We are pleased to introduce the collection Frontiers in Digital Health – Highlights in Digital Mental Health 2021/22. This collection will welcome and showcase a selection of high impact articles authored by leaders in the field. The work presented here highlights the broad diversity of research performed across the Digital Mental Health section, and aims to put a spotlight on the main areas of interest. This collection aims to further support Frontiers’ strong community by shining a spotlight on our authors' highly impactful research.

Faculty of Higher Education Iztacala, National Autonomous University of Mexico

Ferdinand Porsche FernFH - Distance Learning University of Applied Sciences

Close examination of impactful, innovative research across varied topics

This research topic examines the efficacy of digital mental health interventions for different age groups and mental health conditions. Highlights include: <ul> <li>Older adults receiving psychiatric care for depression via a telemental health platform achieved the same outcomes as younger adults, suggesting age is not a barrier to benefitting from telepsychiatric care.</li> <li>Engagement with digital mental health interventions is associated with post-intervention mental health improvements, regardless of intervention type, diagnostic status, or mental health condition targeted.</li> <li>A chatbot intervention for social isolation and loneliness was perceived positively by most participants, with the majority of themes rated as positive.</li> </ul>

Frontiers in Digital Health

Digital Mental Health

Frontiers in Psychiatry

Highlights in Digital Mental Health 2021/22

Editorial on the Research Topic <a href="https://www.frontiersin.org/research-topics/33225/highlights-in-digital-mental-health-202122">Highlights in digital mental health 2021/22</a>The section Digital Mental Health publishes research focused on prevention and treatment of mental disorders that is at the intersection of psychiatry, psychology, and technology. Due to it's multidisciplinary character, the section appears in Frontiers in Digital Health as well as in Frontiers in Psychiatry.In recent years, there has been an increase in initiatives focused on the promotion and intervention mediated by technologies and that have favored access and dissemination of effective interventions regardless of distances, physical and social barriers and with this, reaching people who otherwise would not receive attention. The COVID-19 pandemic has led to a sudden shift in health and care services, moving from face-to-face to online, challenging mental health professionals to quickly adapt to meet user needs. The pandemic presented a double challenge because not only was it necessary to design and develop interventions to meet the demand for mental health services, but these interventions had to be adapted to the requirements of a population that was in confinement. Therefore, the development of projects that provided remote care to the general population was extremely relevant. However, given the emerging transition, it is relevant to point out some ethical and privacy considerations related to the use of technologies applied to psychological interventions aimed at confidentiality, competence and responsibility in their implementation.For this purpose, this collection includes a selection of articles, which gained high interest in 2021/2022 (see <a href="#T1">Table&nbsp;1</a>).The topics that attracted interest include an opinion article discussing digital technologies as mediator of effects of the COVID-19 pandemic on mental health, a meta-analysis and original research to explore factors that might have an influence on the outcomes of digital mental health interventions as well as user experiences with a chatbot.The importance of digital technologies increased sharply during the pandemic. In their opinion article, <a href="https://doi.org/10.3389/fdgth.2021.733151">Gega &amp; Aboujaoude</a> therefore discuss how digital technologies have mediated negative, positive and neutral effects of the COVID-19 pandemic on mental health. Acceptance of digital treatment options for mental illnesses increased during the pandemic and the possibility to stay socially connected during lockdowns by means of digital technologies helped to neutralize some negative effects on mental health. However, the pandemic had pronounced negative effects for certain population groups, and limited access to digital technologies for these groups may have further exacerbated health disparities. The authors thus conclude that we should harness the benefits of digital technologies for mental health while reducing associated risks and inequities to reach those most in need for mental health care.The three original research papers add to the issues raised in the opinion article by <a href="https://doi.org/10.3389/fdgth.2021.733151">Gega &amp; Aboujaoude</a>.During the pandemic older adults were one group with high need for mental health care. They were among the most vulnerable population groups and feared infection through personal contacts, which contributed to social isolation and increased depressiveness. The article by <a href="https://doi.org/10.3389/fpsyt.2022.998401">Belanger and Winsberg</a> deals with the question whether treatment effects of psychiatric care for depression via a telemental health platform for older adults are comparable to those for younger adults. The results are promising, showing that older adults who chose to receive treatment through a telemental health platform showed a similar improvement in depression symptoms as younger adults. This is therefore an example of how digital technologies can help to mitigate the negative impact of a pandemic for a vulnerable group.In order to achieve intervention outcomes in digital health, engagement has been recognized as important (<a href="#B1">1</a>, <a href="#B2">2</a>). However, there was only a narrative synthesis on the relationship between engagement and intervention outcomes available (<a href="#B3">3</a>), but no meta-analysis on the effects of higher engagement on mental health outcomes in digital mental health interventions. <a href="https://doi.org/10.3389/fdgth.2021.764079">Gan et al.</a> closed&nbsp;this research gap. Their already urgently needed work&nbsp;underpins the relationship between engagement and intervention outcomes and the necessity of conducting more research focusing on engagement and targeted strategies to increase user engagement.Users' experiences with a chatbot to combat loneliness and social isolation for adults and older adults were examined by <a href="https://doi.org/10.3389/fdgth.2021.735053">Gilly&nbsp;Dosovitsky &amp; Eduardo Bunge</a>. The results regarding satisfaction are in line with previous findings: most users who answered the question were satisfied with the chatbot. Qualitative analyses revealed that some users prefer human interactions. Others were dissatisfied, because the chatbot misunderstood the user and gave irrelevant responses. It was found that many users tended to personify the chatbot and assigned human traits to it. Furthermore, users were able to bond with the chatbot. Although not everyone is approachable with chatbots they are promising approaches to support people who are amenable to them regarding mental health issues. However, as (<a href="#B4">4</a>) have pointed out, prerequisite for chatbots to be used in mental health care is their implementation in compliance with quality and ethical standards as well as a better evidence base (<a href="#B4">4</a>).Thus, the evidence seems promising, remote interventions with technological implementations have turned out to be novel and innovative; however, not all countries have achieved robust development and research in the field. The articles in this collection identified several promising areas for future research including development of targeted strategies to increase reach of population groups most in need for digital mental health interventions and to increase user engagement as well as further research on the use of chatbots in mental health care. It is necessary to generate a greater degree of research and technological development because it is incipient, not only to cover the existing demand for care after the COVID-19 pandemic, but also to reduce the risk factors that increase the possibility of developing mental health problems or exacerbate pre-existing ones.Both authors contributed equally to the editorial and approved the submitted version.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.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.

