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Measurement-based care (MBC) is an evidence-based approach that can improve management of depression, but its use in clinical settings remains low. The use of digital technology, or technology-enhanced MBC (eMBC), may address some of the barriers to implementation of MBC by enabling patients to easily complete outcome assessments. This study aims to identify the perceived facilitators and barriers to MBC and eMBC from both patient and provider perspectives in Canada.The study recruited 108 clinicians and 131 patients with a self-reported diagnosis of depression to participate in an online survey about the acceptability of both MBC and eMBC.Most clinicians (90/108, 83.3 %) agreed that MBC is important for clinical judgement, and felt trained to interpret their scores; however, only 43/108 (39.8 %) use MBC routinely. Clinicians (95/108, 88.0 %) felt they would be more likely to use MBC if it was automated and available to use electronically. Most patients (117/131, 89.3 %) felt MBC would be helpful for their treatment and were willing to use a mobile app to track their symptoms.Recruitment was done online and, hence, this study may not capture the perspective of patients who are not already familiar with using online programs to complete questionnaires.Clinicians and patients in Canada would be willing to utilize MBC and eMBC in their psychiatric care, but barriers to implementation include perceptions about efficiency, ease of use, and accessibility. These results highlight the importance of engaging both clinicians and patients to effectively implement MBC and eMBC for depression.

Objectives To determine the efficacy and safety of blue-light therapy in seasonal and non-seasonal major depressive disorder (MDD), by comparison to active and inactive control conditions. Methods We searched Web of Science, EMBASE, Medline, PsycInfo, and Clinicaltrials.gov through January 17, 2022, for randomized controlled trials (RCTs) using search terms for blue/blue-enhanced, light therapy, and depression/seasonal affective disorder. Two independent reviewers extracted data. The primary outcome was the difference in endpoint scores on the Structured Interview Guide for the Hamilton Depression Rating Scale - Seasonal Affective Disorder (SIGH-SAD) or the Structured Interview Guide for the Hamilton Depression Rating Scale with Atypical Depression Supplement (SIGH-ADS) between blue light and comparison conditions. Secondary outcomes were response (≥ 50% improvement from baseline to endpoint on a depression scale) and remission rates (endpoint score in the remission range). Results Of 582 articles retrieved, we included nine RCTs ( n = 347 participants) assessing blue-light therapy. Seven studies had participants with seasonal MDD and two studies included participants with non-seasonal MDD. Four studies compared blue light to an inactive light condition (efficacy studies), and five studies compared it to an active condition (comparison studies). For the primary outcome, a meta-analysis with random-effects models found no evidence for the efficacy of blue-light conditions compared to inactive conditions (mean difference [MD] = 2.43; 95% confidence interval [CI], −1.28 to 6.14, P = 0.20); however, blue-light also showed no differences compared to active conditions (MD = −0.11; 95% CI, −2.38 to 2.16, P = 0.93). There were no significant differences in response and remission rates between blue-light conditions and inactive or active light conditions. Blue-light therapy was overall well-tolerated. Conclusions The efficacy of blue-light therapy in the treatment of seasonal and non-seasonal MDD remains unproven. Future trials should be of longer duration, include larger sample sizes, and attempt to better standardize the parameters of light therapy.

Background Smartphone apps have potential for delivering interventions and supporting self-management in bipolar disorder (BD), however clinical trials of mental health apps have high dropout rates and low sustained use in real-world contexts. To support the development of app-based interventions, we explored use of and attitudes towards apps amongst people with BD, specifically concerns about privacy and preferences for various app features. Methods An international web-based survey was used to investigate concerns about privacy and the perceived importance of various app features among people with BD. Quantitative findings were summarised using descriptive statistics. Qualitative content analysis was used to investigate free-text responses. Results A total of 919 people completed the survey; 97.5% reported using smartphone apps in general. Concerns regarding data security were prevalent. Commonly prioritised mHealth features included content quality/accuracy, ease and flexibility of use, cost, and data security. The ability to share data with others, rewards for use, inter-app connectivity, and peer support were endorsed as important by fewer than half of respondents. Qualitative findings suggested that sustained app use could be supported by novel and positive content, customisation, meaningful use of data, interactivity, and perceived real-world benefits. Conclusions The findings of the present study offer important design considerations for the development and evaluation of future app-based interventions for BD. Importantly, some features that have previously been suggested as clinically beneficial or likely to support engagement were perceived ambivalently, emphasising the need for in-depth consultation with potential end users during app development.

Background : Studies exploring disability in bipolar disorder (BD) have primarily assessed clinical samples of full-threshold BD-I and BD-II alongside so-called objective criteria such as unemployment or receipt of government disability payments. This study extends research on disability by examining externally determined and self-identified disability in a community sample and by including subthreshold BD (BDS). Methods : Data were extracted from the USA Collaborative Psychiatric Epidemiology Surveys about individuals who met recognized criteria for BD-I, BD-II and BDS who had completed self-ratings of physical and mental disability, comorbidities, and health risk factors (e.g., obesity). Rates of disability were estimated, and logistic regression analyses were used to determine demographic and clinical variables associated with externally determined and self-identified of disability. Results : Of 408 individuals who met eligibility criteria (BD-I = 100; BD-II=104; BDS=204), 35% met criteria for externally determined disability, about 40% self-reported mental disability and about 23% self-reported physical disability. The odds were three-fold (Odds Ratio (OR): 3.05; 95% Confidence Intervals (CI): 1.69, 5.53) that someone with self-identified physical disability would meet criteria for externally determined disability, but associations with mental disability were non-significant (OR: 1.06; 95% CI: 0.63, 1.80). Regression analyses demonstrated that mental disability was associated with being a current or past smoker and physical disability was associated with BD-I. Limitations : the adequacy of the assessments of disability and definition of BDS can be questioned. Conclusions : Future clinical and community studies need to consider both externally determined and self-identified disability across the entire Bd spectrum.

Background: Psilocybin, the primary psychoactive component of psychedelic ‘magic mushrooms’, may have potential for treating depressive symptoms, and consequent applications for bipolar disorder (BD). Knowledge of the risks and benefits of psilocybin in BD is limited to case studies. Aim: To support the design of clinical trials, we surveyed experiences of psilocybin use in people with BD. Methods: An international web-based survey was used to explore experiences of psilocybin use in people with a self-reported diagnosis of BD. Quantitative findings were summarised using descriptive statistics. Qualitative content analysis was used to investigate free-text responses, with a focus on positive experiences of psilocybin use. Results: A total of 541 people completed the survey (46.4% female, mean 34.1 years old). One-third (32.2%; n = 174) of respondents described new/increasing symptoms after psilocybin trips, prominently manic symptoms, difficulties sleeping and anxiety. No differences in rates of adverse events overall were observed between individuals with BD I compared to BD II. Use of emergency medical services was rare ( n = 18; 3.3%), and respondents (even those who experienced adverse effects) indicated that psilocybin use was more helpful than harmful. Quantitative findings elaborated on perceived benefits, as well as the potential for psilocybin trips to contain both positively and negatively received elements. Conclusions: The subjective benefits of psilocybin use for mental health symptoms reported by survey participants encourage further investigation of psilocybin-based treatments for BD. Clinical trials should incorporate careful monitoring of symptoms, as data suggest that BD symptoms may emerge or intensify following psilocybin use.

Drawing on literature linking bipolar disorder to both creativity and heightened motivation, our aim was to examine whether heightened motivation might contribute to creativity in those with and without bipolar disorder. To examine this, we recruited persons diagnosed with bipolar disorder (n = 49), and persons with no diagnosis of bipolar disorder (n = 37), with over-sampling of those from creative occupations. We gathered measures of lifetime creative accomplishment (Creative Accomplishment Questionnaire), willingness to persist as a creativity task became increasingly difficult (the Compound Remote Associates task) divergent thinking (Unusual Uses Test), self-rated high ambitions (The Willingly Approached Set of Statistically Unlikely Pursuits scale)) and a behavioral measure of willingness to exert physical effort for reward (the Effort Discounting Task). In multiple linear regression models controlling for age and examining the unique effects of the motivation variables, two behavioral indicators from the Effort Discounting task related to creativity. That is, insensitivity to the level of effort required related to higher lifetime creative accomplishment. Insensitivity to the level of reward that could be obtained correlated with more willingness to persist on the creativity task and was higher in the bipolar group than the control comparison group. In sum, effort-based decision-making was related to bipolar disorder, to lifetime creative accomplishment, and to performance on a difficult creativity task. As such, this work contributes to a growing body of research on the role of motivation in creativity. Limitations are discussed.

