Hello and welcome. I'm Dr. John Torres, the Director of the Digital Psychiatry Division at Beth Israel Deaconess Medical Center and technology expert for SMI Advisor. I'm pleased that you're joining us for today's SMI Advisor webinar entitled Digital Mental Health Interventions for Serious Mental Illness in Students. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get answers to the care needs for your patients. Now, it's with great pleasure that I'm happy to introduce today's faculty for the webinar, Dr. Emily Lati. Dr. Lati received a PhD in Clinical Psychology with a specialization in Health Psychology from the University of Miami. She's currently an Assistant Professor of Medical Social Sciences and the Associate Director of Training for the Center for Behavioral Intervention Technology at Northwestern University's Feinberg School of Medicine in Chicago. Her early research was in chronic illness, focusing on both biobehavioral processes and remote delivery of care for populations with access barriers. Dr. Lati's current work focuses on the development and evaluation of technology-enabled mental health services for depression and anxiety delivered via mobile apps or websites. She's particularly interested in adapting these services to some populations of access barriers and examined the context, including school and healthcare settings in which these programs can be implemented. Dr. Lati, thank you so much for joining us and leading today's webinar. Over to you. Thank you. Thank you for having me here today. So, I have no financial relationships or conflicts of interest that I need to report for today. And I'm hoping that by the end of this hour, you will all be able to describe some of the mental health challenges that are facing students in secondary and higher education settings, including major depressive disorder and early onset psychotic disorders, that you'll be able to examine the use of digital mental health tools for depression among student populations and among minoritized populations, and that you'll be able to evaluate the utility of different types of digital mental health interventions that could be used to either help treat or monitor serious mental illness. So, we know that there have been dramatically rising rates of mental illness in higher education. Between 2009 and 2017, which doesn't even account for what students have gone through over this past year, we saw about a 20% increase over time in students who were screening positive for depression. Similarly, we saw big jumps in the percent of students in higher education who are reporting suicidal ideation. This almost doubled between 2007 and 2017. And we're starting to see some early data that due to circumstances over the last year, these rates are even higher now. We also know that the years in which students are typically enrolled in secondary and higher education settings is a developmentally sensitive time period for folks. We know that about 90% of students in public four-year institutions are less than 25 years old. 78% of students in two-year institutions, which are usually community colleges, are less than 25 years old. And this is a really sensitive time of emerging adulthood. And we know that half of all mental health disorders over one's lifetime typically onset when individuals are 24 years old or younger. And so, this is a time period in people's lives where I think we really need to be monitoring and offering appropriate resources and treatment. And college campuses often have a number of mental health services built into them already. Most college campuses offer some forms of individual counseling. There are often additional services offered, like group counseling, couples counseling. Telehealth services used to be an add-on. Right now, they've been the standard, as most campuses have been closed for people closed for face-to-face services. And then, about half of schools offer some form of psychiatric services. And while it's really fantastic that mental health services are available on most campuses, we know that there are a number of barriers for students to receive these kinds of traditional services. And so, students may have a, you know, the campuses that they're on, there might be limited hours that services are available. And so, some college counseling centers are only open during business hours. And students are busy during regular business hours with classes and other activities and working multiple jobs and different types of things. Many college campus, many college campus mental health services have fairly long wait lists. Some schools, students will talk about their being, the campus counseling center being in a fairly inaccessible location to where they spend the majority of their time. There's definitely still stigma around mental health and mental health services. While it's decreasing in this younger generation, it's still there and it still serves as a definite barrier to seeking services. And then, students and younger folks often have complaints about there being potential mismatches between the student body and the therapists who are available. So, while the traditional mental health services that exist are a great start, there are barriers to that. And so, one of my fantastic students had done a study just about two years ago, looking at what younger people wanted in terms of mental health services apart from the traditionally delivered services. And what she found was that people really wanted different kinds of resources. Students wanted guided meditations. They wanted resource lists that were interactive to them. They wanted distraction types of activities and chat rooms available for them. And something that I thought was really valuable to come out of this was that we learned that younger folks were talking about wanting these kinds of technology-enabled