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Digital Mental Health

The research program above has significant clinical implications, highlighting the need for accessible and effective self-guided digital MH interventions for common mental disorders (CMDs). To address this, we developed a smartphone-based mindfulness ecological momentary intervention (MEMI) aimed at reducing repetitive negative thinking and improving executive functioning (EF) in individuals diagnosed with generalized anxiety disorder, including college students and community adults. Whereas excessive worry is a crucial symptom of generalized anxiety disorder, it is relevant across various CMDs and even serious mental illnesses like bipolar disorder and psychosis, making it a crucial area to explore. Additionally, many individuals with CMDs own smartphones and are open to mobile MH therapies. Given potential concerns like shame, financial constraints, and logistical issues associated with seeking in-person treatment for CMDs, self-guided apps offer privacy, portability, and flexibility for individuals to manage their symptoms independently. Considering mindfulness apps' growing popularity, assessing their effectiveness is ethically essential.

Mindfulness Ecological Momentary Intervention (MEMI)

We conducted a randomized controlled trial (RCT) with 110 participants with generalized anxiety disorder to compare a 14-day mindfulness ecological momentary intervention (MEMI) with a self-monitoring app. Participants were randomly assigned to either group. The MEMI included therapeutic elements like breathing techniques and present moment awareness, while the self-monitoring app focused on observing thoughts and feelings without mindfulness exercises. The results, with small-to-moderate effect sizes, showed that the MEMI was more effective in reducing worry, and negative thinking, and improving trait-level mindfulness and inhibition executive functioning (EF) facet over 6 weeks (Zainal & Newman, 2023f). These findings aligned with our meta-analysis of 111 RCTs on therapist-led and digital mindfulness-based interventions' impact on cognitive functioning (e.g., enhanced EF, sustained attention) (Zainal & Newman, 2023d).

MEMI vs. SM on GAD severity from baseline to one-month-follow-up
Forest plot of the efficacy of mindfulness-based intervention vs. control on cognitive functioning domains

Identifying individuals for whom scalable digital MH apps might not be suitable is essential. Early efforts should be made to provide more effective treatments and prevent patients from undergoing multiple ineffective therapies before encountering optimal treatments. For instance, we conducted a similar randomized controlled trial (RCT) in a mostly college student sample in Singapore, comparing the brief mindfulness ecological momentary intervention (MEMI) to a self-monitoring app for targeting social anxiety disorder. The results did not show significant between-treatment effects on social anxiety disorder, depression, worry symptoms, trait mindfulness, or repetitive negative thinking but showed small-to-large effect sizes from baseline to follow-up within each group (Zainal et al., in press). Therefore, mindfulness apps may work better for those with generalized anxiety disorder but not social anxiety disorder. Instead, individuals with social anxiety disorder may benefit more from self-directed CBT-based virtual reality exposure therapy (VRE) that helps them confront and cope with various anxiety-inducing social situations (Zainal et al., 2021). Further, the VRE study highlights the potential for brief, self-guided VRE to improve the accessibility of exposure therapy and suggests it can be used together with traditional psychotherapy without harming the therapeutic relationship.

Example of a virtual reality exposure therapy scene for social anxiety disorder

We have also been researching the effectiveness of transdiagnostic internet-delivered CBT (i-CBT) for college students dealing with moderate-to-severe anxiety and depression. Collaborating with others, we conducted a three-arm randomized controlled trial (RCT) in Colombia and Mexico comparing coach-guided i-CBT with brief weekly phone calls, self-guided i-CBT, and standard treatment (referral to university counseling center). Our findings revealed that minimally coach-guided i-CBT outperformed self-guided i-CBT and treatment-as-usual, leading to higher remission rates and symptom reduction (Benjet et al., in press). In general, scalable MH therapies have the potential to address the global MH treatment gap, especially considering the shortage of highly-trained psychologists and associated barriers like stigma.

Testing cognitive-behavioral theories using bivariate dual latent change score model
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