SISTEM INFORMASI MANAJEMEN

TELAAH ARTIKEL JURNAL TENTANG PERKEMBANGAN SISTEM

INFORMASI DAN TEKNOLOGI DI BIDANG KESEHATAN DAN
KEPERAWATAN

OLEH :
KELOMPOK 4:

Ns. Deko Eka Putra, S.Kep

Ns. Munadir Sj, S.Kep
Ns. Sandra Cassia Amanda, S.Kep
Ns. Yuli Hendro,S.Kep
Ns. Anipah,S.kep
Ns. Gusmunardi,S.Kep
Ns. Destri Wulandari,S.Kep
Ns. Darmayenti, S.Kep

PROGRAM STUDI MAGISTER KEPERAWATAN

FAKULTAS KEPERAWATAN
UNIVERSITAS ANDALAS
2021

2
 KATA PENGANTAR

Puji syukur kami ucapkan atas kehadirat Allah SWT yang telah melimpahkan rahmat,
hidayah, serta inayah-Nya, karena penulis telah diberi kesempatan untuk menyelesaikan makalah
mengenai “Telaah Artikel Jurnal Tentang Perkembangan Sistem Informasi Dan Teknologi
Di Bidang Kesehatan Dan Keperawatan”. Makalah ini ditulis sebagai tugas untuk mata kuliah
Sistem Informasi Manajemen. Dengan membaca makalah ini, diharapkan para pembaca dapat
menambah ilmu pengetahuan tentang konsep sistem informasi dan teknologi berbasis internet di
bidang kesehatan dan keperawatan serta penerapan Evidence Based Nursing.
Terimakasih yang sebesar-besarnya kami ucapkan kepada Bapak Esy Afriyanti, S.Kp,
M.Kes Selaku Dosen Pengampu Mata Kuliah Sistem Informasi Manajemen yang telah
memberikan bimbingan dalam pembuatan makalah ini. Serta teman-teman yang telah
mendukung sehingga terselesaikannya makalah ini.
Kami menyadari bahwa dalam penyusunan dan penulisan makalah ini masih memiliki
banyak kekurangan, oleh sebab itu kami mengharapkan kritik, pengarahan serta saran yang
membangun demi penyempurnaan makalah kami kedepannya. Harapan kami semoga makalah
ini bermanfaat untuk pengembangan wawasan dan peningkatan ilmu pengetahuan bagi kita
semua. Atas semua perhatian pembaca, kami ucapkan terimakasih.

Padang, Oktober 2021

Penulis

i
 DAFTAR ISI
Halaman
KATA PENGANTAR ....................................................................................... i
DAFTAR ISI ...................................................................................................... ii
BAB I PENDAHULUAN
A. LATAR BELAKANG .............................................................................. 1
B. TUJUAN PENULISAN ............................................................................ 2
C. MANFAAT PENULISAN ....................................................................... 2

BAB II TELAAH JURNAL

1. JURNAL 1 : Layanan dan Aplikasi Berbasis IoT untuk
Kesehatan Mental dalam Literatur ......................................... 3
2. JURNAL 2 : Perawatan Kesehatan Mental yang Penuh Kasih
di Era Berbasis Teknologi Digital ........................................ 5
3. JURNAL 3 : Sikap Dan Perilaku Remaja Dalam Kaitannya Dengan
Kesehatan Mental Dan Teknologi: Implikasi Untuk
Pengembangan Layanan Kesehatan Mental Online ............. 7
4. JURNAL 4 : Penggunaan Teknologi dan minat pada aplikasi digital
untuk promosi Kesehatan mental dan intervensi gaya
hidup dikalangan dewasa muda dengan
gangguan mental yang serius ................................................ 9
5. JURNAL 5 : Penggunaan Teknologi dan Preferensi untuk Intervensi
Manajemen Mandiri Kesehatan Mental di antara
Veteran yang Lebih Tua ....................................................... 11

BAB III ANALISIS PENERAPAN ARTIKEL JURNAL ......................... 12

BAB IV PENUTUP
A. KESIMPULAN ......................................................................................... 20
B. SARAN ..................................................................................................... 20

DAFTAR PUSTAKA .................................................................................... 21

ii
 BAB I
PENDAHULUAN
A. LATAR BELAKANG
Pada era teknologi yang canggih ini, suatu sistem informasi merupakan suatu sistem
yang mampu menghasilkan informasi yang dapat memenuhi kebutuhan secara efektif dan
efisien serta dapat juga dijadikan rekomendasi dalam menentukan keputusan pada suatu
organisasi.
Di dalam sistem informasi ada tiga bagian, yakni data sebagai penyedia informasi,
dan sebagai suatu prosedur untuk memandu seseorang agar bisa mengoperasikan sistem
informasi, serta pihak – pihak yang meproduksi atau menghasil suatu jasa, memecahkan
masalah, membuat keputusan, dan bagaimana cara memanfaatkan sistem informasi tersebut.
Dalam sistem informasi ini, ada pihak terkait merancang prosedur untuk mengelola dan
memanupulasi data, menghasilkan informasi kemudian bagaimana informasi ini di
distribusikan ke lingkungan.
Pada suatu sistem ada model dasar, yaitu masukan / input, pengolahan, keluaran /
output. Pengolahan data informasi diperlukan data yang sudah dikumpulkan, kemudian data
tersebut diolah terlebih dahulu. Kemudian data diolah menjadi informasi, pengolahan
informasi juga berguna untuk menyimpan data pada pengguna lanjutan terdapat penambahan
media penyedia data pada bentuk sistem informasi.

input proses output

penyimpanan

Skema Dasar Sistem Informasi (Davis, 1999)

Model dasar sistem informasi bukan hanya bermanfaat unutk pengolahan informasi
secara menyeluruh, melainkan juga dapat di gunakan dalam pengolahan informasi secara
tersendiri. Suatu implementasi dapat di telaah sebagai input, penyimpanan, pengolahan, dan
output.

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B. TUJUAN PENULISAN
Tujuan penulisan dari makalah ini adalah :
1. Mampu menemukan artikel jurnal yang up to date (lima tahun terakhir) dan menarik
tentang perkembangan system informasi dan teknologi di bidang kesehatan dan
keperawatan.
2. Mampu mengkritisi/menelaah artikel jurnal tersebut dengan memperhatikan aspek-aspek
telaah artikel.

C. MANFAAT PENULISAN
Mahasiswa mampu mengembangkan kemampuan berfikir kritis, menelaah hasil
temuan ilmiah terbaru atau evidence based nursing, bekerjasama dan mengemukakan
pendapat serta menghargai pendapat orang lain.

2
 BAB II
KRITISI ARTIKEL JURNAL
1. JURNAL 1
1 Judul : Layanan dan Aplikasi Berbasis IoT untuk Kesehatan Mental dalam Literatur
2 Penulis : Isabel de la Torre Díez & Susel Góngora Alonso & Sofiane Hamrioui & Eduardo Motta Cruz & Lola Morón Nozaleda
& Manuel A. Franco
3 Penerbit : Springer Science+Business Media, LLC, part of Springer Nature 2018
4 Tahun : 2018
5 Kata Kunci : Applications . IoT . Mental health . Sensors
6 Analisis :
No Komponen analisis URAIAN
1. Latar belakang : IoT adalah jaringan perangkat fisik dan elemen lainnya, terintegrasi dengan komponen elektronik, perangkat lunak,
Masalah sensor, dan konektivitas jaringan, yang memungkinkan objek tersebut mengumpulkan dan bertukar data. Teknologi
dan infrastruktur IoT memiliki potensi untuk merevolusi penyampaian layanan kesehatan. Perangkat deteksi fisik
dalam jaringan, bersama dengan sensor di lingkungan hidup kita, memungkinkan pengumpulan informasi secara terus
menerus dan real-time yang berkaitan dengan kesehatan fisik dan mental individu dan perilaku terkaitnya. Ditangkap
secara berkesinambungan dan teragregasi, informasi tersebut harus dimanfaatkan secara efektif untuk memungkinkan
pemantauan, perawatan dan intervensi secara real time, terus menerus dan personal.

2. Tujuan Penelitian : Tujuan dari tinjauan ini adalah untuk memberikan gambaran keadaan seni dalam penelitian tentang layanan, aplikasi,
dan arsitektur IoT dalam penyakit Kesehatan Mental. Studi yang ditemukan menunjukkan manfaat IoT dalam
Kesehatan Mental serta aplikasi dan arsitektur yang dikembangkan untuk meningkatkan kualitas hidup pasien dengan
jenis gangguan ini.

3. Metode Penelitian : Dalam penelitian ini, diperhitungkan kriteria inklusi dan eksklusi tertentu untuk mengembangkan tinjauan sistematis
mengenai layanan dan aplikasi IoT di Kesehatan Mental. Dalam penelitian ini, diperhitungkan kriteria inklusi dan
eksklusi tertentu untuk mengembangkan tinjauan sistematis mengenai layanan dan aplikasi IoT di Kesehatan Mental.

4. Hasil Penelitian : IoT telah berkembang sebagai area baru di bidang penelitian. Hal ini dimaksudkan agar miliaran objek fisik dilengkapi
dengan berbagai jenis sensor dan aktuator ke Internet melalui berbagai jaringan akses yang dibantu oleh teknologi.
Munculnya IoT yang diterapkan pada Kesehatan memungkinkan untuk memantau kondisi kesehatan pasien,

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 mendeteksi gejala penyakit secara umum dan dalam kasus khusus gangguan jiwa ini, memantau perkembangan
penyakit dan membantu dokter dalam mengelola perawatan medis. Dalam penulis mengusulkan penggunaan tekstil
Cerdas dan teknologi yang dapat dipakai sebagai bagian integral dari ekologi IoT, termasuk yang diterapkan di
lingkungan layanan Kesehatan Mental. Mereka mengusulkan protokol berbicara dengan lantang dan pembuatan model
analisis data untuk menganalisis transkrip secara semantik untuk mengidentifikasi peserta yang cemas dan tidak begitu
cemas. Analisis mengungkapkan perbedaan yang signifikan antara kosa kata yang digunakan oleh Banxious dan Bnot
sehingga peserta cemas.

5. Kelemahan pada : Konflik Kepentingan Para penulis menyatakan bahwa mereka tidak memiliki konflik kepentingan. Persetujuan Etis
jurnal ini Artikel ini tidak berisi penelitian apapun dengan partisipan manusia atau hewan yang dilakukan oleh salah satu
penulis.

6. Kelebihan jurnal : Dalam penulis, dengan tujuan menemukan tanda-tanda awal depresiasi keadaan kesehatan, mengevaluasi empat
penyakit gangguan mental yang paling umum untuk menemukan jenis sensor apa yang dapat mendeteksi gejala
spesifik untuk membuat sistem peringatan dini. Dengan cara ini, sistem dapat memprediksi penyakit mana yang
mungkin terjadi dengan mencocokkan beberapa gejala penyakit tertentu.

7. Manfaat Penelitian : Dimasukkannya teknologi IoT baru dalam Kesehatan membawa banyak manfaat dalam hal pemantauan, intervensi
kesejahteraan dan menyediakan layanan peringatan dan informasi.

8 Kesimpulan Konvergensi teknologi informasi dan kedokteran, seperti informatika medis, akan mengubah perawatan medis seperti
yang kita kenal, mengurangi biaya, inefisiensi, dan menyelamatkan nyawa.

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2. JURNAL 2
1 Judul : Perawatan Kesehatan Mental yang Penuh Kasih di Era Berbasis Teknologi Digital

2 Penulis : Gillian Strudwick, RN, PhD

3 Penerbit : Campbell Family Mental Health Research Institute Pusat
4 Tahun : 2020
5 Kata Kunci : Belas kasihan; kesehatan mental; informatika medis; psikiatri; teknologi informasi kesehatan; informatika keperawatan
6 Analisis :
No Komponen analisis URAIAN
1. Latar belakang : Penggunaan teknologi digital dalam pemberian perawatan kesehatan mental telah meningkat secara signifikan dalam
Masalah beberapa tahun terakhir. Peningkatan akses pasien ke layanan kesehatan mental adalah metrik umum untuk
mendukung penggunaan teknologi dalam perawatan kesehatan mental melalui teknologi seperti telepsikiatri. Karena
penyerapan dan perluasan teknologi digital yang muncul ke dalam berbagai pengaturan perawatan tradisional dan
non tradisional, seperti penggunaan teknologi digital di rumah atau penyediaan perawatan secara virtual dan Tanpa
pemahaman yang memadai tentang praktik terbaik dan penggunaan teknologi digital untuk pemberian perawatan
kesehatan mental yang penuh kasih, teknologi ini dapat mengurangi perawatan penuh kasih dan menghambat
hubungan profesional-pasien kesehatan, yang sangat penting dalam konteks perawatan kesehatan mental.

2. Tujuan Penelitian : Mengidentifikasi teknologi digital yang ada yang digunakan oleh pasien dan profesional kesehatan dalam pemberian
perawatan kesehatan mental, memahami bagaimana teknologi digital digunakan dalam pengiriman mental yang penuh
kasih.
1.
Teknologi digital apa yang ada yang paling sering digunakan di kalangan pasien dan / atau profesional
kesehatan dalam pemberian perawatan kesehatan mental?
2.
Bagaimana teknologi digital yang ada digunakan di antara pasien/profesional kesehatan dalam pemberian
perawatan kesehatan mental yang penuh kasih?
3.
Apa fasilitator yang dirasakan dan hambatan untuk menggunakan teknologi digital di antara pasien dan / atau
profesional kesehatan untuk memberikan perawatan kesehatan mental yang penuh kasih?

3. Metode Penelitian : Tinjauan ini dilakukan mengikuti kerangka metodologis untuk studi tinjauan scoping yang diusulkan oleh
Arksey dan O'Malley dan disempurnakan oleh Levac et al. Untuk mengilustrasikan proses peninjauan
scoping, diagram Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA), digunakan
serta daftar periksa ulasan PRISMA-scoping yang menguraikan tonggak utama dari tinjauan scoping

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 (Multimedia Appendix). Sebuah protokol rinci untuk tinjauan scoping ini berjudul Delivery of Compassionate Mental
Health Care in a Digital Technology-Driven

4. Hasil Penelitian : Dari 4472 artikel yang diputar, 37 artikel disertakan untuk ekstraksi data. Telemedicine adalah teknologi yang
paling banyak digunakan oleh para profesional kesehatan mental. Teknologi digital digambarkan sebagai
memfasilitasi perawatan penuh kasih dan diklasifikasikan menggunakan model konseptual untuk mengidentifikasi
setiap persimpangan digital dengan perawatan welas asih. Fasilitator dan hambatan untuk memberikan perawatan
penuh kasih melalui teknologi digital diidentifikasi, termasuk peningkatan keamanan bagi penyedia, persepsi dan
kemampuan profesional perawatan kesehatan, dan penggunaan umpan balik gambar-dalam-gambar untuk
mengevaluasi isyarat sosial.

5. Kelemahan pada : 1. Karena sifat ulasan scoping, kualitas setiap artikel yang diidentifikasi tidak dinilai. Meskipun setiap upaya
jurnal ini dilakukan untuk memastikan semua artikel yang mungkin melibatkan kasih sayang dalam perawatan kesehatan
mental disertakan, sifat subjektif belas kasih mungkin berarti beberapa artikel tidak ditangkap dalam ulasan ini.
2. Metode ini pasien yang mungkin tidak memiliki kesempatan untuk menerima perawatan kesehatan sebelumnya,
atau yang mungkin tidak nyaman atau terbatas dalam interaksi tatap muka langsung

6. Kelebihan jurnal : 1. Penelitian ini telah menjelsakan mamfaat dari perawatan yang penuh kasih
2. Model penelitian menggunakan scoping review

7. Manfaat Penelitian : 1. Memeberikan sumber refrensi bagi para peneliti berikutnya dalam melakukan penelitian yang sama
2. Penelitian ini dapat menjadi landasan memberikan dukungan polas asuh dengan cara system digital dengan cara
penuh kasih .

8 Kesimpulan
Penyelidikan tinjauan ini ke dalam interseksionalitas antara teknologi digital kontemporer dan kasih sayang adalah
topik yang sangat relevan dan muncul, terutama dalam perawatan kesehatan mental. Keadaan teknologi digital saat
ini dalam perawatan kesehatan mental cocok untuk memfasilitasi pemberian perawatan yang penuh kasih, terutama
ketika digunakan untuk melayani pasien yang mungkin tidak memiliki kesempatan untuk menerima perawatan
kesehatan sebelumnya, atau yang mungkin tidak nyaman atau terbatas dalam interaksi tatap muka langsung.

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3. JURNAL 3
1 Judul : Sikap Dan Perilaku Remaja Dalam Kaitannya Dengan Kesehatan Mental Dan Teknologi: Implikasi Untuk
Pengembangan Layanan Kesehatan Mental Online
2 Penulis : Louise A Ellis, Philippa Collin, Patrick J Hurley, Tracey A Davenport1, Jane M Burns and Ian B Hickie
3 Penerbit : Ellis et al. BMC Psychiatry
4 Tahun : 2013
5 Kata Kunci : Young men, Mental health, Help-seeking, Technology, Internet
6 Analisis :
No Komponen analisis URAIAN
1. Latar belakang : Studi metode campuran ini dirancang untuk mengeksplorasi sikap dan perilaku remaja Australia dalam kaitannya
Masalah dengan kesehatan mental dan penggunaan teknologi untuk menginformasikan pengembangan layanan kesehatan
mental online untuk remaja

2. Tujuan Penelitian : Untuk meningkatkan pemahaman kita tentang sikap dan perilaku remaja terhadap kesehatan mental, kebiasaan online
dan penggunaan teknologi, serta pengalaman mereka menggunakan Internet untuk informasi, bantuan atau dukungan,
untuk menginformasikan pengembangan layanan kesehatan mental online untuk pria muda.

3. Metode Penelitian : Dalam penelitian ini, Survei online nasional terhadap 486 pria (berusia 16 hingga 24) dan 17 kelompok fokus yang
melibatkan 118 pria (berusia 16 hingga 24). Studi ini membahas dua kesenjangan utama dalam literatur yang ada: (1)
bukti empiris preferensi teknologi remaja dan sikap serta pengalaman mereka terhadap pencarian bantuan online untuk
masalah kesehatan mental; dan, (2) data kualitatif yang kaya yang mengeksplorasi berbagai pandangan dan
pengalaman remaja dalam kaitannya dengan kesehatan mental dan pencarian bantuan.

4. Hasil Penelitian : Remaja adalah pengguna berat teknologi, terutama dalam hal hiburan dan berhubungan dengan teman, tetapi mereka
juga menggunakan teknologi untuk mencari informasi dan dukungan. Data kelompok fokus menunjukkan bahwa laki-
laki muda akan cenderung mencari bantuan profesional untuk diri mereka sendiri, mengutip preferensi untuk
membantu diri sendiri dan strategi berorientasi tindakan sebagai gantinya. Sebagian besar peserta survei melaporkan
bahwa mereka telah mencari bantuan untuk suatu masalah secara online dan merasa puas dengan bantuan yang mereka
terima. Peserta kelompok fokus mengidentifikasi strategi potensial tentang bagaimana teknologi dapat digunakan
untuk mengatasi hambatan dalam mencari bantuan bagi remaja.

5. Kelemahan pada : Kelemahan dari jurnal ini antara lain ; umpan balik grafis langsung, dan kemampuan untuk terlibat secara aktif

7
 jurnal ini daripada menerima konten secara pasif; pengalaman yang lebih pribadi (termasuk konten yang disesuaikan dengan
kebutuhan pengguna, dan memberi pengguna rasa kontrol dan kepemilikan, dan memungkinkan mereka untuk
memilih jalur mereka sendiri melalui intervensi); dan memfasilitasi kontak dengan beberapa jenis komunitas (paling
jelas rekan-rekan yang menderita, atau sebelumnya pernah menderita, kesulitan serupa).

6. Kelebihan jurnal : Untuk memberikan wawasan penting yang dapat digunakan untuk menginformasikan strategi penggunaan Internet
untuk mempromosikan kesehatan mental dan pencarian bantuan di kalangan pria muda

7. Manfaat Penelitian : Untuk memasukkan perspektif berbagai remaja untuk menangkap kekayaan dan kompleksitas kaum muda. sikap dan
perilaku pria dalam kaitannya dengan penggunaan teknologi dan kesehatan mental.

8 Kesimpulan Studi ini menunjukkan bahwa mungkin ada pandangan kuat terhadap kesehatan mental dan pencarian bantuan yang
spesifik gender. Meskipun pekerjaan lebih lanjut sekarang harus dilakukan, penelitian ini menunjukkan bahwa
mungkin ada kebutuhan mendesak untuk strategi dan intervensi khusus gender. Ini harus diinformasikan oleh
pandangan laki-laki muda dan praktik teknologi dan memperhitungkan peran penting yang dimainkan teman sebaya
dalam proses mencari bantuan. Penelitian sebelumnya dari Australia menunjukkan peningkatan kesadaran akan
masalah kesehatan mental, terutama bagi mereka yang telah menjadi subyek kampanye kesehatan masyarakat yang
luas, seperti depresi. Namun, hasil penelitian ini dengan jelas menunjukkan bahwa meskipun laki-laki muda mungkin
memiliki kesadaran dan pemahaman yang lebih baik, tantangan sebenarnya adalah merancang intervensi yang berbasis
tindakan, yang dipandang relevan, dan fokus pada perubahan perilaku dan stigma. Kesimpulannya, temuan penelitian
ini menunjukkan beberapa wawasan penting yang dapat digunakan untuk menginformasikan strategi penggunaan
Internet untuk mempromosikan kesehatan mental dan pencarian bantuan di kalangan pria muda.

8
4. JURNAL 4
1 Judul : Penggunaan Teknologi dan minat pada aplikasi digital untuk promosi Kesehatan mental dan intervensi gaya
hidup dikalangan dewasa muda dengan gangguan mental yang serius
2 Penulis : Naslund, J. A., & Aschbrenner, K. A.
3 Penerbit : Elsevier B.V. This is an open access article under the CC BY license 2021
4 Tahun : 2021
5 Kata Kunci : Young Adults, Serious mental illness, digital mental health, mHealth, Apps, Smartphone, Health Promotion
6 Analisis :
No Komponen analisis URAIAN
1. Latar belakang : Intervensi gaya hidup dan program promosi kesehatan yang dapat berhasil mengatasi faktor risiko seperti kebugaran
Masalah kardiorespirasi, gaya hidup menetap, perilaku diet, dan suasana hati yang rendah serta gejala yang menghalangi
perubahan perilaku kesehatan yang positif (Firth et al. ., 2019). sedikit orang yang hidup dengan penyakit mental
serius yang memiliki akses ke program ini sebagai bagian dari pemberian layanan kesehatan mental rutin Teknologi
digital menjanjikan untuk menjembatani kesenjangan ini, dan dapat digunakan untuk memperluas jangkauan promosi
kesehatan mental dan Meningkatnya akses dan penggunaan teknologi digital termasuk smartphone, program online,
dan media sosial di antara individu yang hidup dengan penyakit mental serius didokumentasikan dengan baik,
sebagaimana tercermin dari penelitian yang dilakukan di berbagai komunitas dan pengaturan klinis, Pengakuan yang
berkembang dari penggunaan dan minat dalam menggunakan teknologi di antara orang-orang dengan penyakit mental
yang serius sejalan dengan munculnya penelitian selama dekade terakhir yang menunjukkan kelayakan, penerimaan,
dan manfaat klinis dari teknologi digital untuk individu.
2. Tujuan Penelitian : Tujuan dari tinjauan ini adalah untuk memberikan gambaran intervensi gaya hidup kepemilikan dan penggunaan
teknologi untuk menyembuhkan Kesehatan mental dan lainnya
3. Metode Penelitian : Dalam penelitian ini, diperhitungkan kriteria inklusi dan eksklusi tertentu untuk mengembangkan tinjauan sistematis
mengenai penggunaan ponsel dan pengiriman pesan berbeda antara kelompok diagnostic, dengan gangguan non-
psikotik lebih cenderung menggunakan ponsel mereka setiap hari ntuk mengirim pesan teks beberapa kali setiap hari.
4. Hasil Penelitian : Peserta dengan gangguan psikotik lebih cenderung menggunakan obat antipsikotik dibandingkan dengan peserta
dengan gangguan non-psikotik peserta melaporkan memiliki ponsel, dengan tingkat kepemilikan yang tinggi diamati
pada peserta dengan gangguan psikotik, Ada beberapa perbedaan dalam jenis platform yang digunakan antar
kelompok, meskipun tidak ada perbedaan yang signifikan dalam frekuensi penggunaan antar kelompok, dengan
hampir dua pertiga peserta melaporkan bahwa mereka menggunakan media sosial setiap hari.
5. Kelemahan pada : Sebagian besar peserta melaporkan telah menggunakan Internet untuk mencari informasi tentang kesehatan mental
jurnal ini mereka (73%) atau kesehatan umum (79%), proporsi yang lebih besar dari peserta dengan gangguan non-psikotik

9
 dilaporkan menggunakan Internet untuk mencari informasi kesehatan mental bila dibandingkan dengan peserta dengan
gangguan psikotik (78% vs 66%, masing-masing), tetapi perbedaan ini tidak signifikan secara statistik. Sebaliknya,
proporsi yang jauh. Persetujuan Etis Artikel ini berisi penelitian antara teknologi smartphone dengan partisipan
manusia yang dilakukan oleh salah satu penulis.
6. Kelebihan jurnal : Dalam penulis, dengan tujuan menemukan tanda-tanda awal terdapatnya tingginya akses penggunaan dan minat
teknologi dikalangan dewasa muda dengan gangguan jiwa berat atau serius ini menyoroti intervensi digital terintegrasi
untuk menyembuhkan mental dan fisik
7. Manfaat Penelitian : menambah banyak bukti yang mengkomfirmasi yang tersebar luas akses penggunaan dan minat pada teknologi digital
diantara individu dengan penyakit jiwa yang serius
8 Kesimpulan Konvergensi teknologi informasi smartphone yang berisikan informasi tentang intervensi penanggulangan penyakit
fisik dan mental yang serius dalam phenomena teknologi internet untuk mencari informasi Kesehatan mental,
keefesiensinya pengurangan biaya, informasi cepat didapatkan

10
5. JURNAL 5
1 Judul : Penggunaan Teknologi dan Preferensi untuk Intervensi Manajemen Mandiri Kesehatan Mental di antara
Veteran yang Lebih Tua
2 Penulis : Christine E. Gould, PhD, ABPP,Julia Loup, BA, Eric Kuhn, PhD, Sherry A. Beaudreau, PhD, ABPP, Flora Ma, MS,
Mary K. Goldstein, MD, MS, Julie Loebach Wetherell, PhD, ABPP, Aimee Marie L. Zapata, PhD, Philip Choe, DO, &
Ruth O’Hara, PhD
3 Penerbit : Running Head: Technology And Older Veterans
4 Tahun : 2020
5 Kata Kunci : Computers, Internet, Mental Health, Mobile Applications, Self-management, Smartphone, Technology, veteran
6 Analisis :
No Komponen analisis URAIAN
1. Latar belakang : Departemen Urusan Veteran Amerika Serikat menawarkan berbagai intervensi yang diberikan teknologi untuk
Masalah mengatasi masalah kesehatan mental secara mandiri. Namun, tidak diketahui hambatan apa yang dihadapi veteran
militer yang lebih tua untuk menggunakan teknologi ini dan seberapa bersedia mereka menggunakan teknologi untuk
masalah kesehatan mental.

