress disorder, anxiety, depression and other symptoms of distress ( Saladino et al., 2020 ). Studies conducted during covid-19 pandemic in China concluded that almost half of Chinese college students that participated in the study experienced anxiety symptoms ( Fu et al., 2021 ) and are more likely to suffer from stress, anxiety and depression than the general population ( Li et al., 2020 ). Several studies highlight the need to monitor students' mental health during the pandemic and the delivery of timely and appropriate interventions ( Cao et al., 2020 ; Fu et al., 2021 ) such as the importance of technological devices or digital interventions ( Saladino et al., 2020 ). Covid-19 brought several challenges to mental health services delivery, thus many therapists rapidly adhered to telehealth to replace in-person contact ( Taylor et al., 2020 ). The same authors state that this disease presents an imperative for mental health services to make digital mental health interventions available in routine care and not only in response to covid-19 crisis.

Previous systematic reviews with college students and mobile interventions often explore a wide range of mHealth interventions and technology (e.g., Johnson and Kalkbrenner, 2017 ). Our review will focus on (1) mental health mobile applications that include a psychological intervention targeting a mental disorder, (2) college students, and (3) randomized controlled trials and acceptability and feasibility studies. We aim to explore how mobile apps are being developed to address college students' mental health in universities, if they accept and adhere to these interventions and if these interventions demonstrate efficacy. A search will be made for peer-reviewed articles of mental health mobile apps in scientific databases. The present review will not conduct a search in app stores mainly because acceptability and efficacy outcomes are not usually reported in app stores and because it would demand a different type of search strategy. Thus, in the current review we aim to review all published literature, in scientific databases, on psychological interventions using mobile applications, in the last 12 years, for college students. Our main objective is to review efficacy outcomes, through randomized controlled trials, of mobile app-based psychological interventions compared to traditional therapy or a waiting list control group in reducing psychological symptomatology among college students. Additionally, we intend to explore how mobile interventions are being accepted by college students and which conceptual frameworks are being used to develop these interventions. Considering the recent context of covid-19 pandemics, we aim to reflect on the impact and contributions of mHealth interventions for universities and college students.

We used the search method of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) ( Moher et al., 2009 ).

Eligibility Criteria and Information Sources

Inclusion criteria considered (1) target population: college students; (2) types of intervention: psychological interventions delivered through mobile applications (self-guided); mobile applications combined with web-based interventions or mobile applications combined with face-to-face treatments; (3) Primary outcome measures that target specific psychological disorders or symptomatology (i.e., anxiety, depression, social anxiety, stress, PTSD, alcohol abuse); (4) clear report of the psychological intervention, specifying theoretical basis or treatment model and therapeutic techniques; (5) Types of studies: randomized controlled trials (RTC) or quasi-experimental designs that clearly report efficacy outcomes and feasibility and acceptability studies since they contribute with valuable information about conceptual framework and some provide preliminary effectiveness results; (6) written in English; (7) published in the selected scientific databases. Exclusion criteria consisted in (1) studies with young adults (not students); (2) mobile interventions based on text messages; (3a) mobile interventions targeting physical or medical conditions (e.g., diabetes, physical activity, nutrition, weight control etc.); (3b) studies about mobile learning apps (e.g., anatomy); (3c) studies about smartphone addiction; (4) internet and computerized based interventions; (5) study protocols.

Our main objective is to review conceptual framework, acceptability, and efficacy outcomes of mobile app interventions addressing mental health for college students. A search of mobile apps commercially available in the app store was not conducted in this review since, although important, demands a different type of search and selection process, and often don't report acceptability and efficacy results (in the app store). Thus, we considered that it would be more suited to do a review, with this group of apps, separately. A narrative approach was used for extraction and synthesis of the data. Studies were identified through three major electronic databases, namely, Web of Science, Pubmed, and Scopus. An update literature search was performed in January 2021 using the same information sources.

Search and Study Selection Process

The following search keywords were considered “mobile interventions,” “smartphones,” “mobile application,” “mHealth,” “mobile technology,” “college students,” “students,” “university,” “campus.” Two authors independently conducted a thorough search in the three major scientific databases with the mentioned keywords, using primarily the combination “mobile interventions” AND “college students” with year filter between 2008 and 2019. A search update was performed in January 2021 with the same study selection process. In a first instance, studies including keywords in titles and/or abstracts were selected for further thorough review. After identifying eligible studies, duplicates were removed, and full papers were examined regarding eligibility criteria. A list of studies was produced by each author. Afterwards, both authors discussed their list of included studies, and by agreement, a final list of studies was produced.

Data Extraction

Data extraction was performed by two independent researchers and included year of publication, demographic characteristics of participants, study design (RCT, quasi-experimental studies, single-arm pre-test post-test), study participants and interventions (i.e., population, conditions, sample size, outcome measures, mobile app characteristics, theoretical basis, and intervention modality), main results and findings.

Assessment of Methodological Quality

The present review resorted to critical appraisal tools from the Joanna Briggs Institute for randomized controlled trials and quasi experimental studies (non-randomized experimental studies). The Checklist for Randomized Controlled Trials [ The Joanna Briggs Institute (JBI), 2017a ] was utilized to assess the methodological quality of the included RCTs and the Checklist for Quasi-Experimental Studies (non-randomized experimental studies) [ The Joanna Briggs Institute (JBI), 2017b ] to assess methodological quality of quasi-experimental studies and studies with a one group pre-test post-test design. Each study was assessed using JBI checklists for RCT or quasi-experimental studies.

Study Selection

As we can see in Figure 1 our search identified 957 published articles. Afterwards, we removed 23 duplicates and a review of title and abstracts excluded 904 articles. A total of 30 full-text articles were assessed for eligibility, where 11 were excluded due to motives of being a study protocol, thus not presenting feasibility or efficacy outcomes; lack of a psychological intervention or a psychological disorder; being web-based intervention or having no access to article full text. A total of 19 studies were included and examined in accordance with inclusion criteria.

Figure 1 . PRISMA flow diagram. From: Moher et al. (2009) .

Demographic Characteristics

A total of 3,399 college students were included in the selected studies ( n = 19) for this systematic review. Eleven studies included college students with self-reported psychological symptomatology (i.e., elevated stress, generalized anxiety disorder (GAD), PTSD), two studies included first-year college students and the remaining studies included non-treatment seeking college students ( n = 6). Most studies occurred in the USA ( n = 12), others occurred in Germany ( n = 1), Sweden ( n = 1), Canada ( n = 1), United Kingdom (UK) ( n = 2), Australia ( n = 1), and Iran ( n = 1).

Intervention Characteristics

Mobile intervention apps for college students target anxiety ( n = 7), depression ( n = 7), stress ( n = 5), alcohol consumption and risky drinking ( n = 4), smoking ( n = 1), and sexual behaviors ( n = 1), Post-traumatic stress disorder (PTSD) ( n = 1). Table 1 resumes all further interventions characteristics.

Table 1 . Mobile interventions characteristics.

We considered that most studies, with self-guided apps, focus on prevention ( n = 15) and the studies that included human support (therapists and coaches) and a TAU group were more focused on a treatment approach ( n = 4). However, many studies with self-guided apps, included students with elevated psychological symptomatology (i.e., elevated stress, diagnosed PTSD, or GAD), and it isn't always clear the nature of their intervention.

Intervention modality varied between a combination of internet and mobile app intervention ( n = 2) and mobile app intervention only ( n = 17), from these 17 studies, two apps were combined with a wearable band to permit passive data collection. When combining mobile apps with internet interventions, the mobile app functioned mostly as a tool offering support for homework assignment or working as a diary app by enabling monitoring of mood fluctuations or stress levels [e.g., Harrer et al. (2018) ]. Human support was considered in 4 mobile apps (Lantern; TAO; StudiCare Stress; Mind the Moment), two mobile interventions included therapists and two included a coach, StudiCare Stress app included a trained master's student in Psychology (named an eCoach) and Lantern app included a coach with various educational backgrounds. Human support varied from weekly 10–12 min brief videoconferences, to 2 face to face sessions and online sessions only.

Regarding conceptual framework most researchers used CBT intervention or CBT third wave techniques to conceptualize these apps ( n = 17). Most CBT apps include mindfulness exercises ( n = 11), some are solely based on mindfulness ( n = 4) or acceptance and commitment therapy (ACT) ( n = 2). One mobile app is focused on CBT and a biofeedback intervention (BioBase app). Some used CBT intervention as a part of a larger program such as GET.ON Stress, a stress management program, adapted to college students; or BASICS, an alcohol intervention program for college students. In some cases, CBT was combined with other psychological models such as Lazarus Transactional Model of Stress (GET.ON Stress program) or the Unified Theory of Use and Acceptance of Technology (UTAUT). The StudiCare Stress app also included an adherence-focused guidance concept according to the human accountability model. Only two studies did not resort to CBT, the SmarTrek app that used motivational interviewing and the SEX101 that used two psychological models, the Theory of Reasoned Action (TRA; Fishbein and Ajzen, 1975 ) and the Transtheoretical Model (TTM) of behavior Change ( Prochaska and DiClemente, 1984 ). Additionally, SmartTreak and MtM added an Ecological Momentary Intervention (EMI) and Witkiewitz et al. (2014) , BioBase app and ACT daily included an Ecological Momentary Assessment (EMA).

As for specific techniques more than half of the mobile apps include mindfulness exercises; other included psychoeducation or general information about the target disorder; include data collection self-monitoring; exposure; systematic desensitization and relaxation exercises. Other features refer to quizzes and interactive games; virtual coach; passive sensing through sensorband; all apps for risky drinking and excessive smoking included personalized feedback on drinking patterns and motives for drinking, feedback includes information about smoking and “urge-surfing” or strategies to increase student's emotional awareness. All apps were designed to provide education, collect data, monitor/track behavior, some provide personalized feedback or guidance in CBT exercises (in some cases homework assignments).

Few studies gave information regarding privacy and security. For example, Benton et al. (2016) referred that TAO security and privacy included authentication, password protection, and encryption of databases and Lee and Jung (2018) stated that data was collected and stored on secure systems and accessed through computers with password protection and encryption.

Methodological Quality

Tables 2 , 3 resumes the methodological characteristics of the included studies. Eleven studies are randomized controlled trials (RCT) ( Witkiewitz et al., 2014 ; Gajecki et al., 2017 ; Harrer et al., 2018 ; Lee and Jung, 2018 ; Fish and Saul, 2019 ; Huberty et al., 2019 ; Bruehlman-Senecal et al., 2020 ; Flett et al., 2020 ; McCloud et al., 2020 ; Newman et al., 2020 ; Ponzo et al., 2020 ) and two studies are considered quasi-experimental trials ( Benton et al., 2016 ; Borjalilu et al., 2019 ). Four studies considered a single-arm pre-test-post-test study design ( Jackson et al., 2016 ; Leonard et al., 2017 ; Haeger et al., 2020 ; Lattie et al., 2020 ; Reyes et al., 2020 ) and one study included two groups through an iterative process ( Kazemi et al., 2018 ).

