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Mental ill health is a leading cause of disability worldwide, but access to evidence-based support remains limited. Digital mental health interventions offer a timely and low-cost solution. However, improvements in clinical outcomes are reliant on user engagement, which can be low for digital interventions. User characteristics, including demographics and personality traits, could be used to personalize platforms to promote longer-term engagement and improved outcomes. This study aims to investigate how character strengths, a set of positive personality traits, influence engagement patterns with moderated online social therapy, a national digital mental health platform offering individualized, evidence-based digital mental health treatment for young people aged 12-25 years. Data from 6967 young people who enrolled with moderated online social therapy between August 2021 and July 2023 were analyzed. Longitudinal analyses were used to investigate whether scores on 3-character strength dimensions (\"social harmony,\" \"positive determination,\" and \"courage and creativity\") were associated with (1) an accelerated or decelerated rate of dropout from the platform and (2) patterns of engagement over the first 12 weeks following onboarding. Engagement metrics were time spent on the platform, number of sessions on the platform, use of the embedded social network, and messages with the clinical team. On average, young people used the platform for 72.64 (SD 106.64) days. The 3-character strengths were associated with distinct engagement patterns during this time. Individuals scoring higher on \"social harmony\" demonstrated an accelerated dropout rate (coefficient=-0.15, 95% CI -0.26 to -0.04; P=.008). Interestingly, higher scores on this character strength were associated with high rates of initial engagement but a more precipitous decline in platform use over the first 12 weeks, in terms of time spent on the platform (β=-.01; SE 0.00; t2748=-5.05; P<.001) and the number of sessions completed (β=-.00; SE 0.00; t2837=-2.26; P=.02). In contrast, higher scores on \"positive determination\" and \"courage and creativity\" predicted more modest initial platform use but steadier engagement over time, in terms of time spent on the platform (\"positive determination\": β=.01; SE 0.00; t2748=4.05; P<.001 and \"courage and creativity\": β=.01; SE 0.00; t2748=2.66; P=.008). Contrary to our predictions, character strengths did not predict use of the embedded social network or the number of messages sent to the clinical team. Our findings illustrate how character strengths predict distinct engagement trajectories on a digital mental health platform. Specifically, individuals higher on \"social harmony\" showed high initial engagement that quickly declined, while those higher on \"positive determination\" and \"courage and creativity\" demonstrated lower initial engagement but a steadier use of the platform over time. The findings of this study demonstrate an opportunity for digital mental health interventions to be tailored to individual characteristics in a way that would promote greater initial and ongoing engagement.

Chronic stress is a critical factor influencing both physical and mental health. It can weaken the immune system, affect cardiovascular health, and lower quality of life, often leading to psychological disorders like anxiety and depression. This study aims to evaluate the effectiveness of eHealth stress management interventions on psychological health parameters, specifically anxiety, depression, stress, and quality of life in patients with cardiovascular disease (CVD). A comprehensive search was conducted across several databases, including the Cochrane Library, APA PsycInfo, Web of Science, PubMed, Embase, and clinical trial registers. Randomized controlled trials assessing the impact of eHealth stress management interventions, namely internet-based cognitive behavioral therapy (CBT), telephone-delivered CBT, internet-based stress management training, or telephone-delivered stress management training, on the specified psychological outcomes in patients with CVD were included. The control group comprised no intervention, a waitlist, (enhanced) usual care, or a web-based intervention not focusing on stress management. To evaluate potential bias, the Risk-of-Bias 2 tool was applied. A random-effects meta-analysis was performed using standard mean difference (SMD) as the effect size, with a sensitivity analysis using mean difference (MD). A total of 6 randomized controlled studies were considered in the meta-analysis. In 5 studies internet-based CBT interventions were examined, while one study used an eHealth intervention based on a CBT approach. The control groups received either usual care, were placed on a waitlist, or participated in a web-based discussion forum. After the intervention period, which ranged from 8 weeks to 6 months, a significant reduction in depressive symptoms (SMD=-0.46, MD=-2.33; P<.001), as assessed by the Patient Health Questionnaire-9, was observed in the intervention group compared with the control group. Mental health-related quality of life, assessed by the subscale of the 12-Item Short-Form Health Survey, showed significant improvement (SMD=0.38, MD=3.89; P<.001) in the intervention group in comparison to the control group following the intervention period. The meta-analysis demonstrates that eHealth stress management interventions substantially improve psychological health parameters in patients with CVD. Given the significant positive impact, health care providers should consider integrating eHealth stress management programs into standard care for patients with CVD. These programs can be a valuable tool in mitigating the psychological burdens associated with chronic cardiovascular conditions, ultimately improving overall patient outcomes and quality of life.

