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Suicide in the Arab World is grossly understudied. This study sought to understand suicidality among Arabic-speaking individuals visiting an online depression screener. A large sample (N = 23,201) from the Arab World was recruited online. 78.9% (n = 17,042) reported suicidality (thoughts of death or suicide, or a suicide attempt) and 12.4% reported a suicide attempt in the past 2 weeks. Binary logistic regressions indicated that women tended to report more suicidality, and that suicidality tended to decline with age (all ps

The United Nations General Assembly proclaimed the Universal Declaration of Human Rights in 1948. It included the right to medical care. Now, 70 years later, psychologists are recognized as health care providers and have developed several evidence-based health interventions. Digital interventions have the potential to scale access to evidence-based interventions to a degree unimaginable even a few decades ago. This article addresses five key concepts: (a) knowledge is meant to be shared, (b) evidence-based interventions are essential, (c) treatment is not enough to reduce prevalence of mental disorders; prevention is key, (d) nonconsumable interventions have the greatest potential for scalability, and (e) technology now allows us to blanket the world with psychological interventions. By harnessing technology, we can now think globally, act locally, and share globally. Psychology can thus help reduce human suffering beyond our local settings, and contribute to making health care a universal human right.

This manuscript is based on a keynote address presented at the 2020 Marce Society’s Conference celebrating the Society’s 40th anniversary. The address described a 50-year perspective on prevention research, current evidence that perinatal depression can be prevented, and how digital tools could be used to disseminate perinatal depression prevention interventions throughout the world. We utilized the Mothers and Babies Course as a case study to illustrate these goals. The article reviews the gradual progress of depression prevention research, from the time when the state of the science was such that it was believed that the onset of major depressive episodes could not be prevented until the present day. In addition, the article recounts the three consensus reports on prevention of mental disorders published by the National Academies of Science, Engineering, and Medicine, culminating in the 2019 report, which calls on the field to implement known interventions for the prevention of depression and other mental disorders, and to scale up their administration to reduce the prevalence of these disorders in the general population. The paper presents the 2019 recommendations of the US Preventive Services Task Force, which instructs the health system to provide routine referrals to perinatal depression prevention interventions (e.g., the Mothers and Babies Course) to perinatal persons at risk for depression. We now have the knowledge to prevent approximately half of episodes of perinatal depression. It is time to implement this knowledge and begin to do research on how to prevent the remaining half.

Introduction Tobacco disparities persist among low-income smokers who seek care from safety-net clinics. Many of these patients suffer from chronic illnesses (CILs) that are associated with and exacerbated by smoking. The objective of the current study was to examine the differences between safety-net patients with and without CILs in terms of nicotine dependence and related factors (such as depression, anxiety) and self-efficacy regarding ability to abstain from smoking. Methods Sixty-four low-income smokers who thought about or intended to quit smoking were recruited from the San Francisco Health Network (SFHN) and assessed for CILs, nicotine dependence, depression, anxiety, and smoking abstinence self-efficacy. Four one-way analyses of variance were used to examine the difference between those with and without CIL on the latter four variables. Results The CIL group had significantly higher anxiety (CIL: 8.0 ± 5.35; non-CIL: 4.44 ± 3.48; p=0.02) and tended to have higher nicotine dependence (CIL: 5.40 ± 2.58; non-CIL: 3.88 ± 2.28; p=0.04). In the CIL group, nicotine dependence was positively correlated with anxiety [r(62)=0.39; p

Few studies have examined how different characteristics of maternal depression may be associated with developmental outcomes among low-income children. The current study prospectively examined whether the timing (pregnancy vs. early postpartum), severity, and chronicity of maternal depression were associated with child cognitive and social-emotional development in two cohorts of primarily low-income Latinx immigrant mothers and their children. Maternal depression was assessed during pregnancy and at 6 months postpartum. Child development was assessed up to 5 years postpartum. Results showed that maternal depression experienced during pregnancy was associated with lower child cognitive development, particularly among girls. Additionally, both the timing (pregnancy and early postpartum) and severity/chronicity of maternal depression were each independently associated with lower child social-emotional development. These findings highlight the need for early prevention interventions to help offset the adverse effects of maternal depression on child developmental outcomes in this at-risk population.

Introduction Core symptoms of depression are likely universal, however cultural groups differ in their experience of the condition. The purpose of this study was to examine differences and similarities of depression symptom groupings between broad cultural groups. Method 6,982 adults took part in an online multilingual depression screening study, and completed an 18-item major depression screener. Participants were categorized into five broad cultural groups by language and country of residence: Spanish speakers from Latin America (n = 3,411); English speakers from Southeast Asia (n = 1,265); Russian speakers from the former Soviet bloc (n = 642); English speakers from English-speaking Western countries (n = 999); and Chinese speakers from China (n = 665). Principal components analysis with promax rotation was used. Results Both similarities and noteworthy differences in symptom clustering between groups were observed. For instance, though suicide-related items formed a separate cluster for most cultures, for the Latin-American group, worthlessness loaded with suicidality. Changes in appetite and changes in weight tended to load on different factors (except for Chinese and Russian groups). Hypersomnia tended to load with psychomotor agitation, and core depression symptoms tended to load with physical symptoms (except for the Russian group). Limitations Depression was assessed by a self-report measure aligned to DSM-IV. Conclusion The analysis contributes to a nuanced understanding of depression manifestations of various cultures, which may inform culturally sensitive clinical practice.