Table 2 . Methodological characteristics.

Table 3 . JBI Checklist for randomized controlled trials.

Eleven of the included studies are RCTs and the total sample size ranges from 72 to 330 college student participants; the overall duration of the intervention range from 14 days to 3 months and when we consider follow-ups, the longest trial lasted for 9 months. Most RCTs included as a control group a waiting list control trial ( n = 8). Following JBI critical appraisal tool, we consider that all RCTs reported that participants were randomly assigned to treatment groups, 9 out of 11 studies provided detailed description of the randomization procedure and two studies merely stated that the participants were randomly assigned. As for allocation concealment, three studies provided information about allocation concealment. For example, Harrer et al. (2018) stated that the randomization process was performed by a researcher not involved in the study, and although they weren't able to blind participants to study conditions, during the randomization process, they were able to conceal the allocation from participants, researchers, and e-coches. Ten studies provided information and reported similar groups at baseline. As for blinding participants, or those delivering treatment and even outcome assessors to treatment conditions may be difficult and even unachievable in this type of studies; several studies reported this issue, pointing to the inability to blind their participants to treatment conditions. There were incomplete follow-ups; however they were generally adequately described and analyzed. Six RCTs provided detailed information about intention-to-treat analyses (ITT); the remaining studies excluded participants, lost to follow-up, from analysis. All studies used primary outcome measures with good validity and reliability. The large majority of RCTs also included quantitative and/or qualitative self-report measures to evaluate usability, acceptability, user satisfaction, or app adherence.

The studies by Benton et al. (2016) and Borjalilu et al. (2019) were considered as quasi-experimental studies. The first study included a large sample size ( n = 1,241) with overall duration of the intervention of 7 weeks. They included a wait-list treatment as usual control group and the intervention group received the intervention of study. The primary outcome measure was adequately validated and provided multiple measurements along the intervention as well as pre and post assessment. Differences between groups in terms of follow-up were adequately described and analyzed. This study presented many missing data and the linear mixed-effects models was utilized to estimate parameters for missing values. As for Borjalilu et al. (2019) , they conducted a study with three conditions and 68 college students, who were randomly assigned into the three groups, but no further detailed information was given about the randomization process. There were pre- a post-assessments and follow up was complete. Outcomes were measured in a reliable way and participants, from both groups, were assessed in the same way.

In this review there is a significant number of a single group pre-test-post-test design studies that aimed to evaluate acceptability and feasibility; only one study ( Jackson et al., 2016 ) aimed to evaluate efficacy with this design. Sample sizes were similar between studies, ranging from n = 10 to n = 23, with overall duration (intervention) of 3–4 weeks. Adequate and validated main outcome measures were used. The SEX101 ( Jackson et al., 2016 ) had a larger sample size compared to the previous studies and a follow-up assessment of 3 months after intervention completion. However, the overall duration of the intervention was very small (pre-test and intervention had to be complete in 1 week and it takes 40 min to complete) and some outcome measures were developed by the researchers with few information regarding reliability.

Intervention Outcomes and Effect Sizes

A study conducted by Newman et al. (2020) assessed the efficacy of Lantern, a self-help mobile app to treat generalized anxiety disorder. Study results demonstrated a significant reduction on the DASS stress scores ( d = 0.408) and greater probability of remission from GAD ( d = 0.114). Lantern revealed moderate effects in reducing anxiety, stress, and depression. BioBase is a biofeedback self-guided mobile app combined with wearable device (BioBeam), to treat anxiety in college students. Ponzo et al. (2020) conducted a RCT to assess BioBase efficacy and results indicated that a 4-week intervention significantly reduced anxiety ( d = 0.67), depression (d = 0.99), and increased perceived well-being ( d = 0.65) demonstrating moderate to large effects. Sustained large effects at 2-week follow-up was found for anxiety ( d = 0.81) and perceived well-being ( d = 1.16).

McCloud et al. (2020) conducted a RCT to assess efficacy of Feel Stress Free app for the treatment of depression and anxiety symptoms. Results showed that there was a significant reduction of depression symptoms at week 4 ( d = 0.27) and week 6 ( d = 0.39), and significant reduction of anxiety symptoms at week 4 ( d = 0.58). Overall effect sizes ranged from small to moderate.

Bruehlman-Senecal et al. (2020) studied Nod, a mobile app designed to reduce loneliness during the transition to college. Their RCT results indicated significant condition-by-baseline loneliness interaction to predict week-4 depression (Np 2 = 0.02) and sleep quality (Np 2 = 0.04), suggesting that Nod buffered participants with higher baseline loneliness against heightened midquarter depression and poor sleep quality. Calm, is a mindfulness-based app, and its efficacy was tested among students with elevated stress. The study results of Huberty et al. (2019) found significant differences among conditions in all outcomes, namely, significant reduction in perceived stress ( d = 1.24), significant improvements in mindfulness ( d = 1.11), and self-compassion ( d = 0.84).

Harrer et al. (2018) conducted a randomized controlled trial to evaluate the efficacy of Studicare Stress, a stress management intervention app for college students. Their results indicated significant effects of the intervention compared with the waitlist control group for stress at post-test ( d = 0.69) and at 3-month follow-up, other secondary outcome measures also yielded significant effects such as anxiety ( d = 0.76), depression ( d = 0.63), college related productivity ( d = 0.33), and academic work impairment ( d = 0.34). Thus, Studicare Stress revealed moderate to large intergroup effects for the reduction of perceived stress and other health and college related outcomes.

Lee and Jung (2018) conducted a pilot study to evaluate efficacy of DeStressify, a mindfulness-based app on stress, anxiety, depressive symptomatology, sleep behavior, and other variables. Results indicated that when using the app during 4 weeks, students in the experimental group at post-test reported less trait anxiety ( N p 2 = 0.040); an improve in several quality of life subscales, such as general health, that significantly differed between treatment condition in post-intervention scores ( N p 2 = 0.07). A significant difference was also found in energy or fatigue subscale between treatment conditions ( N p 2 = 0.05). An interaction effect was found in the emotional well-being subscale ( N p 2 = 0.05). The author interpreted the partial eta squared values of 0.0099, 0.0588, and 0.1379 as small, medium, and large effect, respectively, following suggestions by Cohen ( Field, 2009 ). This indicates that we can verify small (trait anxiety) to medium effects for general health, energy or fatigue and emotional well-being.

Telecoach app ( Gajecki et al., 2017 ) was evaluated using a 3-arm randomized controlled trial and results demonstrated that the proportion of students with excessive alcohol consumption declined in both intervention and wait list control group compared to controls at first and second follow-ups. Secondary analysis showed reductions for the intervention group in quantity of drinking at first follow up and in frequency of drinking at both follow-ups. Across both follow-ups the odds ratios for not having excessive weekly alcohol consumption in the intervention group (1.95) was almost twice as high as for controls (1.00). Secondary analysis by gender showed that the odds ratio for not having excessive alcohol consumption among men in the intervention group compared to male controls was higher (2.68) than women in the intervention group (1.71) compared to women controls.

Witkiewitz et al. (2014) conducted a 3-arm randomized controlled trial to evaluate a mobile feedback intervention for heavy-episodic drinking (HED) and smoking among college students, and they concluded that at 1-month follow-up there were significant reduction in number of cigarettes per smoking day in both the mobile intervention ( d = 0.55) and mobile assessment conditions ( d = 0.45) with moderate effects. No significant results were observed on HED or concurrent smoking and drinking. As for Benton et al. (2016) quasi-experimental study, the intervention group showed improvements across time significantly greater than treatment as usual participants, for all primary outcomes except Life Functioning (LF) subscale. The size of these effects ranged from small ( d = 0.16) for LF, Global Mental Health and Well-Being (d = 0.20) to medium for Anxiety ( d = 0.31).

Usability, Acceptability, and Feasibility Outcomes

The large majority of the included studies evaluated acceptability and students' satisfaction with the intervention. From the 19 studies, eight studies explored adherence/satisfaction and six used adequately valid scales or methods to assess usability or satisfaction with app use. Some studies also used metrics obtained through the mobile app ( n = 2). Most studies, created their own items to assess satisfaction with the intervention. Overall, we could observe good retention rates across studies, however as Gajecki et al. (2017) specifically noted in there study, there is a possibility that their fairly high retention levels could result from the desire of some participants to win an iPad (reward to participate in the study) with no actual intention to use the app. Out of the 19 studies, 10 gave rewards to their participants.

All studies that evaluated satisfaction reported moderate to high client satisfaction with the intervention. The MtM app ( Leonard et al., 2017 ) demonstrated that 60% of the participants reported “mostly” or “very” satisfied with the sensorband and 50% with the mobile app. Also, 93.9% of the participants were very satisfied or satisfied with the intervention program of SEX101 app ( Jackson et al., 2016 ). However, this particular study produced large attrition rates (50%) and as the authors of this study noted information regarding app components that need to be improved, added or removed should be collected. In the Witkiewitz et al. (2014) EMA app, over 65% of the participants reported an increase in awareness of their drinking and/or smoking and 60% stated that they would recommend this study to a friend because it provided greater awareness and they could help a friend reduce their drinking and/or smoking. Kazemi et al. (2018) demonstrated good usability of SmartTrek and the best feature reported by students was “Games” and the most useful features was “know your BAC” and “My strategies” that monitored alcohol intake, created behavioral change plans and reminded them of their goals. None of the studies, that provided human support (therapists), explored acceptability and satisfaction of the therapist with the intervention.

Implications and Contributions of mHealth Interventions for College Students in Covid-19 Context

Covid-19 infectious disease emerged in China and rapidly expanded around the globe, leading to an unexpected pandemic, which completely changed our daily lives and significantly limited physical and social contact with significant repercussions to our physical and mental health. Specifically in college students that live in a constant and thriving social interaction, covid-19 pandemic had a strong negative impact on mental health and may have contributed to the increase of several preexisting barriers and limitations to college counseling services. Considering these restraints, mHealth interventions may play an important role in a pandemic context due to its ubiquitous, remote and innovative functionalities that may facilitate access to evidence base treatments for mental health and also, its provider and facilitator (therapist).

Taking into consideration the included studies and their characteristics, acceptability, satisfaction and efficacy outcomes, we may determine that these interventions can significantly contribute in several important aspects related to college students' mental health. To our understanding, mobile app technologies may significantly contribute to promote mental health in college students targeting several specific disorders, such as anxiety, stress, depression, smoking, and alcohol abuse. It is also attainable to support students with coping strategies for elevated stress, anxiety, smoking, and alcohol abuse. Through mobile technologies, therapists may monitor and keep track of their patients' symptomatology and well-being, check homework assignments, and contact their patients' regularly through chat or messages, remotely. Overall, mobile technologies provide spontaneous and remote access to app content whenever we want, particularly in the comfort of our home. It helps us maintain physical distance from mental health professionals and counseling services without interrupting treatment.