End-stage kidney disease (ESKD) imposes a significant global health burden, with patients often experiencing poor quality of life (QoL) due to psychological distress and low self-efficacy. Digital health interventions (DHIs) offer potential to address these challenges. However, their effects in this population remain inconsistent, and a comprehensive synthesis of the evidence is lacking. The present study aims to assess the impact of DHIs on the psychological health, self-efficacy, and QoL of patients with ESKD and to evaluate engagement, adherence, and satisfaction with these interventions. A comprehensive search was conducted across six electronic databases (PubMed, Web of Science, Cochrane Library, PsycINFO, Embase, and CINAHL) up to January 21, 2025. Randomized controlled trials (RCTs) examining the effects of DHIs on psychological health, self-efficacy, or QoL in patients with ESKD were included. Two reviewers independently screened studies, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias Tool (RoB 2). A meta-analysis was performed using Review Manager 5.4, with subgroup analyses by treatment modality, intervention type, and duration. Evidence quality was assessed using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. Twenty-three RCTs involving 2407 patients with ESKD from 12 countries were included. DHIs significantly improved depression (standardized mean differences [SMD] -0.41, 95% CI -0.63 to -0.19, P=.003) and overall QoL (SMD 0.55, 95% CI 0.07-1.03, P=.03). While DHIs did not significantly improve overall self-efficacy (SMD 0.56, 95% CI -0.06 to 1.18, P=.08), a benefit was observed in patients on hemodialysis (SMD 0.59, 95% CI 0.34-0.83, P<.001). Engagement was favorable, with completion rates above 63%, adherence rates of 54%-79%, and generally positive patient feedback on DHIs. Application-based interventions improved self-efficacy (SMD 0.66, 95% CI 0.31-1.02, P<.001) and overall QoL (SMD 0.50, 95% CI 0.04-0.96, P=.003); telemedicine improved depression (SMD -0.88, 95% CI -1.21 to -0.56, P<.001) and self-efficacy (SMD 2.76, 95% CI 2.32-3.20, P<.001); and video-based interventions improved depression (SMD -0.34, 95% CI -0.55 to -0.13, P=.002) and overall QoL (SMD 0.31, 95% CI 0.15-0.46, P<.001). Due to high heterogeneity and risk of bias, evidence quality was rated as low for depression and overall QoL, moderate for general anxiety, and very low for stress and self-efficacy. DHIs can significantly improve the psychological health and QoL of patients with ESKD, particularly when tailored to patients' needs and delivered through interactive platforms such as apps and telemedicine. High engagement and positive patient feedback suggest good acceptability in clinical practice. However, low evidence quality warrants cautious interpretation. Future research should involve more high-quality RCTs and design DHIs that address the unique needs of older patients, patients on peritoneal dialysis, and kidney transplant recipients.

