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Background: Mental disorders are prevalent during adolescence. Among the digital phenotypes currently being developed to monitor mental health symptoms, typing behavior is one promising candidate. However, few studies have directly assessed associations between typing behavior and mental health symptom severity, and whether these relationships differs between genders., Objective: In a cross-sectional analysis of a large cohort, we tested whether various features of typing behavior derived from keystroke metadata were associated with mental health symptoms and whether these relationships differed between genders., Methods: A total of 934 adolescents from the Future Proofing study undertook 2 typing tasks on their smartphones through the Future Proofing app. Common keystroke timing and frequency features were extracted across tasks. Mental health symptoms were assessed using the Patient Health Questionnaire-Adolescent version, the Children's Anxiety Scale-Short Form, the Distress Questionnaire 5, and the Insomnia Severity Index. Bivariate correlations were used to test whether keystroke features were associated with mental health symptoms. The false discovery rates of P values were adjusted to q values. Machine learning models were trained and tested using independent samples (ie, 80% train 20% test) to identify whether keystroke features could be combined to predict mental health symptoms., Results: Keystroke timing features showed a weak negative association with mental health symptoms across participants. When split by gender, females showed weak negative relationships between keystroke timing features and mental health symptoms, and weak positive relationships between keystroke frequency features and mental health symptoms. The opposite relationships were found for males (except for dwell). Machine learning models using keystroke features alone did not predict mental health symptoms., Conclusions: Increased mental health symptoms are weakly associated with faster typing, with important gender differences. Keystroke metadata should be collected longitudinally and combined with other digital phenotypes to enhance their clinical relevance., Trial Registration: Australian and New Zealand Clinical Trial Registry, ACTRN12619000855123; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377664&isReview=true., (©Taylor A Braund, Bridianne O’Dea, Debopriyo Bal, Kate Maston, Mark Larsen, Aliza Werner-Seidler, Gabriel Tillman, Helen Christensen. Originally published in JMIR Mental Health (https://mental.jmir.org), 15.05.2023.)

Background: Digital, self-guided cognitive behavioral therapy (CBT) interventions circumvent many barriers to in-person therapy for young people (aged 12-24 years), although adherence to these interventions is low. The absence or insufficient disclosure of recommendations or instructions for appropriate use may account for this. As such, many young people may not self-administer these interventions appropriately or receive the optimal degree of treatment., Objective: This systematic review aims to synthesize the literature on digital CBT for depression and anxiety in young people to describe how appropriate use has been defined and communicated to users as instructions for use, to describe how adherence has been measured, and to determine the associations between adherence and treatment outcomes., Methods: A systematic review was conducted with 2 reviewers (SHL and MRA) extracting data independently. Overall, 4 electronic databases (Embase, MEDLINE, PsycINFO, and Cochrane Library) were searched in April 2021 for studies that met the following inclusion criteria: participants aged between 12 and 24 years, evaluated a digital CBT intervention targeting depression or anxiety, and reported instructions or recommendations for use or measures of adherence. Studies that evaluated non-CBT interventions or cognitive- or behavioral-only interventions were excluded. Methodological quality was assessed using the Cochrane Risk of Bias Tool and the Integrated Quality Criteria for the Review of Multiple Study Designs., Results: There were 32 manuscripts that met the inclusion criteria, of which 28 (88%) were unique studies (N=16,578 youths). Definitions of appropriate use varied among the different interventions in terms of intended recipients, duration and frequency of use, and the features used to support engagement and adherence to appropriate use definitions. Reporting of appropriate use definitions in studies was inconsistent, with no study systematically describing components of appropriate use or providing information on how recommendations for use were relayed to users. Most often, definitions of appropriate use were derived from the study protocol and descriptions of intervention features. Adherence was mostly operationalized as the degree of intervention completion; however, reporting of adherence data was heterogeneous. There was little evidence of an association between degree of use and outcomes in the 9 studies that examined this., Conclusions: Definitions of appropriate use are unique to each digital CBT intervention. However, statements of appropriate use are not systematically reported in the literature. Furthermore, the extent to which recommendations for use are communicated to users is not routinely reported. Despite unique definitions of appropriate use, adherence was most often generically operationalized as the degree of intervention completion and was not consistently associated with outcomes. We proposed a framework to promote systematic reporting of definitions of appropriate use for digital interventions to provide guidance to users and to assist the development of appropriate and nuanced measures of adherence., Trial Registration: PROSPERO CRD42020208668; https://tinyurl.com/4bu2yram., (©Sophie H Li, Melinda R Achilles, Aliza Werner-Seidler, Joanne R Beames, Mirjana Subotic-Kerry, Bridianne O'Dea. Originally published in JMIR Mental Health (https://mental.jmir.org), 17.08.2022.)