services as a supplement or enhancement to traditional services, not as a replacement. And so, as somebody who's been doing technology-enabled mental health research or digital mental health research for some time, I often get questions about, are we trying to replace therapists, psychologists, psychiatrists? And I've always said, no, and I don't think that's what people want either. And we saw that in this study, less than 2% of the young adults listed mobile apps as their first choice for mental health treatment, but about 60% were willing and interested to use them to support their mental health. And so, a lot of what I talk about in terms of digital mental health for young people is intended to be resources, add-ons, different ways of supporting so that we can connect people to where they are at the time. And through a partnership with two universities in my area, we had conducted co-design workshops with 20 college students and 10 College Counseling Center staff members and individual interviews with about 15 students and five Counseling Center staff members. And this was the first study, to our knowledge, that examined these kinds of questions about examining the role played for college students by known peers as well as unknown peers in terms of mental health or college student mental health management. So, past research has focused on how people have used digital tools to seek support, but we hadn't previously studied the nuances of who individuals are turning to to seek mental health support and how they turn to them. And so, this set of co-design workshops and interviews were done to start to identify college students' mental health needs, what types of digital mental health tools could potentially help them address common mental health problems, and to understand how students wanted to learn about these tools. And we saw how the role of peers and other individuals, including faculty from the campus, family members, and peoples from one's own culture of origin, influenced both the types of digital mental health tools students were desiring as well as how they wanted to learn about them. Known peers, so people that they know in their own age group that they identify with, were the most heavily discussed and appeared to really play the strongest roles in students' interest in and decision-making on using mental health tools, while unknown peers and non-peers played smaller, less discussed, yet important roles. And so, this got us thinking about how we really need to consider the varied social roles of college student life when we're thinking about the design of digital mental health tools and the implementation plans for those tools. So, as we better recognize the social ecosystem of college student mental health, we have to recognize that students may have very little physical alone time. They may be doing things independently quite a deal, but they are often in physical spaces with other people, both in their living environments, their working environments, their studying or learning environments. And that can really impact the types of tools or the types of things that people are interested in engaging in due to some privacy concerns. We saw that many desired support from their peers. That's similar to a point from the past study I mentioned, that students often wanted to connect with real-world resources in addition to digital resources. And so, while they wanted technology- enabled types of solutions, they often wanted them to be either pathways to or pathways away from face-to-face types of services and resources that are available for them. And then, we learned that many students preferred, regardless of the severity of mental health symptoms, preferred a framing of well-being around the kinds of tools and services that they were seeking rather than mental health care. And that, if possible, it's really valued by students to be accessing their peer network to disseminate digital mental health resources. And so, messaging that can come out through peers, through champions on campuses, and that sort of thing is typically more meaningful to students than hearing things from kind of the higher-ups on their campus. So, pivoting briefly, digital mental health, when I talk about digital mental health, I'm talking about web-based tools, app-based tools, tools that might be delivered through wearable devices. And the most studied of digital mental health tools is internet-based cognitive behavioral therapy programs. These types of programs have been studied for over 25 years now and has a really large, consistent body of research for a large variety of mental health conditions. And we know that smartphone-based mental health interventions have been deemed efficacious for the management of depressive symptoms, and it can be hard to separate out what's good and helpful from what's not so great. And so, that's what I'm going to be spending the last portion of this presentation talking about. But bringing it back briefly to the evidence around digital mental health for college students, we've seen through systematic reviews of the literature that they can be effective, but there's more rigorous studies needed to ascertain what the effective elements are of these types of interventions. One study found that just over a quarter of college students were open to using mental health apps, yet just about seven percent had already used one, whereas another slightly more recent study had found that just over 50 percent had downloaded a mental health app at one point, but just 19 percent were concurrently using a mental health app, indicating that there's often limited continued engagement. And when this study looked at what drove mental health app choices among students, it was often stress, so things that were feeling relevant to their stress, as well as cost in that less