Engagement with nature is an important part of many people’s lives, and the health and wellbeing benefits of nature–based activities are becoming increasingly recognised across disciplines from city planning to medicine. Despite this, urbanisation, challenges of modern life and environmental degradation are leading to a reduction in both the quantity and the quality of nature experiences. Nature–based health interventions (NBIs) can facilitate behavioural change through a somewhat structured promotion of nature–based experiences and, in doing so, promote improved physical, mental and social health and wellbeing. We conducted a Delphi expert elicitation process with 19 experts from seven countries (all named authors on this paper) to identify the different forms that such interventions take, the potential health outcomes and the target beneficiaries. In total, 27 NBIs were identified, aiming to prevent illness, promote wellbeing and treat specific physical, mental or social health and wellbeing conditions. These interventions were broadly categorized into those that change the environment in which people live, work, learn, recreate or heal (for example, the provision of gardens in hospitals or parks in cities) and those that change behaviour (for example, engaging people through organized programmes or other activities). We also noted the range of factors (such as socioeconomic variation) that will inevitably influence the extent to which these interventions succeed. We conclude with a call for research to identify the drivers influencing the effectiveness of NBIs in enhancing health and wellbeing.

Promoting individual resilience-that is, maintaining or regaining mental health despite stressful circumstances-is regarded as an important endeavor to prevent mental illness. However, digital resilience interventions designed to enhance mental health have yielded mixed results. Such heterogeneous effects reflect a variety of unsolved conceptual challenges in interventional resilience research. These range from grounding interventions in resilience frameworks, using theory or targeting etiologically important resilience factors as intervention content, to a lack of knowledge about the mechanisms underlying effects, and using techniques specifically developed to foster psychosocial resources. The web- and app-based resilience intervention RESIST was designed to address these challenges, mainly by using both the Positive Appraisal Style Theory of Resilience as its theoretical foundation and interventional techniques from Strengths-Based Cognitive Behavioral Therapy. This study's primary aim was to evaluate the effectiveness of RESIST on perceived stress in a general working population as a means of universal prevention, relative to a waitlist control group. A secondary study aim was to explore the resilience factors of self-efficacy, optimism, self-compassion, and perceived social support, the intervention targets as potential mediators of its effect on stress and self-perceived resilience. In total, 352 employees were randomly assigned to either a self-help version of RESIST or a waitlist control group. Data were collected via the web at baseline, postintervention, and at 3- and 6-month (intervention group [IG] only) follow-ups. The primary outcome was perceived stress, measured with the Perceived Stress Scale-10. Secondary outcomes included self-perceived resilience, the resilience factors targeted, and other mental and work-related health outcomes. The IG reported significantly less stress than controls postintervention (Δ=-3.14; d=-0.54, 95% CI -0.75 to -0.34, and P<.001) and at 3-month follow-up (Δ=-2.79; d=-0.47, 95% CI -0.71 to -0.22, and P=.002). These improvements in the IG were maintained at 6-month follow-up. Favorable between-group differences also were detected for self-perceived resilience and the resilience factors. IG participants completed on average 2.2 (SD 2.3) web-based sessions and used the app's core feature a median of 14 times (IQR 4.00-33.75, range 1-220). The positive effects of the intervention on stress and resilience were primarily mediated by changes in optimism and self-compassion. No evidence was found that self-efficacy and social support also acted as mediators. In a sample of employees experiencing heightened work-burden levels, RESIST was effective in reducing perceived stress and increasing self-perceived resilience as well as the targeted resilience factors. Mediation analyses suggested that developing a positive future outlook and a self-compassionate attitude toward oneself may be key drivers to enhance resilience. Changing the quality of social relationships and strengthening the belief in one's abilities may require more time, the involvement of others, or personal support from an eCoach to ensure sufficient learning opportunities.

Internet-based cognitive behavioral therapies (iCBTs) are typically categorized into 2 types: therapist-assisted and self-guided. Both formats have accumulated substantial evidence supporting their cost-effectiveness and efficacy in treating a range of mental health conditions. However, therapist-assisted iCBTs tend to show lower dropout rates than self-guided versions. The relatively high dropout rates in self-guided programs suggest that some degree of therapist involvement may be necessary to improve engagement and treatment adherence. Yet, the specific reasons for therapist support in iCBT and its functions in improving engagement and treatment adherence remain an underexplored area of research. This study aimed to explore patients' experiences with therapist-assisted iCBT to identify the elements they perceive as important for treatment adherence and to clarify the role of therapist support in the iCBT process. This study draws on 89 semistructured in-depth interviews with iCBT users. Patients took part in 9 different therapist-assisted iCBT programs (depression [n=32], anxiety disorder [n=17], obsessive-compulsive disorder [n=10], bipolar disorder [n=5], social phobia [n=5], bulimia [n=3], alcohol abuse [n=1], panic disorder [n=10], and insomnia [n=6]), all provided nationwide by Helsinki University Hospital in Finland. The interviews were transcribed verbatim and analyzed with the qualitative Gioia method. Three key categories help explain why users consider therapist support essential for adherence in iCBTs: (1) the strengthening of individual autonomy, (2) the therapist's commitment to strengthening the therapeutic alliance, and (3) assistance with emotion regulation. Therapist support was shown to be pivotal, often conveyed through small, text-based gestures that had a meaningful impact. The role of the therapist should not be diminished in the pursuit of digitalization, as human support remains a critical element of effective iCBT.