2. Tujuan Penelitian : Untuk megetahui hambatan veteran militer amerika serikat dalm menggunakan teknologi dalam mengatasi masalah
kesehatan mental secara mandiri.

3. Metode Penelitian : Penelitian kualitatif dengan cara case study

4. Hasil Penelitian : Tingginya kemauan veteran militer amerika dalam memperoleh informasi, pelatihan dan dukungan dalam penggunaan
teknologi mengatasi kesehatan mental secara mandiri

6. Manfaat Penelitian : Pentingnya memastikan bahwa penyedia menawarkan pengiriman teknologi yang ada intervensi untuk veteran yang
lebih tua. Preferensi kuat para veteran untuk konseling menekankan perlunya
untuk dukungan manusia di samping manajemen diri.

7 Kesimpulan veteran militer memiliki alat teknologi yang tinggi, namun tidak paham dalam penggunaanya, selain melalui teknologi
untuk mengatasi kesehatan mental mereka berpendapat bahwa dukungan dari orang terdekat juga sengat berpengaruh.

11
 BAB III
ANALISIS PENERAPAN ARTIKEL JURNAL

A. Analisis Penerapan Topik Artikel Yang Dikritisi Di Pelayanan Kesehatan Di Indonesia

1. Layanan dan Aplikasi Berbasis IoT untuk Kesehatan Mental dalam Literatur
Sejumlah aplikasi layanan teknologi informasi dan komunikasi inovatif telah
dikembangkan seperti sistem ehealth, m-health, dan telehealth untuk aplikasi pelayanan
kesehatan tertentu dan/atau penyakit tertentu. Diperlukan pengembangan lebih lanjut
berdasarkan beberapa alasan, diantaranya: perkembangan teknologi TIK yang relatif cepat,
peningkatan kualitas dan pengembangan berbagai jenis infrastruktur telekomunikasi yang
cepat, peningkatan keakraban pengguna untuk menerapkan berbagai sistem ehealth, dan
berkembang pesatnya berbagai macam aplikasi teknologi baru untuk kesehatan.
Aplikasi yang kini berkembang pesat dalam sistem telehealth adalah teknologi
berbasis Internet of Things (IoT). Aplikasi ini memungkinkan sebuah perangkat terhubung
langsung dengan data dan dengan siapa pun. Seperti yang diuraikan, alasan mengapa IoT
berperan penting dalam kesehatan diantaranya :
 Kemampuannya untuk mengambil data pasien secara kontinyu (real time) dapat
membantu pelayanan pencegahan terhadap kondisi gawat darurat (preventive care).
 Dokter dapat melakukan diagnosis dini terhadap komplikasi akut dan pemantauan
kesehatan terhadap pasien yang sedang diterapi dapat dilakukan setiap waktu.
Pemasukan data secara otomatis dapat mengurangi resiko kesalahan yang disebabkan
oleh manusia dan data dapat diperoleh secara otomatis jika diperlukan oleh dokter.
Kemampuan tersebut memberikan peningkatan dalam banyak aplikasi medis seperti
pemantauan kesehatan jarak jauh (remote health monitoring), program fitnes, penyakit
kronik dan pelayanan orang tua (elderly care). Pelayanan kesehatan berbasis IoT diharapkan
dapat mengurangi biaya dan mampu meningkatkan kualitas hidup. IoT telah berkembang
sebagai area baru di bidang penelitian. Hal ini dimaksudkan agar miliaran objek fisik
dilengkapi dengan berbagai jenis sensor dan aktuator ke Internet melalui berbagai jaringan
akses yang dibantu oleh teknologi.
Munculnya IoT yang diterapkan pada Kesehatan memungkinkan untuk memantau
kondisi kesehatan pasien, mendeteksi gejala penyakit secara umum dan dalam kasus khusus
gangguan jiwa ini, memantau perkembangan penyakit dan membantu dokter dalam

12
mengelola perawatan medis. Dalam penulis mengusulkan penggunaan tekstil Cerdas dan
teknologi yang dapat dipakai sebagai bagian integral dari ekologi IoT, termasuk yang
diterapkan di lingkungan layanan Kesehatan Mental. Mereka mengusulkan protokol
berbicara dengan lantang dan pembuatan model analisis data untuk menganalisis transkrip
secara semantik untuk mengidentifikasi peserta yang cemas dan tidak begitu cemas.
Teknologi berbasis IoT dapat menjadi solusi bagi pemerintah Indonesia dalam menurunkan
angka kematian ibu dan anak.
Dalam upaya membantu pemerintah menurunkan angka kematian ibu, bayi dan balita
telah dirancang oleh Kadarina dan Rinto sebuah sistem untuk meningkatkan kualitas
pelayanan kesehatan ibu dan anak (KIA). Dengan sistem ini memungkinkan terjadinya
pertukaran informasi kedokteran secara cepat dan tepat untuk keperluan pemantauan
kesehatan jarak jauh secara real time. Dengan demikian dokter/paramedis dapat melakukan
pemantauan kesehatan dari mana pun dan di mana pun. Pendeteksian dini terhadap suatu
kondisi gawat darurat dapat dilakukan sehingga pasien yang mengalami keadaan kritis dapat
segera ditangani.
Penelitian terkait tentang aplikasi internet of things dalam bidang kesehatan telah
banyak dikembangkan di berbagai negara. Islam et all melakukan studi lengkap terhadap
penelitian terkini dan beberapa permasalahan yang harus diatasi untuk mengembangkan
solusi IoT untuk kesehatan. Mereka mengklasifikasikan studi jaringan kesehatan berbasis
IoT dalam tiga bagian utama. Mereka pun memberikan hasil survei terhadap layanan dan
aplikasi pelayanan kesehatan berbasis IoT dan memberikan wawasan yang luas mengenai
masalah keamanan dan masalah privasi seputar solusi. Jaringan IoT untuk pelayanan
kesehatan memiliki tiga bagian utama. Pertama, topologi jaringan yang mengacu pada
susunan elemen yang berbeda dalam jaringan. Kedua, arsitektur jaringan yang mengacu
pada petunjuk untuk spesifikasi elemen fisik, pengaturan fungsionalnya, serta teknik dan
prinsip kerjanya. Bagian terakhir adalah platform yang mengacu pada model platform
jaringan dan platform komputasi. Nugraha et all telah melakukan analisis terhadap efisiensi
komputasi di cloud dan jaringan nirkabel pada IoT

13
2. Perawatan Kesehatan Mental yang Penuh Kasih di Era Berbasis Teknologi Digital
Indonesia membutuhkan metode layanan kesehatan mental yang mampu menjangkau
masyarakat luas dengan kondisi geografis yang menantang dan populasi penduduk yang
besar. Kebutuhan tersebut menjadi semakin mendesak dengan adanya situasi pembatasan
fisik di masa pandemi yang dihadapi saat ini. Meningkatnya jumlah kasus kesehatan mental
dan keterbatasan ketersediaan sumber daya profesional yang ada tidak cukup memenuhi
kebutuhan pelayanan, sehingga menimbulkan kesenjangan kesehatan mental. Meningkatnya
kebutuhan pendampingan psikologis pada situasi khusus saat ini menjadi tantangan bagi
penyedia layanan.
Pelayanan kesehatan mental di Indonesia memiliki tantangan yang cukup besar. Dalam
kondisi normal, negara ini memiliki struktur geografis pulau dan jumlah penduduk yang
menyebar, serta keberadaan sumber daya tenaga kesehatan yang berperan dalam kesehatan
mental masih sangat minim dibandingkan dengan jumlah penduduk Indonesia secara
keseluruhan. Terlebih dengan adanya situasi khusus atau yang sering disebut Kejadian Luar
Biasa (KLB) seperti adanya bencana, wabah, dan sejenisnya yang semakin membatasi akses
masyarakat ke penyedia pelayanan kesehatan.
Pemanfaatan teknologi informasi dan komunikasi yang optimal menjadi peluang
pengembangan layanan profesional psikolog dalam upaya mewujudkan kesehatan mental di
masyarakat. Keterbatasan sumber daya, kondisi geografis yang menantang, serta situasi
sosial masyarakat yang membutuhkan dukungan kesehatan jiwa dan psikososial terutama
pada masa pandemik, dan pembatasan interaksi tatap muka saat ini menjadi kondisi yang
sangat membutuhkan metode pelayanan alternatif melengkapi pelayanan konvensional yang
telah berlangsung selama ini.
Kolaborasi layanan psikologi dengan menggunakan Teknologi Informasi dan
Komunikasi (TIK) sebagai salah satu peluang dalam era digital ini akan dirangkum dalam
beberapa sub bahasan dalam diskusi artikel reviu ini, yaitu prosedur dan etika; efektivitas
kesehatan telemental; tantangan di Indonesia, kesiapan masyarakat; dan kesiapan
professional. metode penggunaan teknologi telekomunikasi oleh tenaga kesehatan mental,
khususnya psikolog dalam melakukan asesmen, diagnosis yang efektif, pendidikan,
perawatan, konsultasi, transfer data medis, penelitian, dan upaya kesehatan mental lainnya.
Metode ini sebagai pengembangan psikologi yang menyesuaikan dan berintegrasi dengan
teknologi telekomunikasi yang saat ini menjadi bagian vital dalam komunikasi antar

14
manusia. Pada prinsipnya dalam intervensi psikologi pentingnyamenjalin hubungan
baik/keakraban atau yang sering disebut building-rapport dan kehadiran secara fisik bersama
klien memiliki pranan penting untuk memperkuat komunikasi terapeutik. Ulasan berikut
menunjukkan beberapa peluang penerapan telepsikologi.
Perkembangan kesehatan telemental mendapatkan respons cepat dari pengguna,
sejalan dengan perkembangan teknologi yang dengan mudah digunakan dalam genggaman
tangan. Indonesia sebagai negara dengan jumlah penduduk yang besar, menjadi peluang
penyediaan aplikasi-aplikasi konseling online seperti Halodoc, Riliv, YesDok, SehatPedia,
dan beberapa penyedia layanan swasta melihat peluang ini, meskipun secara pembiayaan
masih belum ditemukan acuan baku mengenai prosedur tagihan dan pembayaran yang baku
baik dari organisasi profesi, maupun pemerintah.
Jangkauan pelayanan kesehatan dengan pemanfaatan teknologi informasi seperti
TMH, memberikan peluang pemerataan pelayanan kesehatan mental bagi Indonesia sebagai
negara kepulauan yang luas, dengan akses geografis yang beragam. Meskipun konsekuensi
penerapan teknologi yang semakin berkembang dan canggih akan menciptakan tantangan
baru sejalan dengan potensi risiko yang mungkin timbul dalam praktik bagi penyedia
kesehatan mental. Perlunya penyesuaian standar prosedur, kompetensi klinis dan teknologi
yang sesuai bagi professional demikian halnya dengan etika layanan kerkait kesesuaian jenis
layanan kesehatan telemental bagi klien, informend concern, kerahasiaan, aspek hukum,
keamanan, dan kegawatdaruratan yang menyertai kesehatan telemental.

15
3. Sikap Dan Perilaku Remaja Dalam Kaitannya Dengan Kesehatan Mental Dan
Teknologi: Implikasi Untuk Pengembangan Layanan Kesehatan Mental Online
Remaja adalah pengguna berat teknologi, terutama dalam hal hiburan dan
berhubungan dengan teman, tetapi mereka juga menggunakan teknologi untuk mencari
informasi dan dukungan. Data kelompok fokus menunjukkan bahwa laki-laki muda akan
cenderung mencari bantuan profesional untuk diri mereka sendiri, mengutip preferensi untuk
membantu diri sendiri dan strategi berorientasi tindakan sebagai gantinya. Sebagian besar
peserta survei melaporkan bahwa mereka telah mencari bantuan untuk suatu masalah secara
online dan merasa puas dengan bantuan yang mereka terima. Peserta kelompok fokus
mengidentifikasi strategi potensial tentang bagaimana teknologi dapat digunakan untuk
mengatasi hambatan dalam mencari bantuan bagi remaja.
Pertumbuhan remaja saat ini tidak lepas dari penggunaan teknologi dalam aktivitas
hidupnya. Hal ini disebabkan karena teknologi dapat memenuhi kebutuhan-kebutuhan
remaja, seperti berkomunikasi, eksistensi serta pencarian informasi. Salah satu informasi
penting yang dibutuhkan yaitu mengenai kesehatan mental. Literasi kesehatan mental
merupakan pemahaman dan keyakinan individu terkait dengan gangguan mental serta
prevensinya.
Pelayanan psikologi di Indonesia masih menerima stigma negatif dari masyarakat
yang membuat mereka enggan menemui psikolog dan diperparah dengan terbatasnya
layanan psikologi yang terjangkau baik dari segi finansial maupun lokasi. Untuk
menjembatani hal tersebut, maka mulai bermunculan beberapa teknologi berupa situs dan
aplikasi konsultasi online melalui media internet.

16
4. Penggunaan Teknologi dan minat pada aplikasi digital untuk promosi Kesehatan
mental dan intervensi gaya hidup dikalangan dewasa muda dengan gangguan mental
yang serius
Kehadiran teknologi yang terus berkembang tentu memberikan dampak positif
bagi kehidupan setiap orang saat ini termasuk kesehatan mental. Siapa sangka jika
dampak negatif dari teknologi yang sering kali dianggap dapat mengganggu
kesehatan mental karena membuat adiktif, justru juga memiliki dampak positif
sebaliknya.
Mengacu pada data WHO bahwa hampir sebanyak 800 ribu orang meninggal
akibat bunuh diri setiap tahunnya dan masih banyak orang-orang yang
mengesampingkan masalah kesehatan mental sehingga perlu adanya solusi dalam
mengatasi permasalahan tersebut, salah satunya melalui peran teknologi. Mungkin
kamu masih bingung dengan hal tersebut, namun ada sejumlah alasan yang membuat
teknologi itu justru mampu meningkatkan kesehatan mental
Pemanfaatan teknologi untuk kesehatan mental bisa dibuktikan dengan
kehadiran aplikasi-aplikasi yang diperuntukkan untuk permasalahan tersebut. Di
mana, aplikasi untuk kesehatan mental ini menyajikan solusi berupa meditasi,
konsultasi dengan psikolog, mengelola kecemasan, mengatur pola tidur, dan masih
banyak lainnya.
Era teknologi informasi saat ini telah menyentuh berbagai bidang dan aspek
kehidupan, termasuk diantaranya bidang kesehatan. Pelayanan kesehatan merupakan salah
satu bidang yang telah mempergunakan perkembangan teknologi tersebut, baik yang bersifat
klinis maupun non klinis. Ataupun teknologi informasi yang ‘bersinggungan’ langsung
dengan pasien (teknologi yang mendukung pengambilan keputusan klinis) maupun yang
dipergunakan dalam sistem pengelolaan fasilitas pelayanan kesehatan (penerapan teknologi,
seperti; EMRs, EHRs, dan PHRs).
Penerapan teknologi informasi di bidang kesehatan ini diyakini dapat memberikan
berbagai manfaat bagi provider pelayanan kesehatan. Dengan dukungan teknologi tersebut,
manfaat yang dapat diperoleh diantaranya adalah tersedianya informasi kesehatan pasien
yang akurat dan komprehensif, sehingga provider dapat memberikan berbagai kemungkinan
perawatan terbaik. Lebih lanjut dengan penerapan teknologi informasi yang lengkap dan

17
akurat dapat membantu dalam proses diagnosa, meminimalkan medical error serta dapat
menawarkan pelayanan kesehatan yang aman dengan biaya rendah.
Untuk memperkaya informasi dan pengetahuan terkait penggunaan teknologi
informasi pada proses pelayanan kesehatan khususnya dalam upaya peningkatan mutunya,
website mutu pelayanan kesehatan akan menyajikan berbagai artikel dan informasi terkait
penggunaan teknologi tersebut di berbagai aspek pelayanan kesehatan oleh fasilitas
pelayanan kesehatan. Serta bagaimana perkembangan teknologi informasi dapat
dipergunakan sebagai sarana dalam peningkatan mutu pelayanan kesehatan.
Apalagi sejumlah aplikasi ada yang dirancang khusus untuk membantu
permasalahan mental seperti PTSD, bipolar disorder, hingga depresi. Walaupun bisa
membantu permasalahan kesehatan mental, tentunya tetap harus ada perawatan
profesional terutama memang individu tersebut terdiagnosis gangguan tertentu. Akan
tetapi, hal ini tetap membuktikan bahwa teknologi bisa menjadi dimanfaatkan untuk
membantu kesehatan mental.
Kehadiran internet yang menjadi bagian dari perkembangan teknologi bisa
dimanfaatkan dalam hal positif termasuk kesehatan mental. Di mana, bantuan tersedia
secara online bagi siapapun, di manapun, dan kapanpun. Salah satunya adalah Heads
Together yang menjadi situs penghubung antara relawan dengan pejuang kesehatan
mental dalam berbagi cerita mengatasi permasalahannya. Selain itu, ada situs The
Campaign Against Living Miserably yang mencegah bunuh diri melalui kampanye
dalam meningkatkan kesadaran diri serta menyediakan akses ke saluran bantuan.
Terkadang, sebagian orang yang mengalami permasalahan kesehatan mental
merasa tidak nyaman untuk berbicara maupun bercerita kepada orang lain terkait
masalah yang dialami. Kehadiran asisten suara yang diciptakan dengan kecerdasan
buatan bisa menjadi salah satu solusi dalam menemani orang tersebut saat
menceritakan permasalahannya.
Di mana, ada sejumlah aplikasi yang dikembangkan untuk memantau ekspresi
mikro sehingga mampu menanggapi isyarat wajah, gerakan simpatik, hingga
membangun hubungan baik. Bisa dikatakan jika teknologi ini mampu menjadi terapis
yang siap membantu kesehatan mental seseorang dengan merasa tidak nyaman jika
bercerita kepada orang lain.

18
 Salah satu aplikasi bernama e-teknologi. peran e-teknologi diekplorasi, dengan
penekanan pada keuntungan dan kerugian untuk perawatan kesehatan dan penelitian
kesehatan mental. E-teknologi sangat luas pemahamannya dan dalam beberapa tahun
terakhir, penggunaannya telah berkembang dengan pesat. Internet adalah sumber utama
informasi kesehatan, dan ada potensi untuk memberikan layanan ditingkatkan melalui media
ini.
Selain itu peran E-teknologi dalam pemberian layanan kesehatan mental dan masa
depan penelitian akan terus berkembang sebagai mana banyaknya jumlah atau
meningkatknya konseumen, praktisi kesehatan professional dan masyarakat umum online
terutama karena teknologi ini halus dan membuat pengguna bahkan lebih ramah.

5. Penggunaan Teknologi dan Preferensi untuk Intervensi Manajemen Mandiri

Kesehatan Mental di antara Veteran yang Lebih Tua
Perkembangan trend teknologi tentu memiliki dampak pada berbagai bidang
kehidupan, terutama menyentuh sisi psikologis manusia. Teknologi mungkin erat kaitannya
berkembang dalam rangka memajukan ekonomi dan kesejahteraan hidup, namun
transformasi ini tentu dapat mengakibatkan perubahan dengan ruang lingkup yang lebih luas
dan perubahan pada semua sistem.
Adanya dua trend perkembangan teknologi dan kenaikan angka masalah kesehatan
mental tentu menjadi perhatian penting bagi semua pihak. Kemajuan teknologi membawa
pada era modernitas yang menuntut „otomatisasi dan kecepatan‟ pada berbagai aspek
kegiatan, terutama dalam pekerjaan. Apakah hal ini berpengaruh besar pada kesehatan
mental? World Economic Forum (2019) dalam The Global Risk Report 2019 mencatat
bahwa transformasi yang kompleks, yang menghubungkan aspek sosial, teknologi, dan
pekerjaan, memiliki pengaruh yang amat besar terhadap pengalaman hidup manusia. Isu
seperti stress psikologis, berhubungan dengan perasaan ketidakmampuan dalam mengontrol
atau menghadapi ketidakpastian, dan hal ini tentu memerlukan perhatian khusus untuk
mengurangi resiko berkurangnya kesejahteraan psikologis.

19
 BAB IV
PENUTUP
A. KESIMPULAN
Sistem Informasi suatu sistem didalam organisasi yang mempertemukan kebutuhan
pengolahan transaksi harian yang mendukung fungsi operasi organisasi yang bersifat
manajerial dengan kegiatan strategi dari suatu organisasi untuk dapat menyediakan kepada
pihak luar tertentu dengan laporan-laporan yang diperlukan. Sistem Informasi kesehatan
kombinasi dari ilmu komputer, informasi dan keperawatan yang disusun untuk
mempermudah manajemen, proses pengambilan keputusan, dan pelaksanaan asuhan
keperawatan.
Pelayanan kesehatan mental di Indonesia memiliki tantangan yang cukup besar. Dalam
kondisi normal, negara ini memiliki struktur geografis pulau dan jumlah penduduk yang
menyebar, serta keberadaan sumber daya tenaga kesehatan yang berperan dalam kesehatan
mental masih sangat minim dibandingkan dengan jumlah penduduk Indonesia secara
keseluruhan. Terlebih dengan adanya situasi khusus atau yang sering disebut Kejadian Luar
Biasa (KLB) seperti adanya bencana, wabah, dan sejenisnya yang semakin membatasi akses
masyarakat ke penyedia pelayanan kesehatan.
Pemanfaatan teknologi informasi dan komunikasi yang optimal menjadi peluang
pengembangan layanan profesional psikolog dalam upaya mewujudkan kesehatan mental di
masyarakat. Keterbatasan sumber daya, kondisi geografis yang menantang, serta situasi
sosial masyarakat yang membutuhkan dukungan kesehatan jiwa dan psikososial terutama
pada masa pandemik, dan pembatasan interaksi tatap muka saat ini menjadi kondisi yang
sangat membutuhkan metode pelayanan alternatif melengkapi pelayanan konvensional yang
telah berlangsung selama ini.

B. SARAN
Dalam penulisan makalah ini banyak sekali kesalahan dan sangat jauh dari
kesempurnaan. Tentunya, penulis akan terus memperbaiki makalah dengan mengacu pada
sumber yang dapat dipertanggungjawabkan nantinya. Penulis menyarankan kepada pembaca
agar lebih banyak mencari literatur lain sebagai pembanding supaya memperbanyak
pengetahuan terkait konsep sistem informasi dan teknologi berbasis internet di bidan
kesehatan dan keperawatan.

20
 DAFTAR PUSTAKA

A. Ariani, A.P. Koesoema, and S. Soegijoko, "Innovative Healthcare Applications of ICT for
Developing Countries," in Innovative Healthcare Systems for the 21st Century, Springer
International Publishing, 2017, pp. 15-70.
B. Nugraha, I. Ekasurya, G. Osman, and M. Alaydrus, "Analysis of Power Consumption
Efficiency on Various IoT and Cloud-Based Wireless Health Monitoring Systems: A
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Journal of Medical Systems (2019) 43:11
https://doi.org/10.1007/s10916-018-1130-3

SYSTEMS-LEVEL QUALITY IMPROVEMENT

IoT-Based Services and Applications for Mental Health in the

Literature
Isabel de la Torre Díez1 & Susel Góngora Alonso1 & Sofiane Hamrioui2 & Eduardo Motta Cruz2 &
Lola Morón Nozaleda & Manuel A. Franco4
3

Received: 12 September 2018 / Accepted: 26 November 2018

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Internet of Things (IoT) has emerged as a new paradigm today, connecting a variety of physical and virtual
elements integrated with electronic components, sensors, actuators and software to collect and exchange data. IoT
is gaining increasing attention as a priority research topic in the Health sector in general and in specific areas such
as Mental Health. The main objective of this paper is to show a review of the existing research works in the
literature, referring to the main IoT services and applications in Mental Health diseases. The scientific databases
used to carry out the review are Google Scholar, IEEE Xplore, PubMed, Science Direct, and Web of Science,
taking into account as date of publication the last 10 years, from 2008 to the present. Several search criteria were
established such as BIoT OR Internet of Things AND (Application OR Service) AND Mental Health^ selecting the
most interesting articles. A total of 51 articles were found on IoT-based services and applications in Mental Health,
of which 14 have been identified as relevant works in mental health. Many of the publications (more than 60%)
found show the applications developed for monitoring patients with mental disorders through sensors and
networked devices. The inclusion of the new IoT technology in Health brings many benefits in terms of
monitoring, welfare interventions and providing alert and information services. In pathologies such as Mental
Health is a vital factor to improve the patient life quality and effectiveness of the medical service.