expensive programs and free programs are often going to be deemed more favorable. And responses around people's engagement with these apps were often centered around data privacy and kind of comfort with the data and clarity of the data that was being collected, the user interface, so how easy it was to use and navigate, how credible the information within the app seemed to be, and how customizable they needed to be. And so there are clearly some research-to-practice gaps here in that programs that have been deemed efficacious in research trials haven't made their way to the general public, and I think this is something to particularly pay attention to when we're talking about college student mental health because college students are by and large digital natives at this point, and so if what we had available was largely working for them, there's a lot of ways that I think they could have found it could have been comfortable, but there are some gaps there. And we know that digital mental health tools such as mental health apps could hypothetically help improve health equity, yet a number of challenges have still been remaining, and so Frieze Healy and colleagues did a great review on this that was just published recently that walks through how, while digital mental health tools seem to hold a lot of promise, there remain a lack of culturally grounded digital mental health interventions, and so a lot of digital mental health interventions were built by and tested originally on predominantly white samples, predominantly non-Hispanic white samples, and the information in and the packaging around may not be acceptable to other groups, and the strategies that are employed may not feel relevant. Another challenge that exists here is minimal implementation data, and so there have been a lot of tightly controlled research studies testing these types of programs, and then there's data generated by large commercially available programs, but there have been minimal successful implementations into different healthcare and service settings, which leaves people unsure about how to best use them in the own settings that they're working in, and along with that there's often low provider confidence in the quality of digital mental health products and low consumer confidence in the quality of digital mental health products, and so one of the things that I've definitely observed as I've worked with clinicians on, you know, what they're looking for, how we could better design tools for them, a comment that consistently comes up which may echo with folks in this audience are, you know, I know that people I'm working with would probably like to use these and would benefit from these, but I'm not sure what's going to be good, safe, helpful for them to use, and I don't have the current expertise or necessarily the time to develop full expertise in this, so I need support around figuring out what is an appropriate quality, and then along with that there's a tremendous variability in provider competency with digital mental health in that some providers were really early adopters or they've been trained more recently where digital mental health was part of their training in some way, shape, or form, but there's a lot of folks who just aren't confident, haven't had training in using these kinds of tools, and then a kind of final challenge here in digital mental health to health equity is that there continue to be lower digital access and literacy, digital health, digital literacy in groups that are at the highest risk for experiencing health care inequities, and so some of you have probably seen very early data from the COVID-19 pandemic showing that the rapid switch to telehealth and videoconference services increased access among well-insured individuals and decreased access among individuals who had, who are lower on the socioeconomic spectrum and had public health insurance, and this wasn't because the services weren't being covered, but it was looks like because patients had less access to the kinds of tools to engage with this and were less kind of confident and capable to engage right at the beginning here, so there are a number of digital inequities that can be coming up. One, of course, is socioeconomic status. Other age and level of education can contribute to digital inequities. Given the role of kind of peers, loved ones, other members of one's social support network to help guide people through their health care journeys, the quality of one's social support network can also impact digital inequities, as well as things like immigration status, location, and health literacy, so as reliance on digital health approaches increases, these inequalities may further exacerbate existing health disparities and reduce health care access for those most likely to be affected by ongoing crises, and so to improve digital mental health access and quality, Chris Healey and colleagues developed this set of recommendations that I really like. First, they note that real-world evidence is key. We need to increase transparency and reduce the time to market for digital mental health tools. We need more systematic efforts to educate providers and consumers on digital mental health tools, which is part of why I'm joining in here today. We need to build and support adaptive interventions capable of increasing effectiveness of an intervention and reduce the length of treatment to make things more efficient for folks, and we need to be specifically creating for diverse populations. Far too often, we have been designing and evaluating digital mental health tools with nearly all non-Hispanic white samples and claiming that the results will generalize to more diverse groups, and we've learned over time that's not necessarily the case, so to increase access, uptake, engagement and effectiveness, we need to both create for