espanolExisten evidencias importantes que demuestran que los episodios depresivos mayores pueden prevenirse y tratarse eficazmente con intervenciones psicologicas administradas tanto por profesionales como por no profesionales debidamente capacitados. Tambien hay evidencia de que la depresion se puede prevenir y tratar mediante intervenciones digitales de autoayuda tales como paginas web y aplicaciones y que su eficacia aumenta si estas intervenciones son apoyadas por guias o coaches. En este comentario describimos enfoques digitales para la depresion desarrollados y probados en todo el mundo por el Instituto de Intervenciones Internacionales en Salud por Internet de la Universidad de Palo Alto. Recomendamos la creacion de apotecarias digitales para aumentar el acceso a las intervenciones: 1) capacitando a mas proveedores de ayuda y 2) desarrollando herramientas que estos puedan utilizar para mejorar la eficacia de estas intervenciones y para proporcionar acceso a intervenciones de autoayuda que puedan ser utilizadas directamente por cualquier persona con 3) guias o coaches con el objetivo de reducir el abandono o 4) como intervenciones totalmente automatizadas. EnglishThere is now substantial evidence that major depressive episodes can be prevented and treated effectively with psychological interventions administered by trained lay and professional providers. There is also evidence that depression can be prevented and treated using self-help digital interventions such as websites and apps, and that their effectiveness increases if these interventions are supported by guides or coaches. In this commentary we describe digital approaches for depression developed and tested across the world by Palo Alto University’s Institute for International Internet Interventions for Health. We recommend the creation of digital apothecaries to increase access to in-person interventions by 1) training more providers, and 2) developing tools providers can use to enhance the effectiveness of these interventions, and to provide access to self-help interventions that can be used directly by anyone with 3) either guides or coaches to reduce dropout, or 4) as fully automated interventions.

When screening for suicidality, clinicians usually ask questions in ascending order of severity. Clinicians often discontinue questioning after negative responses to the first question or questions, presuming that these individuals are unlikely to endorse any further suicidality. In this study, the accuracy of this presumption is evaluated in a large international sample.Participants were 21,385 individuals reporting a suicide attempt in the past two weeks. Participants were recruited, primarily via Google Ads, to a quintilingual (English, Spanish, Chinese, Arabic, and Russian) multinational depression and suicide screening study.Examining three initial screening questions (i.e., thoughts of death, wanting to die, and thinking about committing suicide), 14.8 % (n = 3179) of participants denied one or more question, 3.96 % (n = 847) denied two, and 1.95 % (n = 416) denied all three questions. The proportions of individuals with discrepant responses differed between linguistic-geographical groups, with Chinese and South Asian groups being more likely to be discrepant across all questions (all ps .001).Suicidality was assessed using an internet-based self-report measure, and linguistic-geographical groups explored in this study are very broad, which may limit generalizability.Results suggest that prematurely discontinuing suicide screening may fail to capture some individuals who made a recent attempt, and that in some groups, this discrepancy may be more pronounced. Clinicians should assess all individuals as thoroughly as possible regardless of initial responses, inquire about other significant risk factors, and be culturally sensitive.

Objective: Subthreshold depression has been found to be associated with considerable impairment and an increased risk of developing major depression. Although several randomized trials have examined the effects of psychological interventions for subthreshold depression in children and adolescents, no meta-analysis has integrated the results of these trials. Method: We searched 4 bibliographic databases and included randomized trials comparing psychological interventions with control conditions in children and adolescents scoring above a cut-off of a depression questionnaire but not meeting diagnostic criteria for major depression (or persistent depressive disorder) according to a diagnostic interview. Effect sizes and incidence rates of major depression were pooled with random effects metaanalyses. Results: A total of 12 trials with 1,576 children and adolescents met inclusion criteria. The overall effect size indicating the difference between treatment and control at post-test was g ¼ 0.38 (95% CI ¼ 0.14–0.63), which corresponds to a number-needed-to-treat (NNT) of 8.4. Heterogeneity was moderate to high (I 2 ¼ 61; 95% CI ¼ 28–79), and there was significant risk of publication bias (p < .04). The 2 studies in children less than 12 years of age showed nonsignificant effects (g ¼ 0.01; 95% CI ¼ –1.16 to 1.18). We found no significant effect on the incidence of major depression at follow-up (relative risk ¼ 0.52; 95% CI ¼ 0.25–1.08), although this may be related to low statistical power. Conclusion: Interventions for subthreshold depression may have positive acute effects in adolescents. There is currently insufficient evidence, however, that these interventions are effective in children less than 12 years of age, or that they prevent the onset of major depression at follow-up.

Background Rapid growth of the integration of technology and psychotherapeutic interventions has been noted, but no clear quantification of this growth has been done. Aims This bibliometric analysis seeks to quantify the growth, trends, and applications of technology in psychotherapeutic interventions over the last 40 years. Methods Searches were conducted in the Web of Science (WOS) database for all existing technology-psychotherapy-related publications from 1981 to October 2020. Search terms were refined using a systematic screening strategy, based upon Cochrane protocol, generating 52 technology terms. Analyses across 40 years and by decade from 1981 to 2020 were conducted. Results A total of 13,934 peer-reviewed articles were identified. Yearly publication rate has increased from one in 1981 to 1902 by October 2020. The growth rate of publications across decades consistently tripled in size (762.50% from the 1980s to 1990s, 539.71% from the 1990s to 2000s, and 337.24% from the 2000s to 2010s). The author, country, journal, and institution with the most publications were Andersson, G., USA, Journal of Medical Internet Research, and Karolinska Institute, respectively. The most frequent technology search term across all four decades was “internet*.” The trends in percentages of peer-reviewed publications within each decade showed: 1) a declining trend for the term “computer,” 2) an upward trend for the combined terms, “internet,” “online,” and “web,” 3) and a steady but smaller proportion of publications for other terms (“cell phone,” “phone/telephone,” “technology,” “video,” “virtual reality or VR,” “apps,” “digital,” “machine learning,” “electronic,” “robo,” and “telehealth”). Discussion The rapid growth and trends identified in technology and psychotherapy publications can inform related policies addressing the role of technology in mental health. Moreover, pattern analyses may provide direction for a standard nomenclature to address terminology usage inconsistencies across the field., Highlights • This study quantifies growth of technology use in psychotherapeutic interventions. • Publications on psychotherapy and technology tripled in size across each decade. • Publications utilizing the terms “internet/web/online” are continually growing. • The use of the term “computer” is decreasing. • Other technologies appear at lower frequencies but remain relatively stable.