Keywords Applications . IoT . Mental health . Sensors

Introduction IoT technology and infrastructure has the potential to rev-

IoT is a network of physical devices and other elements,
inte- grated with electronic components, software, sensors
and net- work connectivity, which allows these objects to
collect and exchange data [1].
olutionize the delivery of health services. The corporal
detec- tion devices in network, together with sensors in our
life en- vironment, allow the continuous and real-time
collection of information related to physical and mental
health of an indi- vidual and their related behaviors [2].
Captured in a

This article is part of the Topical Collection on Systems-Level Quality

Improvement

* Isabel de la Torre Eduardo Motta Cruz Eduardo.Mottacruz@univ-nantes.fr

Díez isator@tel.uva.es
Lola Morón Nozaleda lolamoron@gmail.com
Susel Góngora Alonso
suselgongoraalonso@gmail.com
Sofiane Hamrioui
Sofiane.Hamrioui@univ-nantes.fr

23
Manu Engineering, University of Valladolid, Paseo de Belén, 15,
el A. 47011 Valladolid, Spain
Franc 2
o Bretagne Loire and Nantes Universities, UMR 6164, IETR
mfm Polytech Nantes, Nantes, France
@intr 3
Nozaleda and Lafora Mental Health Clinic, C/ José Ortega Y
as.es Gasset, 44, 28006 Madrid, Spain
4
1 Psiquiatry Service, Hospital Zamora, Hernán Cortés, Zamora,
Department of Signal Theory Spain
and Communications, and Telematics

24
 J Med Syst (2019) 43:11 Page 2 of 6 11

continuous and aggregated manner, said information must to

be exploited in an effective manner to allow monitoring,
treat- ments and interventions in real time, continuous and
person- alized [3, 4].
The health care industry remains one of fastest to adopt the
IoT [5]. The reason for this trend is that integration of IoT
functions in medical devices greatly improves the quality
and effectiveness of medical service, providing an
especially high value for patients with chronic conditions,
and those that require constant monitoring in real time [6,
7].
As the age profile of many societies continues to increase,
support for health, both mental and physical, is of increasing
importance if one wants to maintain independent living.
Detect, monitor, recognize activities of daily life, ultimately,
delivery of immediate health services has been perceived as
a prerequisite to detect the health status of users [8].
Recent technologies such as IoT have improved the most
conservative diagnostic tools of the last decade, such as
mag- netic resonance imaging, epigenetic, bionics and
neuropsy- chological tests [9]. Bionics, for example, is
improved by IoT sensors to collect patient data from around
the world and use big data analysis to efficiently diagnose
psychiatric dis- eases [10].
IoT offers innovative solutions to promote more efficient
approaches in the domain of Active and Healthy Ageing
(AHA) and has gained a great momentum as a key enabling
technology for a wide range of applications and helps older
adults to live independent lives. Monitor health status, offer
wellness interventions and provide alert and information
ser- vices are examples of how IoT is involved in the
promotion of AHA [11].
Globally, more than a third of the population suffer from
mental disorders, including 35.6 million with Alzheimer’s
disease and other types of dementia, a figure that is expected
to double by 2030, from 7 to 10 million suffer from the
Parkinson’s disease, 400 million people of all ages suffering
from depression and around 21 million suffer from schizo-
phrenia and other psychoses [12].
These pathologies of mental disorders can have a great
impact on daily life, social and economic status, and the pa-
tients quality of life [13]. Hence, variety of applications en-
abled by IoT is a viable solution for better health care in
patients with this type of disorders. Data from networked
sen- sors, whether used in body or embedded in our living
envi- ronments, originate a positive transformative
amendment within the healthcare landscape [14].
In this paper we present a review state of the art regarding
IoT services and applications in Mental Health diseases,
with the purpose of obtaining an overview of the topic and
propose the development of new IoT applications related to
Mental Health field.
There are similar reviews that base their research on chal-
lenges and use of IoT in Healthcare system [15], as well as
 J Med Syst (2019) 43:11 Page 3 of 6 11
investigate barriers and challenges of wearable patient
moni- toring (WPM) solutions adopted by clinicians in
acute, as well as in community, care settings [16].
The points that will be covered in this paper are as follows:
firstly, the methodology that has been followed to identify
the applications and services of IoT in Mental Health;
secondly, the results obtained from the review and finally,
the discussion and conclusions drawn from the work will
be developed.

Methods

In the present study, were taken into account certain

inclusion and exclusion criteria to develop the systematic
review regard- ing IoT services and applications in Mental
Health. The scien- tific databases used in the review are:
IEEE Xplore, Science Direct, Google Scholar, PubMed and
Web of Science. For searching these databases, the following
key terms were used: BIoT OR Internet of Things AND
(Application OR Service) AND Mental Health^, both in
Spanish and English. These terms are searched in Abstract /
Title / Keywords, from 2008 to the present. In Fig. 1 show
the search strategy used in this research. The selection
process of the papers was carried out in the following way:
reading of titles and abstracts of the results obtained. The
selection criteria to take into account to classify the paper
were the following: 1] Studies of IoT services in Mental
Health. 2] Studies of IoT applications in Mental Health.
3) Studies of IoT architectures in Mental Health. 4) Studies
of IoT protocols in Mental Health. 5) Studies aimed at
Health in general and other types of pathologies are
eliminat- ed. The papers were classified by reading their
abstracts as well as the full paper when necessary; all the
articles repeated in more than one database will be
eliminated. A total 51 pub- lications found 15 were
duplicated or with an irrelevant title for this research, the
remaining 36 studies were read and analysed their
abstracts to see which were of interest, obtaining as a
result 14 documents which gave rise to relevant
Relevant
Selected
studies
studies
identified
for evaluation
in databases (n Excluded studies: duplicates or
= 51) (n = 36) irrelevant titles
(n = 15)

Fig. 1 Flow diagram of the search strategy

Relevant Studies Excluded studies (n = 22):
included in the review (n
= 14) By abstract (n = 5)
By content (n = 13)
By other criteria (n = 4)
 J Med Syst (2019) 43:11 Page 4 of 6 11

contributions. Next, in the following section the most Table 1 Studies of the bibliographic review related to IoT services
relevant works found are shown and the main architectures and applications in Mental Health
and appli-
cations found in the literature are analysed. Authors Year of Study proposal Results
publication

Bnot so Ivascu, 2015 The

anxious^ Manate, & Negru [12] authors present a
Results and discussion participants. multi-agent system
that facilitates remote
This monitoring of elderly
In this section, we present the results obtained in the review approach patients who are
regarding services and applications of IoT in Mental Health provides a susceptible to mental
diseases. better disorders.
IoT has been evolving as new area in the research field. It is Darshan & Anandaku- mar [15] 2015 The
understandi authors present a study
intended that billions of physical objects are equipped with ng of how on the use and
various types of sensors and actuators to Internet through var- smart challenges of IoT in
ious access networks assisted by technologies [15]. The emer- textiles can the health system, and
gence of IoT applied to Health allows to monitor health condi- the review of various
be used to works carried out in
tions of the patient, detect symptoms of diseases in general communicat this area of research
and in this specific case of mental disorders, monitor the e the
disease progress and help doctors to manage medical treatment partici-
[12]. pant’s
The proportion of people suffering from mental disorders reactions to
around the world is increasing. Around 21 million people environmen
suffer from schizophrenia and around 35 million people ts and Alam et al. [19]
from depression. In addition, there are 47.5 million people situations as 2016 Present
suffering from dementia and 60 million people suffering a web of objects-
part of a based ambient assisted
from bipolar disorder [17]. living (AAL)
The lapse of mental health and behavioral conditions is framework and
broad and so is associated cost for people and society in propose a prediction
method for the
gen- eral. In addition to financial costs, these disorders
emergency psychiatric
reduce life expectancy; unlike many other health conditions, state.
years of life lost due to neurological, mental and behavioral
disorders have recently increased, representing a growing
burden that will impose new challenges on the health
system. Hence, the IoT is a viable solution for the
development and improvement of patients quality of life
[18]. Table 1 shows the main results found in the literature
regarding IoT-based services and appli- cations in Mental Lekjaroen et al. [20]
2016 They
Health.
propose an
In [12] the authors, with aim of finding depreciation early application: IoT
signs of health state, evaluate four of the most common Planting, which
mental disorder diseases to find what sensors type can detect consists of a
prototype gardening
specific symptoms in order to create an early warning platform for elderly
system. In this way, system can predict which disease is people with mental
likely to occur by matching some specific symptoms of the health disorders.
Raji,
disease. 2016 They
Jeyasheeli, & Jenitha [21]
develop a real-time
In [22] the authors propose the use of Smart textile and monitoring system
wearable technologies as an integral part of IoT ecologies, of patient’s vital
including those implemented in Mental Health service envi- signs in general
ronments. They propose the protocol of speaking aloud and
creation of a data analysis model to semantically analyze the
transcripts in order to identify Banxious^ and Bnot so
anxious^ participants. The analysis revealed significant
differences be- tween the vocabulary used by Banxious^ and
 J Med Syst (2019) 43:11 Page 5 of 6 11
- The system improves diagnostic accuracy by assigning each
sensor to a specific symptom.

-The results show that healthcare quality and efficiency must be

improve and to respond to widespread public health emergencies
through the acquisition, management, and use of information in health
data using IoT.
- The average accuracy of the psychiatric state prediction was
83.03%, in
addition the new AAL framework and prediction model of psychiatric
emergency mental state can be used as an complement to treatment of
psychiatric patients in the home.
- The results show that application helps the welfare and improves
mental health in elderly.

- The results show that model returns the patient’s vital signs data
whether they are healthy or not.
 J Med Syst (2019) 43:11 Page 6 of 6 11

Table 1 (continued) Table 1 (continued)

Authors Year of Study proposal Results Authors Year of Study proposal Results
publication publication

and with mental disorders, for this From this state, digital psychiatry
they use portable sensors. patient takes studies.
medicines to detect Cosma et al. 2017 The authors - The results
early diseases. [22] propose the use of Smart textile provide a better
- The system and wearable technologies as an understanding of
allows high-risk integral part of IoT ecologies, how smart
patients to be including those implemented in textiles can be
controlled on Mental Health service used to
time and environments communicate the
2016 The authors present improve their 2017 The authors participant’s
a device to detect certain quality of life. propose a health architecture based reactions in
Sahu & parameters of brain waves, such - This research on an analysis of energy terms of
Sharma [9] as alpha, beta, delta, etc., and found a harvesting for health monitoring environments and
judge the mental state behavior. promising sensors and the performance of situations.
technique to Babar et al.
reduce [23] - The results show
complexities and the effectiveness
develop a of
general eHealth energy-harvesting
device, which based IoT in
could be further healthcare; and
modified with propose a solution
IoT applications. for smart health
monitoring
Zois [2] 2016 The authors present - The results show Big Data analytics in healthcare and planning.
an overview of the models that are expected to several models 2017 They propose a
support proactive, preventive and personalized that allow system design, which works on
healthcare along with associated solution optimal and Hayati & basis of IoT LoRa, to track and - The results show
techniques sequential Suryanegar- a monitor patients with mental that proposed
They highlight several challenges and decision making [17] disorders. design is
opportunities that arise during the realization of within the feasible in terms
smart and connected healthcare IoT. context of IoT 2017 They propose the of LoRa
healthcare. depression index service using network
knowledge-based crowdsourcing performance
within a smart health platform viability, power
that uses IoT. battery and
Kim & Chung scalability.
[24] - The results show
that it is flexible
service to which
the context
information of
users is applied
and contributes
to the user’s
Aledavood et 2017 The authors - The results show decision making.
al. [13] identify the most important the key design McWhorter, 2017 They propose a - The system has
features for designing a digital features: Brown, & system that monitors nightmares the potential to
platform for data collection for flexibility of Khansa [25] signs, tries to suppress them or positively affect
mental health studies, and to access control, awakens the patient slowly if it is millions of
demonstrate a prototype platform flexibility of not successful, thus improving people with
that they built on the basis of data sources and the patients quality of life post-traumatic stress
these design features. privacy suffering from disorder and reduce
protection of post-traumatic stress disorder. depression and
first order. suicide rates using
- Demonstrated IoT.
how the
incorporation of
these design
principles opens
up new
possibilities for
 J Med Syst (2019) 43:11 Page 7 of 6 11

person-centered approach to intelligent development of textile we know it, reducing costs, inefficiencies and saving lives.
design and services with service providers of Mental Health.
In [9] the authors present a device to detect certain param-
eters of brain waves such as alpha, beta, delta, etc., to judge
the mental state behavior. Using this new approach, several
factors such as attention, stress, breathing index can be
judged efficiently. This research found a promising
technique to re- duce complexities and develop a general
eHealth device, which could be further modified with
Internet of Things (IoT) applications. Therefore, it can be
concluded that this system will help to make electronic
health more compatible
with cost and utility.
Based on the results obtained, it is expected that models
with portable detection technology and intelligent living
envi- ronments will transform current health care practices
by allowing continuous monitoring in real-time of patients
and personalized treatments and interventions that
significantly limit medical visits and associated costs [2].
The new IoT technologies promise enormous potential
benefits in the provision of intelligent health services,
howev- er, it still faces many challenges such as: IoT final
terminals, capacity to process massive data and creation of
networks in order to achieve reliable performance and
effective [23]. The large data volume generated by physical
and virtual devices is also one of these major challenges
since efforts are required to process and analyze said data in
order to implement smart health services [8].
The categories of possible psychiatric biomarkers in- clude
genetics, proteins or other molecules, or neuroim- aging
findings. With rapid emergence and acceptance of digital
technologies, alternative measures of mental state and
behavior are being developed for detection, diagnosis and
monitoring [1, 26].
While physical and mental deterioration is part of healthy
ageing process, premature decline may be an early indicator
of more serious conditions, such as Alzheimer’s disease.
Early detection of risks related to a specific health condition
can help physicians implement appropriate interventions
that can slow the progression of disease itself, with
beneficial effects on the patients quality of life and
treatment costs [27].
The primary computational objectives include
multimodality and interaction modeling, as well as behavior
prediction. If we can overcome engineering obstacles, we
can provide lasting scientific advances and translational
impact in mental health domains [18].

Conclusion

The convergence of information technologies and medicine,

such as medical informatics, will transform medical care as
 J Med Syst (2019) 43:11 Page 8 of 6 11
The purpose of this review was to provide an overview of Int. Conf.
state of the art in research on IoT services, applications and
architectures in Mental Health diseases. The studies found
show the benefits of IoT in Mental Health as well as
applica- tions and architectures developed to improve the
patient’s quality of life with this type of disorder.
Exposed the results achieved in this review where the
existing publications were analyzed in the last 10 years,
taking into account the studies referring IoT services and
applications in Mental Health diseases, we propose as a
future work devel- op a new IoT service in Hospital
Zamora, Spain. Firstly, this service will be focused to
patients with dementia.

Acknowledgements This research has been made within the

Program BMovilidad Investigadores UVA-BANCO SANTANDER
2018^, and it has been partially supported by European Commission
and the Ministry of Industry, Energy and Tourism under the project
AAL-20125036 named BWetake Care: ICT- based Solution for (Self-)
Management of Daily Living^.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no conflict of

interest.

Ethical Approval This article does not contain any studies with
human participants or animals performed by any of the authors.

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 JOURNAL OF MEDICAL INTERNET RESEARCH Kemp et

Review

Delivery of Compassionate Mental Health Care in a Digital

Technology–Driven Age: Scoping Review

Jessica Kemp1,2*; Timothy Zhang1,2*; Fiona Inglis3, MA, MI; David Wiljer3,4,5, PhD; Sanjeev Sockalingam3,6, MD,
MHPE; Allison Crawford3,6, MD, PhD; Brian Lo2,3,5, BHSc, MHI; Rebecca Charow4,5, MSc; Mikayla Munnery5,7,
BCom; Shuranjeet Singh Takhar5, BSc, MSc (oxon); Gillian Strudwick2,5,7, RN, PhD
1
Faculty of Science, University of Waterloo, Waterloo, ON, Canada
2
Information Management Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
3
Office of Education, Centre for Addiction and Mental Health, Toronto, ON, Canada
4
Education Technology and Innovation, University Health Network, Toronto, ON, Canada
5
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
6
Department of Psychiatry, University of Toronto, Toronto, ON, Canada
7
Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
*
these authors contributed equally

Corresponding Author:
Gillian Strudwick, RN, PhD
Campbell Family Mental Health Research Institute
Centre for Addiction and Mental Health
1001 Queen St W Toronto,
ON, M6J 1H4 Canada
Phone: 1 4165358501 ext 39333
Email: gillian.strudwick@camh.ca

Abstract
Background: Compassion is a vital component to the achievement of positive health outcomes, particularly in mental health
care. The rise of digital technologies may influence the delivery of compassionate care, and thus this relationship between
compassion and digital health care needs to be better understood.
Objective: This scoping review aimed to identify existing digital technologies being used by patients and health professionals in
the delivery of mental health care, understand how digital technologies are being used in the delivery of compassionate mental
health care, and determine the facilitators of and barriers to digital technology use among patients and health professionals in the
delivery of compassionate mental health care.
Methods: We conducted this scoping review through a search of Cumulative Index to Nursing and Allied Health Literature,
Medical Literature Analysis and Retrieval System Online (MEDLINE), MEDLINE In-Process and EPub Ahead of Print,
PsycINFO, and Web of Science for articles published from 1990 to 2019.
Results: Of the 4472 articles screened, 37 articles were included for data extraction. Telemedicine was the most widely used
technology by mental health professionals. Digital technologies were described as facilitating compassionate care and were
classified using a conceptual model to identify each digital intersection with compassionate care. Facilitators of and barriers to
providing compassionate care through digital technology were identified, including increased safety for providers, health care
professional perceptions and abilities, and the use of picture-in-picture feedback to evaluate social cues.
Conclusions: Implementing digital technology into mental health care can improve the current delivery of compassionate care
and create novel ways to provide compassion. However, as this is a new area of study, mental health professionals and
organizations alike should be mindful that compassionate human-centered care is maintained in the delivery of digital health
care. Future research could develop tools to facilitate and evaluate the enactment of compassion within digital health care.

(J Med Internet Res 2020;22(3):e16263) doi: 10.2196/16263

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KEYWORDS
compassion; mental health; medical informatics; psychiatry; health information technology; nursing informatics
Introduction
Background
The use of digital technology in mental health care delivery has
increased significantly in recent years [1-5]. Improved patient
access to mental health services is a common metric used to
endorse the use of technology in mental health care through
technologies such as telepsychiatry [6]. Owing to the emerging
uptake and expansion of digital technologies into a variety of
traditional and nontraditional care settings, such as in-home
use of digital technologies or the provision of care in virtual
environments, there exists a greater need to understand best
practices surrounding digital technology use to ensure quality
patient-centered care is delivered through these modalities [7-
11]. Fostering the delivery of compassionate care has been
identified as an important need because compassion has been
shown to positively influence the experience of both patients
and health professionals alike [7]. Without an adequate
understanding of the best practices and uses of digital
technology for the delivery of compassionate mental health
care, these technologies may detract from compassionate care
and hinder health professional-patient relationships, which are
of great importance in the context of mental health care.
However, when employed appropriately, these same
technologies may facilitate and strengthen compassionate
mental health care and create new means for relationships
between mental health professionals and patients [12].
Compassion in Health Care
Compassion encompasses a wide array of meanings [13,14].
The working definition of compassion used for the purpose of
this review defines five dimensions of compassion: (1)
awareness of another’s experience of suffering or need, (2)
feeling moved, (3) recognizing this feeling as a response to the
other’s need, (4) making a judgement that the other is
suffering, and (5) engaging in a behavior in an attempt to
alleviate the suffering [15]. The importance of compassion in
mental health care is central; for many patients, receiving
compassionate care throughout the process of diagnosis,
treatment, and recovery can improve their perceived quality of
care [16-18]. When compassion is present in mental health care
settings, there can be a greater therapeutic alliance (the quality
of the relationship between provider and patient), increased
openness of the patient which improves health professionals’
understanding of a patient’s experiences, and greater
experiences of empathy as part of the health professional-
patient relationship, ultimately supporting patient-centered care
[17-22].
Delivery of Compassionate Mental Health Care
The delivery of compassionate mental health care can take
many forms, with the foundation being to remain patient
focused, establishing interactions based on trust, and ensuring
physical and emotional safety [23]. Compassionate care may be
subjectively experienced; however, the literature suggests that
it is commonly delivered by providing safe and comfortable
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spaces for health professional-patient interactions and is rooted
in an understanding by health professionals of the lived
experiences of patients [19,24,25]. It is important to recognize
that not all patients will experience the feeling of compassion
or build a compassionate relationship in the same way;
however, digital technology has the potential to meet a wide
range of patient needs and provide more personalized care due
to the adaptability of technology [26].
Digital Technology Use and Compassionate Mental
Health Care
Many digital technologies are currently being used in mental
health care contexts, including (but not limited to) mobile apps,
patient portals, electronic health records (EHRs), instant
messaging, telemedicine, and virtual reality [27]. This review
arose out of the motivation to understand what is known about
the suitability of these technologies for facilitating or
enhancing compassionate care and whether any evidence can
guide best practices for use.
Purpose
The purpose of this review was to identify the ways in which
compassionate care can be delivered in mental health care
through and with the use of digital technologies, as well as
across the continuum of mental health care settings and
processes. To develop an understanding of the intersection
between digital technology and compassionate mental health
care, this review examines 3 research questions (RQs):
1.
What existing digital technologies are most commonly
used among patients and/or health professionals in the
delivery of mental health care?
2.
How are existing digital technologies being used among
patients/health professionals in the delivery of
compassionate mental health care?
3.
What are the perceived facilitators of and barriers to using
digital technology among patients and/or health
professionals to deliver compassionate mental health
care?
Methods
Overview
This review was conducted following the methodological
framework for scoping review studies proposed by Arksey and
O’Malley [28] and refined by Levac et al [29]. To illustrate the
scoping review process, the Preferred Reporting Items for
Systematic Review and Meta-Analysis (PRISMA) diagram [30],
shown in Figure 1, was used as well as the PRISMA-scoping
review checklist which outlines the key milestones of a scoping
review [31] (Multimedia Appendix 1). A detailed protocol for
this scoping review titled Delivery of Compassionate Mental
Health Care in a Digital Technology-Driven Age: Protocol for
a scoping review was published in BMJ Open [32]. The
following sections provide a brief overview of the methodology
utilized in this scoping review.
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Figure 1. Preferred Reporting Items for Systematic Review and Meta-Analysis flow diagram of scoping review results.