INTRODUCTION Access to continuing professional development offered at lunchtime is limited by hospital scheduling that has staff members taking their lunch breaks at different times. To overcome this barrier, we developed a three-part training format with (1) a focus group segment soliciting participants' opinions on the training's target behavior, (2) a didactic segment introducing tools to support the behavior, and (3) a question-and-answer segment about the session topic. We rotated through these segments, each 15 minutes long, over 3 hours. Participants could join at any segment and experience the full curriculum after 45 minutes. METHODS We piloted this training format five times at three hospitals. Our training aimed to encourage clinicians to consistently inform involuntary patients about their Mental Health Act rights. We gauged the effect of the training and participants' opinions of the session using the Continuing Professional Development Reaction questionnaire and a session evaluation, respectively. RESULTS Continuing Professional Development-Reaction results (n = 80) showed a detectable increase in clinicians' intent to consistently give involuntary patients rights advice. Participants reported finding the training organized, informative, and valuable. DISCUSSION The open house with rotating short segments is a feasible and adaptable training format to engage clinicians in voluntary continuing professional development.

Background Smartphone apps have recognized potential for improving access to evidence-based care in the treatment of bipolar disorder (BD). Healthcare providers are well-positioned to play a role in guiding patients to access safe, evidence-supported, and trustworthy apps. However, little is known about whether and how clinicians use apps with people with BD: understanding practices and attitudes of healthcare providers is essential to support the implementation of mHealth interventions in a real-world context. Methods A web-based survey was used to explore clinicians’ attitudes towards, and use of apps when working with people with BD. Descriptive statistics were used to summarize quantitative findings. Free text responses were investigated using qualitative content analysis. Results Eighty healthcare providers completed the survey. Approximately half of the respondents reported discussing or recommending apps in clinical practice with BD populations. Recommended apps were most commonly related to mood, sleep, and exercise. Barriers to discussing apps included a lack of healthcare provider knowledge/confidence, concerns about patients’ ability to access apps, and beliefs that patients lacked interest in apps. Conclusion Although research suggests that people with BD are interested in using apps, uptake of such technology among clinicians is more limited. A lack of clinician knowledge regarding apps, combined with concerns about the digital divide and patient interest, may account for this relatively limited integration of apps into the management of BD. These findings emphasise the importance of considering the information needs of healthcare providers when planning dissemination strategies for app-based interventions for BD.

Mobile health (mHealth) applications (apps) have the potential to increase access to mental health care. In China, there is growing interest in mHealth apps for depression. Our objective was to systematically review research on mHealth for depression in China to identify benefits and challenges. A systematic literature search was conducted using Chinese and English databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized and nonrandomized clinical studies on mHealth apps and depression in China were included. Study quality was assessed using the Cochrane Risk of Bias tool. Seven studies met the inclusion criteria with three randomized trials, two quasi-randomized trials, one clinical trial with an uncertain grouping method, and one study with a single-group design. All studies used the WeChat platform and included activities such as psychoeducation, self-management, supervised group chats, and/or remote contact with a healthcare team, in comparison to usual care. All studies reported significant and large benefits for outcomes, but the risk of bias was high. There are few rigorous evaluations of mHealth apps for depression in China, with all included studies involving WeChat programs and most using WeChat to extend nursing discharge care for inpatients with depression. While these studies showed significant improvement in health outcomes as compared to usual care, the results remain inconclusive because of the high risk of bias. mHealth holds promise for increasing access to mental health care in China, but issues such as efficacy, scalability, patient and clinician acceptability, and data privacy must be addressed.

Non-response to first-line treatment for major depressive disorder (MDD) is common; for such individuals, quality of life (QoL) impairments can be severe. Identifying predictors of QoL changes may support the management of cases with persistent depressive symptoms despite adequate initial pharmacological/psychological treatment. The present study aimed to explore predictors of domain-specific QoL improvement following adjunctive aripiprazole treatment for inadequate response to initial antidepressant therapy. We evaluated secondary QoL outcomes from a CAN-BIND (Canadian Biomarker Integration Network in Depression) study in patients with MDD who did not respond to an initial 8 weeks of escitalopram and received a further 8 weeks of adjunctive aripiprazole (n = 96). Physical, psychological, social, and environmental QoL domains were assessed using the World Health Organization QoL Scale Brief Version (WHOQOL-BREF). Clinician-rated depressive symptoms were assessed using the Montgomery–Asberg Depression Rating Scale (MADRS). Functioning was measured with the Sheehan Disability Scale (SDS). Satisfaction with medication was assessed with a single item from the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF). Exploratory t-tests were used to describe domain score changes. A hierarchical linear regression was used to explore demographic, clinical, and treatment-related predictors of improvement. Across domains, QoL improved with adjunctive aripiprazole treatment. Satisfaction with medication and MADRS and SDS scores similarly improved. Symptom reduction was a predictor for positive change to physical and psychological QoL; functioning improvements were predictive of increases to all QoL domains. Satisfaction with medication predicted improvements to physical and psychological domains, whereas number of medication trials was a predictor of worsening QoL in the physical domain. The final model explained the most variance in psychological (68%) and physical (67%) QoL. Less variance was explained for environmental (43%) and social QoL (33%), highlighting a need for further exploration of predictors in these domains. Strategies such as functional remediation may have potential to support QoL for individuals with persistent depressive symptoms. ClinicalTrials.gov identifier: NCT016557.

Introduction Many individuals with major depressive disorder (MDD) do not respond to initial antidepressant monotherapy. Adjunctive aripiprazole is recommended for treatment non-response; however, the impacts on quality of life (QoL) for individuals who receive this second-line treatment strategy have not been described. Methods We evaluated secondary QoL outcomes in patients with MDD (n=179). After 8 weeks of escitalopram, non-responders ( Results Escitalopram responders experienced the most QoL improvements in the first treatment phase. For non-responders, QoL improved with a large effect during adjunctive aripiprazole treatment. At the endpoint, 47% of patients achieving symptomatic remission still had impaired QoL. Discussion Individuals who were treated with adjunctive aripiprazole after non-response to escitalopram experienced improved QoL, but a substantial degree of QoL impairment persisted. Since QoL deficits may predict MDD recurrence, attention to ways to support this outcome is required.

Background Condition-specific quality of life (QoL) instruments are more representative of the priorities of people with lived experience. As such, the development of the first and only bipolar disorder (BD) specific measurement instrument, the Quality of Life in Bipolar Disorder (QoL.BD) questionnaire, marked an important step forward for the literature. The present systematic review aims to characterise applications of the QoL.BD in the BD literature and review empirical findings obtained from studies using this measure. Methods A systematic search identified 37 peer-reviewed publications which reported original empirical data using the QoL.BD in a BD population. No restrictions were placed on language/study type. Results Adaptations to the QoL.BD displayed appropriate psychometric properties. Although clinical trials were typically underpowered, promising effect sizes for a number of treatment modalities were reported. QoL.BD scores were moderately correlated with depressive symptoms; a number of candidate predictors were identified. Limitations Due to resource limitations, the present review used one database (Google Scholar), and a single author reviewed articles for eligibility. On balance the risks of missing relevant studies were deemed minimal. Conclusion A sizeable, international body of evidence now exists regarding the measurement, presentation, and treatment of condition-specific aspects of QoL in BD. Key avenues for future research include large scale, randomized control clinical trials using the QoL.BD as a primary outcome, and granular exploration of potential correlates of QoL.BD domain scores. Finally, longer follow-up periods are required to inform understanding of the dynamic relationship between clinical variables and condition-specific aspects of QoL in BD.

Background Individuals with bipolar disorder (BD) are increasingly turning to smartphone applications (apps) for health information and self-management support. While reviews have raised concerns regarding the effectiveness and safety of publicly available apps for BD, apps surveyed may not reflect what individuals with BD are using. The present study had two aims: first, to characterize the use of health apps to support mood and sleep amongst people with BD, and second, to evaluate the quality, safety and functionality of the most commonly used self-management apps. Methods A web-based survey was conducted to explore which apps people with BD reported using to support self-management of mood and sleep. The characteristics of the most commonly nominated apps were described using a standardized framework, including their privacy policy, clinical foundations, and functionality. Results Respondents (n = 919) were 77.9% female with a mean age of 36.9 years. 41.6% of participants (n = 382) reported using a self-management app to support mood or sleep. 110 unique apps were nominated in relation to mood, and 104 unique apps nominated in relation to sleep; however, most apps were only mentioned once. The nine most frequently nominated apps related to mood and sleep were subject to further evaluation. All reviewed apps offered a privacy policy, however user control over data was limited and the complexity of privacy policies was high. Only one app was developed for BD populations. Half of reviewed apps had published peer-reviewed evidence to support their claims of efficacy, but little research was specific to BD. Conclusion Findings illustrate the potential of smartphone apps to increase the reach of psychosocial interventions amongst people with BD. Apps were largely created by commercial developers and designed for the general population, highlighting a gap in the development and dissemination of evidence-informed apps for BD. There may be risks in using generic health apps for BD self-management; clinicians should enquire about patients’ app use to foster conversations about their particular benefits and limitations.