diverse populations and actively work to build trust with communities that have been underserved by mental health care so that they can be well positioned to use and benefit from digital mental health care services that become available with the purpose of increasing access. So one of the ways that my research team at Northwestern has been trying to address these issues has been through the development and evaluation of this model, the accelerated creation to sustainment model. And this was developed to really think through digital mental health services as developing digital mental health services as trying to provide solutions for specific settings that those solutions could likely scale out, but we have to be invested in the setting from the get-go. And so in this model, we think about developing a technology-enabled service, which we abbreviate as a TESS here, alongside developing the implementation plan. And so we recognize that a technology-enabled service isn't just the technology that might provide people with access to interactive tools or provide them with psychoeducation or prompts about things, but it also includes the service that's around it, how people get the technology, how they are supported in using it, what kinds of interactions there are with any providers or clinicians there. And so the service and the technology have to be created alongside each other while an implementation plan is being developed so that all key stakeholders are in on it at the ground floor. After a technology-enabled service and its implementation plan are created, we look at moving into a hybrid trial to test it. And during the hybrid trial, we're recognizing that not only does technology change, so new software comes out, new types of phones come out, people's expectations around how to use technology change, and when working in healthcare systems, healthcare systems change too. And so rather than trying to think through a, let's test this one locked down version of it, which may or may not be very relevant by the end of the trial, we build in ways to optimize and keep the key intervention principles locked down, but know that we want to be continually improving on the technology-enabled service and how we're implementing it so that we can leave a functioning technology-enabled service in place after research support is removed. And so this looks fairly cyclical on this slide. In, as we're creating a technology, a service and an implementation plan, we're going in between designing things and evaluating them, redesigning as necessary before we get to something that looks fairly acceptable. And then we would move into a hybrid trial, do a little bit of redesign as issues are coming up, as we're optimizing. And then after we've hit a certain mark, move on to a sustainment phase in which just small redesign efforts to respond to detected problems or occasional overhauls are possible. So that's how we've been trying to think through how to improve some of the research-to-practice gaps and improve the health equity potential of digital mental health programs. And now, as I had referenced earlier, digital mental health programs have a lot of evidence for depression in general adult populations. And the evidence for these types of programs in teens and young adults is definitely growing as well. A recent meta-analysis found that digital interventions really do work better than no intervention to improve depression in young people. And so if there's the choice between no intervention and a digital intervention, a digital intervention seems like a really good solution for the person. However, these interventions, when tested with young people, may only be producing really clinically significant changes when the use is supervised, when there's some sort of human support element built into that. And the digital interventions don't always appear to work better than active alternatives. And so as the research on digital mental health interventions for teens and young adults moves forward, we need to be moving beyond the use of digital educational materials, which seem to have been pretty effective and engaging for older populations, and really considering other ways that we can attract and engage young people to ensure the relevance and appeal and continued use so that young people can benefit from these types of tools. So a few examples of digital mental health interventions. First off, for preventing major depression and suicidal ideation. Mood Gym is one of the oldest and most established web-based CBT programs. It's an interactive self-help program that provides cognitive behavioral therapy training to help users prevent and cope with depression. And the program consists of four weekly web-based sessions that last about 30 minutes each. The lessons are on the interplay between thoughts, emotions, and behaviors, and provide information about cognitive restructuring techniques and problem-solving strategies. One RCT found that Mood Gym demonstrated effectiveness in preventing suicidal ideation in a large group of medical interns, which are a high-risk group in general. And another RCT found that it was effective in reducing symptoms of depression and negative thoughts, as well as in increasing depression literacy in a group of college students with elevated distress. So there's some promise there. In general adult populations, internet-based cognitive behavioral therapy appears comparably effective to treating depression with face-to-face CBT. And a lot of the research on college students has focused more on depression prevention and wellness promotion, given that this is a sensitive period of life. Another example of a somewhat popular web-based treatment for depression for students is SilverCloud's Space From Depression program, which is an eight-module online treatment, which users can be