Anxiety is one of the most common mental health problems experienced by children worldwide. In the United Kingdom, many children experiencing anxiety do not receive adequate or timely help. Children living in economically disadvantaged areas experience more mental health problems than those living in high-income areas and are less able to engage in activities that can have a positive or protective impact on their mental health. The need for providing low-cost, accessible, and engaging mental health interventions for children living in these areas is high. The study aimed to explore how a digital mental health therapeutic, \"Lumi Nova: Tales of Courage\" (BfB Labs Ltd), could be used to support children living with anxiety in economically disadvantaged areas. A mixed method study design was used to explore the implementation of Lumi Nova using a supported delivery model with mental health teams based in the North of England. Quantitative data collection on recruitment and engagement patterns were collected and analyzed. Qualitative research explored children's, parents', and practitioners' views and experiences with the Lumi Nova app. 113 children consented to use Lumi Nova and 98 (87%) accessed the intervention at least once. Qualitative semistructured interviews found that children, their parents, and practitioners viewed the Lumi Nova app positively. Quantitative analysis of the recruitment data suggested the feasibility of a future larger roll-out. Analysis of usage data demonstrated varied patterns of engagement with the intervention. The frequency and duration of usage varied across children, as did the activities completed within the game: almost half (49%) completed 3 in-game challenges, indicating progression through the treatment pathway. The study demonstrated that a digital mental health intervention could be successfully deployed within economically disadvantaged areas in the United Kingdom to support children experiencing anxiety. Expected barriers to the deployment of digital mental health interventions in economically disadvantaged areas (eg, lack of access to smartphones, data plans, and lack of technical skills) were not reported. Digital mental health interventions have the potential to address current gaps in mental health provision for disadvantaged individuals and communities.

In the context of a sharp rise in help-seeking in youth mental health, digital mental health interventions offer enormous potential to improve outcomes, facilitate access, and meet the increasing demand for mental health services. For example, for young adults attending third-level education, digital mental health interventions may support help-seeking students while either waiting to attend student counseling or to sustain gains once a brief course of face-to-face counseling sessions has been completed. Moderated Online Social Therapy (MOST) is an online intervention that combines tailored psychotherapeutic content with one-to-one therapist and peer support worker support, and an online community. MOST has an emerging evidence base in multiple mental health contexts, but it has not yet been implemented in the university context. This trial investigated the feasibility of using MOST to support the mental health of third-level students who recently attended a student counseling service. We conducted a pilot randomized controlled study of third-level students who had recently completed ~4 sessions of counseling in their university counseling service. Students were randomly assigned to the intervention or control arm at a rate of 2:1. In the intervention arm, students had access to MOST for 26 weeks, and both groups were assessed at baseline, 12 weeks, and 26 weeks. Outcomes assessed at each time point included social and occupational functioning, cognitive functioning, depression, anxiety, and loneliness. To examine the feasibility of the trial, we examined data on recruitment, trial retention, and engagement with the MOST platform. We calculated effect sizes for outcome variables to explore the preliminary efficacy of the MOST intervention. A total of 74 participants were recruited, meeting the recruitment target of ~3.1 participants per semester month. Retention in the trial was 70% (52/74) at 12 weeks, reducing to 66% (49/74) at 26 weeks. For the intervention group, when engagement was measured in terms of participation in at least one component of the intervention, 81% (38/47) of the intervention group engaged for 5 or more weeks of the trial (~20% of the maximum 26 weeks). Based on the effect sizes observed, the intervention arm was associated with modest gains in social function and cognitive function and reduced clinical symptom severity at 12 weeks. Based on the recruitment, retention, and engagement rates observed, a full randomized controlled trial of MOST with young adults at the university is feasible. Moreover, the effect sizes favoring the intervention arm are consistent with previous studies and support a full trial of MOST as a potentially beneficial support for youth mental health in further education settings.