BACKGROUND Quality of life (QoL) is increasingly recognised as a key outcome of self-management interventions for bipolar disorder (BD). Mobile phone applications (apps) can increase access to evidence-based self-management strategies and provide real-time support. However, while individuals with lived experience desire support with monitoring and improving broader health domains, existing BD apps largely target mood symptoms only. Further, evidence from the broader mHealth literature has shown that the desires and goals of end-users are not adequately taken into account during app development, and as a result engagement with mental health apps is suboptimal. To capitalise on the potential of apps to optimise wellness in BD, there is a need for interventions developed in consultation with real-world users that are designed to support QoL self-monitoring and self-management. Objective: This mixed methods pilot study is designed to evaluate the beta version of the newly developed PolarUs app, which aims to support QoL self-monitoring and self-management in people with BD. Developed using a community-based participatory research framework, the PolarUs app builds on the web-based adaptation of a BD-specific QoL self-assessment measure, and integrates material from a web-based portal providing information on evidence-informed self-management strategies in BD. OBJECTIVE The primary objectives of this project are to: (1) evaluate PolarUs app feasibility (via behavioral usage metrics); (2) evaluate PolarUs impact (via the Brief Quality of Life in Bipolar Disorders, QoL.BD scale, our primary outcomes measure); and (3) explore engagement with the PolarUs app (via both quantitative and qualitative methods). METHODS Study participants will be North American residents (N=150) aged 18-65 years with a DSM-5 diagnosis of BD-I, BD-II or BD not otherwise specified (NOS) as assessed by a structured diagnostic interview. An embedded mixed-methods research design will be adopted; qualitative interviews with a purposefully selected sub-sample (~n=30) of participants will be conducted to explore in more depth feasibility, impact and engagement with the PolarUs app over the 12-week study period. RESULTS At the time of publication of this protocol, the development of the beta version of the PolarUs app is complete. Participant enrollment is expected to begin in February 2022. Data collection is expected to be completed by December 2022. CONCLUSIONS Beyond contributing knowledge on the feasibility and impacts of a novel app to support QoL and self-management in BD, this study is also expected to provide new knowledge on engagement with mHealth apps. Furthermore, it is expected to function as a case study of successful co-design between individuals living with BD, clinicians who specialise in the treatment of BD, and BD researchers, providing a template for future use of community-based participatory research frameworks in mHealth intervention development. Results will be used to further refine the PolarUs app and inform the design of a larger clinical trial.

ObjectiveBipolar disorder (BD) is challenging to treat, and fewer treatments are available for depressive episodes compared to mania. Light therapy is an evidence-based nonpharmacological treatment for seasonal and nonseasonal major depression, but fewer studies have examined its efficacy for patients with BD. Hence, we reviewed the evidence for adjunctive light therapy as a treatment for bipolar depression.MethodsWe conducted a systematic review of databases from inception to June 30, 2019, for randomized, double-blind, placebo-controlled trials of light therapy in patients with BD (CRD42019128996). The primary outcome was change in clinician-rated depressive symptom score; secondary outcomes included clinical response, remission, acceptability, and treatment-emergent mood switches. We quantitatively pooled outcomes using meta-analysis with random-effects models.ResultsWe identified seven trials representing 259 patients with BD. Light therapy was associated with a significant improvement in Hamilton Depression Rating Scale score (standardized mean difference = 0.43, 95% confidence interval [CI], 0.04 to 0.82, P = 0.03). There was also a significant difference in favor of light therapy for clinical response (odds ratio [ OR] = 2.32; 95% CI, 1.12 to 4.81; P = 0.024) but not for remission. There was no difference in affective switches between active light and control conditions ( OR = 1.30; 95% CI, 0.38 to 4.44; P = 0.67). Study limitations included different light treatment parameters, small sample sizes, short treatment durations, and variable quality across trials.ConclusionThere is positive but nonconclusive evidence that adjunctive light therapy reduces symptoms of bipolar depression and increases clinical response. Light therapy is well tolerated with no increased risk of affective switch.

Background In British Columbia, Canada, clinicians are responsible for giving information about rights to patients involuntarily hospitalized under the Mental Health Act. But a survey commissioned by the Ministry of Health and an investigation by the BC Office of the Ombudsperson found that patients were not consistently receiving rights information. Methods Focus groups were used to probe clinicians’ perceived barriers and facilitators to giving patients rights information. Focus group transcripts were thematically analyzed, and the themes were coded using the Theoretical Domains Framework to identify interventions that could encourage clinicians to consistently give patients complete rights information. Results Eighty-one psychiatric clinicians participated. Analysis identified these barriers: (a) clinicians receive inadequate training on the Mental Health Act and rights notification; (b) newly admitted patients might not be receptive to new information; (c) the tool used to communicate rights to patients is inadequate; (d) many patients don’t speak English; (e) clinicians have competing priorities during the admission process; (f) clinicians face pressure from other staff to give incomplete information; (g) the clinical workflow doesn’t facilitate follow-up and accountability; and (h) staff don’t receive enough support from their employer. The following facilitators were identified: (a) a team approach allows clinicians to share knowledge about the Mental Health Act and rights notification, (b) having one person take responsibility for rights information clarifies roles and increases accountability, (c) accreditation reminds clinicians of the importance of giving patients rights information, and (d) checklists remind clinicians of their rights-notification responsibilities. Conclusions These interventions may help clinicians give rights information more consistently: (a) training about the Mental Health Act and rights notification, (b) an accessible legal resource for clinicians and patients, (c) regular group sessions about rights for patients, (d) an improved rights-communication tool, in multiple languages, and (e) checklists, reminders, and accountability and feedback systems.

Background: Adjunctive psychological interventions improve outcomes in bipolar disorder (BD), but people in latter, more refractory illness stages likely have different clinical needs. The objective here was to test the hypothesis that for people with >‾ 10 episodes of BD, an online mindfulness-based intervention improves quality of life (QoL) relative to a quality-matched psychoeducation control. Methods: A rater-blind, pragmatic superiority randomised clinical trial compared Mindfulness with active control (Psychoeducation). Both interventions were 5-week coach-supported self-management programs with treatment as usual continued. Key inclusion criteria were age 18 to 65 years, confirmed diagnosis of BD, and history of >‾ 10 episodes. Measures were collected at baseline, immediate post-intervention, and 3- and 6- month follow-ups. Main outcome was QoL, measured on the self-report Brief Quality of Life in Bipolar Disorder (Brief QoL.BD) at 5 weeks, using intention-to-treat analyses. The study setting was online, and randomisation was automated into the platform. The trial was prospectively registered on 23 June 2017 through ClinicalTrials.gov (http://www.clinicaltrials.gov, NCT03197974). Findings: Recruitment commenced 19 th September 2017, randomisation target reached 28 th November 2018 (N = 302 randomised) and follow-up data collection completed 6 th July 2019. The primary hypothesis of significant improvement in QoL with Mindfulness relative to Psychoeducation was not supported (Treatment X Time β = -0.69, 95% CI: -2·69, 1·31, p = 0·50). Recruitment was feasible, the platform was safe, both interventions were highly acceptable, but usage was suboptimal. Post hoc analyses found both interventions effective for participants not in remission from depression at baseline. Interpretation: In people with latter-stage BD, an online Mindfulness intervention was not superior to Psychoeducation. More effective future variants could combine mindfulness with psychoeducation content, improve engagement via personalised tailoring of QoL goals, and target more symptomatic individuals. Trial Registration: The trial was prospectively registered on 23 June 2017 through ClinicalTrials.gov (http://www.clinicaltrials.gov, NCT03197974). Funding: Supported by Australian National Health and Medical Research Council (NHMRC; APP1102097). Declaration of Interest: GM has received Grant/Research support from National Health and Medical Research Council (NHMRC), BeyondBlue Barbara Dicker Foundation, Readiness P/L, SiSU Wellness P/L – unrelated to this work, with the exception of the NHMRC funding for the project described here. MB has received Grant/Research Support from the NIH, Cooperative Research Centre, Simons Autism Foundation, Cancer Council of Victoria, Stanley Medical Research Foundation, Medical Benefits Fund, National Health and Medical Research Council, Medical Research Futures Fund, Beyond Blue, Rotary Health, A2 milk company, Meat and Livestock Board, Woolworths, Avant and the Harry Windsor Foundation, has been a speaker for Abbot, Astra Zeneca, Janssen and Janssen, Lundbeck and Merck and served as a consultant to Allergan, Astra Zeneca, Bioadvantex, Bionomics, Collaborative Medicinal Development, Janssen and Janssen, Lundbeck Merck, Pfizer and Servier – all unrelated to this work. NT has received Grant/Research Support from the Australian Government Department of Health, Australian Government Department of Veterans Affairs, Barbara Dicker Brain Sciences Foundation, NHMRC, Mental Health Commission, VicHealth and Victorian State Government Department of Health and Human Services, all unrelated to this work. LB has received Grant/Research Support from the NIH, Australasian Society for Bipolar & Depressive Disorders Ltd, GMHBA, National Health and Medical Research Council, and Servier – all unrelated to this work. SJ has received Grant/Research support from NIHR HTA, EME, RfPB and PGfAR streams all unrelated to this work. Ethical Approval: Swinburne University of Technology Human Research Ethics Committee approved the online trial (2016/289) with international recruitment.