Background: Mood disorders are burdensome illnesses that often go undetected and untreated. Sensor technologies within smartphones may provide an opportunity for identifying the early changes in circadian rhythm and social support/connectedness that signify the onset of a depressive or manic episode., Objective: Using smartphone sensor data, this study investigated the relationship between circadian rhythm, which was determined by GPS data, and symptoms of mental health among a clinical sample of adults diagnosed with major depressive disorder or bipolar disorder., Methods: A total of 121 participants were recruited from a clinical setting to take part in a 10-week observational study. Self-report questionnaires for mental health outcomes, social support, social connectedness, and quality of life were assessed at 6 time points throughout the study period. Participants consented to passively sharing their smartphone GPS data for the duration of the study. Circadian rhythm (ie, regularity of location changes in a 24-hour rhythm) was extracted from GPS mobility patterns at baseline., Results: Although we found no association between circadian rhythm and mental health functioning at baseline, there was a positive association between circadian rhythm and the size of participants' social support networks at baseline (r=0.22; P=.03; R 2 =0.049). In participants with bipolar disorder, circadian rhythm was associated with a change in anxiety from baseline; a higher circadian rhythm was associated with an increase in anxiety and a lower circadian rhythm was associated with a decrease in anxiety at time point 5., Conclusions: Circadian rhythm, which was extracted from smartphone GPS data, was associated with social support and predicted changes in anxiety in a clinical sample of adults with mood disorders. Larger studies are required for further validations. However, smartphone sensing may have the potential to monitor early symptoms of mood disorders., (©Taylor A Braund, May The Zin, Tjeerd W Boonstra, Quincy J J Wong, Mark E Larsen, Helen Christensen, Gabriel Tillman, Bridianne O’Dea. Originally published in JMIR Mental Health (https://mental.jmir.org), 04.05.2022.)

Background: Secondary schools are increasingly supporting adolescents' mental health and well-being, yet many teachers report that they lack the skills and confidence to do so. Building Educators' skills in Adolescent Mental Health (BEAM) is a web-based training program developed to improve secondary school teachers' knowledge and confidence in caring for students' mental health., Objective: This pilot study examined the preliminary effectiveness and acceptability of the BEAM program for improving mental health knowledge, attitudes, confidence, helping behaviors, and psychological distress among secondary school teachers., Methods: A single-arm pilot trial was conducted from July to December 2019 among secondary school teachers located in New South Wales, Australia, who were employed in leadership positions responsible for managing student well-being (ie, Year Advisors). Participants had access to the BEAM program for 6 weeks. Self-report surveys, delivered at baseline, postintervention (6-weeks post baseline) and 3-month follow-up (19 weeks post baseline) were used to measure changes in training outcomes. Acceptability was assessed by program use, barriers, satisfaction, and participants' perceptions of program effectiveness., Results: A total of 70 secondary school teachers took part (mean age 36.5 years, SD 9.41 years, range 24-60 years). Significant improvements in confidence were reported at postintervention and 3-month follow-up. Significant improvements in helping behaviors were reported at 3-month follow-up only. There was also a significant reduction in psychological distress at postintervention. Participants agreed that the program content was easy to understand and relevant, but program completion was challenged by lack of time, competing priorities, and forgetfulness., Conclusions: Findings indicated that a web-based training program may be beneficial for improving secondary school teachers' abilities to care for students' mental health; however, program modifications are required to increase training completions., Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619000821190, Universal Trial Number U1111-1232-7680; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377529., (©Belinda L Parker, Melissa Anderson, Philip J Batterham, Aimee Gayed, Mirjana Subotic-Kerry, Melinda R Achilles, Cassandra Chakouch, Aliza Werner-Seidler, Alexis E Whitton, Bridianne O’Dea. Originally published in JMIR Mental Health (https://mental.jmir.org), 22.10.2021.)