Stage 1: Identifying the Research Questions Stage 2: Identifying Relevant Studies

For the purpose of this scoping review, the aforementioned All types of research studies including quantitative, qualitative,
RQs were identified to better understand the delivery of observational, and literature reviews from any country of origin
compassionate mental health care through and with the use of published in English from 1990 to 2019 were included. Given
digital technology. the nature of the topic being investigated, grey literature was
not included. All areas of mental health care, diagnoses, digital
technologies used, and age groups were included. Studies were
selected if they addressed at least 1 of the 3 RQs and involved
the use of digital technology in mental health care in relation
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to compassionate care. As compassion is a difficult concept to
define, the working definition of compassion described earlier
was used to guide the identification of eligible articles
involving compassionate care. Although all types of digital
technology were eligible, some imaging and measurement
technologies such as those intended to measure emotion, blood
pressure, or conduct body scans were excluded [32].
A total of 5 databases were searched: Cumulative Index to
Nursing and Allied Health Literature, Medical Literature
Analysis and Retrieval System Online (MEDLINE),
MEDLINE In-Process and EPub Ahead of Print, PsycINFO,
and Web of Science. A research librarian (FI) completed the
search strategy and database searches. As a part of working
with a librarian, extensive use of synonyms, Boolean operators,
combinations of search terms, and MeSH headings were
employed. The complete search strategy for MEDLINE is
available in the published protocol for this scoping review [32].
Stage 3: Study Selection
All identified articles were screened independently by 2
reviewers (TZ and AM), concluding with an interrater
reliability of 99.22% agreement and a Cohen kappa of 0.59.
Disagreements which could not be resolved between TZ and
AM were discussed with the greater research team, as outlined
in the study protocol [32]. The screening process was
facilitated by Covidence (Veritas Health Innovation), a
literature review streamlining software recommended by
Cochrane [33].
While identifying the relevant studies for the scoping review
through the screening process, the authors selected articles that
either directly facilitated the delivery of compassionate care or
prepared for the delivery of compassionate care while addressing
1 or more of the 5 dimensions of compassion. It is important to
note that compassion was not always explicitly brought up in
some articles and the professional judgement of the authors had
to be used to identify appropriate studies. Upon further
research and completion of data extraction, it was evident that
there was a greater divide among the relevant studies. The
authors chose to use the digital intersections with compassion
to further clarify the role/dimension each technology played in
the delivery of compassionate care.
Stage 4: Data Items and Data Collection Process
During the process of data extraction, the following article
summary information was charted: title, authors, year of
publication, country of origin, research design, RQs addressed,
and answers to the applicable RQs. Data were charted using
Microsoft Excel 2010. The data extraction table is available
upon request from the corresponding author.
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Stage 5: Synthesizing and Reporting the Results
Both quantitative and qualitative methods were used to analyze
the results of the RQs. A descriptive quantitative analysis
(descriptive statistics) was used for RQ1, and a qualitative
content analysis was used for RQ2 and RQ3. To understand
what existing digital technologies are most commonly used
among patients and health professionals in the delivery of mental
health care, the results of RQ1 were organized using the World
Health Organization’s (WHO) classification of digital health
interventions v1.0 [34]. This classification system organizes
digital technologies used in health care based on the user of
each intervention.
Stage 6: Consultation
The consultation phase for this review was completed through
discussions with mental health and digital health researchers,
mental health professionals, and various health care
professionals in Ontario, Canada, selected through the
Associated Medical Services (AMS) health care community.
More specifically, these stakeholders were consulted at
Waypoint Centre for Mental Health Care, the Centre for
Addiction and Mental Health, the University of Toronto, and
Western University. The consultation process was important for
the organization of results and to ensure the strategies used for
knowledge translation were appropriate. These discussions also
supported the identification of important topics to include in
the Discussion section of this paper.
Results
Search Results
A total of 37 articles were included in the final review. Details
regarding the screening process are described in Figure 1.
Study Characteristics
Table 1 describes the characteristics of the studies included in
this review. Studies were identified from 7 countries with 57%
(21/37) of these publications originating from the United
States. Given the novelty of digital technology use in mental
health care, 51% (19/37) of articles were published between
2016 and January 2019. A research focus on a specific mental
health diagnosis was uncommon in the selected articles; only
27% (10/37) of the articles were related to a specific diagnosis.
Articles that did not specify a mental health diagnosis, and
rather addressed mental health care as a single entity or did not
specify the diagnoses of patients, were categorized as
unspecified. Table 1 also includes the methods that were used in
the identified articles.
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Table 1. Study characteristics.
Article characteristics Value (N=37), n (%) References
Country of publication
United States 21 (57) [24,35-54]
United Kingdom 8 (22) [19,20,55-60]
Australia 4 (11) [61-64]
Canada 1 (3) [65]
China 1 (3) [66]
Israel 1 (3) [26]
The Netherlands 1 (3) [67]
Research method

Literature review 16 (43) [20,26,37,40,42,44-48,50,54,62-64,67]

Questionnaire/survey 8 (22) [24,49,52,53,56,61,65,66]
Mixed method 5 (14) [35,55,57-59]
Semistructured interview 4 (11) [38,41,43,60]
a 4 (11) [19,36,39,51]
Other

Year of publication
2016-2019 19 (51) [24,38,40,41,47-55,57,59,61,64-66]
2010-2015 13 (35) [19,20,26,35,37,43-45,56,58,60,62,67]
2000-2009 5 (14) [36,39,43,46,63]
b
Mental health diagnosis

Unspecified 27 (73) [20,24,26,35,37-48,50,54,55,57,59,62-67]

Schizophrenia and psychosis 3 (8) [51,53,61]
Anxiety and depression 3 (8) [19,52,58]
Trauma and stress disorder 2 (5) [36,49]
Alzheimer and dementia 2 (5) [56,60]
Addictions/substance use 0 (0)
—c
Developmental disabilities 0 (0) —
Problem gambling 0 (0) —
Mood and personality disorders 0 (0) —

a
Other research methods include group therapy sessions and personal essays written by health professionals.
b
Categories of mental health diagnosis based on the Centre for Addiction and Mental Health’s Mental Illness and Addiction Index [68].
c
No articles were identified.

comprises personalized information that is delivered to

Research Question 1: Digital Technology Use in Mental individuals or groups of patients from health professionals and
Health Care can be unidirectional (a message can only be sent by the health
Of the 37 articles, 15 [19,24,39,41,42, 45,46,48,51,52,57,58, professional; patients do not have the option to reply) or
64-66] and 22 [20,26,35-38,40,43,44,47,49,50,53-56,59-63,67] bidirectional (patients can reply to messages from the health
articles were specific to digital technology usage by patients professional) [69]. It is important to note that the definition of
and health professionals, respectively. Patient and health this category proposed by the WHO is only limited to
professional digital health interventions were then divided into unidirectional communication from the health professional
detailed categories, as shown in Table 2. On-demand [34]. Some examples of targeted patient communication
information services were the most common digital technology observed in this review included humanoid animated agents
used by patients (eg, educational resources), including websites (computational artifacts used to develop human-like
[52,65], mobile phones [51], and apps [57,64,66]. Targeted relationships with patients through the development of trust,
patient communication technologies [19,24,39,45] had the rapport, and therapeutic alliance [45]) used for the purpose of
second highest frequency among patients. This category computerized cognitive behavioral therapy (CBT) [45], email
communication [39], and
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websites [24]. In all, 2 articles included examples of patient-to-

(providing health care from a distance through the use of
patient communication via digital technology, including online technology [34]) made up 78% (17/22) of all types of digital
peer-support groups and chatrooms [42,46]. Personal health health interventions used by health professionals
tracking interventions included patient portals and EHRs, with [20,26,35,36,38,40,44,47,50,54-56,59,62,6367]. In this review,
the primary function of self-monitoring [41,48]. Untargeted telemedicine was observed through the use of videoconferencing
patient communication (generalized communications distributed [20,26,36,38,40,44,50,54,62,6367], apps [47], telephone
to a large patient population in which all recipients receive communication [55], gaming [35,56], and virtual reality
identical messages [34]) was the least common digital health [20,59] to provide patient care. Digital technology was also
intervention, consisting of a computerized CBT program with a commonly used among health professionals for training
singular set of responses generated for all users [58]. purposes through the use of virtual reality [53,60,61] and apps
There were 22 cases of digital health interventions being used [49]. The last digital health intervention used among health
by health professionals including telemedicine, health professionals included in this review was the use of EHRs
professional training, and patient health records. Telemedicine during patient appointments [43].

Table 2. Digital health interventions.

a
The World Health Organization classification of digital health interventions Frequency References
1.0 Patients 15
—b
1.1 Targeted patient communication 4 [19,24,39,45]
1.2 Untargeted patient communication 1 [58]
1.3 Patient to patient communication 2 [42,46]
1.4 Personal health tracking 2 [41,48]
1.5 Citizen-based reporting 0 —
1.6 On-demand information services to patients 6 [51,52,57,64-66]
1.7 Patient financial transactions 0 —
2.0 Health Professionals 22 —
2.1 Patient identification and registration 0 —
2.2 Patient health records 1 [43]
2.3 Health professional decision support 0 —
2.4 Telemedicine 17 [20,26,35-38,40,44,47,50,54-56,59,62,63,67]
2.5 Health professional communication 0 —
2.6 Referral coordination 0 —
2.7 Health worker activity planning and scheduling 0 —
2.8 Health professional training 4 [49,53,60,61]
2.9 Prescription and medication management 0 —
2.10 Laboratory and diagnostics imaging management 0 —

a
The WHO classification system terminology employs clients and health care providers; in the context of this review, patients and clients will be
interchangeable as well as health care providers and health care professionals.
b
No articles were identified.

of compassionate mental health care. This model illustrates the

Research Question 2: Delivery of Compassionate intersections between the 6 main components of compassionate
Mental Health Care Through and With Digital care and digital technology [70]. An additional category was
Technology created for the purpose of this review to account for articles
Owing to the subjectivity of the definition of compassionate that proposed digital technology use in mental health care may
care, a conceptual model titled Digital Intersections with detract from compassionate care (Table 4).
Compassionate Care, shown in Figure 2 and definitions in
The digital intersections (definitions are included in Table 3)
Table 3, from the textbook chapter Caring in a Digital Age:
addressed in this review include numerous examples of online
Exploring the Interface of Humans and Machines in the
interventions, training and coaching, compassion-oriented
Provision of Compassionate Healthcare [70] was used to
technologies, and artificial emotional intelligence, as shown in
understand and organize the unique roles of digital technology
Table 4.
in the delivery

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Figure 2. Digital intersections with compassionate care. AEI: artificial emotional intelligence.

Table 3. Definitions of the digital intersections with compassionate care.

Digital intersection with compas-
sionate care Definition

Awareness of suffering
Developing an awareness of one’s suffering through the use of digital technology (ie, experiences shared via digital
technology increase awareness of one’s suffering)
Mediated response Online
Utilizing digital technology to mediate or influence one’s response to suffering Responding
intervention Training and
to suffering through an online intervention
coaching
Digital tools used to increase health professional expertise or patient knowledge to ensure the delivery of
compas- sionate care (ie, through digital storytelling, online forums, and messaging systems used to share
knowledge and experiences)
Compassion-oriented technologies
Digital technologies created specifically to assist in or facilitate the delivery of compassionate care
Artificial emotional intelligence
Artificial intelligence used to facilitate compassionate interactions with patients

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Table 4. Digital intersections with compassionate care.
Digital intersection with compassionate care Frequency References
Awareness of suffering 0
—a
Mediated response 0 —
Online intervention 11 [19,20,36,38,40,42,50,57-59,63]
Training and coaching 8 [24,49,51-53,60,65,66]
Compassion-oriented technologies 14 [26,35,37,41,44,46-48,51,54,56,62,64,67]
Artificial emotional intelligence: algorithms of compassion 1 [45]
Detractions from compassionate care 3 [39,43,55]
a
No articles were identified.

Online Intervention Artificial Emotional Intelligence

The development of online interventions to respond to Artificial emotional intelligence use was infrequently
suffering (ie, responding to suffering was a direct goal or result documented in the delivery of compassionate mental health
of the intervention) was observed in 11 articles care but was observed in one instance through the use of
[19,20,36,38,40,42,50, 57-59,63]; this included the use of humanoid animated agents as part of a computerized CBT
online therapy programs [42,57,5863], virtual reality programs program [45]. A humanoid animated agent simulates a face-to-
to portray lived experiences [20,59], email and instant face conversation and utilizes verbal and nonverbal social cues
messaging to respond to patient suffering [19,20], and most to form human-like relationships [45].
commonly, the use of videoconferencing for telemedicine
[20,36,38,40,50]. Detractions From Compassionate Care
A final category was created to distinguish articles that
Training and Coaching
proposed digital technologies that may detract from
Using digital technology to provide training and coaching to compassionate mental health care. A total of 3 articles
increase compassion demonstrates how health professionals [39,43,55] were included in this category and included
can leverage digital technology to better understand the suffering concerns regarding the effect of nonresponses (to email and
experienced by their patients and thus respond appropriately. instant messages) on patients [39], as well as claims from
Virtual reality coaching was often used for health care physicians who felt that relationships equivalent to those
professionals to experience simulated positive symptoms of formed in-person simply could not be achieved through the use
schizophrenia and psychosis [53,61], as well as complex of digital technology [55].
difficulties experienced by patients suffering from dementia
[60]. Additionally, digital training and coaching was also used Research Question 3: Facilitators of and Barriers to
by patients to learn the skills and importance of mindfulness Compassionate Mental Health Care Delivery Through
through mood tracking, tips for overall well-being, and Digital Technology
scheduled reminders to encourage session completion, all of All articles discussed multiple facilitators of and barriers to
which were used to respond to suffering and improve care compassionate mental health care delivery through the use of
[49,52,65,66]. One article discussed digital technology used to digital technology, as shown in Table 5. Facilitators included
provide training to veterans to increase their understanding of feedback on social cues, training/education for health
their mental health notes made accessible to them through a professionals, increased safety, multilevel participation, peer-
patient portal, reducing misinterpretations and improving support, improved accessibility, and optional anonymity.
provider-patient relationships [24]. Barriers included limitations because of health professionals’
Compassion-Oriented Technologies perceptions and abilities, impersonal automated responses, lack
of social cues, effect of non-responses, group size, computer
Digital technologies that were classified as compassion- use during patient encounters, poor quality of technology, and
oriented technologies based on the conceptual model shown in inappropriate uses of technology at various stages of illness.
Figure 2 were the most commonly cited. This digital
intersection with compassionate care involves technologies that Tables 6 and 7 compare functions of digital technologies, as
support compassionate care and are used by health identified in RQ3, and the digital health interventions that
professionals and/or patients, including uses such as shared facilitate each function. The criterion for each category was
gaming time between health professionals and patients to based on the evidence provided in the articles included as part
facilitate bonding time [35,56], mental health apps [26,47,64], of the review; digital health interventions were only confirmed
and patient portals [41,48]. to facilitate a function if specifically mentioned in the
literature. Any facilitated functions that were not applicable to
a particular digital health intervention are indicated as N/A.

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Table 5. Facilitators of and barriers to delivery of compassionate care through digital technology.
Facilitators and barriers
Support
Facilitators
Picture-in-picture functionality
The ability to view oneself on screen while interacting with a patient via videoconferencing; can
allow for the evaluation of one’s own facial expressions and response to social cues [62].
Physical distance Training/education
Patients may feel more at ease when communicating with a health professional through technology
from a distance, and it also provides the opportunity to titrate the experience of distance [44].
Safe for providers Multilevel
Digital technology can be used for training of health professionals as well as to convey lived expe-
riences [53,60].
participation
Digital technology can allow health professionals to provide care without safety concerns in settings
such as prisons [38,59].
Social/peer-support connections
Some digital health interventions allow users to simply observe functionalities with no mandatory
participation, allowing for an easier transition into care [46].
Convenience/accessibility Increased
Technology connects users to people with shared experiences, creating feelings of understanding
and connectedness [42,46].
privacy/anonymity
On-demand use and the ability to reach rural and remote areas through the use of technology
[36,42,50,54,62].
Barriers
Technology can allow for increased privacy and, in some cases, complete anonymity; this may de-
Health professionals’ perceptions and abili- ties crease feelings of judgement and reduce stigma for patients [46,64].
Impersonal Lacking social
cues Some health professionals are reluctant to integrate technology into patient care because of
personal perceptions and abilities [24,44].
Nonresponses Group Users may receive similar resources from apps despite varying mental health concerns [42].
size The use of email and instant messaging does not allow the user to convey or evaluate tone of voice
or facial expressions [19,39,42].
Use of computers during patient encounters Patients may feel neglected because of nonresponses to emails and/or instant messages [19].
Online self-help groups comprising large numbers of users may decrease attentiveness to patient
Quality of technology needs and detract from individual compassionate relationships [46].
Obstructive positioning of computers used by health professionals during a patient encounter may
Stage of illness lead to disengagement and distraction [43].
Issues with lagging, audio problems, and poor video quality can affect the patient experience during
videoconferencing used to provide telemedicine [67].
The use of some types of digital technology may only be appropriate for specific stages of illness
or mental illnesses (ie, not appropriate for a crisis situation) [51].

Table 6. Comparison of facilitated function and associated digital health intervention.

Digital health intervention
Facilitated function
Evaluation of social Physical dis- Personalized care Training for health profes- Increased safety
cues tance sionals
Telemedicine
Personal health tracking Targeted
client communication Untargeted
client communication Client health
records
a
N/A
On-demand information services to
clients
Health care provider training
N/A
Client-to-client communication
N/A
a
Not applicable.

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Table 7. Comparison of facilitated function and associated digital health intervention.
Digital health intervention
Facilitated function
Multilevel partici-
pation
Telemedicine
a nonresponses N/A
N/A
Personal health tracking
Targeted client communication
Untargeted client communication
Client health records N/A
On-demand information services to clients
Health care provider training N/A
Client-to-client communication
a
Not applicable.
Discussion
Digital Technology Use in Mental Health Care
This review sought to examine the relationship between the
emerging use of digital technology and its effect on the
delivery of compassionate care in a mental health context
through 3 RQs. Implications are discussed as follows in light of
the findings.
In addition to the primary findings that technologies are widely
incorporated into mental health care, with an emphasis on
health care delivery methods such as telemedicine (Table 3),
the majority of digital technologies examined in the identified
articles were not targeted toward a particular mental health
diagnosis (Table 2). This finding may be because of the fact
that some interventions commonly facilitated through digital
technologies are applicable to multiple mental health
diagnoses. For instance, while the use of CBT has typically
been associated with the treatment of anxiety and depression,
existing research has established that it can also be effectively
tailored to treat other anxiety disorders (eg, phobias and panic
disorder), schizophrenia, trauma-related disorders, and bipolar
disorders [71]. A computerized CBT intervention would thus
be classified as unspecified because users with a wide variety of
needs may be able to access support and benefits through the
same platform. However, emphasis should be put on the fact
that such increased reach would not be possible without the
delivery medium of digital technology. Similarly, the high
prevalence of telemedicine use, observed in this review (Table
3), is also used as a medium to deliver varying types of mental
health care rather than standing as a tailored intervention for a
specific diagnosis in itself. The relatively high representation of
mental health care delivery methods as opposed to specifically
tailored mental health interventions for a diagnosis in relation
to compassionate care may be an indication of the current
infancy of the state of this area. Future research will be
required to understand if the delivery of compassionate care
through digital technologies varies depending on the mental
health diagnosis of patients. Further, future research
methodologies should include economic analysis to understand
the return on investment of delivering compassionate care
between mental health treatment needs.
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Risk of Peer support Accessibility Reduced stigma
N/A N/A
N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A
Digital Technologies Enabling Compassionate Care
The evolution of digital technologies is fueling the emergence
of new types of health interventions. Although the decrease of
the in-person experience may have been associated with a
reduction in compassionate care [39,43,55], there are instances
where a long-distance delivery of mental health care provides
an improved experience for both the health care professional
and patient. This review was able to substantiate that compassion
is often a core aspect of digital health delivery. In fact, these
new modes of intervention enable novel enactments of
compassion and means to teach or train health care
professionals to provide compassionate health care which
would not be previously possible without digital technology.
For example, for individuals requiring mental health care in
correctional facility settings, escorted transportation to a
satellite care site or conducting care in a monitored, secure
meeting area with physical barriers may hinder the ability to
build a compassionate relationship [38]. Leveraging
telemedicine in situations such as this can not only cut down on
resource use but also provide a more comfortable environment
for both the patient and the health care professional, without
which it would be difficult to deliver compassionate care [38].
In addition to areas of opportunity for improved patient
experiences, emerging tools are also enhancing health
professional education in fostering the delivery of compassionate
care in practice. For instance, Ozelie et al present an immersive
virtual reality system which offers learning through shared
experiences by providing insight into the experience of a
person with schizophrenia through simulated hallucinations
[53]. This initiative is greatly in line with existing research that
demonstrates such access to lived experiences is a highly
valued resource, as shared experiences are inherently different
from simply speaking or hearing about the experiences of
persons with mental illness [72]. Lived experience is
foundational to building relationships with others in recovery,
particularly in peer-delivered services [72]. Vividly
experiencing even a small portion of their patients’ experiences
can allow health care professionals to better understand the
patient perspective, contributing to their awareness of another’s
experience of suffering or need.
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Concurrently, the use of virtual reality also potentially presents Future Steps
itself as a natural advancement in telemedicine. Moving
beyond the limitations of a 2D computer screen, virtual reality Ultimately, the successful use of digital technologies to
can allow for a more in-person experience while still facilitate compassionate mental health care requires health care
capitalizing on the benefits of long-distance care [12,20,37,61]. organizations to invest the time and resources to leverage
However, unique considerations in the delivery or enablement implementation science. In addition, health care professionals
of compassionate care specifically through virtual reality need to adapt to environmental and contextual factors to
remains an area for future exploration. appropriately choose technologies to meet needs at the levels of
patient, organizational, and population health needs. Future
Digital Technologies Detracting From Compassionate research should focus on expanded implementation of digital
Care technologies in mental health care and identifying both
In all, 3 studies identified in this review depicted digital technologies and specific settings where compassionate care
technologies as detracting from compassionate care [39,43,55]. would not be possible without digital technology. This
The articles that did discuss this aspect focused on the use of information can then be used by digital technology developers
provider-based technologies (based on the WHO Classification and institutions to inform the creation and development of
of Digital Technologies), and primarily gathered information technologies that result in the best outcomes for both health
from the provider perspective. A greater understanding of care professionals and patients. Furthermore, identifying how
provider and patient differences in their experiences and to teach health care professionals to meaningfully use
perceptions surrounding the role of digital technology in health technologies in ways that convey compassionate care should be
care is necessary to fully understand the role of digital explored.
technologies in contributing to compassionate care in practice. In addition, future knowledge translation plans include
Considerations for Digital Technology Implementation traditional techniques such as presenting at conferences and
giving lectures to those practicing in the mental health field.
Tables 6 and 7 present a summary of facilitators and barriers Other plans include engaging practicing mental health
associated with each type of digital technology identified in professionals and students in a discussion about the topic to
this review. To our knowledge, this is the first review of its increase awareness of digital compassion.
kind to appraise digital technologies in relation to
compassionate care. Given the limited resources available at Conclusions
health system and organizational levels, investing in This review’s inquiry into the intersectionality between
implementing a new digital technology can be a significantly contemporary digital technology and compassion is a highly
resource-intensive undertaking. This summary can aid in the relevant and emerging topic, particularly in mental health care.
evaluation of digital technologies to ensure decision makers are The current state of digital technology in mental health care
investing in technologies that are aligned with organizational lends itself well to facilitate compassionate care delivery,
values and principles that relate to the provision of person- particularly when used to serve patients who may not have had
centered and compassionate care, and help to audit existing the chance to receive health care previously, or who may be
technologies in relation to delivering compassionate care. uncomfortable or restricted in direct face-to-face interactions.
Limitations Although there is still much to understand and uncover, health
care organizations and professionals must consider the
Owing to the nature of scoping reviews, the quality of each advantages and limitations of each type of digital technology
identified article was not assessed. Although every effort was for practice, particularly at this time where the discussion is
made to ensure all articles which may involve compassion in only at its outset. As technology inevitably continues to diffuse
mental health care were included, the subjective nature of throughout mental health care, these considerations alongside
compassion may mean some articles were not captured in this patient feedback will be instrumental to ensure that digital tools
review. As both compassion and the intersection between are, and continue to be, aligned with provider and patient
digital technologies and compassion are relatively understudied needs. Ultimately, compassion and the integration of digital
fields, the models leveraged in this review to classify the types technology in mental health care should be seen as vital and
of technologies identified may not be the appropriate complementary aspects of obtaining the best patient outcomes,
taxonomies of organization. Grey literature was also omitted in as mediums to accentuate meaningful human connections
this review. rather than inanimate products of modern innovation.

Acknowledgments
This work was made possible through funding from the AMS Healthcare Phoenix Fellowship program. The authors would like
to thank Alicia Morgan for supporting the screening of articles for this review, and to the various stakeholders at Western
University, University of Toronto, Waypoint Centre for Mental Health Care, and the Centre for Addiction and Mental Health for
their ideas, thoughts, and lively discussion regarding the findings of this review. Additional data access may be granted through
reasonable request to the corresponding author.

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Authors' Contributions
This work was first conceived by GS and DW. Article identification and screening was led by TZ, and data extraction was led
by JK. TZ and JK co-led manuscript writing with significant contribution from all authors in editing and revisions, particularly
from SS, AC, and DW in the Results and Discussion.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Preferred Reporting Items for Systematic Review and Meta-Analysis—Scoping Review Checklist for Scoping Review. [DOCX
File , 15 KB-Multimedia Appendix 1]

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72. Marino CK, Child B, Krasinski VC. Sharing Experience Learned Firsthand (SELF): Self-disclosure of lived experience
in mental health services and supports. Psychiatr Rehabil J 2016 Jun;39(2):154-160. [doi: 10.1037/prj0000171]
[Medline: 26653777]

Abbreviations
AMS: Associated Medical Services CBT:
cognitive behavioral therapy EHR: electronic
health record
MEDLINE: Medical Literature Analysis and Retrieval System Online PRISMA:
Preferred Reporting Items for Systematic Review and Meta-Analysis RQ: research
question
WHO: World Health Organization

Edited by G Eysenbach; submitted 15.09.19; peer-reviewed by T Risling, I Mircheva, A Younas; comments to author 14.11.19;
revised version received 19.11.19; accepted 14.12.19; published 06.03.20
Please cite as:
Kemp J, Zhang T, Inglis F, Wiljer D, Sockalingam S, Crawford A, Lo B, Charow R, Munnery M, Singh Takhar S, Strudwick G
Delivery of Compassionate Mental Health Care in a Digital Technology–Driven Age: Scoping Review
J Med Internet Res 2020;22(3):e16263 URL:
https://www.jmir.org/2020/3/e16263 doi:
10.2196/16263
PMID: 32141833

©Jessica Kemp, Timothy Zhang, Fiona Inglis, David Wiljer, Sanjeev Sockalingam, Allison Crawford, Brian Lo, Rebecca
Charow, Mikayla Munnery, Shuranjeet Singh Takhar, Gillian Strudwick. Originally published in the Journal of Medical Internet
Research (http://www.jmir.org), 06.03.2020. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly
cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright
and license information must be included.

https://www.jmir.org/2020/3/e16263 J Med Internet Res 2020 | vol. 22 | iss. 3 | e16263 | p.