ObjectiveNo studies have yet evaluated whether light therapy or negative ion therapy can be used as maintenance treatment after acute treatment with antidepressants in patients with major depressive disorder. To address the importance of this question, we surveyed participants with depression to determine their knowledge and attitudes about light therapy and negative ion therapy, and their willingness to participate in a randomized clinical trial with these therapies substituting for antidepressants for maintenance treatment.MethodsParticipants with a self-reported diagnosis of depression were recruited by email, newsletters, and social media to complete an online survey with questions about awareness and effectiveness of light therapy and negative ion therapy for depression. Vignettes describing the use of these therapies for maintenance treatment were presented with follow up questions about the ease of use and reasons for wanting (and not wanting) to use the therapies instead of antidepressants. Another vignette described a randomized study with these therapies followed by questions on whether participants would likely volunteer for the study. Chi-square tests were used to examine differences in responses between therapies.ResultsA total of 221 participants completed the survey. Most of them were aware of both therapies, but more participants had heard of light therapy (95% compared to 62% for negative ion therapy, pConclusionPeople with depression are generally aware of light therapy and negative ion therapy and believe they would be good therapies to substitute for antidepressants in maintenance treatment. These findings support the importance and feasibility for a randomized relapse prevention trial with light therapy and negative ion therapy in patients with depression.

Objective: To determine the efficacy of measurement-based care (MBC), defined as routinely administered outcome measures with practitioner and patient review to inform clinical decision-making, for adults with depressive disorders. Data Sources: Embase, MEDLINE, PsycINFO, ClinicalTrials.gov, CNKI, and Wanfang Data were searched through July 1, 2020, using search terms for measurement-based care, depression, antidepressant or pharmacotherapy, and randomized controlled trials (RCTs), without language restriction. Study Selection: Of 8,879 articles retrieved, 7 RCTs (2,019 participants) evaluating MBC for depressive disorders, all involving pharmacotherapy, were included. Data Extraction: Two independent reviewers extracted data. The primary outcome was response rate (≥ 50% improvement from baseline to endpoint on a depression scale). Secondary clinical outcomes were remission rate (endpoint score in remission range), difference in endpoint severity, and medication adherence. Results: Meta-analysis with random-effects models found no significant difference between MBC and comparison groups in response rates (3 studies; odds ratio [OR] = 1.66; 95% CI, 0.66-4.17; P = .279). MBC was associated with significantly greater remission rates (5 studies; OR = 1.83; 95% CI, 1.12-2.97; P = .015), lower endpoint severity (5 studies; standardized mean difference = 0.53; CI 0.06-0.99; P = .026), and greater medication adherence (3 studies; OR = 1.68; 95% CI, 1.22-2.30; P = .001). Conclusions: Although benefits for clinical response are unclear, MBC is effective in decreasing depression severity, promoting remission, and improving medication adherence in patients with depressive disorders treated with pharmacotherapy. The results are limited by the small number of included trials, high risk of bias, and significant study heterogeneity.

Background The primary objective is to test the effectiveness of a novel online quality of life (QoL) intervention tailored for people with late stage (≥ 10 episodes) bipolar disorder (BD) compared with psychoeducation. Relative to early stage individuals, this late stage group may not benefit as much from existing psychosocial treatments. Methods An NH&MRC funded international RCT to compare the effectiveness of two 5-week adjunctive online self-management interventions: Mindfulness for Bipolar 2.0 and an active control (Psychoeducation for Bipolar). A total of 300 participants were recruited primarily via social media channels. Evaluations occurred at pre- and post- treatment, and at 3- and 6- months follow-up. A secondary outcome measure was BD-related symptoms (depression). A longitudinal analysis was conducted using random effects mixed models. Results Preliminary results suggest no change in mean QIDS_total over time (p = 0.891). Nor does there appear to be a difference in groups (B coeff= 0.47, 95%CI (-0.60, 1.55), p = 0.613) and no difference in intervention groups over time (p = 0.828). Conclusions The effectiveness of a novel QoL focused, mindfulness based, online guided self-help intervention for late stage BD does not appear to have been any more effective than a psychoeducation intervention for reducing depression. Key messages There may be no significant benefit from using a mindfulness based, online guided self-help intervention over a psychoeducation intervention to reduce the BD symptoms of depression in late stage Bipolar disorder.

Background: Measurement-based care (MBC) is an evidence-based practice that incorporates routine outcome assessment using validated rating scales to guide collaborative clinical decision-making. Although MBC results in improved outcomes for patients with major depressive disorder (MDD), there are barriers to its broad implementation in clinical settings. The use of “enhanced” MBC (eMBC), with mobile apps that allow patients to track outcomes and engage in self-management via WeChat, may address some of these barriers. We hypothesize that implementation with eMBC using WeChat will be superior to standard MBC implementation using paper-pencil assessments at the clinic, for both implementation and clinical outcomes. Methods: We present a trial protocol for a 2-arm cluster randomized controlled trial (RCT) with a hybrid implementation-effectiveness design comparing standard MBC implementation versus eMBC implementation with 6-month follow up in 12 mental health centers in Shanghai, China. The eMBC implementation uses a WeChat mini-program that includes outcome tracking using brief questionnaires and self-management lessons supplemented with support by a lay coach via WeChat. Results: A total of 240 physicians and 1200 patients from the 12 mental health centers will be enrolled in the mixed-methods outcome analysis. The primary implementation outcome is implementation reach, defined as the proportion of eligible patients with a PHQ-9 score recorded in the hospital chart at 6 months after MBC implementation. The primary clinical outcome is clinical remission, defined as a PHQ-9 score of 4 or less at the 6-month follow up. Other implementation and clinical outcomes will be examined, including medication adherence, doctor-patient alliance, and a piggy-back cost-benefit economic analysis. Qualitative interviews will be conducted with physicians and patients to produce an interpretive account of the contextual factors which impact eMBC implementation.Conclusions: The results of this hybrid implementation-effectiveness cluster RCT will inform implementation of eMBC with WeChat mobile apps for patients with depression in other clinical settings in China and internationally.

Background Quality of life (QoL) is increasingly being recognized as a key outcome of interventions for bipolar disorder (BD). Mobile phone apps can increase access to evidence-based self-management strategies and provide real-time support. However, although individuals with lived experiences desire support with monitoring and improving broader health domains, existing BD apps largely target mood symptoms only. Further, evidence from the broader mobile health (mHealth) literature has shown that the desires and goals of end users are not adequately considered during app development, and as a result, engagement with mental health apps is suboptimal. To capitalize on the potential of apps to optimize wellness in BD, there is a need for interventions developed in consultation with real-world users designed to support QoL self-monitoring and self-management. Objective This mixed methods pilot study was designed to evaluate the alpha version of the newly developed PolarUs app, developed to support QoL self-monitoring and self-management in people with BD. Co-designed using a community-based participatory research framework, the PolarUs app builds on the web-based adaptation of a BD-specific QoL self-assessment measure and integrates material from a web-based portal providing information on evidence-informed self-management strategies in BD. The primary objectives of this project were to evaluate PolarUs app feasibility (via behavioral use metrics), the impact of PolarUs (via the Brief Quality of Life in Bipolar Disorder scale, our primary outcome measure), and explore engagement with the PolarUs app (via quantitative and qualitative methods). Methods Participants will be residents of North America (N=150), aged >18 years, with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnosis of BD type 1, BD type 2, or BD not otherwise specified as assessed by structured diagnostic interview. An embedded mixed methods research design will be adopted; qualitative interviews with a purposefully selected subsample (approximately, n=30) of participants will be conducted to explore in more depth feasibility, impact, and engagement with the PolarUs app over the 12-week study period. Results At the time of publication of this protocol, the development of the alpha version of the PolarUs app was complete. Participant enrollment has begun in June 2022. Data collection is expected to be completed by December 2022. Conclusions Beyond contributing knowledge on the feasibility and impact of a novel app to support QoL and self-management in BD, this study will also provide new insights related to engagement with mHealth apps. Furthermore, it will function as a case study of successful co-design between people with BD, health care providers, and BD researchers, providing a template for the future use of community-based participatory research frameworks in mHealth intervention development. The results will be used to further refine the PolarUs app and inform the design of a larger clinical trial. International Registered Report Identifier (IRRID) PRR1-10.2196/36213