Summary of Evidence

Our search for studies addressing mobile health apps for college students in university settings gathered 19 studies with different conceptual frameworks and study designs. In this review we could verify an increase in studies using mobile interventions for college students over the years, particularly in the last year, which may indicate an increasing trend in mobile use for the delivery of health interventions for college students. The large majority of studies are being developed in North America and Europe.

Regarding target disorders we can verify that most apps target anxiety, depression and stress, others target risky or excessive drinking, PTSD and sexual behaviors. Overall, mobile interventions showed promising results to reduce psychological symptomatology associated with stress, depression, anxiety and general student's mental health. As for drinking, smoking, and sexual behaviors, the included apps seemed to reduce excessive drinking and smoking and increase contraceptive use and knowledge but not the intention to reduce sexual risk behaviors or actual risk reduction. Most of the mobile interventions showed medium to large effect sizes for the main variables the app was designed to intervene, which may indicate that these interventions are well conceptualized and grounded according to the best available empirical evidence. Some of the included studies aimed to evaluate acceptability and feasibility and overall, these apps demonstrate good acceptability and feasibility among college students, supporting the hypothesis that students may accept and adhere to these interventions.

When we explore conceptual frameworks of these mobile apps we verify that many studies adopted CBT as the main intervention, particularly Mindfulness exercises. Effectively, CBT is well-established and particularly known as an effective treatment for several mental health disorders, and have demonstrated its efficacy when delivered through apps ( Rathbone et al., 2017 ). In some studies the intervention was complemented with psychological models, which have been shown to increase intervention efficacy ( Webb et al., 2010 ). Aside from psychological models/theories for behavioral change, one study incorporated a technological model, namely the Unified Theory of Use and Acceptance of Technology (UTUAT). There seems to be a strong application of psychological models and intervention techniques, indicating that there is a concern in adequately conceptualizing these interventions following evidence base principles. However, considering that we are studying mobile health interventions with significant emphasis in technology, very few studies incorporated technological models. Also, security and privacy features are also rarely mentioned and increasingly relevant in this type of interventions, best practices should be known and shared, reflecting in a mobile app quality indicator.

Regarding therapist role in mobile interventions, only 4 studies incorporated human support, two studies included therapists and two studies included a trained psychology student. From the mentioned studies, one used the human accountability model to inform this support. We consider that even though most of these apps intend to reduce therapist time and subsequently reduce therapist caseload and overburdened, this process may be optimized and better conceptualized using human support models. Moreover, evidence shows that app based interventions with therapist support has shown to produce larger effects ( Linardon et al., 2019 ).

As for methodological quality of the included studies, most studies aimed to evaluate efficacy and resorted to a randomized controlled trial, which is natural since RCTs are known as the golden standard to evaluate efficacy. All trials randomly assigned their participants to treatment conditions; however the number of studies that performed randomization concealment and blinding was almost non-existent. This reflects the difficulty of concealment and blinding in these type of studies and the limitation of the RCT study design when assessing efficacy in this type of interventions. Most studies also use a waiting list control group; given that many studies included students with elevated psychological symptomatology (that have to wait weeks/months to get access to the intervention) and the difficulty of blinding participants with this type of comparator we wonder if this is the best control group to use in this studies. Other research designs are also being explored in these studies and should be considered, so we can obtain efficacy results timelier and reliably ( Clough and Casey, 2015a ). Many studies adopted a pre-test post-test study design in order to evaluate acceptability and feasibility, even though this research design is considered a weak experimental study design, we consider that for the purpose and objectives of the studies this design was well-applied. Good overall retention rates may indicate treatment feasibility and acceptability. However, most studies were of short duration, with small samples and in controlled settings, with the addition of significant rewards. Additionally, many outcome measures were self-reported and not always congruent with app adherence rates. User metrics (e.g., how many times a participant accessed the app) provided by mobile apps may contribute to more accurate indicators of use and adherence to the intervention. Also, qualitative studies exploring perceived usefulness and user experience with the app intervention may also contribute to understand and overcome some barriers of adherence and engagement. Rewards are sometimes our best option to find participants, however when we are studying acceptability and adherence to these interventions, rewards may produce biased results. Recent studies opted to reward outcome measures completion, rather than app use.

A final question that emerged while exploring the studies is associated with the limited visual content of the apps included in the studies. Few studies included images/visual content of the mobile apps; some studies reported how they developed the app but provided little information about app design. A study by Torous et al. (2018) concluded that most mhealth apps suffer from low engagement and adherence and this may be, along with other issues, due to poor usability and because most apps are not user-friendly. It is important that researchers provide more frequently studies regarding user's needs and report multidisciplinary teams when building (native) apps, since this area often needs involvement of psychologists, software engineers, and designers/interaction designers. Also these tools, in clinical settings (e.g., counseling services), should be designed and optimized regarding all end users: students and therapists. Therapists' point of view and evaluation was often forgotten in the included studies that involved therapists.

Mobile apps may be customized and designed under practically unlimited possibilities. They can be developed to promote, prevent or intervene in a specific mental health disorder; to promote well-being and to deliver treatment under different levels of therapist support in different mental health services. Thus, they can be implemented and tailored according to specific needs. It is important to continue studying these interventions using user-centered designs and rigorous efficacy and effectiveness studies. We consider that universities, including college counseling services, may benefit from mhealth interventions, not only to address college student mental health but to decrease some of its difficulties related to few human resources. In a context of quarantine and confinement at home, where physical and social distance is imperative, these interventions assume special importance. They facilitate mental health promotion and support therapist and patient contact at a safe distance, avoiding treatment interruption.

Limitations

The current review presents a major limitation since we limited our search scope to the mentioned databases. Registered clinical trials and commercially available apps in app stores were not included, thus we may have missed already developed or apps that are being currently studied for college students. We may have failed to identify studies with relevant information regarding the application of mHealth intervention in college settings when we didn't consider “young adults,” since it may not include college students or occur in college settings.

The current systematic review shows that mobile apps for mental health intervention in college students exists and demonstrates good acceptability and feasibility. They also demonstrate efficacy among students. Overall we may conclude that mHealth interventions may turn out to be a great resource and tool to implement in counseling services, offering therapists and students many advantages. Particularly in the current pandemic context, these interventions demonstrate innumerous possibilities and promising solution to address college students' mental health and overcome many barriers associated with treatment access.

Future studies addressing mobile apps in college students, should invest in user-centered design studies so we can better understand what students and therapists (also attending university counseling services workflow) value more in a mobile based psychological intervention, to better adapt and tailor the intervention to user's needs. Effectively, acceptability and feasibility results among therapists are lacking in studies that use mobile intervention with therapist support. Future investigations should also explore diversity when developing and studying future apps, examining the applicability and efficacy of other theories/models. Also, we consider that studies should describe the development process of the mobile application (e.g., by including visual content) so we can better understand what is actually being evaluated and how it may impact efficacy results, in terms of usability and design. Lastly, students are large consumers of technology and so it may be important to invest more in these interventions, doing larger studies with more students, with superior methodological quality and avoiding large monetary rewards.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Author Contributions

CO searched for studies to include in the systematic review and wrote sections of the manuscript. AP and PV revised the manuscript and contributed to the conception of the study. CN, JG, and BA contributed to organize data extraction and the search of studies in the scientific databases. All authors contributed to the manuscript revision, read, and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: college students, mental health, mHealth, cognitive-behavioral therapy, counseling services

Citation: Oliveira C, Pereira A, Vagos P, Nóbrega C, Gonçalves J and Afonso B (2021) Effectiveness of Mobile App-Based Psychological Interventions for College Students: A Systematic Review of the Literature. Front. Psychol. 12:647606. doi: 10.3389/fpsyg.2021.647606

Received: 30 December 2020; Accepted: 06 April 2021; Published: 11 May 2021.

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Towards Development of a Mobile Application to Evaluate Mental Health: Systematic Literature Review

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• Jorge A. Solís-Galván 18 ,
• Sodel Vázquez-Reyes 18 ,
• Margarita Martínez-Fierro 18 ,
• Perla Velasco-Elizondo 18 ,
• Idalia Garza-Veloz 18 &
• Claudia Caldera-Villalobos 18  

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Mental disorders such as depression, anxiety, and stress are increasingly present in the lives of many people, which has led these disorders to be a latent public health problem today. This situation has prompted the development of new solutions focused on improving people’s mental health status, some of these solutions are based on mobile applications. This article presents the results of a systematic literature review that was carried out with the aim of identifying mobile applications that address the most common mental health conditions, focusing on the design, development and/or evaluation of this kind of application. 152 primary studies were selected, 86 of them reported on evaluations of mental health applications. However, 72 of the primary studies addressed more than one mental disorder, highlighting depression, stress, and anxiety.

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Thank you to Dr. Aldonso Becerra-Sánchez, for his advices in the definition of the background and planning the review used in the early stage of this work.

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Solís-Galván, J.A., Vázquez-Reyes, S., Martínez-Fierro, M., Velasco-Elizondo, P., Garza-Veloz, I., Caldera-Villalobos, C. (2021). Towards Development of a Mobile Application to Evaluate Mental Health: Systematic Literature Review. In: Mejia, J., Muñoz, M., Rocha, Á., Quiñonez, Y. (eds) New Perspectives in Software Engineering. CIMPS 2020. Advances in Intelligent Systems and Computing, vol 1297. Springer, Cham. https://doi.org/10.1007/978-3-030-63329-5_16

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Evaluating the Implementation of a Mental Health App for Overseas Filipino Workers in Macao China: A Mixed-Methods Study of Stakeholders’ Perspectives

Andrian liem.

1 Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia

Karmia A. Pakingan

2 Department of Psychology, De La Salle University, Manila, Philippines

Melissa R. Garabiles

3 Scalabrini Migration Center, Quezon City, Philippines

Hao Fong Sit

4 Department of Psychology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China

Sebastian Burchert

5 Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany

Agnes I. F. Lam

6 Department of Communication, University of Macau, Macau, Macau SAR, China

7 Centre for Macau Studies, University of Macau, Macau, Macau SAR, China

Brian J. Hall

8 Center for Global Health Equity, NYU Shanghai, Shanghai, China

9 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States

Associated Data

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Overseas Filipino workers (OFWs) is one of the largest communities of international migrant workers. They face systemic barriers to fulfilling their health needs. The COVID-19 pandemic worsened this condition and provided a context to evaluate the utility of a digital mental health intervention delivered within a stepped-care model to address OFW mental health. Using an implementation science framework, this study aimed to evaluate stakeholders’ perspectives on the implementation of Kumusta Kabayan, a mobile phone-based mental health app, for OFWs in Macao.