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RESEARCH ARTICLE Open Access

Young men’s attitudes and behaviour in relation

to mental health and technology: implications
for the development of online mental health
services
Louise A Ellis1*, Philippa Collin2,3, Patrick J Hurley1,4, Tracey A Davenport1, Jane M Burns1,3,5 and Ian B
Hickie1

Abstract
Background: This mixed-methods study was designed to explore young Australian men’s attitudes and behaviour in
relation to mental health and technology use to inform the development of online mental health services for young
men.
Methods: National online survey of 486 males (aged 16 to 24) and 17 focus groups involving 118 males (aged 16 to
24).
Results: Young men are heavy users of technology, particularly when it comes to entertainment and connecting
with friends, but they are also using technology for finding information and support. The focus group data
suggested that young men would be less likely to seek professional help for themselves, citing a preference
for self-help and
action-oriented strategies instead. Most survey participants reported that they have sought help for a problem online
and were satisfied with the help they received. Focus group participants identified potential strategies for how
technology could be used to overcome the barriers to help-seeking for young men.
Conclusions: The key challenge for online mental health services is to design interventions specifically for young
men that are action-based, focus on shifting behaviour and stigma, and are not simply about increasing
mental health knowledge. Furthermore, such interventions should be user-driven, informed by young men’s

Background Camperdown, NSW 2050, Australia

Full list of author information is available at the end of the article
Young men in Australia have poorer mental health than
their female counterparts including higher rates of com-
pleted suicide, antisocial behaviour, and alcohol and
sub- stance misuse problems [1]. Although gender
differences in help-seeking vary according to type of
problem and source of help [2], young men are also less
likely to seek help during adolescence and young
adulthood: only 13% of young men aged 16 to 24 years
seek help when ex- periencing mental health difficulty
compared with 31% of young females [3]. The factors
associated with poorer help-seeking practices in young
men are complex [4]. Young men have poorer mental
health knowledge and higher mental health stigma than
young females [5,6]. Research also suggests that young
men find it difficult to

* Correspondence: louise.ellis@sydney.edu.au
1
Brain & Mind Research Institute, The University of Sydney, 94 Mallett Street,
 Ellis et al. BMC Psychiatry 2013, 13:119
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seek help as a result of culturally dominant (or hege- which positions men as vic- tims of their own behaviour
monic) masculine traits which place an emphasis on [10]. Rather than inherently blaming and therefore
men to be independent, to suppress emotion, and show attempting to ‘re-educate’ young men, it is now being
a lack of vulnerability [7-9]. For example, to be seen to argued that greater focus should be placed on providing
endure pain and to be strong and resilient about health services that are relevant and meet their needs
mental health or emotional problems has been [10-12].
identified as a key practice of masculinity [9].
Furthermore, while these constructions of masculinity
remain relevant, and are a backdrop for men’s illness The Internet as a tool for health service delivery
behaviours, it should not mean that we adopt a view The Internet has become an important tool for young
people seeking health information [13,14]. Young people
© 2013 Ellis et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Ellis et al. BMC Psychiatry 2013, 13:119
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in Australia report they are twice as likely to seek help
from the Internet than a professional [15]. The Internet
has significant advantages as a method of interacting
with young people: it can reach a wide audience; be
accessed 24 hours a day at little or no cost; websites can
be updated frequently; it is interactive; and, can link to
other relevant resources [11,16]. Furthermore, the Inter-
net may address the strong desire for independence and
autonomy in males and provide a non-confrontational
medium through which to seek help [17,18]. A recent
review of online intervention programs for children and
young people found that overall they had beneficial ef-
fects on their health behaviour; though these programs
were generally focussed on improving physical health
out- comes as opposed to mental health outcomes [19].
Two currently available online programs aimed at
improving mental health outcomes, MoodGYM
(www.moodgym. com.au; an interactive cognitive
behavioural therapy pro- gram designed to prevent and
decrease symptoms of depression and anxiety), and
Reach Out Central (ROC; www.reachoutcentral.com.au; an
interactive game utilising cognitive behavioural principles
to develop practical cop- ing skills for dealing with life
stressors and improve men- tal health), have shown
promise in trials with young people [11,20,21]. However,
these studies have highlighted several important
challenges for MoodGYM, ROC and other self-directed
Internet programs; including how to ensure enough of
the program is received and that users remain engaged
with the program, as well as how to enhance the
sustainability of any benefits. Immediate at- tention
needs to be directed to improving usage and ad- herence
rates [21], and new methods need to be explored which
cater for young men’s mental health needs and ex-
pectations [22].
More needs to be known specifically about young men’s
attitudes towards mental health and help-seeking and
their use of technology if we are to create online in-
terventions that attract and engage young men and en-
hance the sustainability of any benefits. Thus, the aim of
the current study was to increase our understanding of
young men’s attitudes and behaviours towards mental
health, online habits and technology use, as well as their
experiences of using the Internet for information, help or
support, so as to inform the development of online
mental health services for young men. The study
addresses two key gaps in the existing literature: (1)
empirical evi- dence of young men’s technology
preferences and their attitudes and experiences towards
online help-seeking for mental health problems; and, (2)
rich qualitative data ex- ploring a wide range of young
male views and experiences in relation to mental health
and help-seeking. Existing studies are typically
quantitative and measure uptake and engagement, or
involve randomised control trials of exist- ing online
interventions [23], and there is little data that
Page 2 of 10
focuses specifically on young men. A combination of quan-
titative and qualitative methods was therefore used allow-
ing the study to examine both the breadth and depth of
young men’s attitudes and experiences.
Methods
Online survey design and sample
A survey was administered online for a three-month
period. Recruitment was achieved via online snow-ball
sampling, leveraging young people’s high levels of Internet
usage and existing social networks. Online sampling was
used as a way of reaching young people who are normally
difficult to access via random-digit dialling or panel
methods, and as a way of reducing social desirability
effects [24]. An advertise- ment was placed on Facebook, a
popular online social net- working site, and participants
were encouraged to promote the survey to their peers, who
then completed the survey and further promoted the study
through their networks. The Facebook advertisement was
specifically targeted to ap- pear on the pages of Australian
Facebook users between the ages of 16 to 24. The survey
was also specifically adver- tised through youth serving
organisations, including youth centres and clinics, online
service providers, charities, col- leges, universities and
relevant government organisations, via a flyer and link to
the survey which was distributed via email. Participants
gave consent online and understood that their
participation was voluntary, confidential and non-
identifiable. This study received ethics approval from The
University of Sydney Human Research Ethics Committee
(Ref No. 11209).
Survey measures
Interests and technology use
Participants were asked about their use of a range of
technologies (eg. computers, playstation, Facebook) over
the past three months (‘yes/no’).
Attitudes and behaviours in relation to mental health
Two sets of questions were selected from a recent na-
tional survey on mental health in Australia [25]. The first
set of questions asked respondents what they would do if
they thought a friend might be experiencing a men- tal
health problem. Respondents were asked how likely it
would be that they would suggest to their friend that they
seek help from particular sources (eg. ‘family’, ‘friends,’
‘websites’, “doctor”), with items being rated on a five-
point Likert scale (1 = ‘very likely’ to 5 = ‘very unlikely’).
The second set of questions asked respondents whether
they have ever talked about their problems on the
Internet (‘yes/no’), and if so, whether chatting with other
people via the Internet helped (‘yes/no’). Finally,
respondents were asked how satisfied they were with the
information/ support they received on the Internet (1 =
‘very dissatis- fied’ to 4 = ‘very satisfied’).
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Technology and mental health consultation with male Youth Ambassadors involved
A set of questions was developed to measure preferences with Australia’s most accessed online youth mental
for receiving mental health information and support health ser- vice (ReachOut.com) and was used for each
through technology. Respondents were asked ‘if you wee focus group to explore the following themes: interests
to access mental health information using technology, and technology use; knowledge of and attitudes towards
how would you want it presented?’ and the options in- help-seeking and mental health; as well as brainstorming
cluded: ‘website with information and/or factsheets’; ‘web- innovative solu- tions to the problems identified. To
site with a question and answer service that sends short address concerns regarding the willingness of participants
message service (SMS) or emails’; ‘website with online to share their per- spectives of sensitive topics in front of
clinic’; ‘interactive single player games teaching life skills’; others, participants were asked to respond individually
‘interactive multiplayer games teaching life skills’; ‘I to questions about mental health by writing their
don’t know’; ‘not a website’; and ‘other’. answers down on a piece of paper. The focus groups were
recorded, transcribed and analysed along with written
notes.
Demographic variables
The survey also included a set of demographic questions
relating to gender, age, location, ethnicity and employ- Data analysis
ment status. The survey data were analysed using the Statistical
Package for the Social Sciences (SPSS 20.0 for Windows,
Focus group design and sample Chicago, USA). Simple linear regression was used to
A total of 17 focus groups were conducted involving 118 investigate whether any significant age differences were
young men. Focus groups were advertised through a selec- present. Age was included as a continuous variable and a
tion of youth serving organisations, including youth cen- p-value of less than 0.05 was considered statistically
tres and clinics, schools, TAFEs, universities and significant. The focus group data was analysed
businesses that hire young people, via a flyer. The sample thematically using complete tran- scripts of each session.
was purpo- sive in that it was deliberately designed to Separately, two researchers with prior qualitative research
be diverse in terms of age (16 to 24 years), location experience systematically coded the transcripts applying
(multiple states), ethnicity, and level of education (see brief verbal descriptions to small chuncks of data, and
Table 1). then identified themes which inte- grated substantial sets
Each focus group involved four to 10 males and lasted 60 of these codings. The results were then compared and
to 90 minutes. A schedule of questions developed in discussed until the generated themes were agreed upon
[26]. This procedure was applied to

Table 1 Location, profile and age ranges of 17 focus groups run nationally across Australia
Location Profile Age range in years (mean)
Sydney, NSW Graduate employees at a leading accounting firm 22-24 (23.0)
Gosford, NSW Local teenagers who occasionally use the youth centre 16-19 (17.4)
Lidcome, NSW Call centre operators for a major alcohol company 21-24 (22.8)
Canberra, ACT Trade apprentices 16-19 (17.9)
Sydney, NSW Students attending s public high school 16 (16.0)
Sydney, NSW Students attending a public high school 16-17 (16.8)
Wangara, WA Trade apprentices from troubled backgrounds 16-21 (19.0)
Yangebup, WA Regulars at a youth centre dedicated to developing 16-22 (17.9)
leadership among Aboriginal young people
Maddington, WA Local young people who frequent a youth centre in a low 16-19 (17.1)
socio-economic area
Perth, WA University students from private school backgrounds 19-20 (19.1)
Perth, WA Young males identifying with diverse sexuality and gender. 17-24 (19.5)
Glen Forrest, WA Students and apprentices 20-21 (20.1)
Perth WA Students attending a Catholic high school 16-17 (16.2)
Broadmeadows. VIC Recent Iraqi migrants 16-24 (20.7)
Torquay, VIC Graphic designers for a major surfing brand 22-24 (22.7)
Box Hill, VIC Young men who frequent a youth centre at Box Hill 18-24 (20.9)
Sydney, NSW Lebanese Maronite Catholic Church group members 18-24 (20.1)
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ensure that the generated themes were identified and Table 2 Technology use for males aged 16–24 years
clus- tered in a way that was consistent with the views of n (%)
more than one person and not simply a reflection of one 16-18 19-24 Total (16–24 year
re- searcher’s subjective interpretation. year year olds olds)
olds
Landline phone 211 (86.5) 110 (70.1) 321 (80.0)
Results Quantitative Mobile phone 234 (95.4) 154 (97.5) 388 (96.3)
results Online iPod/ Mp3 player 222 (90.6) 133 (85.3) 355 (88.5)
sample
Playstation 146 (59.6) 67 (42.7) 213 (53.0)
A total of 1,038 young people (aged 16 to 24 years) com-
Nintendo/Wii 131 (53.5) 70 (44.3) 201 (49.9)
pleted the survey (52.3% female; n=552; mean age=18.84 -
Xbox 145 (59.2) 60 (38.2) 205 (51.0)
years; SD age=2.75). For the purposes of the current
paper, only the data for young men was considered Desktop computer 204 (83.3) 119 (75.3) 323 (80.1)
(n=486; age range=16-24 years; mean age=18.55; SD Laptop computer 194 (79.5) 134 (84.8) 328 (81.6)
age=2.62). Partici- pation for males varied across MSN 216 (88.2) 94 (59.5) 310 (76.9)
Australian States and Terri- tories [41.0% were from New Skype 86 (35.1) 62 (39.2) 148 (36.7)
South Wales and Australian Capital Territory (n=198/483); Twitter 42 (17.1) 41 (25.9) 83 (20.6)
26.5% were from Victoria and Tasmania (n=128/483); Facebook 225 (91.8) 138 (87.3) 363 (90.1)
18.4% were from Queensland, (n=89/483); and 12.8% Myspace 107 (43.7) 44 (27.8) 151 (37.5)
were from Western Australia, South Australia and the Bebo 39 (15.9) 14 (8.9) 53 (13.2)
Northern Territory (n=68/483)]. Three percent of the male Single player games 174 (71.0) 94 (59.5) 268 (66.5)
sample identified themselves as Abori- ginal and/or Torres
Multiplayer games 149 (60.8) 71 (44.9) 220 (54.6)
Strait Islander origin (2.9%; n=10/346); and, 22.3% spoke
Interactive games 168 (68.6) 81 (51.3) 249 (61.8)
a language other than English at home (n=78/350). Sixty-
Information websites 176 (71.8) 144 (91.1) 320 (79.4)
six percent of the male sample were in full-time study at
school, TAFE or university (65.6%; n=221/337), 13.6% Video websites 206 (84.1) 137 (86.7) 343 (85.1)
were employed full-time (30 or more hours per week; Forums 153 (62.4) 97 (61.4) 250 (62.0)
n=46/337), and 8.9% were employed part- time (less than Bulletin boards 98 (40.0) 60 (38.0) 158 (39.2)
30 hours per week; n=30/337). Note. Row percentages used. Participants were able to select multiple options.

younger males are more likely to use MySpace [β=−.15,

Interests and technology use n=403, p= 003] and MSN [β=−.35, n=403, p<.001].
The vast majority of males reported that they use mobile
phones (96.3%), Ipod/mp3 players (88.5%), and com-
Attitudes and behaviours in relation to mental health
puters (desktops, 80.1%; laptops, 81.6%) (see Table 2).
The most ‘likely’ or ‘very likely’ sources of help they
More than half of the sample identified that they play
would recommend would be: friends (86.6%); a coun-
video games (playstation, 53.0%; Nintendo/Wii, 49.9%;
sellor (70.1%); doctor (67.1%); family member (63.5%);
XBox, 51.0%). Age, however, was a significant predictor
and websites (40.6%) (see Table 3). They would be least
for game play with younger males being more likely to
likely to recommend posters or pamphlets, a church
use a playstation [β=−.19 n=402, p<.001], XBox [β=−.21,
leader, teacher, or community centre. Age, however, was
n=402, p<.001], single player games {β=−.12, n=403,
a significant predictor for websites and church leader,
p=.016], multiplayer games [β=−.13, n=403, p=.011] and with younger males being more likely to recommend
interactive games [β=−.18, n=403, p=.000] than older websites than older males [β=−.15, n=397, p=.004], and
males (in these analyses a positive value of β indicates older males being more likely to recommend a church
that there is a positive relationship between age and the leader than younger males [β=.11, n=396, p=.036].
dependent variable). The age differences are clearly shown
Survey participants were asked whether they had ever
when the results are broken down into narower age groups
sought help for their problems on the Internet. More
(see Table 2). Males reported that they are accessing video
than half of all male respondents reported that they had
websites (85.1%) and information websites (79.4%) far
talked about their problems online (54.9%, n=212/386).
more than forums (62.0%) and bulletin boards (39.2%).
Most said that talking online ‘helped’ (81.3%, n=169/
Facebook is by far the most popular social networking site
208), and that they were ‘satisfied’ or ‘very satisfied’ with
(90.1%), with only 37.5% of the sample using MySpace and
the online help they received (82.9%, n=174/210). Age was
only 20.6% using Twitter. MSN is also still a popular way
a significant predictor for seeking help online, with
to communicate with other people (76.9%). Older males are
younger males being more likely to have talked about their
more likely to access information websites [β=.25, n=403,
problems online than older males [β=.16, t(384)=3.15,
p<.001] and use Twitter [β=.14, n=403, p=.006]; while
p=.002].
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Table 3 Sources of help young men aged 16–24 years would suggest to a friend with a mental health problem
n (%)
Very likely Likely Unlikely Very unlikely Don’t know
Family 104 (24.8) 162 (38.7) 81 (19.3) 54 (12.9) 18 (4.3)
Friends 173 (41.6) 187 (45.0) 36 (8.7) 13 (3.1) 7 (1.7)
Websites 53 (12.9) 114 (27.7) 154 (37.5) 76 (18.5) 14 (3.4)
Telephone helplines 47 (11.2) 96 (23.0) 146 (34.9) 113 (27.0) 16 (3.8)
Posters or pamphlets 20 (4.8) 62 (14.9) 182 (43.8) 137 (32.9) 15 (3.6)
Teacher 32 (7.7) 73 (17.6) 175 (42.3) 114 (27.5) 20 (4.8)
Doctor 106 (25.2) 176 (41.9) 80 (19.0) 44 (10.5) 14 (3.3)
Community centre 33 (8.0) 72 (17.4) 173 (41.8) 116 (28.0) 20 (4.8)
Trusted community member 29 (6.9) 93 (22.2) 166 (39.7) 114 (27.3) 16 (3.8)
Church leader 38 (9.1) 52 (12.5) 112 (26.9) 194 (46.5) 21 (5.0)
Counsellor 115 (27.5) 178 (42.6) 63 (15.1) 48 (11.5) 14 (3.3)
Note. Percentages are given in parentheses. Due to some missing data, the total sample size for each source varied between 411 and 420.

Technology and mental health

sport and pornography, listening to podcasts and online
The survey also asked participants to indicate their prefer-
shopping). Overall, few group differences were identified.
ences for receiving mental health information and support
However, older males tended to be more likely to report
through technology. The top four responses were: website
using technology for reading news, searching for restau-
with information and/or fact sheets (48.1%, n=234); website
rants, as well as for banking purposes than younger
with online clinic (38.5, n=187); website with informa- tion
males. Social networking and video sites were
and multimedia content (29.6%, n=144); and website with
universally reported among focus group participants for
question and answer service that sends sms or emails
socialising, pursing general interests and listening to
(28.8%, n=140). Older males were more likely to report
music, although there was some diversity in the
that they wanted a website with information and/or fact
particular services being
sheets [β=.14, n=370, p=.007] and a website promoting
used. As reported by one young male:
physical wellbeing [β=.12, n=370, p=.027] than younger
males.
“Whenever I go on a computer, the first thing I open is
Facebook and YouTube.” (High school student)
Qualitative results
Focus group sample Consistent with our quantitative survey results, the vast
A total of 118 males (aged 16 to 24 years) from four majority of focus group participants reported using Face-
Australian States [40.7% from Western Australia (48/118), book, with only a small minority using Twitter and My-
33.1% from New South Wales (39/118), 20.3% from Space. As highlighted by one participant: “not MySpace;
Victoria (24/118), and 5.9% from Australian Capital Terri- that’s so last year” (High school student). This comment is
tory (7/118)] participated in the focus groups. Twenty-five consistent with the assertion of Boyd that while particular
% of participants had completed education or training social networking services will come and go, it is the
beyond high-school (25.4%, 30/118), 61.8% were in some activity of communication and socialising that is important
form of employment (73/118), with 33.9% percent working to these young people [27]. Many participants also
full- time (40/118), and 39.0% of participants identified indicated that they are enthusiastic about searching “funny
with a cultural background other than Australian (46/118). stuff” and fol- lowing a trail of linked videos:

Interests and technology use “I just type in ‘lol’ or ‘funny’ and watch like 30 videos.. .it takes
The vast majority of focus group participants indicated me on a tangent.” (High school student)
that they are enthusiastic and heavy users of technology.
Across all focus groups, participants listed at least 10 dif-
Beliefs about mental health
ferent technology-based practices they regularly engage in.
The focus groups explored young men’s beliefs about
Most frequently reported was Internet use via
health and mental health with some very consistent
computers, computer/console games, mobile phones and
themes emerging. Firstly, consistent with previous
portable audio devices for a range of activities (eg.
research [28], most focus group discussions of ‘what it
downloading movies and music, reading online news,
means to be healthy’ were dominated by references to
blogs, watching
physical fitness
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and diet, revealing that young men generally have a
narrow conception of health. However, more educated
participants and students studying Personal Development,
Health and Physical Education (PDHPE) in high school
tended to have a more holistic, multidimensional concept
of health. One high school student summed it up well:
“It’s all about being spiritually, mentally, physically and
socially healthy.” (High school student)
Secondly, across all 17 focus groups, the term ‘mental
health’ had overwhelmingly negative connotations among
focus group members and was associated, with things
like “insanity”, “being crazy”, “straight jackets”, “mental
institu- tions” and “unstable people”. While most
respondents ac- knowledged that mental health
problems are relatively prevalent in the wider
community, many of those tended to believe they would
never be personally affected a men- tal health difficulty:
(3) the role of self-help strategies; and, (4) perceptions of
current mental health services.
Firstly, across all 17 focus groups, participants indi-
cated that they would find it difficult to seek help as a
result of culturally dominant masculine traits that place
an emphasis on males to be “strong” and to “not show any
emotion”, a finding that is consistent with previous
research [7-9]. Participants’ comments highlighted that
help-seeking is associated with “weakness” and a “loss of
manhood”. For example:
“.. .[to seek help is] almost an admission of weakness. You
may not want to show that weakness to certain people,
because that might change their opinion of you.”
(Graduate accountant)
“The first time you to [to a counsellor] you think ‘I’m not
going to be a man anymore’.” (High school student) One
other young male summed it up well:

“I can‘t really see it affecting me.” (University student) “.. .[seeking help] just doesn’t fit the male stereotype.”
(Youth centre member)
“I can‘t really imagine having a mental health
problem to be honest.” (Call-centre operator) Across a number of focus groups, there were partici-
pants who expressed strong views that they wouldn’t
In addition, when asked what they know about mental need – or seek – help under any circumstances:
health, many participants said they knew relatively little:
“For me, I just don‘t feel like that there would be any issue
“Mental health? Not that much.” (High school student) that I would need to go to someone externally for.”
(Graduate accountant)
“I don’t even know what mental health means.”
(Youth Centre member) Some also expressed a tendency for self-denial in rela-
tion to mental health issues:
“I don’t know a lot about it.” (University student)
“.. .I guess there‘s still a stigma of mental health being a
Nevertheless, depression was correctly identified in all weakness and not something you want to show. I realise
but two focus groups as a common mental health condi- that it‘s not but it‘s just something that I‘d find difficult
tion for young people [1]. Some participants also noted coming to terms with - like ‘that kind of shit doesn‘t happen
that depression is experienced mainly by young girls, to me’.” (University student)
and to a lesser extent older men. For example, one par-
ticipant commented: A second major theme that emerged related to com-
munication barriers. Regardless of age, geographic loca-
“I think younger girls [get depressed] more, and older tion or level of education, many participants indicated
guys.. .I’ve seen heaps of girls when I was at school that that they would be uncomfortable “talking” about their
cut their wrists and stuff. And that’s the first indication problems with either their friends or a professional:
that they’ve got something wrong to me.” (Trade
apprentice) “For some reason its harder for dudes to open up and
express their feeling; maybe the way we communicate is
different to girls; we communicate through sport and
Attitudes towards help-seeking physical activity and stuff whereas girls will sit down and
Focus group discussions provided insights into the gap talk about their problems.” (High school student)
between existing help options and young men’s actual
help-seeking, which can be summarised in four key Furthermore, participants’ comments revealed that
themes: “talking” is generally considered a feminine characteristic:
(1) notions of masculinity; (2) communication barriers;
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“.. .[Talking about your problems] is not a thing that’s “I wouldn’t like to speak about my problems. I really like
really accepted. Guys don’t want to feel like they’re all to do things my own way, independently.” (High school
girly.” (Trade apprentice) student)

As well as not wanting to discuss mental health issues
themselves, participants across various focus groups in-
dicated that they would not want to hear others talk
about mental health issues, particularly if they were
talking with someone other than a “best mate”. For ex-
ample, disclosing personal or sensitive information to
someone else who is not their closest friend was de-
scribed in one focus group as “over-sharing” and strongly
discouraged. Participants who held such views indicated
they would be unreceptive listeners:
“Even if one of my friends is just whinging about
something, I’m like ‘Man, get over it, I don’t want to hear
it.” (Call centre operator)
Many other participants explained that they would
prefer not to directly raise an issue with a friend showing
signs of poor mental health. Rather, they would first at-
tempt to ‘help’ their friend by encouraging them to par-
ticipate in sport, socialising or drinking as opposed to
engaging with the cause of the problem directly. How-
ever, participants across virtually all focus groups indi-
cated that would address the issue directly or actively
encourage their friend to seek professional help if they
felt it was absolutely necessary. Interestingly, these dis-
cussions also revealed that some would only see a pro-
fessional if a close friend or family member actively
encouraged them to do so:
Finally, across all focus groups, participants displayed a
range of negative attitudes in relation to mental health
professionals; specifically, counsellors and psychologists.
When asked to list the persons that participants would
feel comfortable discussing personal problems with, very
few mentioned counsellors; a finding that is consistent
with previous research involving young people [29]. Partic-
ipants generally expressed low trust and lack of
confidence in professionals’ maintaining confidentiality
and ability to actually help. Some participants said they
would not want to pay for services and were sceptical of
the professional’s motives (i.e. professionals have a
monetary incentive to keep clients coming to sessions);
others believed that they could get the same support for
free from close friends, family or online. The logistical
issues of seeking profes- sional support were also sighted
as a significant barrier. Having to make an appointment,
travel to an unfamiliar location and then discuss
emotional issues at a specific time were all reasons given
for not accessing professional services. Mental health
professionals were described as older, with different life
experiences and hard to relate to. When asked what
would make a professional more appeal- ing participants
felt they should be “down to earth” (eg. “not use big,
medical words”), non-judgemental and have experienced a
mental health problem themselves. These factors
contribute to the view across all groups that professional
support services are the ‘option of last resort’.