BACKGROUND Cognitive dysfunction is an impairing and difficult to treat feature of psychiatric illnesses. Virtual Reality (VR) has shown promise in improving cognition in neurologic disorders, but its role in improving cognitive outcomes in adults with major psychiatric disorders is unclear. OBJECTIVE To conduct a review of the efficacy and usability of VR interventions to improve cognitive functioning in psychiatric disorders. METHODS Following PRISMA guidelines, a systematic review of controlled and uncontrolled English-language studies that assessed changes in cognition following an immersive or non-immersive VR intervention, in adults with a mood, psychotic, anxiety, or substance use disorder was conducted. Studies were searched on MEDLINE, EMBASE, PsychINFO, and Web of Science until May 2021. RESULTS Thirteen studies were included [primary psychotic disorder (n=10), substance use disorder (n=2) and major depressive disorder (n=1)]. Intervention strategies included drill and practice cognitive remediation (i.e. repeated practice of targeted skills, n=2), social cognitive/skills training (n=5), real world simulations (n=3) and vocational training (n=3). VR social cognitive/skills training resulted in improvements in social cognition, while the other remediation strategies resulted in generalized improvements across multiple cognitive domains. Both immersive and non-immersive VR appeared to be effective. In studies with an active control group (n=5), therapist led VR treatment resulted in equivalent or greater cognitive improvements versus non VR therapist led training. Changes in real-world functioning were inconsistently reported. CONCLUSIONS Preliminary evidence suggests VR interventions can improve cognitive outcomes in psychiatric disorders; however, significant variability in study design and outcome measures, small sample sizes and a focus on primary psychotic disorders limit the literature. More rigorous assessment of long-term cognitive and functional outcomes, and the comparative utility of immersive versus non-immersive modalities and different remediation strategies, is required. CLINICALTRIAL

The lived experience of people with mood disorders may be leveraged to inform priorities for research, define key treatment outcomes, and support decision-making in clinical care. The aim of this mixed-methods project was to provide insight into how people with depression and bipolar disorder experience the impact of symptoms, their treatment preferences, and their definitions of wellness.The project was implemented in two phases. In Phase 1, community-based participatory research was used to develop a web-based survey enquiring about living with a mood disorder, treatment experiences, and wellness priorities. In Phase 2, a series of focus groups were conducted to explore aspects of wellness in greater detail.Respondents (n= 6153) described the symptoms of mood disorders as having a significant, chronic impact on their lives. A holistic approach to treatment was desired by participants, but not necessarily experienced. Qualitative findings were used to further describe four highly ranked wellness priorities identified in the survey: ability to act independently or according to my own will; purpose in life; getting through the day; and contentment.Experience of a mood disorder was self-reported, and no formal confirmation of diagnosis occurred. Although the survey could not incorporate all possible wellness definitions, this was supplemented by qualitative focus groups.The present findings provide important insights from the perspectives of individuals with lived experience of mood disorders. Implications of this for research and clinical practice are discussed, particularly with regards to measurement-based care and use of wellness-oriented clinical outcome assessments.

Background Metacognitive knowledge (MK; general awareness of cognitive functioning) and metacognitive experience (ME; awareness of cognitive performance on a specific cognitive task) represent two facets of metacognition that are critical for daily functioning, but are understudied in bipolar disorder. This study was conducted to evaluate MK and ME across multiple cognitive domains in individuals diagnosed with bipolar disorder and unaffected volunteers, and to investigate the association between metacognition and quality of life (QoL). Methods Fifty-seven euthymic participants with bipolar disorder and 55 demographically similar unaffected volunteers provided prediction and postdiction ratings of cognitive task performance across multiple cognitive domains. Self-ratings were compared to objective task performance, and indices of MK and ME accuracy were generated and compared between groups. Participants rated QoL on the Quality of Life in Bipolar Disorder Scale (QoL.BD). Results Metacognitive inaccuracies in both MK and ME were observed in participants with bipolar disorder, but only in select cognitive domains. Furthermore, most metacognitive inaccuracies involved underestimation of cognitive ability. Metacognitive indices were minimally associated with medication variables and mood symptoms, but several indices were related to QoL. Conclusions Individuals with bipolar disorder demonstrate inaccuracies in rating their cognitive functioning and in rating their online cognitive task performance, but only on select cognitive functions. The tendency to underestimate performance may reflect a negative information processing bias characteristic of mood disorders. Metacognitive variables were also predictive of QoL, indicating that further understanding of cognitive self-appraisals in persons with bipolar disorder has significant clinical relevance.

Background Exercise is now recommended as a primary treatment for mild-moderate depression in Canada. The ‘Exercise and Depression Toolkit’ was developed to help health care providers (HCP) integrate these treatment guidelines into practice. The purpose of this study was to evaluate acceptability and perceived effectiveness of the toolkit in practice by HCPs working with individuals with depression. Methods A case study design was utilized. The toolkit was given to 6 HCPs to use in practice for 4 weeks. Pre- and post-intervention phone interviews were conducted, and weekly logs were provided to track use and satisfaction of interactions with individuals with depression when using the toolkit. The study was conceptually guided by a hybrid theoretical approach using the Diffusion of Innovation Theory and the Theoretical Framework of Acceptability. Results All HCPs used the toolkit at least once. Participants viewed their interactions when using the toolkit to be successful (considering individuals’ receptiveness, its usefulness and general satisfaction.) The average success score for all participants was 5.5/7. HCPs found the toolkit to be acceptable. All participants (n = 6) viewed the toolkit as having relative advantage in helping them to discuss exercise with individuals with depression, and as relatively simple and easy to use (not complex) and adaptable to their practice needs (having trialability). Participants liked the toolkit and had mostly positive things to say about it. Participants had mixed feelings about whether changes in the people they worked with (such as mood and activity levels) could be observed (observability) and whether the toolkit changed their belief in their ability to recommend or discuss exercise (self-efficacy). Recommended dissemination strategies were adopted in promoting the toolkit. Conclusions Future work should address observability and the ability for health care providers to see other providers using it, as well as effectiveness considering outcomes for people with depression such as mood and activity changes. The results of this initial evaluation seem promising for uptake and future adoption of the toolkit by health care providers working with adults with depression in Canada.

Delphi consensus consultation methods and community-based participatory research (CBPR) are distinct approaches that have traditionally been employed separately. This paper explores the integration of Delphi methods with CBPR in a research project that sought to identify effective self-management strategies for bipolar disorder (BD). We introduce our Canadian-based network which specializes in CBPR in BD, and outline the key principles of CBPR approaches. Delphi consensus consultation methods are described and we present the five phases of our Delphi consensus consultation project, conducted within a CBPR framework. Examples of how each project phase incorporated the principles of CBPR are provided, as are personal reflections of community members involved in the project, and broader reflections on challenges commonly encountered in CBPR projects.

BACKGROUND Web-based resources can support people with bipolar disorder (BD) to improve their knowledge and self-management. However, publicly available resources are heterogeneous in terms of their quality and ease of use. Characterizing digital health literacy (the skillset that enable people to navigate and make use of health information in a web-based context) in BD will support the development of educational resources. OBJECTIVE The aim of this study was to develop understanding of digital health literacy and its predictors in people with BD. METHODS A web-based survey was used to explore self-reported digital health literacy (as measured by the e-Health Literacy Scale [eHEALS]) in people with BD. Multiple regression analysis was used to evaluate potential predictors, including demographic/clinical characteristics and technology use. RESULTS A total of 919 respondents (77.9% female; mean age 36.9 years) completed the survey. Older age (β=0.09; P=.01), postgraduate education (β=0.11; P=.01), and current use of self-management apps related to BD (β=0.13; P CONCLUSIONS Levels of self-reported digital health literacy were comparable or higher than other studies in the general population and specific physical/mental health conditions. However, individuals with BD who are younger, have completed less education, or are less familiar with mental health apps may require extra support to safely and productively navigate web-based health resources. Relevant educational initiatives are discussed. Future studies should evaluate skill development interventions for less digitally literate groups.