completing at their own pace, and users can have access to trained online supporters to help provide guidance. And an open trial of this program with a large college student population did find that participants had significant decreases in depressive symptoms. And so there does seem to be effectiveness there. Digital mental health interventions for severe mental problems have a growing research base. A recent study found views for digital mental health intervention, examining views for digital mental health interventions for severe mental health problems, found that digital mental health interventions could be empowering tools that instigate reflection and change. They found that society is already divided, though, and these interventions could further increase this divide, as I've noted some concerns earlier. They found that considerations must be made about who has access to this data and how the data is used. And digital mental health interventions should not be delivered without other support options for serious mental health problems, such as psychotic disorders. And they should be providing something that's positive, fun, practical, and interactive for self-management. And so the findings of this study are really in line with research indicating that digital mental health tools could be used as part of an array of, or a toolbox of mental health symptom management options, rather than as a standalone treatment. So while standalone treatments have been effective in depression, they appear to hold less promise for psychotic disorders. To go through a couple examples, the first is ACT-ASSIST, which was a digital health intervention that consisted of self-assessment and self-monitoring tools, CBT-based strategies, and a collection of relaxation exercises and psycho-ed content. And there was a small group of early psychosis patients who were randomized to the program or to a symptom monitoring control. And the program demonstrated feasibility, acceptability, and safety with high levels of user satisfaction. 75% of the participants used the program at least once a day. The uptake was high, with 97% of participants remaining in the trial, and they had really high follow-up rates. 90% of participants said they would recommend it to others, and it was safe in that there were zero serious adverse events. Treatment effects were large on negative symptoms, general psychotic symptoms, as well as on mood. And then the second example here is PRIME. So PRIME was a mobile-based digital health intervention designed to improve motivation and quality of life. In this program, participants were working towards goals that they had self-identified with the support of a virtual community of age-matched peers who had schizophrenia spectrum disorders, as well as motivational coaches who were part of the program. And about half of the participants were randomized to the PRIME program, whereas half were randomized to a treatment-as-usual control. And the participants who had received PRIME had significantly greater improvements in self-reported depression, to fetus beliefs, self-efficacy, and then there were trends towards higher motivation and pleasure, as well as negative symptoms post-trial. And they had significantly greater improvements in components of social motivation post-trial, so improvements in anticipated pleasure, improvements in effort expenditure. So you might be wondering, where do people find these mental health apps and web-based interventions? And often, unfortunately, they're being found in somewhat unreliable sources. And so a lot of people, when they're looking for a mental health app, they wind up getting directed to articles that are saying, you know, here are the best mental health apps for different things with the methods behind navigating or assigning best status being relatively unclear. And so today, I'm going to demonstrate two great tools for finding digital mental health tools, the OneMind CyberGuide project and the mHealth Index and Navigation database. So OneMind CyberGuide is a nonprofit project that aims to help people use technology to live mentally healthier lives. The goal is to provide accurate and reliable information free of preference, bias, or endorsement. And so apps reviewed by CyberGuide are reviewed for credibility, user experience, and transparency. They get each of these scores, which I'll go through just now. So the credibility score is a measure of the research support that backs an app or a digital tool. And this measure aims to give users an idea of how likely it is that the app will work. So the apps get scored on what level of research support they have, who funded the published papers supporting the effectiveness, how specific the intervention is to the app that the app proposes it is. So is it designed to target a specific condition? Is it designed to help with overall well-being or tracking? And the more specific an intervention is, the higher an app will score here. And then apps also receive scores for things like the number of ratings in app stores, the level of expert clinical input in their development, and how recently they've been updated. But it provides a much more thoughtful score than just going by app store ratings alone. The user experience rating is an app quality score. And so the mobile app rating scale gets used here to assess the quality of user experience of apps. Engagement is scored on how fun, interesting, customizable, interactive an app is. So interactive will be things like it sends alerts, messages, reminders, and enables sharing, that kind of thing, as well as how well-targeted the app is to the audience. Functionality is scored on how the app's functioning, the ease of learning for a user, how well they can navigate through it, the flow logic, and the gestural design of the app. And then information gets scored