“Well, I know that my friends and family would always Using the Internet for information, help or support
be honest with me, so even if I couldn’t see it in myself Across all focus groups, participants indicated a willing-
they’d tell me that I need to see someone. I’d like to think ness to seek information and support from the Internet:
that I’d accept that and take on board those thoughts of
theirs. So it would probably take that for me to go.” “I’d prefer to talk to someone on the Internet and then
(Graphic designer) maybe make my way to a counsellor or a psychiatrist,
rather than just jumping straight in the deep end and
This suggests a ‘catch-22’ situation whereby these young going to a psychiatrist.” (Trade Apprentice)
men would tend to resist encouraging a friend to seek
help but at the same time would require a close friend’s In this way, the Internet was seen as a gateway to in-
intervention if they themselves were going through a formation and support. Some also highlighted the im-
tough time. portance of peer rating and reviews of both online and
The third major theme that emerged related to the role offline help-options:
of self-help strategies. The vast majority of focus group
participants expressed the view that dealing with one’s “I don’t really have any info on who’s good, who’s not,
own problems was preferable to seeking help from what’s good, what’s not. I don’t really know anything about
others: it. So I might do an Internet search to see if I can find
anyone talking about going to see a counsellor or a
“People have different mentalities, mine is ‘I can resolve psychiatrist.” (Call centre operator)
my issues myself ’, so I don’t need to seek help.” (Call
centre operator) In line with previous research, most participants indi-
cated the need for online information and support
services
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to be an anonymous process and fears of being identified
when seeking help were key themes when the value of
seeking information and support online was discussed
[17]. Finally, focus group participants brainstormed
strategies for using technology to address some of the
barriers to help-seeking. These were grouped under
common themes with three key insights emerging. Firstly,
most participants indicated that they would be fearful of
being judged by their peers, family or a professional but
said this could be mitigated by being able to seek
information and help an- onymously online. Secondly, many
participants emphasised the importance of interventions
being relevant and relating to their everyday lives and
interests. This could include delivering mental health
content in young men’s online communities of interest
(eg. sports sites, music sites or male magazines). Some
also recommended male role models, such as boxers,
sports players, and actors. Thirdly, many participants
indicated a preference for action-based rather than talk-
based strategies. One participant requested
the following:
“.. .really advanced search tool or questionnaire – or self-
diagnosing thing... and it would link you to some kind of
page with testimonials” (Youth centre user).
Broadly, participants were interested in opportunities to
build skills in ‘how’ to identify, discuss and manage
mental health issues.
Discussion
This study is unique in its focus on exploring and under-
standing young men’s attitudes and behaviours in
relation to technology use and mental health.
Methodologically, the use of both quantitative and
qualitative findings is a strength of this study.
Not surprisingly, this study confirms that technology is
an integral part of young men’s lives. The survey data is
consistent with national data on technology access and
use [30,31], and the focus groups provide insight into the
complex ways in which technology is integrated into
their everyday lives as well as the ways in which they use
technology to mediate the different issues and
experiences they face. Both the survey and focus group
data were consistent in demonstrating that young men
use technology predominately for entertainment and
connecting with others. Facebook and YouTube appear to
be a key source of entertainment and an integral part of
their lives. However, it is important to recognise that the
popularity of particular sites can change quickly, as the
con- tinued demise of MySpace demonstrates, and
emphasises the importance for research in this area to be
undertaken regularly to keep up with the ever-changing
landscape [32].
The findings of this research also build on existing stud-
ies [2,6,33-35], particularly in terms of the role of the
Page 8 of 10
Internet for promoting help seeking in young men. Firstly,
consistent previous research [36], the survey data
indicated that if young men were to refer help to someone
with a mental health problem, they would most likely
recommend an informal source of help (ie. a friend) rather
than a phy- sician or mental health professional. Likewise,
participants in the focus groups displayed strong
resistance and lack of skills to seek mental health
information, support and help for themselves when
needed [5]. They associate mental health with illness and
pathology and as something that happens to ‘other
people’. The focus group data suggested that they would
be unlikely to seek professional help for themselves, citing
a preference instead for self-help and action-oriented
strategies; though they may be more likely to seek
professional help if a friend intervened and actively
encouraged them to do so. Although the findings were
remarkably consistent across all 17 focus groups, there
was evidence to suggest that those with a higher level of
education or those currently studying PDHPE may have
more informed understandings of mental health. Thus,
these findings correspond with recommendations made by
Rickwood et al. [29], and point to the need for interven-
tions to reach young men beyond formal educational set-
tings, focus on behaviour change through self-help and
action-oriented strategies, and leverage the significant
role that peers play in the pathway to professional
services.
Across all focus groups participants presented negative
views on professional services, and a related perception
that seeking professional help challenges their sense of
masculinity. As identified in previous research, a variety
of masculinity ideologies, norms and gender roles appear
to play a part in discouraging males from seeking profes-
sional help [37]. However, young men’s fears of being
judged as weak or ‘unmanly’ could also be the key to
building knowledge and skills that support help-seeking.
Research participants themselves suggested that interven-
tions should not be explicitly branded as ‘mental health in-
terventions,’ but rather tap into male sub-cultures and
focus on building strength or improving performance.
Interven- tions must therefore be relevant and engaging
for young men and should carefully balance peer-
recommendation with anonymity. Furthermore,
interventions which are action-based, rather than talk-
based may be more engaging. In addition, the survey and
focus group data was con- sistent in indicating a strong
willingness for young men to use the Internet to find
mental health information and support. The Internet
addresses their desire for anonymity and self-help.
Notably, the survey data suggested that when young
men obtain information and help-seeking on- line, they are
satisfied with the help they receive, which suggests that
the Internet is an appropriate setting to en-
gage with young men around their mental health.
Finally, the findings of this study point to some im- portant
insights that can be used to inform strategies to
 Ellis et al. BMC Psychiatry 2013, 13:119
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use the Internet to promote mental health and help-
seeking among young men. Internet supported strategies
to support mental health have increased tremendously
over the past decade and now offer a real alternative, or
supplement, to traditional, face-to-face therapeutic
inter- ventions. Existing interventions take a number of
differ- ent forms and can be broadly distinguished as:
primarily self-guided web-based interventions (eg.,
mental health information websites and online
treatment programs without therapist interaction);
online counseling (via tex- tual communication between
a therapist and consumer); or Internet-operated
therapeutic software that uses ad- vanced computer
capabilities (eg., for robotic simulation of therapists
providing dialog-based therapy, gaming, and three-
dimensional virtual environments) [38]. The find- ings
from this study suggest that we may need to look at
gaming and three-dimensional virtual environments as in-
spiration to enhance enjoyment for and engagement
with young men. The term “gamification” has been
adopted as an umbrella term for the use of gaming
elements in non- gaming systems to improve user
experience and engage- ment. However, Monk et al. [39]
introduced a note of caution stating that the challenge
for research in this field is to “systematically address
hedonic (non-utalitarian) re- quirements and combine
them with goal oriented require- ments”. This has
particular relevance in a mental health context where
designers must place an emphasis on en- gagement with
the treatment, rather than engagement with the
technology [40]. Our study is concordant with current
views that Internet interventions may be more likely to
be successful for young men if they provide: a more
interactive experience (with richer and more varied
experiences, immediate graphical feedback, and the ability
to engage actively rather than passively receiving content); a
more personal experience (including content that is tai-
lored to the user’s needs, and gives users a sense of
control and ownership, and allowing them to choose
their own pathway through the intervention); and
facilitate contact with some kind of community (most
obviously peers who are suffering, or have previously
suffered from, similar dif- ficulties [40]. However, further
research is needed to build on these findings.
Three potential limitations should be considered when
interpreting the results of the study that relate to the
sam- pling methodology. First, given that we recruited
partici- pants for the survey using online methods, our
sample was limited to young people with Internet access.
Never- theless, Internet access and use in Australia is
very high: 97% of young people have personal access to
the Internet
[30] and the results for the survey concerning ICT use
are comparable with previous research [31,41]. Secondly,
our survey sample was recruited via Facebook
advertising and snowball sampling which again raises
questions about the generalizability of the results. A
third potential limitation
Page 9 of 10
relates to the representativeness of our focus group sam-
ple. An analysis of the Australian Bureau of Statistics
SEIFA Index [42] in relation to participants’ home
address postcodes suggests that our sample may have
been skewed towards young men from higher
socioeconomic back- grounds. However, postcode
measures of socioeconomic status are notoriously
problematic, but due to ethical con- cerns, we were
unable to collect more accurate measures of
socioeconomic status, such as family income. However,
the primary aim of the qualitative component of this
study was not to recruit a statistically representative
sample of all young men across Australia, but rather to
include the perspective of a broad range of young men in
order to capture the richness and complexity of young
men’s atti- tudes and behaviours in relation to
technology use and mental health, and to use these
findings to build on the survey results.
Conclusions
This study suggests that there may be powerful views to-
wards mental health and help seeking that are gender
spe- cific. Though further work must now be undertaken,
this study suggests that there may be a compelling need
for gender-specific strategies and interventions. These
should be informed by young men’s views and technology
prac- tices and take into account the important role that
peers play in the help-seeking process. Previous research
from Australia indicates an increase in awareness of
mental health issues, particularly for those who have been
the sub- ject of extensive public health campaigns, such as
depres- sion [43]. However, the results of this study
clearly indicate that although young men may have better
awareness and understanding, the real challenge is to
design interventions that are action-based, seen as
relevant, and focus on shifting behaviour and stigma. In
conclusion, the findings of this study point to some
important insights that can be used to inform strategies to
use the Internet to promote mental health and help-
seeking among young men.
Competing interests
The authors declare that they have no conflicts of interest.
Authors’ contributions
PH carried out the interviews and participated in the qualitative data
analysis. PC led the qualitative data analysis and LE led the quantitative
data analysis and wrote the first draft of the article. All authors participated
in the drafting of the final article. All authors read and approved the final
manuscript.
Acknowledgements
The survey was funded by an Australian Research Council Linkage
Grant (LP0883035). The authors wish to thank the young men who took
part in this study.
Author details
1
Brain & Mind Research Institute, The University of Sydney, 94 Mallett Street,
Camperdown, NSW 2050, Australia. 2Institute for Culture and Society,
University of Western Sydney, Bankstown Campus, NSW 2751, Australia.
3
Young and Well Cooporative Research Centre, Abbotsford, VIC 3067,
 Ellis et al. BMC Psychiatry 2013, 13:119
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Australia. 4Inspire Foundation, Camperdown, NSW 2050, Australia. 5Orygen
Youth Health Research Centre, Centre for Youth Mental Health, University of
Melbourne, Parkville, VIC 3052, Australia.
Received: 13 August 2012 Accepted: 23 March 2013
Published: 20 April 2013
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Accepted Article

RUNNING HEAD: TECHNOLOGY AND OLDER VETERANS

This article is protected by copyright. All rights reserved.
Ellis et al. BMC Psychiatry 2013, 13:119 Page 12 of
http://www.biomedcentral.com/1471-244X/13/119

Technology Use and Preferences for Mental Health Self-Management Interventions among

Older Veterans

Christine E. Gould, PhD, ABPP,1,2* Julia Loup, BA,1 Eric Kuhn, PhD,2,4 Sherry A. Beaudreau,

PhD, ABPP,2,9 Flora Ma, MS,1,3 Mary K. Goldstein, MD, MS,5,6 Julie Loebach Wetherell, PhD,

ABPP,7,8 Aimee Marie L. Zapata, PhD,1 Philip Choe, DO,1 & Ruth O’Hara, PhD2,9

1. Palo Alto Geriatric Research, Education, and Clinical Center (GRECC), VA Palo

Alto Health Care System, Palo Alto, CA, USA

2. Department of Psychiatry and Behavioral Sciences, Stanford University School of

Medicine, Stanford, CA, USA

3. Pacific Graduate School of Psychology, Palo Alto University, Palo Alto, CA, USA.

4. National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, CA, USA

5. Medical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA

6. Stanford University, Center for Primary Care and Outcomes Research (PCOR),

Stanford, CA, USA

7. Psychology Service, VA San Diego Healthcare System, San Diego, CA, USA

8. Department of Psychiatry, University of California, San Diego, CA, USA

9. Sierra Pacific Mental Illness Research Education and Clinical Center (MIRECC), VA

Palo Alto Health Care System, Palo Alto, CA, USA

* Corresponding Author: Christine E. Gould, PhD, Veterans Affairs Palo Alto Health

Care System, GRECC (182B), 3801 Miranda Ave., Palo Alto, CA 94304. Email:

cegould@stanford.edu

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process which may
lead to differences between this version and the Version of Record. Please cite this article
as doi: 10.1002/gps.5252
This article is protected by copyright. All rights reserved.
 Ellis et al. BMC Psychiatry 2013, 13:119 Page 13 of
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Acknowledgements: The authors wish to thank Sujatha Kalle, MBBS, for assistance with

comorbidity ratings. This work was supported by a Career Development Award (IK2 RX001478;
Accepted Article
PI: Gould) from the United States (U.S.) Department of Veterans Affairs Rehabilitation Research

and Development Service. Views expressed in this article are those of the authors and not

necessarily those of the Department of Veterans Affairs or the Federal Government.

Aimee Marie Zapata is now at Kaiser Permanente, Department of Psychiatry, San Jose, CA. Julia

Loup is now at University of Alabama, Tuscaloosa, Department of Psychology.

Conflicts of Interest Summary: Dr. Gould reports grants from Department of Veterans Affairs,

Rehabilitation Research and Development Service, during the conduct of the study. Ms. Loup, Ms.

Ma, and Drs. Kuhn, Beaudreau, Goldstein, Wetherell, Zapata, Choe, and O'Hara have nothing to

disclose.

The data that support the findings of this study are available from the corresponding author upon
reasonable request.

This article is protected by copyright. All rights reserved.

 Ellis et al. BMC Psychiatry 2013, 13:119 Page 14 of
http://www.biomedcentral.com/1471-244X/13/119

Abstract

Objectives: The United States Department of Veterans Affairs offers numerous technology-
delivered interventions to self-manage mental health problems. It is unknown, however, what
barriers older military veterans face to using these technologies and how willing they would be to
use technologies for mental health concerns.
Accepted Article
Methods: Seventy-seven veterans (Mage = 69.16 years; SD = 7.10) completed interviews in a
concurrent mixed methods study. Interviewers asked about technology ownership and described
four modalities of delivering self-management interventions: printed materials, DVDs, Internet,
and mobile apps. Interviewers obtained feedback about each modality’s benefits, barriers, and
facilitators. Participants ranked their self-management modalities preferences alone and compared
with counseling. Multi-variable adjusted logistic regression and qualitative analyses were
conducted to investigate the reasons contributing to preferences.
Results: Most reported owning a computer (84.4%), having home Internet (80.5%), and a
smartphone (70.1%). Participants preferred printed materials (35.1%) over mobile apps (28.6%),
Internet (24.7%), and DVDs (13.0%). Lower computer proficiency was associated with preferring
DVDs; higher proficiency was associated with Internet and mobile interventions.
Residing in an urban area was associated with mobile apps. When counseling was an option,
66% identified this as their first preference. Qualitative findings showed veterans’ desire for
information, training, and provider support with technology.
Conclusions: Older veterans reported high technology ownership rates, but varied preferences for
self-management interventions. Notably, two-thirds preferred some form of technology, which
points to the importance of ensuring that providers offer existing technology-delivered
interventions to older veterans. Veterans’ strong preference for counseling emphasizes the need for
human support alongside self-management.

Key Words: Computers, Internet, Mental Health, Mobile Applications, Self-management,

Smartphone, Technology, veteran

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Key-points
 This study investigated older military veterans’ ownership of devices and modality
preferences for technology-delivered mental health self-management
interventions.

 Older veterans reported high rates of technology ownership. Thirty-five percent

Accepted Article
preferred printed materials for self-management, whereas the remaining majority
preferred some form of technology for accessing a mental health self-management
intervention.

 Qualitative findings suggest that technology training, and particularly provider

support may facilitate the use of self-management interventions.

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More than half of United States (U.S.) military veterans are 60 years or older1 and many suffer from

mental health disorders.2 Approximately 9.7 million veterans or 48% of all veterans received care

from the U.S. Veterans Health Administration (VHA) annually. 1 The VHA encompasses 1,255
Accepted Article
health care facilities and is the largest health care system in the U.S. with mental health care

providers integrated in providers including primary care. Studies examining the VHA mental health

service usage have shown that older veterans are less likely to use services than are younger

veterans.3,4 Lower mental health care utilization among older adults is related to barriers to care,

including difficulty navigating the referral process, lower identification of late-life mental health

disorders, transportation difficulties, concerns regarding cost of care, and stigma about mental

health.5–7 To address these barriers, VHA has integrated behavioral health providers into primary

care and implemented clinical video telehealth options to overcome geographical and mobility

barriers for patients in remote areas. Still, the scarcity of geriatric mental health providers limits the

scalability of telehealth as providers are needed to deliver telehealth services. 8 Taken together, these

factors underscore a need to offer alternative methods of delivering mental health care for older

adult populations, such as self-management.9

A vast body of research supports self-management as efficacious for chronic health and mental

health.10–13 In particular, interest in mental health self-management interventions has grown with

the wide-scale adoption and use of technologies capable of delivering these interventions. While

technology-delivered interventions may increase access to mental health care,14,15 older adults are

often omitted from this research due to barriers to accessing technology and sampling bias that

may reflect ageist stereotypes of older adults’ interest in technology.16,17

Digital mental health interventions, such as Internet and mobile app-based interventions can

address geographical, mobility, and provider-shortage barriers, as they may be used as self-

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management or with varying levels of provider or peer support.18 These interventions may be used

anonymously, discreetly, and usually at no to minimal cost, benefiting individuals who may be

reluctant to seek treatment. In addition, incorporating these interventions into existing mental
Accepted Article
health care could expand access to services by enabling providers to allocate resources to more

patients requiring intensive mental health interventions (e.g., weekly psychotherapy).

The VHA surpasses the private sector in the availability of self-management technology- based

interventions for mental health spanning from Internet to mobile applications.19–21 Research on

veterans’ attitudes toward mobile apps demonstrates that most have positive attitudes towards this

intervention modality.22–24 Yet, little attention has been given to older veterans’ attitudes towards

technology. In one of the few studies that considered older veteran technology use, researchers

conducted a series of semi-structured interviews and found no qualitative differences for older

veterans (50 to 70 years old) compared with younger veterans (18 to 49 years old).24 However,

older veterans had lower rates of smartphone ownership (32% vs. 56%) and more difficulties using

technology compared with younger veterans. Another study25 found that 17.6% and 56% of older

veterans had access to smartphones and home Internet respectively. The older veterans also

endorsed willingness to reach out to their social networks for technology assistance. The VHA is a

leader in home telehealth monitoring, in which technologies, such as biometric devices for blood

pressure and weight, assist with the monitoring of chronic health conditions.26 While this approach

has been successful for chronic health conditions, it has been less used in monitoring mental health

conditions such as depression or posttraumatic stress disorder (PTSD).26 These findings suggest

that, similar to the general Veteran population, older veterans are open to using technology to

monitor their mental and physical health, but may have limited access to smartphones in particular.

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Not only are there few investigations of technology use for mental health in older adults, to date

there have been no studies investigating older veterans’ barriers to using technology for mental

health. Examining access to and preferences for different modalities of delivering mental health
Accepted Article
interventions is critical in facilitating usage of existing VHA technology-delivered interventions.

Thus, the present study examined older veterans’ experience with, willingness to use, and

preferences for four different intervention modalities that represent varied methods of conveying

psychoeducation and coping skills to manage mental health problems. The modalities examined

were: (1) printed materials, (2) DVDs, (3) Internet-based, and (4) mobile apps. The core content of

the self-management interventions would be similar across modalities, but the delivery methods

vary, including text, videos, or a combination of information-delivery methods. We hypothesized

that greater computer proficiency, residing in an urban area, and elevated mental health symptoms

would be related to preference for Internet and mobile apps. These hypotheses were grounded in

findings that older veterans seek information about mental health conditions online27 and findings

that veterans with mental health symptoms are interested in technology-based mental health

interventions.22

Methods

Study Design

The study used a concurrent mixed methods design. Study procedures were approved by Stanford

University Institutional Review Board, the IRB of record for the VA Palo Alto Health Care

System (32454).

Participants

Purposive sampling was used to recruit veterans aged 60 years or older from a single VA Health

Care System catchment area. Participants were recruited using flyers posted at VA clinics

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and senior centers, contacting previous research participants, holding community presentations, and

advertising online (Craigslist) and in print media.

Telephone screening assessed two inclusion criteria: age < 60 years old or absence of possible
Accepted Article
cognitive impairment suggested by Short Blessed Test28,29 score of ≥ 6. Figure 1 displays the

participant flow, yielding 77 completing the semi-structured telephone interview and 74

completing mailed questionnaires.

Procedures

Participants were mailed a packet of information that included a copy of the consent form to be

reviewed by phone, questionnaires to complete and return, and a guide with brief explanations of

the modalities including pictures and screenshots. Informed consent included permission to review

their VHA medical record. A brief demographic questionnaire was administered followed by the

Technology Semi-Structured Interview. Interviews were completed by phone (n = 75) or in person

(n = 2) between September 2016 and April 2018.

Measures

Technology Ownership, Preferences, and Proficiency. The Technology Semi-Structured

Interview (see Supplemental Material) contained questions about participants’ technology use and

if they have ever used each modality to cope with emotional difficulties. Then participants were

invited to ask questions about the modality. Next, they rated their willingness to use the modality

(willingness ratings) on a 1 (No, definitely not willing) to 10 (Yes, definitely willing) scale and

were asked about barriers and facilitators of use. Nine technology use and ownership questions,

drawn from the Pew Internet Life Survey,30 were included. At the end of the interview, participants

rank ordered their choice of the four modalities to use if theoretically

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faced with a mental health problem (ranked preferences) and then re-ranked their preferences with

counseling/psychotherapy included as an option.

The Computer Proficiency Questionnaire (CPQ)31 assesses proficiency using computers in six
Accepted Article
domains represented by subscales (basics, printer, communication, Internet, calendar, and

entertainment). The 33 items ask about how easily one can complete each task on a computer with

items rated on a five-point scale ranging from 1 (never tried) to 5 (very easily). Total scores are

generated from average scores from each subscale, with higher scores indicating greater computer

proficiency.

Health and Medical Burden. Perceived health was measured using the question: “In general,

would you say your health is: excellent, very good, good, fair, poor.” Medical burden was rated

using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G)32 with total scores ranging

from 0 to 56. Trained raters completed the CIRS-G retrospective medical record review. 33 Raters

co-reviewed five charts for training and achieved an Intra-class Correlation Coefficient (ICC)

of .94 for the CIRS-G total score. Sixty-eight medical records were reviewed. Reasons for the

missing CIRS-G ratings were: (1) not receiving care at VHA (n = 6); and (2) insufficient notes to

complete the CIRS-G rating (n = 3).

Psychiatric Symptom Measures. Three measures of psychiatric symptoms with established

validity among older adults were used to create a composite variable of elevated psychiatric

symptoms with two groups: elevated symptoms (i.e., meeting the cut-point on one or more

measures) or no elevated symptoms. The first measure, the Patient Health Questionnaire

depression scale (PHQ-8)34 is an eight-item measure of depressive symptoms that has comparable

validity to the PHQ-9.35 The PHQ-8 omits the suicide ideation item for use with asynchronous data

collection. Scores 10 or greater are suggestive of elevated depressive

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symptoms. The Geriatric Anxiety Scale (GAS)35 is a 30-item measure that assesses a broad range of

anxiety symptoms. The first 25 items are summed; the remaining five items can be used to better

understand content of worries and fears (e.g., finances, health). A score 16 maximizes sensitivity
Accepted Article
and specificity for the detection of anxiety disorders in older adults.37 The Posttraumatic Stress

Disorder Checklist for DSM-5 (PCL-5)38 is a 20-item measure of PTSD symptoms. Scores  33 are

suggestive of PTSD.39

Rural status. Rural status was characterized using zip codes aggregated using the Rural Urban

Commuting Area (RUCA) codes40 as employed in a previous study of veterans’ technology

attitudes.24 Veterans’ place of residence were grouped as urban (i.e., metropolitan areas) or rural

(small, isolated towns ranging to large rural towns) using categorization method C.41

Statistical Analyses

We aimed to recruit a sample of 75 individuals based on a power analysis to detect a medium size

effect (.3) for to the quantitative research aim regarding preferences. With regard to the qualitative

aims, it was estimated that approximately 25 interviews would provide sufficient data to address

the research questions42 and would yield code saturation with a complex understanding of the

data.43 Thus, we expected to reach data saturation before achieving our targeted sample size for the

quantitative aim.

Quantitative. Frequencies and percentages were calculated to summarize participant characteristics,

and technology use, ownership, and preferences. Mean willingness and percentages of ranked

preferences for each modality were calculated. Differences in willingness and rankings were

examined with a non-parametric test (Friedman’s ANOVA).

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Logistic regressions were conducted to examine whether rural status; CPQ total score; and

presence of elevated psychiatric symptoms were related to preferences. Years of education were

included as a covariate. Follow-up models included the CIRS-G as a predictor. Analyses were
Accepted Article
conducted with SPSS version 24.44

Qualitative. Transcribed interviews were analyzed using Dedoose version 8.0.45 The coding

scheme was developed based on CREATE model of older adult technology use46,47 with deductive

codes related to the user (individual characteristics), technological system (software,

hardware/interface), and the task (task engagement, intervention content). Inductive codes were

added based on transcript review. Two authors (CEG, AMZ) trained in qualitative analyses coded

the data. The codebook was adjudicated 7 times across 20 interviews resulting in a final pooled

kappa of .90. We achieved data saturation soon after adjudicating the codebook. The remaining

interviews completed after reaching data saturation focused on exploring variations on the themes

and subthemes. Team-based thematic analysis converged on factors underlying participant’s

preferences for technology delivery platforms and identified barriers and facilitators to use.

Results

Participants were older veterans (Mage = 69.16, SD = 7.10 years, range 60-90+), with the majority

being white, non-Hispanic individuals (63.6%), male (81.8%), and retired (72.7%) (Table 1).

With regard to mental health conditions, 45.9% of participants endorsed psychiatric symptoms

above clinical cut-points on at least one of three self-report measures. Based on the CIRS-G

ratings, 72.1% (n = 49 of 68 completed reviews) experienced some level of psychiatric illness

(mild to severe). Nearly all participants owned a cellphone (92.2%), and most (70.1%) owned a

smartphone (Table 2). Most also owned either a desktop or laptop computer (84.4%)

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and a slightly lower percentage had Internet service at home (80.5%). Technology use or

ownership did not differ by demographic characteristics. Of smartphone owners, 96.3% (n = 52)

had sent a text message, 90.7% (n = 49) had downloaded an app, 88.9% (n = 48) had sent an
Accepted Article
email, and 87.0% (n = 47) had used the Internet on their phone. Of tablet users, 76.3% (n = 29)

had downloaded an app. However, of the mobile device owners (smartphone and/or tablet), only

11.9% (n = 7) had downloaded an app to learn about or manage physical health, emotional health,

or stress.

Intervention Delivery Modality Experience and Preferences

Participants’ experience using the modalities to cope with emotional difficulties varied

considerably. Seventy percent (n = 54) had used printed materials for mental health self-

management, 25.6% had used the Internet (n = 20), 16.9% had used DVDs (n = 13), and 9.1% had

used mobile apps (n = 7). Overall, 72% (n = 56) reported using any type of self- management. Of

those 53.5% (n = 30) used only one modality, while 46.4% (n = 26) used more than one modality.