Background: Anxiety disorders and depression are prevalent among youth. General practitioners (GPs) are often the first point of professional contact for treating health problems in young people. A Web-based mental health service delivered in partnership with schools may facilitate increased access to psychological care among adolescents. However, for such a model to be implemented successfully, GPs' views need to be measured., Objective: This study aimed to examine the needs and attitudes of GPs toward a Web-based mental health service for adolescents, and to identify the factors that may affect the provision of this type of service and likelihood of integration. Findings will inform the content and overall service design., Methods: GPs were interviewed individually about the proposed Web-based service. Qualitative analysis of transcripts was performed using thematic coding. A short follow-up questionnaire was delivered to assess background characteristics, level of acceptability, and likelihood of integration of the Web-based mental health service., Results: A total of 13 GPs participated in the interview and 11 completed a follow-up online questionnaire. Findings suggest strong support for the proposed Web-based mental health service. A wide range of factors were found to influence the likelihood of GPs integrating a Web-based service into their clinical practice. Coordinated collaboration with parents, students, school counselors, and other mental health care professionals were considered important by nearly all GPs. Confidence in Web-based care, noncompliance of adolescents and GPs, accessibility, privacy, and confidentiality were identified as potential barriers to adopting the proposed Web-based service., Conclusions: GPs were open to a proposed Web-based service for the monitoring and management of anxiety and depression in adolescents, provided that a collaborative approach to care is used, the feedback regarding the client is clear, and privacy and security provisions are assured., (©Mirjana Subotic-Kerry, Catherine King, Kathleen O'Moore, Melinda Achilles, Bridianne O'Dea. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 23.03.2018.)

Background: Adolescence can be a fertile time for relationship issues, with interpersonal conflict being a risk factor for poor mental health. Mobile app interventions may have a significant appeal to young people in assisting with relationship distress. However, currently available apps have not been formally evaluated. Youths' perspectives on engaging with mobile technology to assist with relationships are also unknown., Objective: This study aimed to examine adolescents' attitudes toward the concept of a mobile phone app for relationship help and support, and whether they would be likely to use such an intervention., Methods: A cross-sectional Web survey consisting of 42 questions, including 13 free responses, was delivered. The proposed app, including character vignettes, was presented, and participants were asked to indicate whether they had experienced the same relationship issues, whether their peers would relate to the issues, and how helpful they found the proposed advice. Participants were also asked to provide their own suggestions for help, which were analyzed using thematic analyses., Results: A total of 150 adolescents (aged 15 to 18) participated. Overall, 60.7% (91/150) were likely to use an app for relationship problems, and this was not associated with demographics or social support (all P values >.05). Likelihood of app usage was found to be influenced by perceived need for help, personal beliefs about app effectiveness, and whether the app is engaging and easy to use. Overall, adolescents were receptive of the proposed content with an average of 99.3% (149/150), rating the strategies provided as somewhat to very helpful., Conclusions: Adolescents were likely to use a mobile phone app for relationship support, and use was not influenced by gender, age, social support, or any other background characteristic. Instead, likely use was influenced by need, personal beliefs, usability, and the appropriateness of app content. App developers must address these factors if the app is to have a wide-scale uptake., (©Bridianne O'Dea, Melinda Rose Achilles, Aliza Werner-Seidler, Philip J Batterham, Alison L Calear, Yael Perry, Fiona Shand, Helen Christensen. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 08.03.2018.)