The authors regret that in this paper the NNT was not correctly reported in the Abstract and in the Discussion. The correct NNT is 18.8 (as reported in the Results section). The authors would like to apologise for any inconvenience caused.

Suicide is a public health crisis, yet few online resources that specifically target suicidality are available. The aim of the present study was to develop an automated, self-guided Internet-Based Safety Plan (IBSP) and to explore how intended users – members of the Internet community who endorsed past or current suicidality – utilized this resource. Participants (N = 150) were adult visitors to an automated Internet-based depression/suicidality screening website, who were either invited to take part in the present study or redirected to the present study from the referring website. Participants were offered comprehensive prompts to guide them through creating a personalized Safety Plan. Participants provided feedback regarding their use of IBSP; data entered in the Safety Plan itself were also analyzed. Participants gave largely positive ratings regarding website navigation, explanations, and examples and reported an overall positive impression of IBSP. Qualitative analysis of the responses suggested that several aspects of IBSP could be enhanced; these included making the IBSP even more predictable and modifying instructions for specific steps. These data will be critical for creating future versions of IBSP, to develop a highly usable and effective Internet-based safety plan to help individuals during crises.

Background Decrements in attentional function-perceived effectiveness in everyday functioning related to cognitive dysfunction-are frequently reported by cancer patients during treatment. However, patients vary widely in their experiences of changes in attentional function. Objective The aim of this study was to understand differences in attentional function among cancer patients during chemotherapy. Methods Patients (n = 1329) undergoing chemotherapy were assessed at 6 time points during 2 rounds of chemotherapy. Latent profile analysis was used to identify subgroups of patients based on patterns in changes on the Attentional Function Index. Differences among the subgroups in demographic and clinical characteristics, psychological symptoms, and stress were evaluated. Results Three latent classes (ie, high, moderate, and low attentional function) were identified. Patients in the low and moderate classes were younger, more likely to be female, and less likely to be employed compared with those in the high class. Patients in the low class had higher levels of depressive and anxiety symptoms, cancer-related distress, and perceived stress compared with those in the moderate class, who, in turn, reported higher levels of these symptoms compared with those in the high class. Conclusions Different experiences of changes in self-perceived attentional function are associated with psychological symptoms in cancer patients. Implications for practice Relationships between changes in attentional function and psychological symptoms and stress suggest that clinicians should attend to the potential that patients' cognitive and psychological experiences may be closely linked and may need to be addressed as related phenomena. Clinical trials are needed that evaluate treatments for both attentional and psychological symptoms.

This manuscript is based on a keynote address presented at the 2020 Marcé Society's Conference celebrating the Society's 40th anniversary. The address described a 50-year perspective on prevention research, current evidence that perinatal depression can be prevented, and how digital tools could be used to disseminate perinatal depression prevention interventions throughout the world. We utilized the Mothers and Babies Course as a case study to illustrate these goals. The article reviews the gradual progress of depression prevention research, from the time when the state of the science was such that it was believed that the onset of major depressive episodes could not be prevented until the present day. In addition, the article recounts the three consensus reports on prevention of mental disorders published by the National Academies of Science, Engineering, and Medicine, culminating in the 2019 report, which calls on the field to implement known interventions for the prevention of depression and other mental disorders, and to scale up their administration to reduce the prevalence of these disorders in the general population. The paper presents the 2019 recommendations of the US Preventive Services Task Force, which instructs the health system to provide routine referrals to perinatal depression prevention interventions (e.g., the Mothers and Babies Course) to perinatal persons at risk for depression. We now have the knowledge to prevent approximately half of episodes of perinatal depression. It is time to implement this knowledge and begin to do research on how to prevent the remaining half.

Few studies have examined how different characteristics of maternal depression may be associated with developmental outcomes among low-income children. The current study prospectively examined whether the timing (pregnancy vs. early postpartum), severity, and chronicity of maternal depression were associated with child cognitive and social-emotional development in two cohorts of primarily low-income Latinx immigrant mothers and their children. Maternal depression was assessed during pregnancy and at 6 months postpartum. Child development was assessed up to 5 years postpartum. Results showed that maternal depression experienced during pregnancy was associated with lower child cognitive development, particularly among girls. Additionally, both the timing (pregnancy and early postpartum) and severity/chronicity of maternal depression were each independently associated with lower child social-emotional development. These findings highlight the need for early prevention interventions to help offset the adverse effects of maternal depression on child developmental outcomes in this at-risk population.