Notably, users of any type of self-management were not more likely to have elevated psychiatric

symptoms, χ(74) = 1.32, p = .25. Willingness to try each modality to manage emotional

difficulties was high (Table 2) and did not differ significantly among participants, χ F 2 (3) = 6.37,

p = .10.

Friedman’s ANOVA found rank differences among the four self-management modalities, χ F 2 (3) =

9.25, p =.03. Printed materials were preferred the most, followed by mobile apps,

Internet, and DVDs (Table 2). Pairwise comparisons demonstrated that the only difference in

rankings emerged for the DVDs. When counseling was added as an option, most (n = 51, 66%)

preferred this option while the remaining third (n = 26) preferred a self-management option as

their first choice.

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Logistic regression analyses identified characteristics associated with preferences for each self-

management modality (See Table 3). Models, adjusted by years of education, examined computer

proficiency, rural status, and presence of elevated psychiatric symptoms. Lower computer
Accepted Article
proficiency was associated with preference for using DVDs, whereas greater computer proficiency

was associated with preference for Internet interventions. Residing in an urban area was associated

with preference for using mobile interventions. No variables were associated with preference for

printed materials. Sensitivity analyses examined models with CIRS-G total scores; however, scores

were not associated with preferences (results not shown).

Qualitative Analysis

Preferences. Qualitative analysis of participants’ justification for their ranked preferences revealed

similar themes across modalities and some differences based on specific features of each modality

(See Table 4). One similar theme was that participants prefer what they know (i.e., comfort,

familiarity) and what they have used in the past. Second, convenience, accessibility, and portability

influenced preferences. Differences among modalities were related to multiple factors including:

(1) preferences for special features or specific equipment (i.e., having a larger computer monitor vs.

small phone screen); (2) lack of security/privacy concerns; (3) interactivity; and (4) amount of

available information. Concerns about security and privacy issues were noted among participants

who ranked either printed materials or DVDs highly, as these modalities generally do not involve

sharing of one’s information. Participants mentioned preferences for listening to information,

benefits of pictures and visuals, and demonstrations of skills as reasons for ranking DVDs first.

Participants who ranked Internet and mobile applications highly described the importance of

interactive, multimedia information delivery, and access to current information. Internet

interventions were valued due to the unlimited

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information available; however, combing through the Internet’s breadth of information was noted

as a drawback. Individuals who ranked mobile apps highly mentioned the value of having skills at

one’s fingertips, their phone being readily available (“always on me”), and the ability to use their
Accepted Article
phone to call for help if needed.

Barriers to Using Self-Management Technology Modalities. The primary and most concrete barrier

was lack of access, which was attributed to cost, owning older devices that are less compatible with

software or apps, or frustration with ongoing maintenance, such as required computer updates.

Insufficient knowledge of technical lexicon, menu symbols, and general comfort using the

technologies, particularly related to mobile apps, limited use of these technologies. Additional

barriers were related to individual user’s sensory abilities, such as changes in vision functioning that

affected their ability to view information on a small screen.

Others noted the importance of having subtitles or adjustable volume to accommodate hearing

impairment. Finally, some described challenges navigating a touch screen using their fingers due to

small screen size and “fat fingers”.

Facilitators. The primary facilitator identified was the role of a person to support the participant

during an intervention. Some suggested that a provider could serve as a navigator, directing them

to evidence-based resources specific to their problem. One participant described that their “first

choice would probably be to talk to another person on the phone or hotline and then they could

help direct [me] to other sorts of resources.” Other person-based supports included teaching about

using technology, answering technology questions, discussing intervention content, and

encouraging adherence. One participant highlighted the importance of knowing both technology

and mental health interventions: “[the] person has to be kind of like multi-tool– part-time therapist

and very skilled in technology.”

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Conclusion
Accepted Article
Our findings highlight that older veterans have high rates of technology ownership.

Notably, these rates of ownership did not differ significantly among those in urban versus rural

regions. Despite 100% of participants owning technology, preferences for self-management

treatment delivery varied. More veterans preferred printed materials (35%) than any specific form

of technology. However, 65% preferred some form of technology (i.e., DVDs, Internet, or mobile

app-delivered interventions). These data confirm that older veterans are interested and willing to

use mental health self-management interventions, particularly if human support accompanies the

intervention. While the findings do support willingness to try self-management, when provided

with the option of counseling, the majority of participants expressed interest in trying this option

first.

Key factors related to preferences for treatment delivery modalities included access, experience,

and comfort with modalities. Consistent with our predictions, findings demonstrated the

importance of computer proficiency, which aligns with qualitative themes regarding people

preferring what they know. Regarding mobile apps, the preference for apps was stronger for

veterans living in an urban compared with rural regions and are in line with our predictions and

previous research.24 Contrary to our predictions, presence of elevated mental health symptoms,

present in 46% of participants, were not related to preference for any modalities. With a larger

sample or more detailed mental health information, such as treatment histories, an association with

preferences may have emerged.

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Qualitative findings further uncovered factors underlying these preferences. Mobile apps were

valued for their convenience, portability, and multimedia intervention delivery. Internet

interventions were valued for multimedia delivery and for the ability to view these interventions on
Accepted Article
a larger computer screen compared with a smartphone screen. Although our findings demonstrate

that past experience, knowledge, access, and portability underlie older veterans’ preferences for

self-management intervention delivery modalities, high willingness to try all the modalities

suggests their openness to different self-management options. A question that remains is whether

matching with older veterans’ intervention delivery preferences would lead to better outcomes. It is

possible that considering patient preferences and characteristics (e.g., technology proficiency) when

recommending mental health self-management interventions may lead to greater acceptance of

these interventions and improved outcomes through providing person- centered care.

Our findings highlight the varied roles that a provider may play in supporting mental health in

older veterans. Many participants showed a preference for traditional counseling, if available. Yet,

the qualitative findings suggested that they wanted providers to provide personalized

recommendations about the different self-management tools, such as brief readings or books,

videos, websites, and mobile apps. Furthermore, one third were interested in exploring and using a

self-management tool as a first step to treatment, which aligns with others’ findings that a common

reason for not seeking mental health treatment is the desire to work out problems on one’s own.48

Older adults are often novice technology users and may need personalized support and teaching to

improve their technology proficiency. The participants’ desire for human support when using self-

management technology interventions affords an opportunity to implement new

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models of mental health care that integrate basic teaching about technology and ongoing human

support around the implementation of these interventions. Extant models of support, such as the

efficiency model of support,18 address the importance of adherence, but do not consider the need to
Accepted Article
teach technology-use basics or to provide ongoing support for novice users. New models should

consider direct instruction about technology, use of assistive devices (e.g., stylus pens, screen

magnifier, accessibility features), and sharing tailored informational handouts targeted at

improving knowledge of technology basics.

Several limitations to this study should be acknowledged. First, the study did not collect

information on participants’ mental health treatment history, socioeconomic status, or income,

which all could influence preferences for delivery modalities. Second, the study may not have

been sufficiently powered to examine all the quantitative factors underlying preferences. Third, the

study did not directly examine the impact of these interventions on mental health symptoms or

address whether older veterans derive similar benefits from technology-delivered interventions

compared with younger veterans. Fourth, many of the individuals in the study resided in proximity

to a technology hub and had higher years of education, but similar levels of multimorbidity to

older veterans in other studies.5

Study strengths included the use of telephone interviews to reach veterans in remote areas,

employment of qualitative analysis to understand factors underlying preferences, and the

measurement of mental health symptoms and medical comorbidity. This study provides key

information about veterans’ preferences through the use of qualitative interviewing methods to

ensure that the veterans understood the different modalities prior to inviting them to select their

preference among multiple options. This person-centered approach provides nuanced information

about preferences that would not otherwise have been obtained in a survey alone.

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Our findings suggest that providers play a critical role in recommending credible self-

management options for older veterans in addition to providing traditional psychotherapy

interventions. Recommendations should include multiple self-management delivery options to

Accepted Article
meet older veterans’ preferences. With over fifty percent interested in Internet or mobile apps, it is

important that providers offer existing digital mental health interventions to older veterans;

however, special consideration is needed for rural individuals who may not be as interested in

mobile apps. Recommending these interventions may necessitate technology training for providers

or health coaches, new models of behavioral health delivery, and making instructional support for

technology available within health care systems.

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Table 1. Participant Characteristics (N=77)

Characteristic n (%) M (SD)
Age 69.16 (7.10)
Years of Education
≤ 15 years 29 (37.7%)
≥ 16 years 48 (62.3%)
Accepted Article
Sex
Male 63 (81.8%)
Female 14 (18.18%)
Race/Ethnicity
Black/African American 9 (11.69%)
White, Non-Hispanic 49 (63.64%)
White, Hispanic 5 (6.49%)
Other 14 (18.19%)
Marital Status
Single 18 (23.4%)
Married 28 (36.4%)
Divorced/Separated 24 (31.2%)
Widowed 7 (9.1%)
Employment
Full/Part-time 11 (14.3%)
Unemployed 6 (7.8%)
Retired 56 (72.7%)
Disabled 4 (5.2%)
Rural Status
Urban 62 (80.5%)
Rural 15 (19.5%)
General Health
Excellent 5 (6.5%)
Very Good 22 (28.6%)
Good 32 (41.6%)
Fair 11 (14.3%)
Poor 4 (5.2%)
Elevated Psychiatric Symptoms
Present 34 (45.9%)
Absent 40 (54.1%)
Measures
CIRS-G Total Score 12.07 (4.93)
GAS 16.20 (12.20)
PHQ-8 6.31 (6.15)
PCL-5 20.36 (18.69)
CPQ Total Score 23.80 (6.53)
Note. CIRS-G = Cumulative Illness Rating Scale for Geriatrics (N = 68). GAS = Geriatric Anxiety
Scale, PHQ-9 = Patient Health Questionnaire-8 item; CPQ = Computer Proficiency Score (N =
74). Race/ethnicity approximates that of the local VA Health Care System.

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Table 2. Technology Use, Modality Ratings, Mental Health, and Medical Burden Measures
n (%) M (SD) Min-Max
Technology Ownership and Services
DVD Player 57 (74.0%)
Computer 65 (84.4%)
Cellphone 71 (92.2%)
Accepted Article
Smartphone 54 (70.1%)
Tablet 38 (49.4%)
Smartphone or Tablet 59 (76.6%)
Internet Service in Home 62 (80.5%)
Any Technology 77 (100%)

Willingness Rating
Printed Materials 8.79 (1.89) 3-10
DVD 8.04 (2.57) 1-10
Internet 8.24 (2.40) 1-10
Mobile app 7.75 (2.97) 1-10

First Preference for Delivery Modality

Printed Materials 27 (35.1%)
Mobile app 22 (28.6%)
Internet 19 (24.7%)
DVD 10 (13.0%)

First Preference for Delivery Modality when Included Counseling

Counseling 51 (66.2%)
Internet 10 (13.0%)
Mobile apps 8 (10.4%)
Printed Materials 6 (7.8%)
DVD 3 (3.9%)

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Accepted Article
Table 3. Factors Associated with Self-Management Preferences
Printed Materials DVDs Internet Interventions Mobile App
Interventions
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Education
≤ 15 years (Ref)
≥ 16 years 2.42 (0.72, 8.21) 1.81 (0.21, 5.70) 0.45 (0.13, 1.54) 0.67 (0.19, 2.34)
Rural Status Rural
(Ref) Urban
0.82 (0.23, 2.97) 0.00 (0.00, 0.00)a 0.40 (0.08, 2.14) 5.14 (1.37, 19.28)
Elevated Psychiatric Symptoms
Absent (Ref)
Present 0.61 (0.22, 1.70) 3.49 (0.69, 17.81) 0.99 (0.33, 3.00) 1.14 (.38, 3.43)
CPQ Total Score 0.92 (0.85, 1.01) 0.84 (0.73, 0.95) 1.15 (1.02, 1.30) 1.12 (1.00, 1.24)
Note. CPQ = Computer Proficiency Questionnaire. Not shown are models adjusted by CIRS-G total scores because CIRS-G was not a
significant predictor. Bolded ORs indicate that that predictor was significant at p < .05. aNo rural-dwelling individuals ranked DVDs
first, but model remained unchanged when excluding this variable, so variable retained in model.

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Accepted Article
Table 4. Qualitative Themes Underlying Preferences
Themes Description First Choice and Example Quote
People Experience using, Printed Materials: “I am most comfortable with books and printed materials. And the
prefer comfort/familiarity with, and Internet, I’m okay with that, I mean I Google and do that, but I find that frustrating too
what they enjoyment of modality because there are so many options.”
know
DVDs: “The DVD, you know it’s like going to school. It’s like learning something. It has
that feature to it that it’s outside of yourself and somebody’s explaining it and you can
interact with the DVD as well.”
Ease of Portability, convenience of Mobile apps: “I have my phone 100% of the time and my computer 80-90% of the time. So
access the modality, and device the mobile apps I would place as number one because I always have my phone with me. It is
wherever ownership more convenient than having to go to a computer to run a DVD, or to go home to pick up a
and brochure that I got mailed last time.”
whenever
Printed Materials: “A book is a highly efficient tool because you can put a book marker in
it and you can just go straight to that paragraph and whereas with a mobile app your battery
might be low, the noise level in the car or the train or the bus is too high or you don’t
understand the symbols. A book is easy to access.”
Specific Interactivity, multimedia DVDs: “I would pay attention more to DVDs. The pictures and writing and that would
Modality delivery probably be more helpful to me.”
Features
Internet: “The Internet is a lot better [than mobile apps] and a lot easier to be able to
communicate, manipulate, move your way around, so that would be my choice. It gives you
more freedom of movement, more access to what you want to know, and being able to ask
questions.”
Ease navigation and user Internet: “On my desktop computer, I have a large monitor, a 27 inch. So, I can turn up the
experience fonts and it makes it easy to read.”
Mobile Apps: “Ease of entry for me would be having it as an app where I can click on it and
get into all the information that would be available on that program.”
Data security and Printed Materials & DVDs: “I’m comfortable with the security of those [printed materials
information privacy issues and DVDs] because I have them with me and I know that I have control over what comes on
and what goes off. Internet-based and mobile apps, there is always that possibility of the
material being hacked. And don’t tell me it doesn’t because it happens all the time
nowadays.”

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Figure 1. Flow of participants through the study
Accepted Article

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 Ellis et al. BMC Psychiatry 2013, 13:119 Page 39 of
Journal of Affective Disorders Reports 6 (2021) 100227
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Contents lists available at ScienceDirect

Journal of Affective Disorders Reports

journal homepage: www.sciencedirect.com/journal/journal-of-affective-

Research Paper

Technology use and interest in digital apps for mental health promotion
and lifestyle intervention among young adults with serious mental
illness
John A. Naslund a,*, Kelly A. Aschbrenner b

a
Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, United States
b
Department of Psychiatry, Geisel School of Medicine at Dartmouth, NH, Lebanon

ARTICLEINFO
ABSTRACT
Keywords:
Young adults Background: Digital technology holds promise for reaching young adults with serious mental illness. This study
Serious mental illness seeks to characterize technology use and explore interests in digital health interventions among young adults
Digital mental health with serious mental illness.
mHealth
Methods: A survey was collected from participants age 18–35 enrolled in a lifestyle intervention trial about their
Apps
technology ownership and use; technology use for mental health or other health reasons; and interest in health
Health promotion
apps.
Smartphone
Results: Responses from 150 participants were summarized. Differences in technology use were compared be-
tween individuals with psychotic (n = 65) and non-psychotic disorders (n = 85). Most participants owned
mobile phones (92%) and used social media (95%). Smartphone ownership was higher among participants
with non- psychotic (98%) compared to psychotic (84%) disorders. Many participants searched online for
information about their mental health (73%) or general health (79%). More participants with non-psychotic
compared to psychotic disorders expressed interest in apps for depression (71% vs. 54%) or anxiety (78% vs.
54%). Interest in apps for lifestyle, behavioral health, and other health needs was similar between diagnostic
groups.
Limitations: These findings may not generalize to all young adults with serious mental illness.
Conclusions: There is high access, use, and interest in technology among young adults with serious mental
illness. This highlights potential for integrated digital interventions for mental and physical health in this high-
risk group.

1. Introduction
lifestyle interventions tailored to at-risk young adults with serious mental
Individuals living with serious mental illness face an early mortality illness (Naslund and Aschbrenner, 2019).
disparity reflected by upwards of 30 years shorter life expectancy when The increasing access to and use of digital technologies including
compared to the general population (Liu et al., 2017). Mounting evi- smartphones, online programs, and social media among individuals
dence supports the effectiveness of lifestyle interventions and health living with serious mental illness is well documented, as reflected by
promotion programming that can successfully address risk factors such studies conducted across different community-based and clinical set-
This article is protected by copyright. All rights reserved.
as cardiorespiratory fitness, sedentary lifestyle, dietary behaviors, and tings (Aschbrenner et al., 2018; Brunette et al., 2019; Firth et al., 2015;
low mood and symptoms that get in the way of positive health behavior Naslund et al., 2016). In particular, research shows that young people
change (Firth et al., 2019). However, few individuals living with serious with serious mental illness use popular technologies such as social
mental illness have access to these programs as part of routine mental media at comparable rates as the general population (Birnbaum et al.,
health service delivery. Additionally, there has been less attention 2017), and express interest in accessing mental health services through
directed at addressing these risk factors in early adulthood, which could these popular digital platforms (Beard et al., 2019; Naslund et al., 2019).
have greater impact in mitigating harmful consequences over the life This growing recognition of the use and interest in using technology
course. Digital technologies hold promise for bridging these gaps, and among people with serious mental illness parallels the emergence of
could be used to extend the reach of mental health promotion and studies over the last decade demonstrating the feasibility, acceptability,
and clinical benefits of digital technologies for individuals living with

* Corresponding author.
E-mail address: john_naslund@hms.harvard.edu (J.A. Naslund).

https://doi.org/10.1016/j.jadr.2021.100227
 Ellis et al. BMC Psychiatry 2013, 13:119 Page 40 of
Received 24 April 2021; Received in revised form 31 July 2021; Accepted 7 September 2021
http://www.biomedcentral.com/1471-244X/13/119
Available online 12 September 2021
2666-9153/© 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

This article is protected by copyright. All rights reserved.

 J.A. Naslund and K.A. Aschbrenner
serious mental illness (Berry et al., 2016; Naslund et al., 2015). This
includes smartphone-delivered interventions for improving symptom
management, functioning and engagement in clinical care (Ben-Zeev et
al., 2018), and monitoring symptom changes over time (Niendam et al.,
2018).
More recently, there has been growing emphasis on the use of digital
interventions specifically for reaching young adults with serious mental
illness (Melbye et al., 2020). There have been preliminary feasibility and
pilot studies of smartphone interventions for symptom tracking and
improving functional outcomes (Bucci et al., 2018; Schlosser et al.,
2018), as well as targeting loneliness and social anxiety (Lim et al.,
2020; McEnery et al., 2021). This has also involved carefully tailoring the
design and interface of digital interventions to appeal to the interests of
younger demographic groups by incorporating peer moderators or
interactive features that are similar to the look and feel of popular social
media platforms (McEnery et al., 2021; Schlosser et al., 2016). Despite
the early promise and acceptability of these digital interventions, as
reflected by reports of high satisfaction among participants across many
studies (Melbye et al., 2020), there remain several notable challenges.
Many of the studies enrolling young adults with serious mental illness
have included small feasibility or proof-of-concept studies, show diffi-
culty in sustaining participant engagement over time, and have not been
widely tested or implemented in routine service delivery settings (Mel-
bye et al., 2020). Furthermore, there is ongoing need to sufficiently
account for the characteristics and interests of the target group of par-
ticipants in the design and delivery of these interventions (Mohr et al.,
2017), as well as exploring opportunities for integrating strategies and
content aimed at promoting both mental and physical health given that
these are co-occurring health concerns among young adults with serious
mental illness, and together contribute to significant reductions in life
expectancy compared to the general population (Naslund and Asch-
brenner, 2019).
To address these gaps in the literature, and to continue to advance
the reach and impact of digital interventions for young adults with
serious mental illness, it is necessary to better understand patterns of
technology access and use in this high-risk group, as well as to capture
insights about their interests in using technology for mental and physical
health promotion programs. Successful digital interventions are
frequently tailored to the needs of the target user group (Yardley et al.,
2015), and for persons with serious mental illness this often means ad-
aptations to the digital content and interface in order to accommodate
users’ psychosocial context, cognitive functioning, and literacy levels
(Ben-Zeev et al., 2014; Biagianti et al., 2017). It is also important to
consider whether there may be differences in technology interest and
use between diagnostic groups, recognizing that young adults with
psychotic disorders such as schizophrenia spectrum disorders may have
different priorities for using a mobile app and interests when compared
to young adults with non-psychotic disorders such as mood disorders,
anxiety disorders, or post-traumatic stress disorder. Furthermore, digital
mental health technologies are often developed for specific mental
illness diagnoses, making it necessary to consider if there are
differences in preferences or interest in digital interventions between
diagnostic groups. Therefore, the purpose of this exploratory study was
to char- acterize the patterns and type of technology use and interest in
digital interventions for promoting mental health and physical health
among young adults with serious mental illness receiving care in
community mental health centers. Specifically, our goal was to explore
differences in technology access, use of different types of technology for
mental health and physical health, and interest in digital interventions
between participants with psychotic and non-psychotic disorders.
2. Methods
2.1. Participants and setting
Participants in this study were young adults (ages 18–35) with
2
Journal of Affective Disorders Reports 6 (2021) 100227
serious mental illness enrolled in the Fit Forward randomized clinical trial
of a lifestyle intervention (ClinicalTrials.gov registration: NCT02815813).
Details about the Fit Forward trial and methods are described elsewhere
(Aschbrenner et al., 2018)(Aschbrenner et al., 2021). Participants were
recruited from community mental health centers in the Northeastern
United States from 2017 to 2019. Eligible participants were required to
be receiving services, be at elevated car-
diovascular risk defined as being overweight or obese based on body
mass index (BMI) 25 ≥kg/m2, and have a diagnosis of a serious mental
illness defined in the DSM-5 as a psychotic disorder (i.e., schizophrenia
spectrum disorders and psychotic disorders) or a non-psychotic disorder
(i.e., mood disorders, anxiety disorders, or post-traumatic stress disor-
der). The current study reports on baseline data collected from partici-
pants on their use of technology. The Committee for the Protection of
Human Subjects at Dartmouth College approved all study procedures.
2.2. Measures
Demographic and clinical characteristics were collected from par-
ticipants at baseline. In addition, participants completed the Consumer
Technology Use Survey, the primary measure of interest in this report.
This measure was developed by our team based on prior research
assessing technology use among individuals with SMI (Aschbrenner et
al., 2018; Aschbrenner et al., 2019; Naslund et al., 2016) and covers
three major topic areas related to technology use: (1) access and use of
various types of digital technology including mobile phones, smart-
phones, the Internet and social media; (2) use of digital technology for
health purposes, including for seeking information about mental health or
physical health; and (3) interest in using smartphone apps for accessing
programs for mental health, physical health, and other health reasons.
2.3. Statistical analysis
Participants’ responses to the Consumer Technology Use Survey were
tabulated to provide summary statistics. Chi-square tests were used to
explore differences in participants’ demographic characteristics and
patterns of technology use, access, and interest in technology between
participants with psychotic disorders and non-psychotic disorders. SPSS
Software was used for all statistical analyses. P-values <0.05 were
considered statistically significant.
3. Results
3.1. Demographic characteristics
Participant characteristics are listed in Table 1. Of 150 participants,
about 43% had psychotic disorders (N 65), =and the remainder had non-
psychotic disorders (N 85), = including mood disorders (37%), post-
traumatic stress disorder (17%), and anxiety disorders (3%). The
= and 55% (N
average age of participants was 28.38 years (SD 4.54),
82) identified as being white and 26% (N = 39) as Black, with 30% (N
45) identifying as being Hispanic. Greater proportions of participants with
non-psychotic disorders were married (25% vs. 5%; p =0.01), had
completed some college or were college graduates (55% vs. 25%; p =
0.017), and were living independently (57% vs. 34%; p =0.016) when
compared to participants with psychotic disorders, respectively. Par-
ticipants with psychotic disorders were more likely to be taking anti-
psychotic medication compared to participants with non-psychotic
disorders.
3.2. Access and patterns of digital technology use
As outlined in Table 2, 92% of participants reported owning a mobile
phone, with high rates of ownership observed in participants with psy-
chotic (86%) as well as non-psychotic disorders (97%). Among
 J.A. Naslund and K.A. Aschbrenner Journal of Affective Disorders Reports 6 (2021) 100227

Table 1
Baseline demographic characteristics of participants with psychotic disorders compared to non-psychotic disorders.
a
Total Sample(N = 150) Psychotic disorders(N = 65) Non-Psychotic Disorders(N = 85) P-value
Characteristic N % N % N %

Age (M ± SD) 28.38 ± 4.54 28.37 ± 4.40 28.39 ± 4.67 .980

Weight (M ± SD lbs) 106.38 ± 24.12 105.95 ± 19.06 106.71 ± 27.48 .843
Body mass index (M ± SD) 37.14 ± 7.4 36.88 ± 6.86 37.34 ± 8.55 .724
Smoking status .736
Not Smoking 92 61.3 39 60 53 63.1
Smoking 57 38.7 26 40 31 36.9
Birth sex .096
Male 64 42.7 33 50.8 31 36.5
Female 86 57.3 32 49.2 54 63.5
Race .051
White 82 54.7 26 47.3 55 69.6
Black 39 26 21 38.2 17 21.5
Asian 1 7 1 1.8 0 0
More Than One 12 8 7 12.7 7 8.9
Latino .472
Yes 45 30 22 33.8 23 27.4
No 104 69.3 43 62.2 61 72.6
Marital Status .01
Married 13 8.7 3 4.6 21 25
Never married 125 83.3 62 95.4 63 75
Education .017
Less than high school 22 14.7 12 18.7 10 11.8
High school graduate 63 42 37 56.9 26 30.6
Some college 50 33.3 14 21.5 36 42.4
College graduate 15 10 2 3 11 13
Employment status .405
Working 28 18.7 10 15.4 18 21.2
Not working 120 80 55 84.6 67 78.8
Residential .016
Living independently 70 46.7 22 33.8 48 56.5
Living with family 43 28.7 23 35.4 20 23.5
Supervised or supported housing 37 24.7 20 30.7 14 16.5