Background Bright light therapy has been shown to improve depressive symptoms in patients with nonseasonal major depressive disorder (MDD) but there are few studies examining functional outcomes. Methods We examined secondary functional outcomes in the 8-week randomized, placebo-sham-controlled LIFE-D trial comparing light therapy, fluoxetine, and the combination in patients with nonseasonal MDD. Functional assessments included the Sheehan Disability Scale (SDS) and, for employed participants, the Lam Employment Absence and Productivity Scale (LEAPS). Analysis of covariance (ANCOVA) was conducted with SDS and LEAPS change scores from baseline to week 8 as dependent variables, treatment modality (light, fluoxetine) as an independent variable, and baseline SDS and LEAPS scores as covariates. Results Of 122 randomized participants, SDS data were available for 105 and LEAPS data for 70. For the SDS, there were no interaction effects, but there was a significant small- to medium-sized main effect of light treatment on total SDS scores with corresponding significant effects in the Social Life and Family Life domains, but not in the Work/Study domain. There were no significant interaction or main effects with LEAPS scores. Conclusion Light therapy significantly improved social and family life functioning in patients with MDD. However, work functioning was not significantly improved despite large effect sizes; these results were limited by low statistical power because of small sample sizes. Future studies should use longer treatment durations and be powered to detect clinically relevant differences in functional outcomes.

Growing evidence suggests that psilocybin, the active ingredient in hallucinogenic mushrooms, can rapidly and durably improve symptoms of depression, leading to recent breakthrough status designation by the FDA and legalization for mental health treatment in some jurisdictions. Depression in bipolar disorder is associated with significant morbidity and has few effective treatments. However, there is a dearth of available scientific data on the risk of psilocybin use in bipolar disorder. Individuals with bipolar disorder have been excluded from modern clinical trials, out of understandable concerns of activating mania or worsening the illness course. As psilocybin becomes more available, people with these disorders will likely seek psilocybin treatment for depression and have likely been doing so in unregulated settings. Our goal was to summarize the known risks of psilocybin use (and similar substances) in bipolar disorder and to systematically evaluate the examples of published case history data, in order to critically evaluate the relative risk of psilocybin as a treatment for bipolar depression. We found 15 possible cases suggesting that there is potential risk for activating a manic episode, thereby warranting caution. Nonetheless, the relative lack of systematic data or common case examples indicating risk appears to show that a cautious trial, using modern trial methods focusing on appropriate ‘set’ and ‘setting’, targeted at those lowest at risk for mania in the bipolar spectrum (e.g., bipolar 2 disorder), is very much needed, especially given the degree to which depression impacts this population. Sources of direct funding, support, or sponsorship Dr. Woolley is funded in part via VA CSR&D 1IK4CX002090-01. Grant title: Quantifying and Treating Social Deficits in Veterans with Mental Illness: a Five Year Plan. Role of the sponsor Not applicable Potential conflicts of interest Dr. Woolley is a paid consultant for Psilo Scientific Ltd. and Silo Pharma.

Background The COVID-19 pandemic is expected to have profound mental health impact, including in the Asia Pacific Economic Cooperation (APEC) region. Some populations might be at higher risk of experiencing negative mental health impacts and may encounter increased barriers to accessing mental health care. The pandemic and related restrictions have led to changes in care delivery, including a rapid shift to the use of e-mental health and digital technologies. It is therefore essential to consider needs and opportunities for equitable mental health care delivery to the most at-risk populations. This rapid scoping review: 1) identifies populations in the APEC region that are at higher risk of the negative mental health impacts of COVID-19, 2) identifies needs and gaps in access to standard and e-mental health care among these populations, and 3) explores the potential of e-mental health to address these needs. Methods We conducted a rapid scoping review following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). We searched Medline, Embase and PsychInfo databases and Google Scholar using a search strategy developed in consultation with a biomedical librarian. We included records related to mental health or psychosocial risk factors and COVID-19 among at-risk groups; that referred to one or more APEC member economies or had a global, thus generalizable, scope; English language papers, and papers with full text available. Results A total of 132 records published between December 2019 and August 2020 were included in the final analysis. Several priority at-risk populations, risk factors, challenges and recommendations for standard and e-mental health care were identified. Results demonstrate that e-mental health care can be a viable option for care delivery but that specific accessibility and acceptability considerations must be considered. Options for in-person, hybrid or “low-tech” care must also remain available. Conclusions The COVID-19 pandemic has highlighted the urgent need for equitable standard and e-mental health care. It has also highlighted the persistent social and structural inequities that contribute to poor mental health. The APEC region is vast and diverse; findings from the region can guide policy and practice in the delivery of equitable mental health care in the region and beyond.

Background In British Columbia (BC), Canada, clinicians are responsible for giving involuntary psychiatric patients rights information upon admission. Yet an investigation by the BC Office of the Ombudsperson found that clinicians are not always fulfilling this responsibility. The Ombudsperson recommended that the provincial government fund an independent body to give rights advice to patients. Methods To understand how clinicians feel about this recommendation, focus groups of clinicians who may give psychiatric patients rights information (n = 81) were conducted in Vancouver, BC, to probe their attitudes toward independent rights advisors. The focus group transcripts were thematically analyzed. Results Most clinicians believe that giving rights information is within their scope of practice, although some acknowledge that it poses a conflict of interest when the patient wishes to challenge the treatment team’s decisions. Participants’ chief concerns about an independent rights-advice service were that (a) patients may experience a delay in receiving their rights information, (b) integrating rights advisors into the workflow would complicate an already chaotic admission process, and (c) more patients would be counselled to challenge their hospitalization, leading to an increased administrative workload for clinical staff. However, many participants believed that independent rights advisors would be a positive addition to the admission process, both allowing clinicians to focus on treatment and serving as a source of rights-related information. Conclusions Participants were generally amenable to an independent rights-advice service, suggesting that the introduction of rights advisors need not result in an adversarial relationship between treatment team and patient, as opponents of the proposal fear. Clearly distinguishing between basic rights information and in-depth rights advice could address several of the clinicians’ concerns about the role that independent rights advisors would play in the involuntary admission process. Clinicians’ and other stakeholders’ concerns should be considered as the province develops its rights-advice service.

Background Measurement-based care (MBC) is an evidence-based practice for depression, but its use by clinicians remains low. Enhanced MBC (eMBC), which uses digital technologies, can help to facilitate the use of MBC by clinicians and patients. Understanding factors that act as barriers and drivers to the implementation of MBC and eMBC is important to support the design of implementation strategies, promoting uptake by clinicians and patients. Objective This situational analysis identifies barriers and facilitators to the implementation of standard and eMBC at mental health centers in Shanghai, China. Methods We used mixed methods to develop a comprehensive understanding of the factors influencing MBC and eMBC implementation in Shanghai. This study took place across three mental health centers in Shanghai. We used situational analysis tools to collect contextual information about the three centers, conducted surveys with n = 116 clinicians and n = 301 patients, conducted semi-structured interviews with n = 30 clinicians and six focus groups with a total of n = 19 patients. Surveys were analysed using descriptive statistics, and semi-structured interviews and focus groups were analysed using framework analysis. Results Several potential barriers and facilitators to MBC and eMBC implementation were identified. Infrastructure, cost, attitudes and beliefs, and perceptions about feasibility and efficacy emerged as both challenges and drivers to MBC and eMBC implementation in Shanghai. Conclusions The results of this study will directly inform the design of an implementation strategy for MBC and eMBC in Shanghai, that will be tested via a randomized controlled trial. This study contributes to the emerging body of literature on MBC implementation and, to the best of our knowledge, is the first such study to take place in Asia. This study identifies several factors that are relevant to the equitable delivery of MBC, recognizing the need to explicitly address equity concerns in global mental health implementation research.

Measurement-based care (MBC) can be defined as the clinical practice in which care providers collect patient data through validated outcome scales and use the results to guide their decision-making processes. Despite growing evidence supporting the effectiveness of MBC for depression and other mental health conditions, many physicians and mental health clinicians have yet to adopt MBC practice. In part, this is due to individual and organizational barriers to implementing MBC in busy clinical settings. In this paper, we briefly review the evidence for the efficacy of MBC focusing on pharmacological management of depression and provide example clinical scenarios to illustrate its potential clinical utility in psychiatric settings. We discuss the barriers and challenges for MBC adoption and then address these by suggesting simple solutions to implement MBC for depression care, including recommended outcome scales, monitoring tools, and technology solutions such as cloud-based MBC services and mobile health apps for mood tracking. The availability of MBC tools, ranging from paper-pencil questionnaires to mobile health technology, can allow psychiatrists and clinicians in all types of practice settings to easily incorporate MBC into their practices and improve outcomes for their patients with depression.