Editorial: Highlights in digital mental health 2021/22

BackgroundTelemental health platforms may increase access to care for older adults. Historically, older adults have tended to adopt new technologies at a slower rate which creates a perception that they may not be able to benefit from them. The purpose of this study was to determine whether or not older adult patients receiving psychiatric care for depression via a telemental health platform achieve the same outcomes as younger adults.</sec>MethodParticipant data utilized in the current investigation were obtained from a national mental health telehealth company (i.e., Brightside) and consisted of 12,908 U.S.-based adult patients receiving psychiatric care for depression between October, 2018 and January, 2022. Propensity matching was used to create an older and younger sample (n = 141 in each) using 23 covariates. These samples were then compared using repeated measures ANOVA on Patient Health Questionnaire-9 (PHQ-9) scores at start of treatment, 6 weeks, 8 weeks, 10 weeks, 12 weeks, 14 weeks, and 16 weeks.</sec>ResultsDespite matching, the groups still significantly differed on prior mental health treatment, such that more older adults reported having had prior mental health treatment. There were no other differences between the groups on assessed variables. Both younger and older adults had decreasing scores over time with no significant differences between them.</sec>ConclusionOlder adults have similar improvement in depression symptom severity over time following initiation of psychiatric treatment via a telehealth platform. These findings suggest that age is not a barrier to benefitting from telepsychiatric care.</sec>

Background: Telemental health platforms may increase access to care for older adults. Historically, older adults have tended to adopt new technologies at a slower rate which creates a perception that they may not be able to benefit from them. The purpose of this study was to determine whether or not older adult patients receiving psychiatric care for depression via a telemental health platform achieve the same outcomes as younger adults.Method: Participant data utilized in the current investigation were obtained from a national mental health telehealth company (i.e., Brightside) and consisted of 12,908 U.S.-based adult patients receiving psychiatric care for depression between October, 2018 and January, 2022. Propensity matching was used to create an older and younger sample (n = 141 in each) using 23 covariates. These samples were then compared using repeated measures ANOVA on Patient Health Questionnaire-9 (PHQ-9) scores at start of treatment, 6 weeks, 8 weeks, 10 weeks, 12 weeks, 14 weeks, and 16 weeks.Results: Despite matching, the groups still significantly differed on prior mental health treatment, such that more older adults reported having had prior mental health treatment. There were no other differences between the groups on assessed variables. Both younger and older adults had decreasing scores over time with no significant differences between them.Conclusion: Older adults have similar improvement in depression symptom severity over time following initiation of psychiatric treatment via a telehealth platform. These findings suggest that age is not a barrier to benefitting from telepsychiatric care.

Do older adults benefit from telepsychiatric care: Comparison to younger adults

Digital mental health interventions (DMHIs) present a promising way to address gaps in mental health service provision. However, the relationship between user engagement and outcomes in the context of these interventions has not been established. This study addressed the current state of evidence on the relationship between engagement with DMHIs and mental health outcomes. MEDLINE, PsycINFO, and EmBASE databases were searched from inception to August 1, 2021. Original or secondary analyses of randomized controlled trials (RCTs) were included if they examined the relationship between DMHI engagement and post-intervention outcome(s). Thirty-five studies were eligible for inclusion in the narrative review and 25 studies had sufficient data for meta-analysis. Random-effects meta-analyses indicated that greater engagement was significantly associated with post-intervention mental health improvements, regardless of whether this relationship was explored using correlational [r = 0.24, 95% CI (0.17, 0.32), Z = 6.29, p < 0.001] or between-groups designs [Hedges' g = 0.40, 95% CI (0.097, 0.705), p = 0.010]. This association was also consistent regardless of intervention type (unguided/guided), diagnostic status, or mental health condition targeted. This is the first review providing empirical evidence that engagement with DMHIs is associated with therapeutic gains. Implications and future directions are discussed.Systematic Review Registration: PROSPERO, identifier: CRD 42020184706.