Contact with parents by Telephone .496

Not at all 13 8.7 6 9.2 7 8.3
Everyday 64 4.3 28 43.1 36 42.9
Once a week 40 26.8 21 32.3 19 22.6
Once a month 18 12.1 6 9.2 12 14.3
Less than once a month 14 9.4 4 6.2 10 11.9
Contact with parents by text message .117
Not at all 42 28.2 24 36.9 18 21.4
Everyday 47 31.5 19 29.2 28 33.3
Once a week 31 20.8 9 13.8 22 26.3
Once a month 10 6.7 3 4.6 7 8.3
Less than once a month 19 12.8 10 15.4 9 10.7
Contact with parents in person .129
Not at all 17 11.4 5 7.7 12 14.3
Everyday 59 39.6 33 50.8 26 31
Once a week 31 20.8 11 16.9 20 23.8
Once a month 20 13.4 9 13.8 11 13.1
Less than once a month 22 14.8 7 10.8 15 17.9
Taking antipsychotic medication 106 70.7 59 92.2 47 56 <.001

a
Bold face denotes statistical significance, defined as P value ≤0.05.

participants who own mobile phones, most have smartphones (92%),

use of social media between diagnostic groups, with most participants
though smartphone ownership was significantly higher among partici-
with non-psychotic (98%) and psychotic (92%) disorders using social
pants with non-psychotic compared to psychotic (98% vs. 84%; p 0.007)=
media platforms. There were some differences in the types of platforms
disorders. Furthermore, frequency of mobile phone use and messaging
used between groups, though there were no significant differences in
differed between diagnostic groups. Participants with non- psychotic
frequency of use between groups, with close to two thirds of participants
disorders were more likely to use their mobile phone daily (99% vs. 88%;
reporting that they use social media on a daily basis.
p =0.019), to send text messages several times each
day (77% vs. 55%; p = 0.020)
compared to participants with psychotic disorders. Participants with 3.3. Use of technology for mental health and other health concerns
mood disorders were more likely to use their mobile phone to connect to
the Internet (98% vs. 79%; p < 0.001) compared to participants with Most participants reported having used the Internet to search for
psychotic disorders, yet overall Internet use between diagnostic groups information about their mental health (73%) or general health (79%). As
did not differ. Daily use of the Internet was higher among participants reflected in Table 3, a larger proportion of participants with non-
with non-psychotic disorders (96%) compared to participants with = psychotic disorders reported using the Internet to search for mental
psychotic disorders (76%; p 0.001). health information when compared to participants with psychotic dis-
Most participants (95% of overall study sample) reported using social orders (78% vs. 66%, respectively), but this difference was not statisti-
media. Interestingly, there were no statistically significant differences in cally significant. By contrast, a significantly greater proportion of

3
 J.A. Naslund and K.A. Aschbrenner Journal of Affective Disorders Reports 6 (2021) 100227

Table 2 Table 2 (continued )

Technology use among participants with psychotic disorders compared to non-
Total Psychotic Non- P-
psychotic disorders. Sample(N disorders Psychotic value
a

Total Psychotic Non- P- = 150) (N = 65) Disorders

Sample(N a (N = 85)
disorders (N = Psychotic value
= 150) Mobile Phone Use N % N %N %
65) Disorders

Mobile Phone Use N % N % (N = 85) Every day 127 87.6 47 75.8 50 96.4
N % Several times each week 13 9 10 16.1 3 3.6
Do you have a mobile phone?
.30 How do you typically connect to
the Internet
Yes 137 91.9 55 85.9 82 96.5 My computer 61 40.7 31 47.7 30 35.3 .135
No 12 8.1 9 14.1 3 3.5 Family member’s or 18 12 9 13.8 9 10.6 .616
What type of phone plan
.533 friend’s computer
do you have? Computer at library 25 16.7 14 21.5 11 12.9 .188
Prepaid phone plan 40 29 9 33.9 21 25.6 Computer at workplace 9 6 5 7.7 4 4.7 .502
Post paid phone plan 9 6.5 3 5.4 6 7.3
Monthly phone plan at 44 31.9 14 25 30 36.6
fixed price
Corporate phone plan 1 .7 1 1.8 0 0
Family phone plan 38 27.5 16 28.6 22 26.8
Don’t know/not sure 6 4.3 3 5.4 3 3.7
your mobile phone a
smartphone?

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 J.A. Naslund and K.A. Aschbrenner Journal of Affective Disorders Reports 6 (2021) 100227
Computer at community center 28 18.7 15 23.1 13 15.3 .291

Is .007 Mobile phone 131 87.3 49 75.4 82 96.5 <.001

Table (such as iPad) 31 20.7 14 21.5 17 20 .841
Internet caf´e 13 8.7 5 7.7 8 9.4 .777
Other 4 2.7 0 0 4 4.7 .133
Where do you typically access
the Internet?
At home 129 86 56 86.2 73 85.9 1.0
Yes 127 92 47 83.9 80 97.6 Library or school 37 24.7 17 26.2 20 23.5 .849
No 11 8 9 16.1 2 2.4
H .019 Public areas with free WiFi 67 44.7 28 43.1 39 45.9 .744
ow often do you use
your Cafes or restaurants with free
Everymobile
day phone? 130 94.2 49 87.5 81 98.8
WiFi 53 35.3 18 27.7 35 41.2 .120
Several times each week 6 4.3 5 8.9 1 1.2
Social Media Use
Less than once per week 2 1.4 2 3.6 0 0
How often do you use your .020 Do you use social media? .240
mobile phone to send or Yes 143 95.3 60 92.3 83 97.6
receive text messages (SMS)? No 7 4.7 5 7.7 2 2.4
Several times each day 94 68.1 31 55.4 63 76.8 Do you use any of the
Several times each week 35 25.4 22 39.3 13 15.9 following popular social
Less than once per week 5 3.6 2 3.6 3 3.7 media?
Facebook 121 80.7 49 75.4 72 84.7 .210
Never, I don’t use text Twitter 30 20 12 18.5 18 21.2 .837
4 2.9 1 1.8 3 3.7
messaging Instagram 67 44.7 21 32.3 46 54.1 .009
Who do you share your Snapchat 50 33.3 16 24.6 34 40 .056
.580
mobile phone with? YouTube 126 84 54 83.1 72 84.7 .826
Partners or spouse 3 2.2 1 1.8 2 2.4 LinkedIn 21 14 7 10.8 14 16.5 .353
Parents 2 1.4 1 1.8 1 1.2 Tumblr 9 6 3 4.6 6 7.1 .732
Children 4 2.9 0 0 4 4.9 Pinterest 38 25.3 10 15.4 28 32.9 .015
Brother or sister
Periscope 1 .7 0 0 1 1.2 1.0
Friends 3 2.2 1 1.8 2 2.4
Google Plus 19 12.7 10 15.4 9 10.6 .460
I do not share my mobile 125 90.6 53 94.6 72 87.8 Reddit 15 10 4 6.2 11 12.9 .272
phone with anyone else Other 8 5.3 2 3.1 6 7.1 .467
Do you use your mobile <.001 No, I don’t use social 7 4.7 5 7.7 2 2.4 .240
phone to connect to the media
Internet? How often do you use any .339
Yes 124 89.9 44 78.6 80 97.6 type of social media?
No 14 10.1 12 21.4 2 2.4 Every day 92 64.8 37 61.7 55 67.1
What type of operating .508 Several times each week 35 24.6 14 23.3 21 25.6
system do you have on your Less than once per week 15 10.6 9 15 6 7.3
smartphone? What devices do you use to
Android 83 65.4 31 66 52 65 access social media?
Apple iOS 42 33.1 15 31.9 27 33.8 Mobile phone 126 84 47 72.3 79 92.9 .001
Windows 1 .8 0 0 1 1.3 Tablet 27 18 11 16.9 16 18.8 .832
Don’t know/not sure 1 .8 1 2.1 0 0 Computer 59 39.3 31 47.7 28 32.9 .091
Do you have a tablet? .068 Other 3 2 1 1.5 2 2.4 1.0
Yes 48 34.8 14 25 34 41.5
a
No 90 65.2 42 75 48 58.5 Bold face denotes statistical significance, defined as P value ≤0.05.
What type of operating .761
system do you have on your participants with non-psychotic compared to psychotic disorders re- ported
tablet? 22 45.8 7 50 15 44.1
using the Internet to search for general health information (86% vs. 71%,
Android Apple
iOS Windows
17
2
35.4
4.2
4
1
28.6
7.1
13
1
38.2
2.9
= similar proportions of par- ticipants with
respectively; p 0.039). Though
Don’t know/not sure 2 4.2 0 0 2 5.9 either non-psychotic or psychotic disorders reported using social media
Other 5 10.4 2 14.3 3 8.8 platforms such as Facebook to search for information about their mental
Internet Use health (33% vs. 32%, respectively) and general health (40%
vs. 35%, respectively).
Do you use the Internet? .318
Yes 145 97.3 62 95.4 83 98.8 There were few differences between diagnostic groups with regards to the
No 4 2.7 3 4.6 1 1.2 types of digital health tools a doctor may have recommended for
How often do you use the .001 mental health or overall health, with one notable exception; nearly half
Internet? of participants with non-psychotic disorders (48%) reported that their
doctor recommended use of a crisis helpline when compared to about

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 J.A. Naslund and K.A. Aschbrenner Journal of Affective Disorders Reports 6 (2021) 100227

Table 3 54%, respectively; p = 0.003). A significantly greater proportion of

Technology use for mental health and other health reasons among participants participants with psychotic disorders expressed interest in smartphone
with psychotic disorders compared to non-psychotic disorders. apps to help with voices when compared to participants with non-

Total Psychotic Non- P- psychotic disorders (39% vs. 14%, respectively; p = 0.001). Whereas,
a
Sample(N
disorders (N = Psychotic value as summarized in Fig. 2, in response to the following question “Would you be
= 150)
65) Disorders interested in any of these health apps?”, there were no significant
(N = 85)
differences in the selection of various health related apps between
N % N % N %
diagnostic groups. It is noteworthy that roughly two thirds of all par-
Have you ever used the .130 ticipants’ expressed interest in apps for exercise or fitness (66%) or for
Internet to search for any
information about your diet (69%). Interestingly, over half of participants expressed interest in
mental health? apps for cognition such as brain trainer or mind teaser games (51%), and
Yes No 106 73.1 41 66.1 65 78.3 apps for stress, relaxation, or sleep (65%).
Have you ever used the 39 26.9 21 33.9 18 21.7
Internet to search for any .039
information about your own 4. Discussion
health?
Yes No The findings described here are consistent with existing literature showing
Have you ever used social 115 79.3 44 71 71 85.5 high access, use, and interest in mobile technology among young adults
media (e.g., Facebook) to 30 20.7 18 29 12 14.5
search for information about
with serious mental illness (Brunette et al., 2019; Young et al., 2020),
1.0
your mental health? while also illustrating patterns of mobile technology use between
individuals with psychotic and non-psychotic disorders. It is noteworthy
that even though technology access was high across both
diagnostic groups, significantly fewer individuals with psychotic disor-
Yes 46 32.2 19 31.7 27 32.5
No 97 67.8 41 68.3 56 67.5
ders had access to smartphones, and their frequency of smartphone use
Have you ever used social .603 and Internet use was lower when compared to individuals with non-
media (e.g., Facebook) to psychotic disorders. Prior studies have found similar lower tech- nology
search for information about access in patients with psychotic disorders compared to non-psychotic
your health?
disorders (Young et al., 2020), a gap that that may reflect various clinical
Yes 54 37.8 21 35 33 39.8
No 89 62.2 39 65 50 60.2 or socio-demographic characteristics, such as more se- vere mental
Has your doctor ever health symptoms, not living independently, or having lower level of
recommended any of the educational attainment. For instance, the higher rates of inde- pendent
following for your mental living observed among participants with non-psychotic disor- ders may
health?
necessitate more frequent phone or Internet use, and thereby contribute
Internet website 20 13.3 9 13.8 11 12.9 1.0
Smartphone/tablet app 14 9.3 3 4.6 11 12.9 .096
to greater smartphone ownership in this diagnostic group. Interestingly,
Specialized software 2 1.3 1 1.5 1 1.5 1.0 despite these differences, the proportion of participants who reported
Crisis helpline 61 40.7 20 32.8 41 48.2 .044 using social media, and the frequency of social media use did not appear
Other 1 .7 0 0 1 1.2 1.0 to differ between diagnostic groups. This is also consis- tent with prior
None of the above 73 48.7 39 60 34 40 .021
reports showing comparable patterns of social media use in young people
Has your doctor ever
recommended any of the
with psychotic and non-psychotic disorders (Birnbaum et al., 2017).
following for your health? In the current study, we also did not find any differences in access to and
use of mobile technology between racial and ethnic minority groups. This
Internet website 14 9.3 7 10.8 7 8.2 1.0 is consistent with recent national survey data showing that Black and
Smartphone/tablet app 16 10.7 6 9.2 10 11.8 .096
Hispanic young adults have comparable rates of smartphone ownership
Specialized software 2 1.3 1 1.5 1 1.2 1.0
Other 1 .7 1 1.5 0 0 .433 as whites (Pew Research Center, 2021b), as well as compa- rable or
a None of the above 121 80.7 52 80 69 81.2 1.0 higher use of social media platforms as whites depending on the platform
Bold face denotes statistical significance, defined as P value ≤0.05. type (Pew Research Center, 2021c). These findings likely reflect the
young age of our study sample, which is aligned with research
one third of participants with psychotic disorders (33%), a statistically showing that younger individuals with less education, lower-income,
significant difference (p = 0.044). Furthermore, a significantly larger and from racial/ethnic minority groups are highly likely to be depen- dent
proportion of participants with psychotic disorders (60%) reported that on their smartphones (Tsetsi and Rains, 2017). It is also noteworthy that
their doctor had never recommended any type of digital tools for mental while we did not observe any differences between race and ethnic
health when compared to participants with non-psychotic disorders groups, that recent studies continue to illustrate that the digital divide
= With regards to doctor recommendations for digital tools
(40%; p 0.021). persists in the United States in terms of access to and use of health-
for general health, there were no differences between diagnostic groups, related technologies among older adults, whereby Blacks and Hispanics
though over 80% of participants indicated that their doctor had not use technologies for health-related purposes less than whites (Mitchell
recommended any digital technology for their health. et al., 2019). Furthermore, our study was focused on the use of mobile
technologies, which could hold potential to bridge gaps in access and
quality to mental health services (Friis-Healy et al., 2021), yet we did not
3.4. Interest in smartphone apps for mental health, lifestyle capture details about use of home broadband internet, where there
intervention, and other health reasons remain considerable gaps in access among low-income in- dividuals,
young people, and underrepresented racial and ethnic mi- nority groups
As illustrated in Fig. 1, in response to the following question: “Would you (Pew Research Center, 2021a; Singh et al., 2020). We also
be interested in any of these apps for mental health?” a significantly did not explore participants’ digital literacy, reflected as their skills or
greater proportion of participants with non-psychotic compared to competencies required to effectively use and benefit from digital mental
psychotic disorders expressed interest in smartphone apps to help with health tools, which is an emerging ‘second digital divide’ among in-
depression (71% vs. 54%, respectively; p = 0.041) and anxiety (78% vs. dividuals living with serious mental illness that likely parallels existing

6
 J.A. Naslund and K.A. Aschbrenner Journal of Affective Disorders Reports 6 (2021) 100227

Fig. 1. Participants’ interest in smartphone apps for mental health a

*p < 0.05 a Participants responded to the following question: “Would you be interested in any of these apps for mental health?”.

Fig. 2. Participants’ interest in smartphone apps for health promotion and other health reasons a
*p < 0.05 a Participants responded to the following question: “Would you be interested in any of these health apps?”.

inequities in the use of digital technologies due to race and ethnicity,

income, age, and education (Hoffman et al., 2020).
In this study, a large proportion of young adult participants with psychotic
and non-psychotic disorders reported having searched for information
about their mental health or physical health online. Roughly one third of
participants across diagnostic groups also reported using social media to
search for mental health or physical health in- formation. This is
consistent with high rates of searching for health in- formation online and
on popular social media among young adults from
the general population (Fox and Duggan, 2013; Zhao and Zhang, 2017).
Research from the general population has also demonstrated that in-
dividuals from lower income groups have significantly lower health
literacy, and as a result, are less likely to search for health information
online (Estacio et al., 2019). While we did not assess health literacy
among participants in this study, our sample represents an at-risk pa-
tient group with serious mental illness, which is further reflected by the
low rates of employment and low educational attainment. Our results
suggest that even with potentially lower levels of health literacy, these

7
 J.A. Naslund and K.A. Aschbrenner
young adult participants are actively using online technologies to seek
information about their health. This is important to recognize because
searching for health information online can be especially empowering
for making sense of one’s own diagnosis and symptoms, and can help
promote informed choices in seeking health care (Ziebland et al., 2004),
while affording the flexibility to navigate between professional websites
or medical resources, as well as more informal user-generated content
and first person illness accounts posted on social media (Fergie et al.,
2016). Yet, concerns have also been raised about the varying quality of
online health information (Daraz et al., 2019), and specifically in studies
with young adults, there have been challenges pertaining to the trust-
worthiness and relevance of online mental health information (Gowen,
2013; Lal et al., 2018). Therefore, our study highlights an additional
important need to consider what information these young adults may be
finding online, how they are interpreting or using this information, and
how best to support them in identifying reliable and trustworthy online
resources for their mental and physical health needs.
When considering the role of clinicians, it is interesting that we found few
differences between the diagnostic groups with regards to the types of
digital health tools a doctor may have recommended for mental health or
overall health. However, we found that a larger proportion of participants
with non-psychotic disorders reported that their doctor had
recommended use of a crisis helpline when compared to participants
with psychotic disorders. This may reflect the greater lifetime risk of
suicidal ideation that has been reported among individuals with mood
disorders compared to psychotic disorders (Harvey et al., 2018). This
difference could also reflect the wider availability of crisis helplines and
well-established reputation of many of these services. Importantly, a
larger proportion of participants with psychotic disorders relative to non-
psychotic disorders indicated that their doctor had not recom- mended
any type of digital tools for mental health. This may be reflec- tive of the
limited availability of quality mobile apps and other digital tools
specifically designed for psychotic disorders. This is consistent with a
recent review of commercial app marketplaces that found out of
over 700 apps containing the terms “schizophrenia” or “psychosis” in
the description, only 6 were clinical relevant and had supporting evi-
dence (Lagan et al., 2020b). The remainder of the apps were mostly
games, and some were even stigmatizing or derogatory towards
persons living with psychotic disorders (Lagan et al., 2020b). Most
participants across both diagnostic groups also indicated that their
doctor had not recommended any digital tools for their general health.
This appears to parallel the common disconnect in services for young
adults with serious mental illness, where mental health care is typically
separated from physical health care (Lawrence and Kisely, 2010). Digital
health in- terventions could yield new opportunities to integrate
evidence-based content aimed at simultaneously addressing physical
and mental health needs of this high-risk patient group (Naslund and
Aschbrenner, 2019).
Importantly, we found high interest in smartphone apps for mental health
across both diagnostic groups. Over half of participants expressed
interest in smartphone apps to help with depression and anxiety, with
interest being substantially greater among participants with non-
psychotic disorders. As expected, interest in smartphone apps for help-
ing with voices was higher among participants with psychotic disorders.
There was also comparable, and high interest in using smartphone apps
for exercise, fitness or diet among participants. This is mostly likely
reflective of participants’ enrollment in a clinical trial of a lifestyle
intervention, where as a result, they were already motivated and
interested in health promotion activities. Nevertheless, this is an
important finding showing that young adult participants expressed in-
terest in digital interventions for both their mental health and physical
health. To date there has been less emphasis on using digital
technology to address the physical health needs of young adults with
serious mental illness. Recent studies have demonstrated the
acceptability and initial effectiveness of digital programs for smoking
cessation but that have mainly enrolled middle-age samples (Brunette
et al., 2020; Vilardaga
8
Journal of Affective Disorders Reports 6 (2021) 100227
et al., 2020), while challenges have emerged with engaging persons with
serious mental illness in online weight loss programs (Olmos-Ochoa et
al., 2019). However, digital technology for health promotion among
young adults with serious mental illness is an area ripe for further
exploration. In particular, digital interventions could have a combined
focus on physical health while accounting for mental health symptoms
that create challenges for sustaining engagement and achieving benefits
from these programs.
Given the detrimental effects of serious mental illness on cognitive
function, as well as the frequently disrupted sleep patterns in this patient
group, it is not surprising that we also found that there was high interest
in apps for cognition, stress, and sleep across both diagnostic groups.
Similarly, among young adults in the general population, a survey found
that there was high interest in brain training apps (Torous et al., 2016);
therefore, this could be a similar trend reflected among our young adult
participants. Overall, these findings emphasize the potential to expand
digital mental health apps to accommodate additional important health
targets, which is a research area that is gaining momentum especially as
wearable devices and sensors become more widely available, thereby
enabling more reliable and continuous tracking of behaviors, cognition,
mood, and sleep patterns (Aledavood et al., 2019; Torous et al., 2019).
Our findings of high use of technology for health reasons, combined with
interest in using a wide range of health related apps for both mental
health and physical health, suggest that young adults with serious
mental illness are likely already searching commercial app market-
places, either the Google Play store or iOS store, to find apps to meet
their health needs. This raises important considerations for the digital
mental health field, because despite promising scientific advances sup-
porting the potential clinical benefits of digital mental health apps, the
reporting of research findings substantially lags behind the commercial
sector. There continues to be unprecedented growth in the number of
available commercial digital mental health technologies, with well over
10,000 mental health apps available for download via commercial app
stores (Torous et al., 2019). It is worrisome that so few of these
commercially available apps are supported with reliable or high-quality
scientific evidence, and in the most egregious examples even report
false or misleading claims of clinical effectiveness (Larsen et al., 2019;
Lau et al., 2020). To address this considerable challenge, there have
been numerous calls for more robust standards to guide the evaluation
and dissemination of mental health apps (Torous et al., 2019), as well as
the
recent dissemination of objective approaches for evaluating the quality
of different features of mobile apps including safety, privacy, and
accessibility (Lagan et al., 2020a).
4.1. Limitations
Several limitations with this study should be considered. Firstly, this was
an exploratory study, and therefore was not sufficiently powered to test
any specific hypotheses related to technology use and interest in
technology in this patient group. Second, this study offers cross
sectional
findings, and as a result it is not possible to interpret participants’ in-
terests in technology beyond what is reflected in their responses.
Additional follow up interviews and focus group discussions could help to
expand on the findings described here. For instance, with most par-
ticipants’ in this study reporting generally high technology use, further
in-depth exploration into how and when participants use their mobile
devices, and whether there are socio-demographic differences, such as
between gender or racial/ethnic minority groups, could offer valuable
insights for informing the development and implementation of digital
mental health interventions. Third, participants in this study were
enrolled in a trial of a lifestyle intervention using digital technology, and
therefore may have already been interested in using technology for
either their mental health or physical health. Additionally, participants
had elevated cardiovascular risk and were interested in health promo-
 J.A. Naslund and K.A. Aschbrenner Journal of Affective Disorders Reports 6 (2021) 100227
tion, which may limit generalizability to other samples of young persons
with serious mental illness. However, participants were not required to

9
 J.A. Naslund and K.A. Aschbrenner Journal of Affective Disorders Reports 6 (2021) 100227

own or use technology at the time of enrolling in this study, with the only controlled trial. Contemp. Clin. Trials 74, 97–106.
requirement that they be actively receiving services at either of study
sites. While we recognize that this may be a limit to generaliz- ability,
this sample is reflective of young adult populations at risk of early
mortality receiving services in community mental health settings.

5. Conclusion

This study adds to mounting evidence confirming the widespread

access, use, and interest in digital technologies among individuals
with serious mental illness. A novel contribution from this study is the
emphasis on young adults with serious mental illness, a patient
group that is often difficult to reach and engage in clinical services as
well as research, and where digital technologies may be especially
impactful in targeting the combination of mental health and
behavioral health risk factors that contribute to early mortality earlier
in the lifecourse. While this study also highlights notable differences
in the patterns of tech- nology use between young adults with
psychotic compared to non- psychotic disorders, overwhelmingly
there was consistent interest in digital interventions for both mental
health and physical health across both groups. This highlights the
potential for future studies to consider ways to support the integration
of health promotion and lifestyle intervention content into existing
digital mental health interventions, or vice versa, to meet the specific
interests and health needs of this target user group. These findings
also suggest that continued efforts are needed to support young adults
with serious mental illness in accessing digital technologies, and in
particular mobile apps, that are safe, reliable, and draw from an
established scientific evidence-base, while considering whether
young adults have the digital literacy and skills to fully benefit from
the potential of these devices. This will require involvement of
clinicians who are positioned to recommend apps to their clients, as
well as additional resources to assist young people with serious mental
illness in confidently navigating the vast commercial app
marketplaces.

Author statement

Contributors: This paper is not under consideration elsewhere, and

neither it nor any part of its content has been published or been
accepted by another journal. All authors meet the authorship criteria
outlined by the International Committee of Medical Journal Editors.
All authors approved its current contents and the decision to submit
the manuscript for publication.

Declaration of Competing Interest

The authors report no conflicts of interest.

Acknowledgments

This study was supported with funding from the National Institute of
Mental Health (Grant number: 1R01MH110965). The funder played no
role in the study design; collection, analysis, or interpretation of data;
writing of the manuscript; or decision to submit the manuscript for
publication.

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