Objective To describe demographic and clinical characteristics of Spanish- and English-speaking visitors to a “Healthy Mood” website. Methods An online study intended to prevent depression by teaching users mood management skills recruited participants globally using primarily Google Ads. Those who consented responded to the Patient Health Questionnaire (PHQ-9) and the MDE Screener (Muñoz, 1998) upon entry into the study. Results 1423 participants consented, 437 English speakers and 986 Spanish speakers. Of the 1271 participants with sufficient depression symptom data, 65% screened positive for a current major depressive episode, 30% were at high risk for onset of a major depressive episode, and 5% were in the low-risk category. Conclusion Websites intended to be preventive appear to attract primarily individuals who are currently experiencing enough symptoms to screen positive for a major depressive episode. Only 30% of participants were appropriate for a depression prevention intervention. Therefore, such sites must be ready to encourage those with current depression to obtain professional help as well as ensure that the online self-help interventions are appropriate for participants who could benefit from both preventive and treatment interventions., Highlights • 1423 participants consented to a study intended for depression prevention. • Consented participants represented 86 countries. • 69% of the 1423 participants who consented were Spanish speaking. • Two thirds of participants screened positive for current depressive episode. • Future prevention studies should accommodate those with higher symptom levels.

Background and objective Neutrophil extracellular traps (NETs) are a recently discovered antimicrobial mechanism used by neutrophils that have been proposed as an intervention in the pathogenesis of periodontitis. The objective of our study was to characterize the expression of NETs in gingival tissues with periodontitis and controls and to compare the expression of these traps in gingival tissue samples of patients with gingivitis and periodontitis. Material and methods An observational cross-sectional study was conducted on patients with periodontitis, gingivitis, and controls that needed tooth extraction. Gingival tissue biopsies were gathered after clinical examination and tooth extraction. Electron microscopy and immunofluorescence were performed to characterize NETs, comparing periodontitis and control patients. Immunohistochemical analysis was performed to quantify neutrophil extracellular trap expression through extracellular citrullinated histone H3 and myeloperoxidase in biopsies from patients with gingivitis and periodontitis. Results Thirteen biopsies were gathered from 13 patients: five gingivitis, six periodontitis, and two controls. Electron microscopy and immunofluorescence imaging showed greater expression of neutrophils present in periodontal inflamed tissue compared with controls. Release of nuclear content to the extracellular space was observed, compatible with the formation of NETs. The expression of citrullinated histone H3 was higher in gingivitis samples than periodontitis samples (P = 0.0106). Myeloperoxidase expression was higher in periodontitis than gingivitis, but without achieving statistical significance. Conclusion Neutrophil extracellular traps were found in tissue samples of periodontitis as extracellular components of chromatin, along with neutrophil enzymes, that were not present in healthy controls. The comparison of NETs expression in periodontitis and gingivitis showed higher expression in gingivitis, associating them to acute phases of the periodontal inflammatory process.

Abstract. Background and Aims: Suicidality research in developing countries, including India, faces logistical and cultural challenges. Technology may help address these challenges and offer data to providers treating a diverse clientele. Method: The relationship between perceived stress and suicide-related beliefs was examined in two populations: Indians in India (n = 374) and Caucasians in English-speaking countries (n = 326); the influence of depression on that relationship was also explored. The study was conducted via an Internet-based survey. Results: Three-way interactions (Ethnicity × Perceived stress × Depression status) were observed, predicting strength of the belief that suicide is a solution to problems, F(1,679) = 4.18, p < .05, and that suicide is a good option if quality of life worsens, F(1,675) = 9.53, p < .01. For both beliefs, Caucasians screening positive for depression exhibited the strongest relationship between stress and suicide-related beliefs; for Indians, that relationship was not moderated by depression status. Caucasians also exhibited a stronger association between higher stress and greater belief strength that suicide is a good option assuming a steady quality of life than did Indians, F(1,680) = 6.05, p < .05. Limitations: Participants were recruited through a depression screening website; results may not generalize to those who are uninterested in depression screening or to those who are unwilling or unable to use the internet for that purpose. Conclusion: Our findings may help to better target interventions to reduce suicidality, for example, employ stress reduction techniques for Caucasians who are depressed, and monitor suicidality for Indians reporting high stress regardless of depression.

Background Individuals suffering from mental as well as physical conditions often face stigma, which can adversely affect functioning, treatment seeking, and emotional health. We compared levels of stigma experienced by individuals with depression and/or chronic pain, to contrast the perception of stigma experienced by the sufferers with that of individuals who have never experienced these conditions, and to determine whether depression is related to greater experience of stigma for chronic pain. Methods Four groups of participants (N=236) took part in the study: depression only, chronic pain only, comorbid depression and chronic pain, and healthy controls. Participants underwent a clinical interview and completed a stigma measure that assessed general self-stigma, public stigma, treatment stigma, secrecy, and stigmatizing experiences. Results Healthy controls largely underestimated the stigma experienced by individuals with depression, but were not inaccurate in estimating stigma experienced by individuals with chronic pain. Further, individuals with chronic pain alone generally perceived less stigma for their condition than did those with depression alone. However, comorbid individuals perceived worse stigma of chronic pain compared to individuals with chronic pain alone, suggesting that depression may affect the stigma felt by sufferers of conditions other than depression. Limitations Social desirability may have influenced stigma scores. Comparing several groups required adapting a standardized instrument. Conclusions Results suggest that depression may play a role in the social experience of having a health condition, as well as indicate that the general public continues to fail to appreciate the negative social pressures experienced by individuals with mental health conditions.

Objective Depression is a prevalent and costly mental health problem that affects women as well as their larger communities, with substantial impacts on mother and infant during childbearing years. Face-to-face care has not adequately addressed this global concern due to difficulties in scaling these resources. Internet interventions, which can provide psychological tools to those lacking adequate access, show promise in filling this void. Method We conducted a 2-condition proof-of-concept pilot randomized trial comparing brief Internet-based cognitive behavioural therapy (CBT) and brief Internet-based compassionate mind training (CMT) for women who are currently pregnant, became pregnant within the last year, and intend to become pregnant in the future. Results We found that, although CMT and CBT demonstrated near equivalence in improving affect, self-reassurance, self-criticism, and self-compassion, CMT showed superiority to CBT in reducing depression and anxiety symptoms. Conclusion These findings provide a compelling initial argument for the use of CMT as an avenue for addressing problems associated with negative affect. Implications, limitations, and future directions along this line of research will also be discussed.