Digital mental health interventions (DMHIs) present a promising way to address gaps in mental health service provision. However, the relationship between user engagement and outcomes in the context of these interventions has not been established. This study addressed the current state of evidence on the relationship between engagement with DMHIs and mental health outcomes. MEDLINE, PsycINFO, and EmBASE databases were searched from inception to August 1, 2021. Original or secondary analyses of randomized controlled trials (RCTs) were included if they examined the relationship between DMHI engagement and post-intervention outcome(s). Thirty-five studies were eligible for inclusion in the narrative review and 25 studies had sufficient data for meta-analysis. Random-effects meta-analyses indicated that greater engagement was significantly associated with post-intervention mental health improvements, regardless of whether this relationship was explored using correlational [r = 0.24, 95% CI (0.17, 0.32), Z = 6.29, p &lt; 0.001] or between-groups designs [Hedges' g = 0.40, 95% CI (0.097, 0.705), p = 0.010]. This association was also consistent regardless of intervention type (unguided/guided), diagnostic status, or mental health condition targeted. This is the first review providing empirical evidence that engagement with DMHIs is associated with therapeutic gains. Implications and future directions are discussed.Systematic Review Registration: PROSPERO, identifier: CRD 42020184706.

Effect of Engagement With Digital Interventions on Mental Health Outcomes: A Systematic Review and Meta-Analysis

Social isolation has affected people globally during the COVID-19 pandemic and had a major impact on older adult's well-being. Chatbot interventions may be a way to provide support to address loneliness and social isolation in older adults. The aims of the current study were to (1) understand the distribution of a chatbot's net promoter scores, (2) conduct a thematic analysis on qualitative elaborations to the net promoter scores, (3) understand the distribution of net promoter scores per theme, and (4) conduct a single word analysis to understand the frequency of words present in the qualitative feedback. A total of 7,099 adults and older adults consented to participate in a chatbot intervention on reducing social isolation and loneliness. The average net promoter score (NPS) was 8.67 out of 10. Qualitative feedback was provided by 766 (10.79%) participants which amounted to 898 total responses. Most themes were rated as positive (517), followed by neutral (311) and a minor portion as negative (70). The following five themes were found across the qualitative responses: positive outcome (277, 30.8%), user did not address question (262, 29.2%), bonding with the chatbot (240, 26.7%), negative technical aspects (70, 7.8%), and ambiguous outcome (49, 5.5%). Themes with a positive valence were found to be associated with a higher NPS. The word “help” and it's variations were found to be the most frequently used words, which is consistent with the thematic analysis. These results show that a chatbot for social isolation and loneliness was perceived positively by most participants. More specifically, users were likely to personify the chatbot (e.g., “Cause I feel like I have a new friend!”) and perceive positive personality features such as being non-judgmental, caring, and open to listen. A minor portion of the users reported dissatisfaction with chatting with a machine. Implications will be discussed.

Social isolation has affected people globally during the COVID-19 pandemic and had a major impact on older adult&apos;s well-being. Chatbot interventions may be a way to provide support to address loneliness and social isolation in older adults. The aims of the current study were to (1) understand the distribution of a chatbot&apos;s net promoter scores, (2) conduct a thematic analysis on qualitative elaborations to the net promoter scores, (3) understand the distribution of net promoter scores per theme, and (4) conduct a single word analysis to understand the frequency of words present in the qualitative feedback. A total of 7,099 adults and older adults consented to participate in a chatbot intervention on reducing social isolation and loneliness. The average net promoter score (NPS) was 8.67 out of 10. Qualitative feedback was provided by 766 (10.79%) participants which amounted to 898 total responses. Most themes were rated as positive (517), followed by neutral (311) and a minor portion as negative (70). The following five themes were found across the qualitative responses: positive outcome (277, 30.8%), user did not address question (262, 29.2%), bonding with the chatbot (240, 26.7%), negative technical aspects (70, 7.8%), and ambiguous outcome (49, 5.5%). Themes with a positive valence were found to be associated with a higher NPS. The word &#x201c;help&#x201d; and it&apos;s variations were found to be the most frequently used words, which is consistent with the thematic analysis. These results show that a chatbot for social isolation and loneliness was perceived positively by most participants. More specifically, users were likely to personify the chatbot (e.g., &#x201c;Cause I feel like I have a new friend!&#x201d;) and perceive positive personality features such as being non-judgmental, caring, and open to listen. A minor portion of the users reported dissatisfaction with chatting with a machine. Implications will be discussed.