on if the app contains high-quality information like text, feedbacks, measures, references from a credible source. The transparency score gives a rating of acceptable, questionable, or unacceptable. And so people will go through all the apps in this database and examine if the product has a privacy policy that provides sufficient and easily accessible privacy for the user. And then the user experience rating that provides sufficient and easily accessible information on policies related to data collection, storage, and exchange, and looks at how that conforms to established standards. And so if one wanted to look for a specific type of digital mental health tool on the OneLine CyberGuide site, they would likely wind up on this page, which is a Help Me Find an App. And you can select by treatment method, like cognitive behavioral principles or cognitive training. You can select by the model of the program, like I know that I want to get a chatbot, or you can select by the treatment target, like eating disorders or mood disorders. And then the mHealth Index and Navigation Database is a great alternative resource for clinicians and for app end users. And I recognize that you may have heard about this in previous sessions in this group. But the review approach here looks at, is the app accessible for a user? Does the app uphold user safety, security, and privacy by protecting data? Is the app supported by research? Is it usable and customizable? And data sharing towards a therapeutic goal. So how easily can the app share data in a clinically meaningful way? And so one of the things that I really like about this review approach is that it is more clinically focused and hits home a little bit more how we know young people and people across the board often want to be using digital tools as a supplement or additional resource to other healthcare services that they're receiving. And so question samples for scoring here include things like, for accessibility, who's the app developer? How much does the app cost? Does it work offline? Does it have accessibility features? These kinds of questions can be really important to be considering. And somebody without expertise in digital mental health might not know how to evaluate those. And so these are really valuable to be including here. Looking at the engagement style of an app, what kinds of features does it have? How does a user engage with the app? Oftentimes when we're working with individuals, we may know as clinicians what types of things we think a patient, client, general user might really benefit from. And so you can help sort that out more easily here. Oftentimes people have concerns about the privacy and security of anything that they might be recommending or referring people to. And so this is a nice set of, is there a privacy policy here? What kind of security measures are in place? What kind of user data does the app collect? And is that data shared? Unfortunately, there are apps out there that look really solid. And then the data is shared in ways that is not comfortable and acceptable to a lot of people. And so engaging in this kind of review can really help guide people to programs and services that are going to be acceptable and allowable. Looking at inputs and outputs, what kinds of inputs and outputs are the app? What kind of information does the app take in and what's returned to the user? Oftentimes if a user is spending time inputting information into an app, they want to get that information back in a meaningful way. And at the same time in some clinical work, some clinicians may believe that it's not going to be as helpful for the user to be able to see like point by point changes in some of their mental health assessment scores because they think the person might perseparate on it too much and we need to get like quicker pictures of it. And so these can be valuable things for considering. And then in terms of interoperability and sharing, is the app able to share data with external parties like family members or providers? And so programs that either have shared accounts where people can look into it or are able to easily export valuable data to share with a clinician or with a loved one can be really valuable. And then finally, the last question sample set is on the clinical foundations of an app. So is the app evidence-based? Does it accomplish what it claims to do? And does it work offline and with accessibility features? Here are a bunch of citations that were across these slides. And that is it. And so I think we'll move into the next section now. So thank you so much for such an interesting presentation, Dr. Lady. Before we switch into Q&A, I wanna take a moment and let everyone know that SMI Advisor is actually accessible from a mobile device, which is quite relevant given this presentation. So you can use the SMI Advisor app to access resources, education, and upcoming events. You can complete digital mental health rating scales and even submit questions directly to our SMI experts. So you can download the app. But I wanna jump into question and answer on the next slide. If anyone has any extra questions, we have a pretty full set, but you can also add them still to the Q&A below and I'll moderate them. But the first question that we'll jump into is, I think, Emily, when you showed initially the 1.5% kind of to be in a talk of people that are interested in actually using an app, it's just that difference between 1.5% of what I was saying. What do you think is driving that from kind of everyone's talking about apps, but that number is so lower? Yeah, so that 1.5% was, in this study, we gave people a list of different, both traditional, so to speak, like meeting with a psychologist, psychiatrist, or therapist types of services, and a set of non traditional types of services like peer counseling, mobile apps, self