A mixed-methods convergent design was used by conducting two parallel steps, including quantitative and qualitative measures. The quantitative data was collected from Filipino team members and local non-governmental organization (NGO) staff members ( N = 12). The qualitative data were gathered from interviews with OFWs in Macao who used the app ( N = 25; 80% females, 76% domestic workers).

From the online survey, the staff members of the local partner NGO and the Filipino team members strongly perceived that their organization could adapt Kumusta Kabayan to their program and generally evaluated that Kumusta Kabayan achieved its goal and was received well by OFWs. In the interviews, the OFW app users shared their experiences in using Kumusta Kabayan, which was thematically organized into six aspects of the participants’ experience: (1) promotional channel and expectation; (2) when to use the app and in what language; (3) lessons learnt; (4) memorable aspects; (5) key facilitators and barriers; and (6) suggestions.

Kumusta Kabayan was well accepted and shows potential to be integrated into the existing support services for OFWs in Macao. This app has the promise of being scaled-up for OFWs in other countries by collaborating with local and overseas stakeholders. Lessons learnt from this evaluation could also be implemented in wider digital mental health services in different settings.

Introduction

Overseas Filipino workers (OFWs) is one of the largest international migrant worker communities, with an estimated number of over 10 million worldwide ( 1 ). They work in both high-skill and low-skill sectors across countries to improve their lives and the livelihoods of their family members who remain in the Philippines ( 2 ). However, OFWs and other migrant workers struggle to fulfill their health needs because of systemic barriers they experience including language difficulties, adverse working conditions, lack of available healthcare providers, and inadequate social protection for migrant workers in the host countries ( 3 , 4 ). Consequently, migrant workers, including OFWs, experience higher risks for developing mental disorders like anxiety and depression than local people in the host countries ( 5 – 7 ).

The COVID-19 pandemic worsened this condition as migrant workers were forced to take temporary unpaid leaves from employment or suddenly lost their jobs and social protections ( 8 , 9 ). Additionally, OFWs and other migrants who worked as domestic workers encountered other challenges like excessive work load from their employers who began to work from home and some were not permitted to take their normal day-off due to employer’s fears of COVID-19 contamination and lack of trust in the domestic workers’ hygiene ( 10 , 11 ). Due to cultural and language barriers, migrant workers were also at risk of having inadequate knowledge and awareness of the latest COVID-19 situation and policies in their host countries ( 12 ). Consequently, OFWs and other migrant workers’ mental health deteriorated and they have to survive with the limited mental health support in the host countries ( 13 ).

The inequity in healthcare access during the pandemic may be reduced by implementing digital mental health interventions within a stepped-care approach, which includes providing the least intensive intervention based on clients’ needs and monitoring them regularly ( 14 ). Digital mental health interventions, including via the internet and mobile phones, were found to be consistently effective in reducing mental disorders like depression and anxiety ( 15 , 16 ). Furthermore, mobile phone-based health apps can also accurately screen mood disorder symptoms ( 17 ). Furthermore, a previous study on OFWs’ attitude toward digital health interventions found that the community showed their acceptance and willingness in accessing mobile phone-based mental health interventions ( 18 ). However, mobile phone-based mental health applications for improving mental health of OFWs and other migrant workers were still limited as previous interventions were mostly developed for inpatient adults ( 15 ).

With the limited internet and mobile phone-based mental health interventions for non-clinical groups, the World Health Organization (WHO) developed Step-by-Step, an online guided self-help intervention for people with depressive symptoms ( 19 ). Step-by-Step is an online version of the WHO’s offline transdiagnostic psychological intervention for common mental health problems named Problem Management Plus (PM+) ( 19 , 20 ). The Step-by-Step website version has been piloted among Lebanese, Palestinian, and Syrian adults in Lebanon ( 21 ) and the mobile application version was tested among adult Syrian refugees residing in Germany, Sweden and Egypt ( 22 ). These studies showed that Step-by-Step was a promising stepped-care digital mental health intervention for OFWs. The Step-by-Step program was also culturally adapted for use among Filipino overseas workers.

The current study evaluated stakeholders’ perspectives on the implementation of Step-by-Step for OFWs in Macao using a mixed-methods design. The study utilized an implementation science approach, which emphasized the practical aspects of how to scale-up an evidence-based intervention ( 24 ). The current study presents the results of the implementation evaluation of the program utilizing questionnaire data collected from our local non-governmental organization (NGO) partner and e-helpers (digital lay health workers) in the Philippines as well as interviews with OFWs in Macao as end users of the Filipino version of Step-by-Step named Kumusta Kabayan, which means “Hello, fellow Filipino.” The roles of each stakeholder member are presented in Figure 1 below. Using an implementation science framework, this study was designed to accelerate the translation of evidence-based intervention into real-world system of care and address inequities in healthcare delivery for migrant workers ( 25 , 26 ).

Stakeholder members’ roles.

Materials and Methods

This implementation science evaluation study used a mixed-methods parallel convergent design ( 27 ). The evaluation was conducted in two parallel steps, using quantitative and qualitative measures, which complemented each other and provided more comprehensive evaluation results ( 28 ). Details of the study is described in sub-sections below. Ethical approval for the study was granted from the Research Ethics Committee at the University of Macau (SSHRE19-APP074-FSS).

Sampling and Procedure

For the quantitative measure, total population sampling ( 29 ) was used where the lead author sent message invitations to the anonymous online evaluation survey to all e-helpers, clinical supervisors, staff and volunteers of the local NGO partner. The online survey for staff and volunteers of the local NGO partner were provided in English and Chinese to increase the participants’ understanding. Before completing the survey, electronic informed consent forms were provided to the participants.

For the qualitative measure, participants were recruited with a convenience census-approach sampling. All participants who participated in the Kumusta Kabayan ( N = 206) and were screened with the Patient Health Questionnaire (PHQ)-9 for depressive symptoms ( 6 ) were considered as eligible respondents and were asked if they were willing to participate in the interview. Participants who either completed or did not complete the program were purposively invited to represent diverse experiences. Not all potential interviewees joined the interviews as illustrated in Figure 2 .

Participants recruitment for interviews from both completer and non-completer groups.

Before the interviews were audio-recorded, participants were informed about the aim of interview and verbally asked for their consent. One-to-one audio interviews from October 2020 to February 2021 were conducted by e-helpers using voice over IP services. Interviews lasted an average of 25 min (SD = 8) and were conducted in English or Tagalog. Participants were compensated with a food voucher worth MOP 100 (≈USD $12) for their time. In order to improve participants’ openness, they were assigned to a different e-helper for the interview if they were previously assisted by an e-helper during the intervention period. Moreover, e-helpers were also trained for doing the interviews using a role play method prior to the data collection.

Participants

The demographic information (e.g., age and sex) of participants in the survey ( N = 12) was not asked to protect their anonymity, given the small sample sizes of e-helpers and NGO partner members. Participants in this quantitative measure consisted of a team in the Philippines ( n = 8), including two clinical psychologists, two Master of Psychology students, and four Bachelor of Psychology students; and a team in Macao ( n = 4), including three social workers and one logistical staff.

The interviewed OFW participants’ demographic information ( N = 25) was retrieved from their biodata in the app. The interviewed participants were mostly female ( n = 20), with an average age of 39 years old (SD = 8), and dominated by a domestic work job ( n = 19). On average, they have been working as OFWs for 59 months (SD = 78), having 66 working hours per week (SD = 16), and with a monthly salary of MOP 4,664 (SD = 1,182) (≈USD $580, exchange rate in July 2021). The interviewed participants consisted of both completers and non-completers. The demographic information of interviewees’ and non-interviewees were comparable ( Supplementary Material ).

Instruments

The online survey was adapted from previous studies on evaluation of innovative health programs promotion and implementation ( 30 – 33 ). The measures included organizational climate scale, awareness and concern scale, perceived advantage scale, perceived complexity scale, and level of success scale. Also, one open-ended item to ask for general feedback and suggestion was located at the end of the online survey (see Supplementary Material ).

The 11-item organizational climate scale consisted of three parts: mission, teamwork, and infrastructure support. An item from this measure is “Our team is willing to take a chance on a good idea” that was measured with Likert’s scale from 1 (strongly disagree) to 5 (strongly agree), where higher summed scores represent more positive organizational climate in adapting a new program. This scale was given only to the team in Macao due to the nature of the items. The internal reliability (Cronbach’s alpha) of this measure was 0.94. The 9-item awareness and concern scale consisted of three parts: awareness, concern, and interest. An item example of this measure is “I am aware that Kumusta Kabayan addresses depressive symptoms.” Item responses were on a Likert-type scale from 1 (not at all true) to 4 (very true), where higher summed scores represent higher awareness and concern of participants to the program. The Cronbach’s alpha of this measure was 0.77.

The perceived advantage scale was measured with a 3-item Likert scale from 1 (strongly disagree) to 5 (strongly agree), where higher summed scores represent greater perceived level of program’s advantage. An item from this measure is “The Kumusta Kabayan program can improve the mental health of Filipino workers in Macao.” The Cronbach’s alpha of this measure was 0.71. The perceived complexity scale was measured with a single item of organizational level (Part A, “The Kumusta Kabayan would be difficult for our organization/institution to explain to potential Filipino migrant worker users”) and 2-item Likert scale (Part B) from 1 (strongly disagree) to 5 (strongly agree), where higher total score represents higher perceived complexity of the program. A sample item from Part B is “The Kumusta Kabayan program would be hard for Filipino migrant workers to understand.” The Cronbach’s alpha of this measure (Part B) was 0.74. These reliability coefficients around 0.70 are considered moderately reliable ( 34 ). The last question, level of success, asked the participants to choose one of eight continuum options based on their experience and observation. It started from Option 1 (The Kumusta Kabayan program not only failed to meet its goals, but it caused a loss of resources and create other problems) to complete successful perception of Option 8 (The Kumusta Kabayan program fulfilled all of its goals and also provided other benefits for Filipino migrant workers and/or for other stakeholders).

For the qualitative measure, all e-helpers followed the interview guide ( Supplementary Material ) that was developed for this study. The guideline was pilot tested among e-helpers and with three participants. During the interviews, e-helpers introduced themselves and asked for participants’ verbal consent. Consented participants were asked about the following themes: referral channel and initial thoughts about the program, period of use, lessons learnt, key facilitators and barriers, and improvement suggestions for the program.

Data Analysis

Results from the online survey were descriptively analyzed. The inferential analysis was not conducted due to the limited number of responses and demographic variables of online survey participants were not collected to protect participants’ anonymity. Data from the research team in Macao and the Philippines were visually compared to show any contrast or similarity between the stakeholders in evaluating the program.