Tackling mental disorders before they arise in pregnant women and new mothers is an approach that could be scaled up online — and would aid the overall health of populations. Tackling mental disorders before they arise in pregnant women and new mothers is an approach that could be scaled up online — and would aid the overall health of populations.

This randomized controlled trial investigated the effect of a brief unsupported behavioral activation Internet intervention (BAII) designed to improve mood. A total of 671 participants were recruited through Amazon’s Mechanical Turk (AMT) (M age = 35.71 years; SD = 12.34, 32.3% male) and 187 (27.9%) individuals completed the 1-week follow-up survey. Participants were randomly assigned to a behavioral activation “Activities” condition or a waitlist control (WLC) and assessed for depression (PHQ-9), anxiety (GAD-7), self-reported mood, and confidence and motivation to make behavioral changes. Repeated measure ANOVAs showed that individuals in the Activities condition significantly improved their motivation and confidence from baseline to immediate-post intervention. Mixed-effect modeling was used to determine the within-subject effect (time) and between-subject effect (WL vs. Activities condition). Significant main effects for time (but not condition) were found for PHQ-9 depression scores (F (1, 393) = 13.24, p

Untreated depression remains one of the largest public health concerns. However, barriers such as unavailability of mental health providers and high cost of services limit the number of people able to benefit from traditional treatments. Though unsupported Internet interventions have proven effective at bypassing many of these barriers given their reach and scalability, attrition from interventions has been an ongoing concern. Microinterventions, or ultra-brief online tools meant to produce a rapid improvement in mood, may offer a way to provide the benefits of unsupported Internet interventions quickly, before attrition might occur. This study examined the immediate and lasting effects of three microinterventions (breathing exercises, thought records, and a pleasant activities selector) on mood and distress. Participants (N = 122) were randomized into three groups, each group completing two of the three microinterventions. Participants were asked to rate their mood and level of distress before and after completing the microintervention. Depression and perceived stress were assessed at baseline and at four weekly follow-ups. Although lasting effects were not found, a significant within-group reduction in distress and improvement in mood were observed immediately following the completion of the microintervention. This study demonstrates the potential benefits of microinterventions to individuals for their immediate needs vis-à-vis mood and distress., Highlights • Tested three unsupported interactive microinterventions (Breathing Exercise, Thought Record, Pleasant Activities Selector). • 122 participants were randomized into pairs of microinterventions. • Within-group improvements in mood and distress were observed immediately following the completion of microinterventions. • Lasting effects (4 weeks) on depression symptoms and level perceived stress were not observed.

Objective Clinical trials are necessary for evaluation of novel treatments. However, concerns have been raised about the vulnerability of depressed individuals when joining clinical trials, that is, about their abilities to make good decisions about clinical trial participation. The purpose of this study was to determine whether depression compromises decisions to join clinical trials, by comparing the decisions of 3 groups: depressed individuals, individuals suffering from chronic pain, and individuals with comorbid depression and chronic pain. Method Participants (depressed: n = 61; chronic pain: n = 60; comorbid: n = 58) completed, via a clinical interview, common decision-making tasks from the field of judgment and decision making (time trade-off and standard gamble). The rationality of decisions was defined as the concordance between the evaluations of their health and the amount of risk participants would accept to improve health. Results Depressed individuals made less rational decisions than individuals with chronic pain (partial η2 = 0.075, 90% confidence interval [CI] [0.009, 0.180]); however, the discrepancy was in the direction of risk aversion, suggesting that depressed individuals were overly cautious about clinical trial participation. Furthermore, this risk aversion was not limited to clinical trials for depression, but also extended to clinical trials for chronic pain (partial η2 = 0.041, 90% CI [0.002, 0.117]), suggesting that depressed individuals may be overly cautious in their health choices more broadly. Conclusion Our findings suggest that concerns about depressed individuals making overly risky "desperate" decisions is likely unfounded, and it is more likely that depressed individuals may forgo valuable care options in an attempt to avoid risk. (PsycINFO Database Record

The goal of this study is to determine whether different types of activities have a differential effect on mood and enjoyment. Methods. A secondary analysis of the data of 754 participants (Mage = 35.8 years, SDage = 12.6; MPHQ-9 = 7.6, SDPHQ-9 = 7.0) who were recruited via Amazon Mechanical Turk (AMT) to participate in a brief online study. Participants completed an activity log and reported retrospectively about three types of activities (Pleasant, Meaningful, and Mastery) at baseline and one week follow-up. A mixed effects ANOVA was used to analyze the effect of weekly activities on mood, and a temporal analysis model was used to test for the effect of daily activities on enjoyment. Results. Participants who reported higher number of Mastery activities for the week had higher mood ratings at follow-up (F (1, 39) = 4.89, p<.05), regardless of depression status at baseline. Pleasant and Meaningful activities did not have a significant effect on mood. Daily engagement in any of the three activity types increased enjoyment of that day (Pleasant: b=0.312, t (1811) = 46.73, p<.001; Meaningful: b=0.254, t (1814) = 11.65, p<.001; Mastery: b=0.290, t (1816) = 13.07, p<.001]. Conclusions. These findings contribute to the understanding on how brief behavioral activation interventions delivered online may influence participants’ mood and enjoyment, and can inform clinicians’ recommendations about types of activities.