Background: Mental health problems are common among youth in high school, and school counselors play a key role in the provision of school-based mental health care. However, school counselors occupy a multispecialist position that makes it difficult for them to provide care to all of those who are in need in a timely manner. A Web-based mental health service that offers screening, psychological therapy, and monitoring may help counselors manage time and provide additional oversight to students. However, for such a model to be implemented successfully, school counselors' attitudes toward Web-based resources and services need to be measured., Objective: This study aimed to examine the acceptability of a proposed Web-based mental health service, the feasibility of providing this type of service in the school context, and the barriers and facilitators to implementation as perceived by school counselors in New South Wales (NSW), Australia., Methods: This study utilized an online cross-sectional survey to measure school counselors' perspectives., Results: A total of 145 school counselors completed the survey. Overall, 82.1% (119/145) thought that the proposed service would be helpful to students. One-third reported that they would recommend the proposed model, with the remaining reporting potential concerns. Years of experience was the only background factor associated with a higher level of comfort with the proposed service (P=.048). Personal beliefs, knowledge and awareness, Internet accessibility, privacy, and confidentiality were found to influence, both positively and negatively, the likelihood of school counselors implementing a Web-based school mental health service., Conclusions: The findings of this study confirmed that greater support and resources are needed to facilitate what is already a challenging and emotionally demanding role for school counselors. Although the school counselors in this study were open to the proposed service model, successful implementation will require that the issues outlined are carefully addressed., (©Bridianne O'Dea, Catherine King, Mirjana Subotic-Kerry, Kathleen O'Moore, Helen Christensen. Originally published in JMIR Mental Health (http://mental.jmir.org), 20.11.2017.)

Background: Sleep disturbances are common in young people and have consequences for academic, social, emotional, and behavioral development. The most effective treatment is cognitive behavioral therapy for insomnia (CBT-I), with evidence suggesting that it is efficacious even when delivered digitally., Objective: There are no commercially available digitally delivered CBT-I programs for use by young people. The aim of this project was to develop a smartphone app that delivers CBT-I to young people to improve sleep., Methods: To inform the development of the app, young people (N=21) aged between 12 and 16 years attended one of the 3 focus groups (each with 4-10 participants). These focus groups were conducted at different stages of the development process such that the process could be iterative. Participants were asked the reasons why they might use an app to help them sleep, the kinds of features or functions that they would like to see in such an app, and any concerns they may have in using the app. Data were analyzed using a thematic analysis approach. Of the issues discussed by the participants, the researchers selected themes associated with content, functionality, and accessibility and user experience to examine, as these were most informative for the app design process., Results: In terms of content, young people were interested in receiving information about recommended sleep guidelines and personalized information for their age group. They reported that keeping a sleep diary was acceptable, but they should be able to complete it flexibly, in their own time. They reported mixed views about the use of the phone's accelerometer. Young people felt that the functionality of the app should include elements of game playing if they were to remain engaged with the app. Flexibility of use and personalized features were also desirable, and there were mixed views about the schedule of notifications and reminders. Participants reported that for the app to be accessible and usable, it should be from a trusted developer, have engaging aesthetics, have a layout that is easy to navigate, not rely on Internet coverage, and preferably be free. Participants felt that being able to conceal the purpose of the app from peers was an advantage and were willing to provide personal information to use the app if the purpose and use of that information was made clear. Overall, participants endorsed the use of the app for sleep problems among their age group and reported motivation to use it., Conclusions: The Sleep Ninja is a fully-automated app that delivers CBT-I to young people, incorporating the features and information that young people reported they would expect from this app. A pilot study testing the feasibility, acceptability, and efficacy of the Sleep Ninja is now underway., (©Aliza Werner-Seidler, Bridianne O'Dea, Fiona Shand, Lara Johnston, Anna Frayne, Andrea S Fogarty, Helen Christensen. Originally published in JMIR Mental Health (http://mental.jmir.org), 28.07.2017.)