Interview audio-recordings were transcribed by the e-helper who did the interview within 2 weeks from the interview then sent to the clinical supervisor and research coordinators. Following a Rapid Evaluation and Assessment Method ( 35 ) that was used in a similar evaluation study ( 36 ), the lead author with a doctoral degree in psychology and mixed-method research experience read each transcript and summarized the information into a table for each participant using a deductive content analysis approach (i.e., promotional channel and initial expectation). This summary table was sent to other research team members and clinical supervisors for iterative analysis and discussion using an inductive content analysis method, in which the interpretation focused on the explicit data given by the participants ( 37 , 38 ). Steps in this method included open coding, creating categories, and abstraction for each aspect. Data saturation was reached in the interview with the 14th participant where the responses shared similarity with previous responses. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) ( 39 ) was used as a guideline for the qualitative portion of the study.

Reflexivity

This study was part of an ongoing implementation study that involved research team members from multiple sectors and countries that might have different perspectives and cultural backgrounds. Therefore, at the beginning of the study, regular intensive meetings were conducted to build mutual understanding and improve transparency, including the challenges that might be faced and alternative solutions. Along the way, regular meetings were also conducted among e-helpers, clinical supervisors, and research coordinators to discuss any experiences and reflective thoughts during the interviews. The research coordinators emphasized that all opinions shared within the meeting were valid and important to encourage members to share both positive and negative experiences. The e-helpers also had their regular meetings with their clinical supervisor, in which the information in the minutes could be anonymized when necessary so they could openly share their thoughts without worry of being judged. The same step was also conducted when collecting quantitative feedback by using an anonymous online survey.

Findings were presented in the two sub-sections below. The quantitative results from local NGO staff members and research team members in the Philippines ( N = 12) cover organizational climate, awareness and concern, the app’s advantage and complexity, and level of success. Findings from the interviews with OFWs in Macao ( N = 25) cover six aspects from promotional channel and expectation to suggestions.

Online Evaluation of Local and Overseas Partner Member Perspectives

Table 1 displays the quantitative findings from the local NGO partner and overseas research team members. The median score of organizational climates from the teams in Macao and the Philippines are 4 and 5, respectively. The local partner NGO staff members and overseas members strongly perceived that their organization could positively incorporate Kumusta Kabayan into its program. However, staff members in Macao indicated their worry on infrastructure support, with a relatively lower score on this sub-scale than on other sub-scales and when compared with e-helpers in the Philippines. On the awareness and concern, both groups were highly aware of the app’s purpose, with score median of 4 in Macao and the Philippines. Both groups agreed that Kumusta Kabayan would be helpful for the OFWs. However, their perception toward the complexities of the app was ambiguous. For level of success, the teams in Macao and the Philippines generally evaluated that Kumusta Kabayan had achieved its goal.

Characteristics of participants in online survey.

A = From 1 (strongly disagree) to 5 (strongly agree); B = From 1 (not at all true) to 4 (very true).

Interviews With Overseas Filipino Workers in Macao

Findings from the interviews with the completers and non-completers are organized into six aspects of the participants’ experience, including (1) promotional channel and expectation; (2) when to use and in what language; (3) lessons learnt; (4) memorable aspects; (5) key facilitators and barriers; and (6) suggestions. Relatable quote(s), regardless of participants’ completion status, were provided for each aspect with information of participant’s number at the end of the quote.

Promotional Channel and Expectation

Participants learned about the program from several promotional channels including social media like Facebook and flyers that were distributed in churches and restaurants where OFWs gather on weekends ( Supplementary Material ). Some of them read the news about about Kumusta Kabayan’s launching and talked about it with friends. Participants were also informed about the program from The Philippines Consulate in Macau and the local NGO partner, Caritas Macau. Participants commonly expected that the program could assist them in managing emotions, sharing experiences, or connecting with other OFWs, particularly because they recognized the name of the program in Tagalog. However, some participants who learned about the program from the Consulate thought that Kumusta Kabayan was part of the employment and visa process or it would provide monetary aid.

“I just knew about this application from my friends here in Macao so I installed it like them. My first impression about the Kumusta Kabayan is that it would be helpful for us, our fellow Filipinos to check up on each other, to check up on how they are doing. At first, I really do not know. But, while reading the questionnaires, it is really related to the lives of the OFW and also to our personal life, so in a way it touches us .” (Participant #94).

When to Use and in Which Language

Participants who completed the program typically used the app in the morning before work, sometimes in the afternoon, or at night before sleeping, depending on their free time. They used the mobile app almost every day to check for new content or use the mood tracker. Participants who partially completed or discontinued the program used the app only on their day-off on weekends. However, during weekends, they still had difficulties finding time to use the app as they were also busy with extra works or were too tired. Both English and Filipino language versions were used by participants. Some words related to psychological questions were reported hard to understand, especially in English.

“ Sometimes I was able to open it but I did not continue answering … Recently I wasn’t able to use it because I got busy with my work. … When I answer it, when I want to finish the questionnaire, there are times that I wasn’t able to finish when my boss calls me, and also when their child [who I take care of] needs me. I answer it during my rest hour. When the child is sleeping, that’s when I open it. ” (Participant #28).

“ English, for me it’s easy. But, I can’t speak for other. Ay Ineng [young girl], I don’t want to sound overconfident. But, I somehow understand the questions since I’m also a college graduate. That means I understand it. But, for those that didn’t aim a higher degree, they may not be able to answer it well. I’m not generalizing. But, in my opinion, the question and the English are okay. It’s easier for me to understand if it’s in English. ” (Participant #40).

Lessons Learnt

Participants explained some lessons that they learnt from the program. The basic lesson is doing reflective thinking or self-checking and managing their emotions and feelings. Participants learnt how emotions and feelings are connected to their physical state so they also understand why doing exercise is important. When feeling stressed, participants learnt from the app to divide their focus and to do self-care by doing activities they enjoy like cooking or applying breathing exercise. Moreover, they learnt the importance of making, opening themselves to others, and finding support from the local society.

“ Before when I hadn’t installed the Kumusta Kabayan, I was always stressed. I don’t go out of the boarding house. I just go from work to home all the time. But after opening Kumusta Kabayan, it was a huge help for me especially the things I’m reading from the app, including the questions from Kumusta Kabayan. There were times, when I was reading the questions or stories, then suddenly I started crying. I said to myself “This Kumusta Kabayan is such a big help for me because before I’ve forgotten to interact with other people. But this time, I’m doing well. Now I’m able to socialize with other people all because of Kumusta Kabayan. ” (Participant #207).

Memorable Aspects

Participants felt grateful for the program that they never knew existed before joining the study. The name of the program, Kumusta Kabayan, also made it easy for participants to understand the program’s aim. They praised the story and the characters that highly resembled participants’ lives as OFWs. Having someone like them overcome life’s challenges as an OFW made them hopeful and boosted their confidence. The psychological questions encouraged participants to reflect and disclose their feelings to their friends, including things they never told others before. From the content, participants remember breathing exercises that they could apply in their daily lives, especially when they get stressed.

“ What I like about the app are the stories that are really, sometimes it gives me a boost of self-confidence most especially that we live alone and slowly losing hope. But after reading the stories there is still hope. Something like that, we just have to keep fighting. You can do it. It’s just a problem and it will eventually end. Just like the saying that goes in every problem there is a solution. ” (Participant #50).

“ Contents related to my experiences, experiences of an OFW … about missing your family, and also stress. … and there were times when you encountered a misunderstanding with your employer. Something like that, those kinds of situations. I liked the story, I feel excited also. The character [Ate Sonia] is very inspiring too. The activity is very relaxing, especially the exercising part, Inhale-Exhale [breathing exercise]. It helped me relax my mind. ” (Participant #194).

Key Facilitators and Barriers

The main facilitators for successful implementation of Kumusta Kabayan were the accessibility of this app on Play Store and App Store, and the app’s small size. On another side, four key barriers for participants using the app were recognized. First is the time barrier that the majority of participants were migrant domestic workers with only one day-off. Some of them had extra work to do during their day-off and some used it for resting, and they had minimal time to prioritize the app. Second are technological barriers including lack of phone memory to accommodate the app, incompatible operating system, poor signal reception, limited or no mobile data, limited or unstable Wi-Fi, and technical glitch where the app always return to the start and did not record their responses to questionnaires. Third is the lack of the digital literacy where participants changed their phone or formatted it so they had to re-install the app. However, they could not re-install by themselves and needed assistance by research assistants. Fourth are human factors including forgetting their username or password that was case sensitive, changing phone numbers so they could not receive access code when they forgot username or password, and psychological barriers because the questions were triggering of homesickness, as explained by Participant 94 below:

“… while answering the questionnaire, we are also in another country, it feels difficult, you really take in the emotions of each question that you will be answering. It is like you are going back to the time before you leave the Philippines, you are thinking about the past and how can you be better compared before. ” (Participants #94).

Suggestions

Participants suggested several points for the improvement of Kumusta Kabayan, namely (1) connectivity, (2) connectedness, (3) content, (4) feedback or brief explanation on participants’ responses to the questionnaires, (5) add-ons, and (6) promotional methods. First was about connectivity, which they recommended to connect the app with their social media account so they do not need to remember another username and password. Participants also shared their expectation for Kumusta Kabayan that does not require an internet connection because they did not always have mobile data or Wi-Fi. However, on another side, some participants disclosed that their mobile phone memory was full so they had to use the website version. Second was about connectedness, where participants would like to see a video call feature with the e-helper and group chat feature with other participants. This suggestion was motivated by participants’ need to be connected and to share stories with other OFWs and people in their home country, which would ease their homesickness. Third was about the content, which participants suggested to also integrate their positive and uplifting and positive experiences of being OFWs besides the struggles to balance the negative feelings as illustrated below. In addition, participants who came from various occupational backgrounds recommended making several storylines and characters that users could choose base on their type of job. Fourth was about feedback or brief explanation on their responses to the questionnaires so they could understand their condition. Fifth was about add-ons, which participants suggested to add entertainment features and news on the app so they still could use the app while waiting for the next session to be opened. Sixth was about the promotional methods, which participants suggested to involve the OFWs who are also YouTubers or TikTokers to promote Kumusta Kabayan because many OFWs watch these social media celebrities.

“… maybe give many examples of the OFWs’ lives, not only the sad stories. … they should put stories about the bright side of being an OFW so that people will be encouraged to use the application. … because sometimes when the story is sad, the delivery of it is also negative, it should be something nice too. ” (Participant #28).

This study evaluated the stakeholders’ perspectives on the Kumusta Kabayan implementation for OFWs in Macao using a mixed-methods design. Three stakeholders were involved in this study: staff members of local NGO partner, research team members in the Philippines, and OFWs in Macao as the app users. The quantitative measure among NGO staff members and Filipino team members found that Kumusta Kabayan was perceived fit to be integrated into their organizations. In particular, the NGO staff members strongly agreed that Kumusta Kabayan was in line with the NGO’s aim of assisting migrant workers.