Objective: The goal of this study was to validate the French version of the Quality of Life in Bipolar Disorder (QoL.BD) scale, a condition-specific measure for bipolar disorder (BD). Method: The QoL.BD scale was translated into French in accordance with the recommendations for transcultural adaptation. It was administered to 125 participants with BD living in Quebec, Canada. Construct validity was evaluated through correlations with other measures of self-reported quality of life (QoL), functioning, and symptoms. Factorial structure was examined through an exploratory factor analysis. Results: Internal reliability and test–retest reliability standards were met. Correlations in expected directions with other QoL, functioning, and depressive symptom scales supported convergent validity. The item loadings structure of the French QoL.BD largely replicated the original English version, with some modifications. Conclusion: The French version of the QoL.BD (full and brief) is comparable in its psychometric properties to the English version. It is a valid and sound measure for the evaluation of the QoL of French-speaking patients with BD.

Downloading a mobile health (m-health) app on your smartphone does not mean you will ever use it. Telling another person about an app does not mean you like it. Using an online intervention does not mean it has had an impact on your well-being. Yet we consistently rely on downloads, clicks, ‘likes’ and other usage and popularity metrics to measure m-health app engagement. Doing so misses the complexity of how people perceive and use m-health apps in everyday life to manage mental health conditions. This article questions commonly used behavioural metrics of engagement in mental health research and care, and proposes a more comprehensive approach to measuring in-app engagement.

IMPORTANCE: The mechanisms by which engagement with internet-delivered psychological interventions are associated with depression and anxiety symptoms are unclear. OBJECTIVE: To identify behavior types based on how people engage with an internet-based cognitive behavioral therapy (iCBT) intervention for symptoms of depression and anxiety. DESIGN, SETTING, AND PARTICIPANTS: Deidentified data on 54 604 adult patients assigned to the Space From Depression and Anxiety treatment program from January 31, 2015, to March 31, 2019, were obtained for probabilistic latent variable modeling using machine learning techniques to infer distinct patient subtypes, based on longitudinal heterogeneity of engagement patterns with iCBT. INTERVENTIONS: A clinician-supported iCBT-based program that follows clinical guidelines for treating depression and anxiety, delivered on a web 2.0 platform. MAIN OUTCOMES AND MEASURES: Log data from user interactions with the iCBT program to inform engagement patterns over time. Clinical outcomes included symptoms of depression (Patient Health Questionnaire-9 [PHQ-9]) and anxiety (Generalized Anxiety Disorder-7 [GAD-7]); PHQ-9 cut point greater than or equal to 10 and GAD-7 scores greater than or equal to 8 were used to define depression and anxiety. RESULTS: Patients spent a mean (SD) of 111.33 (118.92) minutes on the platform and completed 230.60 (241.21) tools. At baseline, mean PHQ-9 score was 12.96 (5.81) and GAD-7 score was 11.85 (5.14). Five subtypes of engagement were identified based on patient interaction with different program sections over 14 weeks: class 1 (low engagers, 19 930 [36.5%]), class 2 (late engagers, 11 674 [21.4%]), class 3 (high engagers with rapid disengagement, 13 936 [25.5%]), class 4 (high engagers with moderate decrease, 3258 [6.0%]), and class 5 (highest engagers, 5799 [10.6%]). Estimated mean decrease (SE) in PHQ-9 score was 6.65 (0.14) for class 3, 5.88 (0.14) for class 5, and 5.39 (0.14) for class 4; class 2 had the lowest rate of decrease at −4.41 (0.13). Compared with PHQ-9 score decrease in class 1, the Cohen d effect size (SE) was −0.46 (0.014) for class 2, −0.46 (0.014) for class 3, −0.61 (0.021) for class 4, and −0.73 (0.018) for class 5. Similar patterns were found across groups for GAD-7. CONCLUSIONS AND RELEVANCE: The findings of this study may facilitate tailoring interventions according to specific subtypes of engagement for individuals with depression and anxiety. Informing clinical decision needs of supporters may be a route to successful adoption of machine learning insights, thus improving clinical outcomes overall.

The ongoing COVID‐19 pandemic has to date infected more than one million people and led to tens of thousands of deaths across the globe. Thus, many governments have imposed regional or national mass shelters‐in‐place in an effort to slow its rapid spread. In this global health emergency, special attention should be paid to the potential impact of the measures taken to combat the pandemic on patients with bipolar disorders (BDs).

Objective: Bright light therapy is increasingly recommended (alone or in combination with antidepressant medication) to treat symptoms of nonseasonal major depressive disorder (MDD). However, little is known about its impacts on quality of life (QoL), a holistic, patient-valued outcome. Methods: This study utilizes secondary outcome data from an 8-week randomized, controlled, double blind trial comparing light monotherapy ( n = 32), fluoxetine monotherapy ( n = 30), and the combination of these ( n = 27) to placebo ( n = 30). QoL was assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF). Treatment-related differences in QoL improvements were assessed using a repeated measures analysis of variance. The influence of potential predictors of QoL (demographic variables and change in depressive symptoms) were investigated via hierarchical linear regression. Results: Q-LES-Q-SF scores significantly improved across all treatment conditions; however, no significant differences were observed between treatment arms. QoL remained poor relative to community norms by the end of the trial period: Across conditions, 70.6% of participants had significantly impaired QoL at the 8-week assessment. Reduction in depressive scores was a significant predictor of improved QoL, with the final model accounting for 54% of variance in QoL change scores. Conclusion: The findings of this study emphasize that improvement in QoL and reduction in depressive symptoms in MDD, while related, cannot be taken to be synonymous. Adjunctive therapies may be required to address unmet QoL needs in patients with MDD receiving antidepressant or light therapies. Further research is required to explore additional predictors of QoL in order to better refine treatments for MDD.

Background Quality of life (QoL) is considered a key treatment outcome in bipolar disorder (BD) across research, clinical, and self-management contexts. Web-based assessment of patient-reported outcomes offer numerous pragmatic benefits but require validation to ensure measurement equivalency. A web-based version of the Quality of Life in Bipolar Disorder (QoL.BD) questionnaire was developed (QoL Tool). Objective This study aimed to evaluate the psychometric properties of a web-based QoL self-report questionnaire for BD (QoL Tool). Key aims were to (1) characterize the QoL of the sample using the QoL Tool, (2) evaluate the internal consistency of the web-based measure, and (3) determine whether the factor structure of the original version of the QoL.BD instrument was replicated in the web-based instrument. Methods Community-based participatory research methods were used to inform the development of a web-based adaptation of the QoL.BD instrument. Individuals with BD who registered for an account with the QoL Tool were able to opt in to sharing their data for research purposes. The distribution of scores and internal consistency estimates, as indicated by Cronbach alpha, were inspected. An exploratory factor analysis using maximum likelihood and oblique rotation was conducted. Inspection of the scree plot, eigenvalues, and minimum average partial correlation were used to determine the optimal factor structure to extract. Results A total of 498 people with BD (349/498, 70.1% female; mean age 39.64, SD 12.54 years; 181/498, 36.3% BD type I; 195/498, 39.2% BD type II) consented to sharing their QoL Tool data for the present study. Mean scores across the 14 QoL Tool domains were, in general, significantly lower than that of the original QoL.BD validation sample. Reliability estimates for QoL Tool domains were comparable with that observed for the QoL.BD instrument (Cronbach alpha=.70-.93). Exploratory factor analysis supported the extraction of an 11-factor model, with item loadings consistent with the factor structure suggested by the original study. Findings for the sleep and physical domains differed from the original study, with this analysis suggesting one shared latent construct. Conclusions The psychometric properties of the web-based QoL Tool are largely concordant with the original pen-and-paper QoL.BD, although some minor differences in the structure of the sleep and physical domains were observed. Despite this small variation from the factor structure identified in the QoL.BD instrument, the latent factor structure of the QoL Tool largely reproduced the original findings and theoretical structure of QoL areas relevant to people with BD. These findings underscore the research and clinical utility of this instrument, but further comparison of the psychometric properties of the QoL Tool relative to the QoL.BD instrument is warranted. Future adaptations of the QoL Tool, including the production of an app-based version of the QoL Tool, are also discussed.