BACKGROUND: Smoking cessation Internet interventions have been shown to be comparable in effectiveness to the nicotine patch. The aim of this study was to develop a Spanish/English smoking cessation web app using input from low-income smokers, and to evaluate modifications to the online intervention in terms of its ability to engage smokers. METHODS: Three versions of a smoking cessation web app were developed and tested. Measures of engagement, such as completion of study registration, utilization of cigarette, mood, and craving trackers, and completion of follow-up assessments, were collected to determine whether changes in the website resulted in increased engagement. RESULTS: The third version of the website, which featured improved look-and-feel and fewer barriers to engagement, markedly increased tracker engagement from the first two versions. However, follow-up rates remained low across all three versions. CONCLUSIONS: The increase in engagement was attributed to the following modifications: A more inviting landing page with key intervention elements available immediately; an easily accessible dashboard with users’ data; and tracking tools that were more user friendly. We conclude that in addition to adequate and functional elements, design principles are key factors in increasing engagement in online interventions.

OBJECTIVE To explore the prevalence of recent (previous 2 weeks) suicide attempts and estimates of likelihood of future suicide attempts as well as demographic characteristics associated with such attempts among residents of the Arab region looking for depression information online. METHODS Google Ads were used to recruit 1,003 Arabic-speaking adults mostly from February 2014 to June 2014 to take part in a depression and suicidality screening study using a self-report questionnaire based on DSM-IV diagnostic criteria. RESULTS Of the eligible participants (N = 900), 10.6% reported a suicide attempt in the previous 2 weeks, and 16.1% indicated a likelihood of making a suicide attempt in the following month. Men, those declining to state their sexual orientation, those from lower subjective social status (SSS), and unemployed individuals had higher odds of reporting a past suicide attempt (P = .001, P = .002, P < .001, P = .023, respectively). Younger individuals, those less religious, those with past suicide attempt, and those with lower SSS had higher odds of a likelihood of a future suicide attempt (P = .03, P = .02, P < .001, P = .001, respectively). Comparing the 4 countries with highest number of participants (Algeria, n = 148, Egypt, n = 260, Morocco, n = 118, and Saudi Arabia, n = 99), lower SSS was associated with higher odds of an attempt for Algeria, Morocco, and Saudi Arabia, but not for Egypt (P = .002). Lower religiosity was related to higher odds of estimates of future suicide for Algeria, Egypt, and Saudi Arabia, but not for Morocco (P = .014). CONCLUSIONS Suicidality among residents of Arab-speaking countries warrants further exploration. Common predictors of risk may be less relevant for some populations.​.

This article is a partially revised version of a keynote address presented at the 10th Scientific Meeting of the International Society for Research on Internet Interventions (ISRII) in Auckland, New Zealand. It addresses six points: 1) the meanings of indigeneity, diversity, and equity, 2) the strong emotional reactions elicited by the inequities experienced by indigenous groups throughout the world, 3) the aspirations of members of ISRII in terms of what we would like our field to accomplish to address these inequities, 4) the United Nations goal of making health care a universal human right, 5) the difficulties encountered by other health sciences in attempting to include diverse populations into major studies, and 6) ways in which the Internet interventions and digital health field could include indigeneity, diversity, and equity in our work, and by doing so, contribute to the United Nations goal of making health care a universal human right. The authors suggest that providing access to health care to all people, no matter where they are on the socioeconomic continuum, is a key strategy to pursue. The field of Internet interventions could contribute by creating digital apothecaries that would develop, evaluate, and disseminate evidence-based Massive Open Online Interventions to anyone in the world who needs them., Highlights • An examination of how indigeneity, diversity, and equity are relevant to the field of Internet interventions • United Nations declarations regarding health care as a universal human right and the rights of indigenous peoples • The difficulties encountered by other health sciences in attempting to include diverse populations into major studies • How the digital health field could address indigeneity, diversity, and equity and help make health care a universal right

Introduction We use multilevel modeling to parse out the effects of time-varying smoking abstinence and baseline depression (history and severity) on depression severity over 1 year. Aims and Methods Participants were 1000 smokers recruited worldwide for an online randomized controlled tobacco cessation trial. We examined whether changes in depression severity over time were associated with self-reported 7-day point prevalence smoking status assessed at 1-, 3-, 6-, and 12-month follow-up (FU) using baseline major depressive episode (MDE) history and baseline depression severity as time-invariant covariates. We present depression severity means and smoking abstinence at each FU. Results Regardless of concurrent abstinence status, baseline MDE history was significantly related to depression severity over time: those reporting a past MDE had worse depressive symptoms over time compared with those reporting no MDE history. Baseline depression severity interacted significantly with time-varying abstinence status: for every 1-unit increase in baseline scores on the Center for Epidemiological Studies—Depression Scale (CES-D), individuals who were smoking at FU reported CES-D scores that were 0.17 points higher than those who were abstinent. In this context, nicotine dependence, gender, age, or marital status did not affect depression severity. Conclusions In the context of cessation, having an MDE history plays a significant role in the trajectory of depression severity over the course of 1 year, regardless of abstinence status. Abstinence is related to lower depressive symptoms at each FU, and this effect was stronger at higher levels of baseline depression severity. Implications This study indicates that depressive symptoms are not exacerbated among individuals who are quitting smoking at 1-, 3-, 6-, and 12-month FUs. Depression severity is worse with a baseline history of MDE. Further, those with high baseline depression severity who continue smoking have worse depressive symptoms throughout a 1-year period compared with their abstinent counterparts.