On the other hand, infrastructure support was a concern to both NGO staff members and Filipino members. Infrastructure support covered the available organization’s equipment and technology, human resources, and financial situation. Their concerns might be associated with the sustainability of the program as staff numbers in the NGO were limited and Filipino e-helpers were volunteer students. Moreover, the app maintenance fee was relatively high (≈USD $2,367/year) for the NGO.

Generally, the NGO staff members and overseas members perceived that Kumusta Kabayan achieved its goals. From the survey, some Filipino members chose an evaluation option that despite this success, the app caused other problems. This finding might be associated with the difficulty experienced by users when they forgot their passwords. For safety reasons, a one-time-password (OTP) would be sent to user’s phone number registered in the system if user forgot their password. However, some app users changed mobile phone numbers during the program so they could not retrieve the OTP and could not access their account privacy settings. This unfortunately led to users being unable to use the app in some instances. Future iterations of the application should provide easier and more stable access to the application.

Moreover, the OFWs also used a variety of smartphone brands and not all of the operating systems were compatible with the app. Users with inadequate digital literacy could not follow the instructions to check their smartphone configuration nor to download and install the app directly which frustrated them. This finding reflected similar results in Step-by-Step testing among refugees in European countries where technical literacy was the main barrier for them for accessing the app ( 22 ). Therefore, OFWs in the interviews suggested an easier log-in method such as linking it with their social media accounts. However, this recommendation should be thought through carefully so it will not compromise user’s data privacy. An alternative is posting FAQs, including the steps in accessing the app, in the Kumusta Kabayan program’s social media account.

Users also suggested that video calls and group chat features should be incorporated into the app. This suggestion might be driven by social isolation and loneliness among people from communal cultures ( 40 ). Moreover, the mobility restriction during the pandemic amplified the social isolation because migrant workers, particularly the migrant domestic workers, were not allowed by their employers to take the day-off or asked to stay at home during their day-off ( 9 ). This also explains why users were very touched and appreciative of the storyline because it was relatable and educational. This finding highlighted the importance of cultural adaptation as the storyline was developed carefully by involving the OFWs themselves in the adaptation process ( 23 ). However, from the interviews it was found that some users would like to see more characters from different types of jobs because of different challenges faced by these OFWs.

In the interviews we also explored the main barriers for OFWs when using the app, including from the users who discontinued using it. The primary reason was they did not have time to use the app because they were busy with their jobs, which some also did extra work during their day-off. The demographic information showed that our participants could work up to 14 h per day on average. OFWs who worked as domestic workers had difficulty opening the app because they were also taking care of the children or older adults in the family. This finding supported previous study on migrant workers’ health that migrant domestic workers were at high risk for injuries, mental problems, and low quality of life because of long working hours, low wages, and inadequate health insurance ( 41 ). Furthermore, the working condition of OFWs shared by the users also explained their suggestion about entertainment add-ons so they could relax when using the app. Moreover, many users opened the app at night after long working hours and could not concentrate on reading on their screen. Therefore, a format of video or animation could be an alternative in delivering the content for OFWs.

Lastly, the interviews enlightened us about the promotional channels and methods. It was clear that using social media as an online method and face-to-face promotion at church and restaurants worked well in recruiting potential users. Moreover, collaboration with the local NGO that was well-known for its programs in assisting migrant workers enhanced the trust of OFWs for the app. However, when the app was launched and covered by the mass media, the local people showed divided attitude toward this program as some viewers commented that the citizens should be taken care more than the foreigners [i.e., ( 42 )]. This resistance and sentiment toward migrant workers confirmed a previous study on fear and disgust toward migrant workers, particularly domestic workers, as their professions were perceived as low-end 3D jobs (dangerous, difficult, and dirty) ( 43 ). The insight emerged from the interviews was to collaborate with OFWs who were popular YouTubers and TikTokers to promote the app on their channels. Also, the interviews revealed that collaborations with the Government’s representatives either from the host country or sender country, was like a double-edged sword because it could reach many OFWs but not all of them trust these entities and were thinking that the app was a surveillance program.

Implications for Practice and Future Studies

The findings from this study could be extended to the improvement of mobile mental health apps implementation, particularly for migrant workers. Moreover, lessons learnt from this evaluation could also be useful to be implemented in wider digital mental health services for other group of users. For example, the very appreciated storyline and characters were designed from a cultural adaptation process, which also being a critical step for in designing digital health intervention for Chinese young adults ( 44 ). The local partner and Filipino e-helpers contributed substantially to the successful implementation of Kumusta Kabayan. Therefore, it is also important to involve the stakeholders at the earliest possible time during the planning phase, to minimize the potential barriers in implementing digital mental health. Also, it is crucial to assess the digital literacy level of potential users when designing the app as having a smartphone does not guarantee that the owner could use it easily.

Another practical implication, the users’ recommendations of adding additional features including feedback on questionnaires, video chat, group chat, entertainment, and news could be integrated with gamification principles to improve user engagement and increase retention ( 45 ). For example, an app user might creatively design an avatar for their profile picture that would increase the connectedness to the app. Leaderboard and progress bar ( 46 ) could also be introduced to encourage users to complete the challenges during the sessions such as planning and executing the social activities as a part of behavioral activation intervention. Users might collect virtual coins from completing activities or just from opening the app that these coins can be used to access the suggested add-ons. Future studies could investigate the effectivity of these gamification principles in mobile phone app for migrant workers. Additionally, a future study could explore the virtual connections among app users within the app online community using a digital ethnography method ( 47 ).

Limitations

This study has two limitations. First, despite its anonymity, evaluation from the local and overseas partners relied on self-report questionnaires that might lead to social desirability. Second, despite data saturation and engagement with discontinued users, evaluation from the OFWs might be affected by self-selection bias as disappointed users might ignore the interview invitation so their perspective was less represented. Regardless of these limitations, the quantitative and qualitative findings in our study were complimentary of one another and provided key directions to improve subsequent implementation of Kumusta Kabayan among OFWs in Macao and elsewhere.

This study reported the implementation evaluation of Kumusta Kabayan, a mobile mental health app for OFWs, from the perspective of stakeholders including staff members of local NGO as a collaborator, team members in the Philippines, and OFWs in Macao as the app users. The Kumusta Kabayan program was accepted by the users because the character’s story highly resonated with their lives as OFWs and the app was relatively easy to use. The Kumusta Kabayan has the potential of being integrated into the existing support services for migrant workers in Macao by collaborating with the local NGO stakeholder. This app could be scaled-up for OFWs in other countries by paying attention to the key facilitators, barriers, and the suggestions shared by the users that reported in this study.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by the ethical approval for the study was granted from the Research Ethics Committee at the University of Macau (SSHRE19-APP074-FSS). The patients/participants provided their written informed consent to participate in this study.

Author Contributions

AL, HS, and BH: study conceptualization and design. AIFL and BH: secured funding. AL, AIFL, BH, HS, KP, MG, and SB: data collection and final draft writing, review, and editing. AL, KP, and MG: data analysis. AL: draft manuscript writing. All authors contributed to the article and approved the submitted version.

Conflict of Interest

BH is co-editing the Frontiers special topic “Global mental health among marginalized communities in pandemic emergencies” but was not directly involved in the review of this article. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We thank Caritas Macau, the Macau Foundation, Centre for Macau Studies – University of Macau, and the Philippine Consulate General in Macau (SAR) for their support and partnership in this research; also Hybrid Heroes, the application developer team for the technical assistance and research assistants at the Global and Community Mental Health Research Group for their support in the research and team members from De La Salle University, particularly Professor Allan B. Bernardo, Alma Grace De Vera, Andrae Joseph Yap, Angelica Julienne Tan, Genevive Koa Chua, Jamilla Marie B. Luces, Jesus Antonio D. Marcelo, and Michaella Lobaton. We also thank the overseas Filipino migrant workers in Macao for their time, effort, and guidance in the adaptation of Step-by-Step.

BH and AIFL were supported by the Research Services and Knowledge Transfer Office (RSKTO), University of Macau and the Macau Foundation. Funding for this work was provided by the Li Ka Shing Foundation.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2022.836156/full#supplementary-material

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Home > Student Research, Creative Works, and Publications > Honors Theses > 387

Honors Theses

The effects of virtual reality on mental health software user satisfaction and retention.

William Hooten , University of Tennessee at Chattanooga Follow

Project Director

Sartipi, Mina

Department Examiner

Howell, Roland; Shelton, Jill T.

Dept. of Computer Science and Engineering

University of Tennessee at Chattanooga

Place of Publication

Chattanooga (Tenn.)

Mental health issues have become increasingly important in today's society. With that being said, researchers and consumers are looking for new ways to manage and treat mental health using new technologies in labs and the consumer space. This innovation has led to the presence of mobile self-help mental health applications, applications for peoples’ phones that are used to manage symptoms of mental health problems, such as depression and anxiety, track goals, meditate, and more. However, mobile mental health applications, and mobile applications in general, have a problem concerning user satisfaction and overall user retention – studies have shown that 95% of mobile apps downloaded are abandoned by users within a month (Gu et al., 2022). Virtual reality is a relatively new and blossoming technology that provides the illusion of being physically present in virtual environments, opening an entirely new realm of possibilities across many industries. Virtual reality has already been shown to be effective in treating mental health due to its immersive nature, yet few applications exist for mental health self-help in VR. This thesis aims to answer the question of whether an immersive VR application for consumer VR systems, such as the Meta Quest 2, can have a positive effect on user satisfaction and potential user retention when compared to mobile applications.

Acknowledgments

I would like to thank my thesis director Dr. Mina Sartipi for directing this project. I would also like to thank Dr. Jill Shelton and Professor Roland Howell for being a part of my thesis committee and helping significantly with the design of the virtual reality application and the testing process.

B. A.; An honors thesis submitted to the faculty of the University of Tennessee at Chattanooga in partial fulfillment of the requirements of the degree of Bachelor of Arts.

Virtual reality in medicine; Mobile apps; Mental health services

virtual; reality; mental; health; mobile; application

Other Computer Engineering

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Hooten, William, "The effects of virtual reality on mental health software user satisfaction and retention" (2022). Honors Theses. https://scholar.utc.edu/honors-theses/387

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Research Topics & Ideas: Mental Health

100+ Mental Health Research Topic Ideas To Fast-Track Your Project

If you’re just starting out exploring mental health topics for your dissertation, thesis or research project, you’ve come to the right place. In this post, we’ll help kickstart your research topic ideation process by providing a hearty list of mental health-related research topics and ideas.

PS – This is just the start…

We know it’s exciting to run through a list of research topics, but please keep in mind that this list is just a starting point . To develop a suitable education-related research topic, you’ll need to identify a clear and convincing research gap , and a viable plan of action to fill that gap.

If this sounds foreign to you, check out our free research topic webinar that explores how to find and refine a high-quality research topic, from scratch. Alternatively, if you’d like hands-on help, consider our 1-on-1 coaching service .