The global shortage of mental health professionals, exacerbated by increasing mental health needs post COVID-19, has stimulated growing interest in leveraging large language models to address these challenges. This systematic review aims to evaluate the current capabilities of generative artificial intelligence (GenAI) models in the context of mental health applications. A comprehensive search across 5 databases yielded 1046 references, of which 8 studies met the inclusion criteria. The included studies were original research with experimental designs (eg, Turing tests, sociocognitive tasks, trials, or qualitative methods); a focus on GenAI models; and explicit measurement of sociocognitive abilities (eg, empathy and emotional awareness), mental health outcomes, and user experience (eg, perceived trust and empathy). The studies, published between 2023 and 2024, primarily evaluated models such as ChatGPT-3.5 and 4.0, Bard, and Claude in tasks such as psychoeducation, diagnosis, emotional awareness, and clinical interventions. Most studies used zero-shot prompting and human evaluators to assess the AI responses, using standardized rating scales or qualitative analysis. However, these methods were often insufficient to fully capture the complexity of GenAI capabilities. The reliance on single-shot prompting techniques, limited comparisons, and task-based assessments isolated from a context may oversimplify GenAI's abilities and overlook the nuances of human-artificial intelligence interaction, especially in clinical applications that require contextual reasoning and cultural sensitivity. The findings suggest that while GenAI models demonstrate strengths in psychoeducation and emotional awareness, their diagnostic accuracy, cultural competence, and ability to engage users emotionally remain limited. Users frequently reported concerns about trustworthiness, accuracy, and the lack of emotional engagement. Future research could use more sophisticated evaluation methods, such as few-shot and chain-of-thought prompting to fully uncover GenAI's potential. Longitudinal studies and broader comparisons with human benchmarks are needed to explore the effects of GenAI-integrated mental health care.

Mental health disorders significantly impact global populations, prompting the rise of digital mental health interventions, such as artificial intelligence (AI)-powered chatbots, to address gaps in access to care. This review explores the potential for a \"digital therapeutic alliance (DTA),\" emphasizing empathy, engagement, and alignment with traditional therapeutic principles to enhance user outcomes. The primary objective of this review was to identify key concepts underlying the DTA in AI-driven psychotherapeutic interventions for mental health. The secondary objective was to propose an initial definition of the DTA based on these identified concepts. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for scoping reviews and Tavares de Souza's integrative review methodology were followed, encompassing systematic literature searches in Medline, Web of Science, PsycNet, and Google Scholar. Data from eligible studies were extracted and analyzed using Horvath et al's conceptual framework on a therapeutic alliance, focusing on goal alignment, task agreement, and the therapeutic bond, with quality assessed using the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. A total of 28 studies were identified from an initial pool of 1294 articles after excluding duplicates and ineligible studies. These studies informed the development of a conceptual framework for a DTA, encompassing key elements such as goal alignment, task agreement, therapeutic bond, user engagement, and the facilitators and barriers affecting therapeutic outcomes. The interventions primarily focused on AI-powered chatbots, digital psychotherapy, and other digital tools. The findings of this integrative review provide a foundational framework for the concept of a DTA and report its potential to replicate key therapeutic mechanisms such as empathy, trust, and collaboration in AI-driven psychotherapeutic tools. While the DTA shows promise in enhancing accessibility and engagement in mental health care, further research and innovation are needed to address challenges such as personalization, ethical concerns, and long-term impact.