Abstract. Background: The Internet may offer resources for individuals who struggle with suicidality but have no access to other resources or fail to use them. Aims: To develop an automated, self-guided Internet-based safety plan (IBSP), and to evaluate its use and perceived utility among individuals who report suicidality online. Method: Participants ( N = 150) were recruited from a depression/suicide screening website. Participants developed personalized safety plans and reported their perceived utility. Results: Participants reported moderate utility of the IBSP. Participants' demographic and clinical characteristics were not related to any metrics reflecting the perceived utility of the IBSP, suggesting that the ISBP does not appeal more or less to any particular group. Similarly, participant characteristics were largely unrelated to IBSP completion rates. The sole exception was gender, with males completing fewer steps ( p < .001). Interestingly, participants were more likely to believe that IBSP could be helpful for others than for themselves ( p < .001). Limitations: Quality and use of IBSPs were not assessed; poststudy assessments were limited to those completing the study; participants uninterested in reducing suicidality are not represented. Conclusion: The IBSP may eventually be an acceptable tool for Internet users at risk for suicide.

Purpose: Depressive disorders are common and have a considerable impact on patients and societies. Several treatments are available, but their effects are modest and reduce the burden only to a limited extent. Preventing the onset of depressive disorders may be one option to further reduce the global disease burden. Methods: We conducted a meta-analysis of randomized controlled trials in participants without a diagnosis of depression at baseline, who were assigned to a preventive psychological intervention, or a care-as-usual, or comparable control group and in which incident cases of depression at follow-up were ascertained with a diagnostic interview. Results: Our systematic searches resulted in 50 trials (14,665 participants) with relatively high quality, in high risk groups of all ages. The psychological interventions were mostly based on cognitive behavioral interventions. One year after the preventive interventions, the relative risk of developing a depressive disorder was RR = 0.81 (95% CI: 0.72–0.91), indicating that those who had received the intervention had 19% less chance to develop a depressive disorder. Given the average control event rate of 30%, twenty-one people had to participate in the intervention to prevent one depressive disorder compared to people in the control conditions. Conclusions: Prevention is a promising approach to reduce the global disease burden of depression in addition to treatments.

Ethical principles in conducting technology-based research require effective and efficient methods of ensuring adequate informed consent. This study examined how well participants understood the informed consent form for an online postpartum depression trial. Pregnant women ( N = 1,179) who consented to the trial demonstrated an understanding of the purpose (86.1%) and procedures of the study (75.8%), and the minimal risks associated with answering sensitive questions online (79%). Almost all (99.6%) understood that psychological treatment was not offered. Participants with current depression incorrectly indicated that participation would replace current psychological treatment relative to participants with a lifetime or no depression history (19.6% vs. 13.5 % vs. 10.4%, respectively) and that there were no associated risks with participation (29.6% vs.17.6% vs. 16.7%, respectively). Findings provide initial evidence that most individuals who seek online psychological resources are informed consumers.

This study compares life stressors and school outcomes among newcomer immigrant adolescents from Latin America, Asia, and the Caribbean. Participants attended a predominantly low-income, urban international public high school in the northeast. The Latina/o students were exposed to more life stressors and had lower attendance and achievement than non-Latina/o students. Life stressors mediated the relationship between ethnicity and academic outcomes. Results deepen experts’ understanding of the achievement gap, suggesting that newcomer immigrant adolescents from Latin America face unique risks and deserve intervention efforts focused on sociocontextual stressors that may prevent these students from achieving their full academic potential.

Background Recruitment for research is usually expensive and time consuming. Facebook (FB) recruitment has become widely utilized in recent years. The main aim of this study was to assess FB as a recruitment tool in a study for Spanish- and English-speaking smokers. Additionally, the study set out to compare performance of ads by language (Spanish vs. English), location (U.S. vs. San Francisco) and content (self-efficacy ad vs. fear appeal ad). Methods Participants of a one-condition smoking cessation webapp study were recruited utilizing FB ads and posts through two phases: a recruitment-focused phase and an experimental phase comparing language, location and content. Results During the recruitment phase 581 participants in total (U.S. = 540, San Francisco = 41) provided consent. Of the U.S. participants 275 were Spanish-speakers and 265 English-speakers. The cost-per-consent was $25.81 for Spanish-speakers, and $15.49 for English-speakers. During the experimental phase U.S. users performed better (i.e. more clicks, engagement and social reach) than San Francisco users, Spanish-speakers engaged more than English-speakers, and the self-efficacy ad performed better than the fear appeal ad. Conclusions This study showed that although there were differences in cost-per-consent for Spanish- and English-speakers, recruitment of Spanish-speakers through Facebook is feasible. Furthermore, comparing performance of ads by location, language, and ad content may contribute to developing more efficient campaigns., Highlights • Recruitment of English-speakers and Spanish-speakers smokers through Facebook is feasible. • Cost-per-consent was higher for Spanish-speakers smokers than for English speakers • Ads for U.S. Facebook users performed better than for San Francisco users. • Spanish-speakers engaged more with the Ads than English-speakers. • A self-efficacy ad performed better than the fear-appeal ad.