Overview: Mental Health Topic Ideas

• Mood disorders
• Anxiety disorders
• Psychotic disorders
• Personality disorders
• Obsessive-compulsive disorders
• Post-traumatic stress disorder (PTSD)
• Neurodevelopmental disorders
• Eating disorders
• Substance-related disorders

Mood Disorders

Research in mood disorders can help understand their causes and improve treatment methods. Here are a few ideas to get you started.

• The impact of genetics on the susceptibility to depression
• Efficacy of antidepressants vs. cognitive behavioural therapy
• The role of gut microbiota in mood regulation
• Cultural variations in the experience and diagnosis of bipolar disorder
• Seasonal Affective Disorder: Environmental factors and treatment
• The link between depression and chronic illnesses
• Exercise as an adjunct treatment for mood disorders
• Hormonal changes and mood swings in postpartum women
• Stigma around mood disorders in the workplace
• Suicidal tendencies among patients with severe mood disorders

Anxiety Disorders

Research topics in this category can potentially explore the triggers, coping mechanisms, or treatment efficacy for anxiety disorders.

• The relationship between social media and anxiety
• Exposure therapy effectiveness in treating phobias
• Generalised Anxiety Disorder in children: Early signs and interventions
• The role of mindfulness in treating anxiety
• Genetics and heritability of anxiety disorders
• The link between anxiety disorders and heart disease
• Anxiety prevalence in LGBTQ+ communities
• Caffeine consumption and its impact on anxiety levels
• The economic cost of untreated anxiety disorders
• Virtual Reality as a treatment method for anxiety disorders

Psychotic Disorders

Within this space, your research topic could potentially aim to investigate the underlying factors and treatment possibilities for psychotic disorders.

• Early signs and interventions in adolescent psychosis
• Brain imaging techniques for diagnosing psychotic disorders
• The efficacy of antipsychotic medication
• The role of family history in psychotic disorders
• Misdiagnosis and delayed treatment of psychotic disorders
• Co-morbidity of psychotic and mood disorders
• The relationship between substance abuse and psychotic disorders
• Art therapy as a treatment for schizophrenia
• Public perception and stigma around psychotic disorders
• Hospital vs. community-based care for psychotic disorders

Personality Disorders

Research topics within in this area could delve into the identification, management, and social implications of personality disorders.

• Long-term outcomes of borderline personality disorder
• Antisocial personality disorder and criminal behaviour
• The role of early life experiences in developing personality disorders
• Narcissistic personality disorder in corporate leaders
• Gender differences in personality disorders
• Diagnosis challenges for Cluster A personality disorders
• Emotional intelligence and its role in treating personality disorders
• Psychotherapy methods for treating personality disorders
• Personality disorders in the elderly population
• Stigma and misconceptions about personality disorders

Obsessive-Compulsive Disorders

Within this space, research topics could focus on the causes, symptoms, or treatment of disorders like OCD and hoarding.

• OCD and its relationship with anxiety disorders
• Cognitive mechanisms behind hoarding behaviour
• Deep Brain Stimulation as a treatment for severe OCD
• The impact of OCD on academic performance in students
• Role of family and social networks in treating OCD
• Alternative treatments for hoarding disorder
• Childhood onset OCD: Diagnosis and treatment
• OCD and religious obsessions
• The impact of OCD on family dynamics
• Body Dysmorphic Disorder: Causes and treatment

Post-Traumatic Stress Disorder (PTSD)

Research topics in this area could explore the triggers, symptoms, and treatments for PTSD. Here are some thought starters to get you moving.

• PTSD in military veterans: Coping mechanisms and treatment
• Childhood trauma and adult onset PTSD
• Eye Movement Desensitisation and Reprocessing (EMDR) efficacy
• Role of emotional support animals in treating PTSD
• Gender differences in PTSD occurrence and treatment
• Effectiveness of group therapy for PTSD patients
• PTSD and substance abuse: A dual diagnosis
• First responders and rates of PTSD
• Domestic violence as a cause of PTSD
• The neurobiology of PTSD

Neurodevelopmental Disorders

This category of mental health aims to better understand disorders like Autism and ADHD and their impact on day-to-day life.

• Early diagnosis and interventions for Autism Spectrum Disorder
• ADHD medication and its impact on academic performance
• Parental coping strategies for children with neurodevelopmental disorders
• Autism and gender: Diagnosis disparities
• The role of diet in managing ADHD symptoms
• Neurodevelopmental disorders in the criminal justice system
• Genetic factors influencing Autism
• ADHD and its relationship with sleep disorders
• Educational adaptations for children with neurodevelopmental disorders
• Neurodevelopmental disorders and stigma in schools

Eating Disorders

Research topics within this space can explore the psychological, social, and biological aspects of eating disorders.

• The role of social media in promoting eating disorders
• Family dynamics and their impact on anorexia
• Biological basis of binge-eating disorder
• Treatment outcomes for bulimia nervosa
• Eating disorders in athletes
• Media portrayal of body image and its impact
• Eating disorders and gender: Are men underdiagnosed?
• Cultural variations in eating disorders
• The relationship between obesity and eating disorders
• Eating disorders in the LGBTQ+ community

Substance-Related Disorders

Research topics in this category can focus on addiction mechanisms, treatment options, and social implications.

• Efficacy of rehabilitation centres for alcohol addiction
• The role of genetics in substance abuse
• Substance abuse and its impact on family dynamics
• Prescription drug abuse among the elderly
• Legalisation of marijuana and its impact on substance abuse rates
• Alcoholism and its relationship with liver diseases
• Opioid crisis: Causes and solutions
• Substance abuse education in schools: Is it effective?
• Harm reduction strategies for drug abuse
• Co-occurring mental health disorders in substance abusers

Choosing A Research Topic

These research topic ideas we’ve covered here serve as thought starters to help you explore different areas within mental health. They are intentionally very broad and open-ended. By engaging with the currently literature in your field of interest, you’ll be able to narrow down your focus to a specific research gap .

It’s important to consider a variety of factors when choosing a topic for your dissertation or thesis . Think about the relevance of the topic, its feasibility , and the resources available to you, including time, data, and academic guidance. Also, consider your own interest and expertise in the subject, as this will sustain you through the research process.

Always consult with your academic advisor to ensure that your chosen topic aligns with academic requirements and offers a meaningful contribution to the field. If you need help choosing a topic, consider our private coaching service.

Good morning everyone. This are very patent topics for research in neuroscience. Thank you for guidance

What if everything is important, original and intresting? as in Neuroscience. I find myself overwhelmd with tens of relveant areas and within each area many optional topics. I ask myself if importance (for example – able to treat people suffering) is more relevant than what intrest me, and on the other hand if what advance me further in my career should not also be a consideration?

This information is really helpful and have learnt alot

Phd research topics on implementation of mental health policy in Nigeria :the prospects, challenges and way forward.

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Published on 14.8.2024 in Vol 11 (2024)

Application of Positive Psychology in Digital Interventions for Children, Adolescents, and Young Adults: Systematic Review and Meta-Analysis of Controlled Trials

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Marital and Family Therapist Permanent License

Marital and family therapist temporary license, mental health counselor permanent license, mental health counselor temporary license, behavior analyst or assistant behavior analyst.

• Supervision Plan Form
• Supervision Report Form

Forms and reports may be submitted electronically to the board office as follows:

Email: [email protected]

A list of approved behavioral health supervisors is available here .

You can renew your license up to 60 days before your current license expires.

Renewal notifications will be emailed to your email address on file with the board at 60, 50, 40 and 30 days prior to the license expiration date. Renew your license early to avoid a late fee or lapse in licensure. All continuing education requirements must be completed prior to license renewal. 

• Behavioral Analyst Renewal Application

Continuing Education

Licensees are responsible for meeting all continuing education requirements and should review the rules carefully and frequently. Review the rules for detailed information about continuing education definitions, requirements, standards, criteria and other important specific to this profession.

How to Select and Document Continuing Education

The licensing board does not pre-approve continuing education providers, sponsors or individual programs. It is the licensees’ responsibility to determine if the continuing education programs they attend meet the requirements of their professional licensing board.

A percentage of licensees are randomly audited following each license renewal cycle. If selected, the licensee must submit to the board office an individual certificate of completion issued to the licensee or evidence of successful completion of the course from the course sponsor. These documents must contain the course title, date(s), contact hours, sponsor and licensee's name. In some instances, licensees will be requested to provide to the board additional information, including program content, objectives, presenters, location and schedule. Many times an inclusive brochure meets this requirement.

When selecting continuing education programs, licensees need to make sure they are compliant with administrative rule requirements. Some professions require licensees to meet specific requirements as a condition of renewal.  These may include limits on presentation method (e.g. self-study, ICN, etc.), specific hours on ethics and Iowa law and rules, clinical content, or hours required in a specific practice discipline.

To ensure compliance, each licensee must understand the continuing education administrative rules for their profession prior to choosing and attending a particular program. No matter what a program brochure indicates, it is the responsibility of the licensee to ensure compliance with licensing requirements.

In summary all licensees should:

• Be familiar with the continuing education requirements of their professional boards.
• Obtain inclusive written materials about continuing education programs from program sponsors for post-renewal auditing purposes.
• Maintain certificates of completion that includes the program or course title, date(s), contact hours, sponsor and licensee's name for four years.

Extension or Exemption for Disability or Illness

A licensee who had a physical or mental disability or illness during the license period may apply for an extension or exemption. An exemption provides for an extension of time or exemption from some or all of the continuing education requirements. An applicant shall submit a completed application form approved by the board for an exemption.

• Application for Continuing Education Extension/Exemption for Disability or Illness

The application requires the signature of a licensed health care professional who can attest to the existence of a disability or illness during the license period.

If the application is from a license who is the primary caregiver for a relative who is ill or disabled and needs care from that primary caregiver, the physician shall verify the licensee's status as the primary caregiver.

A licensee who applies for an exemption shall be notified of the decision regarding the application. A licensee who obtains approval shall retain a copy of the exemption to be presented to the board upon request.

Guidelines for Continuing Education Sponsors

The licensing board does not pre-approve continuing education providers, sponsors or individual programs. It is the licensees’ responsibility to determine if the continuing education programs they attend meet the requirements of their professional licensure board.

Potential sponsors are responsible for independently determining if the programs they provide conform to the continuing education requirements set forth in the rules regulations of the professional boards.

To make this determination, thoroughly review the rules for the board(s) in which you are interested prior to offering continuing education to Iowa licensees. By providing inclusive information about the content, objectives and applicability of your program to professional practice, you will assist licensees to make informed decisions when selecting continuing education.

A percentage of licensees in every profession regulated by a licensing board are randomly selected following each license renewal cycle. For auditing purposes the licensee must submit to the board office an individual certificate of completion issued to the licensee or evidence of successful completion of the course from the course sponsor. These documents must contain the course title, date(s), contact hours, sponsor and licensee's name. In some instances, licensees will be requested to provide to the board additional information to assure compliance with continuing education requirements, including program content, objectives, presenters, location and schedule. For this reason, sponsors should provide these items to licensees in writing. An inclusive brochure may meet this requirement.