Quality of life (QoL) is increasingly a target of interventions for bipolar disorders (BD). While the subjective experience of consumers is often elevated as central to the construct of QoL in BD, limited investigation in this area means subjective QoL remains poorly understood. The present qualitative study seeks to address this by investigating how people with BD appraise the quality of their lives in the context of a QoL self-management intervention. Semi-structured interviews were conducted with 43 individuals who had participated in a self-management intervention for improving QoL in BD. Individuals were questioned about experiences of the intervention and perceptions of their QoL. Thematic analysis was used to explore participants’ appraisal of their QoL. An overarching theme concerned the intrinsic relativity of subjective QoL: individuals located QoL as relative to self, others and possible futures. Incorporating illness-related reference points for QoL (‘given my circumstances…’) was associated with perceptions of improved QoL. Deliberately modifying reference points for QoL was perceived as self-compassionate. The present study generates novel hypotheses about how individuals with BD make sense of their QoL. Data suggest that individuals located their QoL relative to a variety of reference points, use of which was flexible. In accord with gap theories of QoL, individuals experienced acceptance of illness impacts as improving subjective sense of QoL. Rather than ‘settling for’ a lower standard of QoL, individuals experienced these changes as adaptive and positive. Findings are discussed in relation to the measurement and amelioration of QoL in BD.

Growing evidence suggests that psilocybin, the active ingredient in hallucinogenic mushrooms, can rapidly and durably improve symptoms of depression, leading to recent breakthrough status designation by the FDA and legalization for mental health treatment in some jurisdictions. Depression in bipolar disorder is associated with significant morbidity and has few effective treatments. However, there is little available scientific data on the risk of psilocybin use in people with bipolar disorder. Individuals with bipolar disorder have been excluded from modern clinical trials, out of understandable concerns of activating mania or worsening the illness course. As psilocybin becomes more available, people with these disorders will likely seek psilocybin treatment for depression and have likely already been doing so in unregulated settings. Our goal here is to summarize the known risks of psilocybin use (and similar substances) in bipolar disorder and to systematically evaluate examples of published case history data, in order to critically evaluate the relative risk of psilocybin as a treatment for bipolar depression. We found 17 cases suggesting that there is potential risk for activating a manic episode, thereby warranting caution. Nonetheless, the relative lack of systematic data or common case examples indicating risk appears to show that a cautious trial, using modern trial methods focusing on appropriate ‘set’ and ‘setting’, targeted at those lowest at risk for mania in the bipolar spectrum (e.g., bipolar 2 disorder), is very much needed, especially given the degree to which depression impacts this population.

Background Web-based resources can support people with bipolar disorder (BD) to improve their knowledge and self-management. However, publicly available resources are heterogeneous in terms of their quality and ease of use. Characterizing digital health literacy (the skillset that enable people to navigate and make use of health information in a web-based context) in BD will support the development of educational resources. Objective The aim of this study was to develop understanding of digital health literacy and its predictors in people with BD. Methods A web-based survey was used to explore self-reported digital health literacy (as measured by the e-Health Literacy Scale [eHEALS]) in people with BD. Multiple regression analysis was used to evaluate potential predictors, including demographic/clinical characteristics and technology use. Results A total of 919 respondents (77.9% female; mean age 36.9 years) completed the survey. Older age (β=0.09; P=.01), postgraduate education (β=0.11; P=.01), and current use of self-management apps related to BD (β=0.13; P Conclusions Levels of self-reported digital health literacy were comparable or higher than other studies in the general population and specific physical/mental health conditions. However, individuals with BD who are younger, have completed less education, or are less familiar with mental health apps may require extra support to safely and productively navigate web-based health resources. Relevant educational initiatives are discussed. Future studies should evaluate skill development interventions for less digitally literate groups.

BackgroundAlthough quality of life (QoL) is receiving increasing attention in bipolar disorder (BD) research and practice, little is known about its naturalistic trajectory. The dual aims of this study were to prospectively investigate: (a) the trajectory of QoL under guideline-driven treatment and (b) the dynamic relationship between mood symptoms and QoL.MethodsIn total, 362 patients with BD receiving guideline-driven treatment were prospectively followed at 3-month intervals for up to 5 years. Mental (Mental Component Score – MCS) and physical (Physical Component Score – PCS) QoL were measured using the self-report SF-36. Clinician-rated symptom data were recorded for mania and depression. Multilevel modelling was used to analyse MCS and PCS over time, QoL trajectories predicted by time-lagged symptoms, and symptom trajectories predicted by time-lagged QoL.ResultsMCS exhibited a positive trajectory, while PCS worsened over time. Investigation of temporal relationships between QoL and symptoms suggested bidirectional effects: earlier depressive symptoms were negatively associated with mental QoL, and earlier manic symptoms were negatively associated with physical QoL. Importantly, earlier MCS and PCS were both negatively associated with downstream symptoms of mania and depression.ConclusionsThe present investigation illustrates real-world outcomes for QoL under guideline-driven BD treatment: improvements in mental QoL and decrements in physical QoL were observed. The data permitted investigation of dynamic interactions between QoL and symptoms, generating novel evidence for bidirectional effects and encouraging further research into this important interplay. Investigation of relevant time-varying covariates (e.g. medications) was beyond scope. Future research should investigate possible determinants of QoL and the interplay between symptoms and wellbeing/satisfaction-centric measures of QoL.

Objective Internet (eHealth) and smartphone-based (mHealth) approaches to self-management for bipolar disorder are increasingly common. Evidence-based self-management strategies are available for bipolar disorder and provide a useful framework for reviewing existing eHealth/mHealth programs to determine whether these strategies are supported by current technologies. This review assesses which self-management strategies are most supported by technology. Method Based on 3 previous studies, 7 categories of self-management strategies related to bipolar disorder were identified, followed by a systematic literature review to identify existing eHealth and mHealth programs for this disorder. Searches were conducted by using PubMed, CINAHL, PsycINFO, EMBASE, and the Cochrane Database of Systematic Reviews for relevant peer-reviewed articles published January 2005 to May 2015. eHealth and mHealth programs were summarized and reviewed to identify which of the 7 self-management strategy categories were supported by eHealth or mHealth programs. Results From 1,654 publications, 15 papers were identified for inclusion. From these, 9 eHealth programs and 2 mHealth programs were identified. The most commonly supported self-management strategy categories were "ongoing monitoring," "maintaining hope," "education," and "planning for and taking action"; the least commonly supported categories were "relaxation" and "maintaining a healthy lifestyle." eHealth programs appear to provide more comprehensive coverage of self-management strategies compared with mHealth programs. Conclusions and implications for practice Both eHealth and mHealth programs present a wide range of self-management strategies for bipolar disorder, although individuals seeking comprehensive interventions might be best served by eHealth programs, while those seeking more condensed and direct interventions might prefer mHealth programs. (PsycINFO Database Record

Rationale, aims and objectives Current Web technologies offer bipolar disorder (BD) researchers many untapped opportunities for conducting research and for promoting knowledge exchange. In the present paper, we document our experiences with a variety of Web 2.0 technologies in the context of an international BD research network: The Collaborative RESearch Team to Study psychosocial issues in BD (CREST.BD). Methods Three technologies were used as tools for enabling research within CREST.BD and for encouraging the dissemination of the results of our research: (1) the crestbd.ca website, (2) social networking tools (ie, Facebook, Twitter), and (3) several sorts of file sharing (ie YouTube, FileShare). For each Web technology, we collected quantitative assessments of their effectiveness (in reach, exposure, and engagement) over a 6-year timeframe (2010-2016). Results In general, many of our strategies were deemed successful for promoting knowledge exchange and other network goals. We discuss how we applied our Web analytics to inform adaptations and refinements of our Web 2.0 platforms to maximise knowledge exchange with people with BD, their supporters, and health care providers. Conclusions We conclude with some general recommendations for other mental health researchers and research networks interested in pursuing Web 2.0 strategies.

Current adjunctive psychosocial interventions for bipolar disorder (BD) aim to impact illness course via information sharing/skill development. This focus on clinical outcomes contrasts with the emergent recovery paradigm, which prioritises adaptation to serious mental illness and movement towards personally meaningful goals. The aim of this review is to encourage innovation in the psychological management of BD by considering three recovery-oriented trends in the literature. First, the importance of quality of life as a target of recovery-oriented clinical work is considered. Second, the recent staging approach to BD is described, and we outline implications for psychosocial interventions tailored to stage. Finally, we review evidence suggesting that mindfulness-based psychosocial interventions have potential across early, middle and late stages of BD. It is concluded that the humanistic emphasis of the recovery paradigm provides a timely stimulus for development of a next generation of psychosocial treatments for people with BD.