Introduction Although evidence-based, the 5A’s (Ask, Advise, Assess, Assist, and Arrange) for smoking cessation are often incompletely delivered by primary care providers. This study examines whether a computer tablet 5A’s intervention improves primary care provider adherence to the 5A’s. Study design Cluster RCT. Setting/participants All primary care providers in three urban, adult primary care clinics were randomized for participation. Any English- or Spanish-speaking patient with a primary care appointment who had smoked >100 lifetime cigarettes and at least one cigarette in the past week was eligible. Intervention A cluster RCT comparing computer-facilitated 5A’s with usual care assessed effects on provider adherence to each of the 5A’s as determined by patient report. Intervention subjects used a computer tablet to complete the 5A’s immediately before a primary care appointment. A tailored, patient handout and a structured, clinician guide were generated. Data were collected in 2014–2015 and analyzed in 2016–2017. Main outcome measures Provider adherence to the 5A’s. Results Providers (N=221) saw 961 patients (n=412 intervention, n=549 control) for a total of n=1,340 encounters with n=1,011 completed post-visit interviews (75.4% completion). Intervention providers had significantly higher odds of completing Assess (AOR=1.32, 95% CI=1.02, 1.73) and Assist (AOR=1.45, 95% CI=1.08, 1.94). When looking at first study visits only, intervention providers had higher odds for Arrange (AOR=1.72, 95% CI=1.23, 2.40) and all 5A’s (AOR=2.04, 95% CI=1.35, 3.07) but study visit did not influence receipt of the other 5A’s. Conclusions A computer-facilitated 5A’s delivery model was effective in improving the fidelity of provider-delivered 5A’s to diverse primary care patients. This relatively low-cost, time-saving intervention has great potential for smoking cessation and other health behaviors. Future studies should identify ways to promote and sustain technology implementation. Trial registration This study is registered at www.clinicaltrials.gov NCT02046408.

Evidence-based psychological interventions are growing in number but are not within reach of many individuals who could benefit from them. The recent revolution in digital technologies now makes it possible to reach people around the globe with digital interventions in the form of web sites, mobile applications, wearable devices, and so on. Although a plethora of digital interventions are available online few are evidence-based and individuals have little guidance to decide among the multitude of options. We propose the development of "digital apothecaries," that is, online repositories of evidence-based digital interventions. As portals to effective interventions, digital apothecaries would be useful to individuals who could access evidence-based interventions directly, to health care providers, who could identify specific digital tools to suggest to or use with their patients, and to researchers, who could study a range of tools with large samples, enabling comparative tests and evaluation of moderators of effects. We present a taxonomy of types of in-person and digital interventions ranging from traditional therapy without the use of digital tools to totally automated self-help interventions. This taxonomy highlights the potential of blending digital tools into health care systems to expand their reach. Digital apothecaries would provide access to evidence-based digital interventions (both free and paid versions), provide data on effectiveness (including effectiveness for diverse populations), and encourage the development and testing of more such tools. Other issues discussed include: criteria for inclusion of interventions into digital apothecaries; how digital tools could enhance health care for diverse populations; and cautionary notes regarding potential negative unintended consequences of the adoption of digital interventions into the health care system. In particular, we warn about the potential misuse of evidence-based digital interventions to justify reducing access to live providers. Digital apothecaries bring with them the promise of reducing health disparities by reaching large numbers of individuals across the world who need health interventions but are not currently receiving them. The health care field is encouraged to mindfully develop this promise, while being alert not to cause inadvertent harm.

Objective This article studies the impact of country level and individual level socioeconomic factors as predictors of smoking cessation from a worldwide online smoking cessation participant preference study conducted from 2008 to 2011. Method We collected data through the San Francisco Stop Smoking Internet website. A total of 13,620 adult smokers from 109 countries and territories entered the study. Participants were able to choose from among nine components. Once selected, participants had access to their customized homepage that displayed a navigation bar with only the selected elements. The intervention was designed to take up to 8 weeks to complete. Participants received emails to complete follow-up assessments at 1, 3, 6, and 12 months after enrolling in the study. Results Of those who provided data at any follow-up (n = 4678), 38.3% reported quitting smoking for at least seven days at one of the follow-ups. Multilevel logistic regression models demonstrated that greater gross domestic product (GDP) per capita, higher level of individual education, and subjective socioeconomic status, significantly predicted the likelihood of quitting at 1-month follow-up. Conclusions Higher socioeconomic status at country and individual levels are associated with greater success in online smoking interventions. Future studies should address this disparity.

Background Postpartum depression (PPD) is a maternal mental health problem that affects women from all regions of the world. Unfortunately, even in developed countries, half of the cases go undetected and, consequently, untreated. Individuals from low and middle income countries trend toward underutilization of mental health services, partly due to the limited number of available psychological resources. The primary aims of this pilot randomized controlled trial were to adapt to the Internet using the Mothers and Babies Course/Curso Mamas y Bebes, a prevention of PPD intervention, to describe the characteristics of the pregnant women who engaged in the intervention site, and to obtain preliminary data on the efficacy of the Internet intervention to reduce the risk of PPD. Methods Pregnant women, 18 years or older who were interested in using the site for themselves were recruited and randomly assigned to a fully-automated self-help Internet intervention or to an information-only control condition. Randomized participants were invited to complete monthly depression assessments up to six months postpartum. To examine the prevention effects of the Internet intervention, pregnant women who did not meet current criteria for a major depressive episode, who engaged with the study website, and who provided depression data during the postpartum follow-up period were included in the study analyses. Results Participants were 111 predominantly Spanish-speaking (82.9%) and Latino/Hispanic (71.3%) pregnant women residing in 23 countries worldwide. The effect of the prevention intervention condition failed to reach significance at the a priori alpha-level. However, the observed coefficient trended in the hypothesized direction (b = − 0.514, χ2 (1) = 3.43, p = .061; HR = 0.598). The benefits of receiving the e-MB Internet intervention were greater for pregnant women reporting high (vs. low) levels of prenatal depression symptoms (b = − 0.605, χ2 (1) = 5.20, p = .023). Conclusions This study provides preliminary evidence that Internet interventions are a promising method toward expanding the reach of psychological resources to perinatal women at-risk for PPD.