Additionally, sponsors should consider profession-specific requirements that licensees must address to assure compliance with continuing education rules when preparing written materials such as method of presentation (home study, ICN, etc.), inclusion of specific hours on ethics and Iowa law and rules, certification status by national associations or boards, clinical content, and hours required in a specific practice discipline.

In summary sponsors should:

• Be familiar with the continuing education requirements of their professional audiences.
• Provide inclusive written materials to all program participants.
• Notify licensees that materials should be retained for four years for auditing purposes.
• Provide a certificate of completion that includes the program or course title, date(s), contact hours, sponsor and licensee's name.

Definitions, requirements, standards, criteria and other important specific to this profession.

Laws. Laws are contained in the Iowa Code. They are enacted by the Iowa Legislature and provide statutory authority to the professional licensure boards.

• Chapter 154D -- Behavioral Science Board Law

Administrative Rules. The professional licensure boards adopt rules to interpret and implement the Iowa Code. Administrative rules have the force and effect of law.

• Chapter 31 -- Licensure of Marital and Family Therapists and Mental Health Counselors
• Chapter 32 -- Continuing Education for Marital and Family Therapists and Mental Health Counselors
• Chapter 33 -- Discipline for Marital and Family Therapists and Mental Health Counselors

Laws Common to Licensing Boards

The following laws apply to professional licensure boards.

• Chapter 17A - Iowa Administrative Procedure Act
• Chapter 147 - General Provisions, Health-Related Professions
• Chapter 272C - Continuing Education and Regulation - Professional and Occupational

Iowa Administrative Codes Common to Licensing Boards

The following codes apply to professional licensing boards.

• Chapter 4 - Board Administrative Processes
• Chapter 6 - Petitions for Rule Making
• Chapter 7 - Agency Procedure for Rule Making
• Chapter 8 - Declaratory Orders
• Chapter 9 - Complaints and Investigations
• Chapter 10 - Public records and Fair Information Practices
• Chapter 11 - Contested Cases
• Chapter 12 - Informal Settlement
• Chapter 13 - Discipline
• Chapter 14 - Use of Criminal Convictions in Eligibility Determinations and Initial Licensing Decisions
• Chapter 16 - Impaired Practitioner Review Committee
• Chapter 17 - Materials for Board Review
• Chapter 18 - Waivers of Variances from Administrative Rules
• Chapter 19 - Licensure by Verification and of Applicants with Work Experience
• Chapter 20 - Military Service and Veteran Reciprocity

Rulemaking Notices

• Administrative Bulletin

Rulemaking notices, along with adopted rule changes, are published in the Iowa Administrative Bulletin. The preamble for each notice includes a summary of the proposed rule changes. The notice includes information about how to submit public comment when applicable. All comments are forwarded to the board for review prior to making a final decision on the outcome of rule change proposals.

Petition for Waiver

The process for seeking a waiver from an administrative rule and the standards under which the petition will be evaluated are described in Chapter 18.

• Petition for Waiver Form 

Iowa Practitioner Program

The Iowa Practitioner Program (IPP) is available to licensees across multiple licensing boards in Iowa. The Iowa Practitioner Review Committee (IPRC) reviews self-reports made by licensees to determine eligibility for participation. 

IPP was established in 1996 to support licensees who struggle with impairments due to alcohol or drug abuse, mental health conditions, and/or physical disorders. 

The IPRC designs an individualized health contract to meet the needs of the licensee. State law mandates that information in the possession of the IPRC remain confidential. Participation in the program is not a matter of public record.

" Impairment " means an inability to practice with reasonable safety and skill as a result of alcohol or drug abuse, dependency, or addiction, or any mental or physical disorder or disability.

" Self-report " means the licensee providing written or oral notifications to the board that the licensee has received or may receive a diagnosis as having an impairment before the board's receiving a complaint or report alleging an impairment before the date of self-report.

Criteria for Participation in IPP

The IPRC determines whether practitioners are eligible to participate in the program monitored by the committee. A person is ineligible to take part in the program for any of the following reasons:

• The practitioner engaged in the unlawful diversion or distribution of controlled illegal substances to a third party, or for personal gain or profit;
• The practitioner is already under a board order;
• The practitioner has caused harm or injury to a patient;
• The board is investigating the practitioner that concerns serious matters related to the practitioner's competence;
• The practitioner failed to provide truthful information or refused to cooperate with the board or the IPRC; or
• The practitioner has been subject to a civil administrative or criminal sanction for serious infractions of law, professional ethics, or administrative rules related to the practice.

The Health Contract

Based upon the recommendation of an approved evaluator, the IPRC creates an individualized health contract, which provides a detailed description of the goals of the program, requirements for successful completion, and the practitioner's obligations.

Note: The IPRC may refer to the board participants who are not compliant with the terms of their contract for consideration of disciplinary action.

IPRC Composition

The chairperson of the board appoints the members of the IPRC. The IPRC includes, but is not limited to, the following:

• Executive Director of the board or the director's designee from the board's staff;
• A practitioner who has remained free of addiction for two or more years after completing a recovery program for drug or alcohol dependency, addiction, or abuse;
• A physician/counselor with expertise in substance abuse/addiction treatment programs;
• A psychiatrist or psychologist; and
• A public member.

Why Use IPP?

The program encourages practitioners who have impairments to get the help they need. All information received by IPP and IPRC remains confidential as long as the practitioner complies with the terms of their agreement or health contract.

By self-reporting to IPP, the practitioner may avoid formal disciplinary action by the licensing Board. Formal disciplinary action taken against a practitioner is a matter of public record. The board reports the action to the press, the National Practitioners Data Bank (NPDB), insurance companies, and to other state and federal authorities. Participation in the program is confidential.

Health care practitioners must report knowledge of another practitioner's possible impairment to the board. Health care practitioners who fail to report colleagues with a possible impairment may be subject to disciplinary action by the board. It is in the practitioner's best interest to self-report an impairment before someone else files complaint or report.

When Should Someone Self-Report to IPP?

If any of the following apply to a practitioner, it is in that person's best interest to self-report to IPP as soon as possible:

• Charged with, and/or arrested for OWI, or for another alcohol or drug related offense;
• Disciplined by another federal or state agency for alcohol or drug abuse;
• Evaluated or treated for a substance use disorder, or is currently enrolled in a recovery program;
• Diagnosed with a mental health condition and/or a physical health condition;
• Practiced after drinking alcohol or taking an illegal or mind/mood altering substance;
• Addiction/dependence on drugs, alcohol or prescription medication; and/or
• Urged by friend(s), family or colleagues to get help for alcohol or drug abuse, or a mental or physical condition.

How to Submit a Self-Report to IPP

To self-report, a licensee may:

• Complete and submit a self-report form online ;
• Dental Board Licensees/Registrants :  [email protected] ; or
• Licensees of other Boards : [email protected]
• Dental Board Licensees/Registrants:   515.725.3491  or 
• Licensees of other Boards : 515.725.1221 .

IPP Online Forms

IPP Self-Report

Quarterly Report: IPP Participant

Behavioral Science

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Alumni Spotlight: Aries Nuño, MSPH '23

• Degree Program: MSPH
• Area of Interest: Women's, Sexual and Reproductive Health
• Graduation Year: 2023 
• Hometown: Balch Springs, TX
• Previous Degree(s) Earned: BS in Public Health, University of North Texas

What sparked your interest in public health?

For as long as I can remember,  I have always been driven to support my community through volunteer opportunities, which allowed me to witness firsthand the need for accessible and equitable health services. From AmeriCorps to the Peace Corps, my passion for public health grew, especially while serving in the Peace Corps in Lesotho, where I worked as an HIV/AIDS Prevention Specialist. This experience opened my eyes to the profound impact that public health initiatives can have on an individual's life, particularly in underserved and marginalized communities. I desired to pursue a career focused on creating sustainable, culturally sensitive health solutions that empower individuals and improve sexual health outcomes worldwide.  

What led you to choose Bloomberg School of Public Health and join the Department of Population, Family and Reproductive Health?

The Bloomberg School's renowned reputation and strong focus on Women's Sexual and Reproductive Health were major factors in my decision. The Department of Population, Family, and Reproductive Health (PFRH) offered a curriculum that aligned perfectly with my interests regarding socio-cultural implications on sexual and reproductive health.

How did your degree prepare you for current and future roles? What aspects of the PFRH degree program did you find most useful? 

The degree program provided me with essential skills in qualitative and quantitative research, data analysis, and program development. My focus on female genital mutilation/cutting (FGM/C) and assisting with local and international projects on this topic significantly built my foundational and applicable skills. These projects required in-depth research and practical application of my studies, culminating in my master’s thesis on FGM/C ( Exploring the Experiences of FGM/C Affected Migrant Women in Western Nations: A Scoping Review of Accessing Sexual and Reproductive Health Services ). 

Balancing academics with practical experiences is valuable, but finding your unique path and staying true to your passions is what will ultimately lead to a fulfilling career and personal growth.

Describe your current position and responsibilities in a way that will inform current and prospective students about career opportunities in your field.

As the Training and Technical Assistance Coordinator at  Sahiyo , my role revolves around designing and implementing educational and advocacy programs to address FGM/C, primarily in the US. My primary responsibilities include developing training modules tailored to diverse audiences, establishing partnerships with NGOs, governmental bodies, and community organizations, project management and capacity building of local and international partners by providing training and technical assistance, and producing comprehensive reports that showcase program outcomes, organizational impact, and areas for improvement.

How did you build your sense of community during your time as a PFRH student?

While it's easy to get caught up in schoolwork, meeting deadlines, and writing papers, It was important for me to set aside time for social and outdoor activities. Whether it was grabbing ice cream with a friend, attending a board game night, or a day hike, these moments helped me connect with my peers and have a much-needed break with fresh air! 

What was your favorite thing about living in Baltimore while you were a student?

While I lived in Baltimore briefly, I enjoyed engaging with community locals who shared stories about the city's history and what they personally loved about it. Their tales of Baltimore's past gave me a deeper appreciation for the city's rich cultural heritage. One of my favorite places to study on weekends was the Peabody Library , with its stunning architecture and calming atmosphere. 

Do you have any advice for prospective students?  

I would encourage prospective students to actively engage with the community, both on and off-campus. It's important to take advantage of networking opportunities, seek mentorship, and participate in research or volunteer activities. However, it's equally important not to get caught up in the prestige or the allure of what others are doing. While some opportunities may seem competitive, remember that the goal is not to compete or outdo your peers; instead, you should focus on discovering what opportunities truly with your interests and goals. Balancing academics with practical experiences is valuable, but finding your unique path and staying true to your passions is what will ultimately lead to a fulfilling career and personal growth.