help books, that sort of thing. And it was just 1.5% of people picked mobile apps as being their first choice treatment. And so, but 60% were saying that they would be interested and willing to use a mobile app. And so I think where that comes in is that there are a lot of people who are interested, willing to use mobile apps, yet there are other services that they would prefer as their first line treatment, which makes a lot of sense. And so we also saw from this study that people typically were, this was a sample of folks who had largely sought some types of mental health services in the past, were largely already using multiple types of services for managing mental health, like online communities, some mobile apps themselves, having a mental health clinician. So it was kind of more of a, if you had to pick one, what would be your first choice? Apps are very rarely the first choice. But if you're able to use resources available to you, as people are able to in the real world, a lot of folks are interested in using them in conjunction with other resources and services. That makes sense. We're talking more about extending and augmenting as of today, not quite replacing. Yeah, definitely. And then this is a question saying, do you find that mobile apps work well with teenagers? Clearly know many serious mental illnesses can begin into teenage years, early psychosis, first episodes of depression, bipolar. So anything specific you've seen to teenagers in this work? Yeah, so there's definitely a growing evidence base for mental health management apps for teenagers. And I think that there are a lot of really great strengths for mental health apps for teens in that, you know, particularly this last year, but generally, teenagers are on their screens a lot. Mental health management apps can provide access to increasing their mental health literacy, teaching them mental health management strategies, prompting them to reflect on and practice those kinds of strategies in ways that can be, I think, so easily woven into the fabric of most teens lives. At the same time, too, mental health apps for teens can often overcome some of the additional barriers that teens have to getting mental health services. Particularly when we talk with, you know, older teens about their mental health management and preferences, depending on family relationships and what's accessible to them, it can be really challenging for people to get the right level of support and feel comfortable asking for the help that they're thinking through already. The one thing that had come up to me is really interesting. A couple of years ago, I was doing a study with a big community mental health service organization in another state here in the Midwest. And while I was speaking with clinicians who were serving teenagers, one of them had pointed out that they were very aware some of their teens got their phones taken away from them for punishment, and had concerns about if a mental health app is kind of the primary way that a teen is trying to manage and target their own mental health improvement, how challenging it can be when those types of tools and services get taken away at points where, you know, the teen may be most stressed of all when they're being punished for something else that they did. And so one of the kind of advisements that came out of that was, if a teen is engaged in any kind of, you know, digital mental health app, as part of care that they're receiving with a clinician, that it could be really valuable for the clinician and the teen to, you know, try to set some guidance around when the teen will be able to have access to that tool and how technology punishments work in their house and that sort of thing. That makes sense. Another related question. Someone said, thank you for kind of talking about internet CBT resources we can use in Serious Mental Illness and how to think about and evaluate apps. Do you recommend, when do you think, when do you turn to an app versus kind of a internet-based kind of therapy or internet-based CBT? I think a lot of it depends on kind of what's accessible and acceptable to a, you know, an individual user, an individual potential patient. And so some of the web-based, internet-based CBT programs, they mirror pretty closely what happens in face-to-face CBT. And so if somebody already has access to face-to-face cognitive behavioral therapy, and they're liking it and are benefiting from it, I would think one of those more formal ICBT programs probably isn't going to add as much because the content in it is really delivering what will be what will likely be happening in face-to-face care too. And so if somebody is engaged in a course of CBT or a course of another type of evidence-based therapy, and there are digital mental health tools that can support that, a clinician is probably more, will probably benefit the patient and the clinical relationship more to have the patient engaging in either a web-based or app-based tool that helps them practice the skills that they're already working on in therapy. Whereas if somebody doesn't have access to a, you know, a clear course of therapy, and they, you know, it's indicated that they would benefit from it, I think those web-based programs, particularly pitching them as like, this is kind of a mental health course for you to take to get the basics down, and we'll be working from there, can be really helpful for folks. That makes sense. And a related question, someone said, it makes sense these web-based programs can kind of work trans-diagnostically, they can help people with depression, they can help, I mean, the CBT skills can help with psychosis, depression, bipolar. Yeah. Is there anything that when you look at them without, we're clearly not going to endorse any product, but you kind of go, that one's exciting, or you go, Oh, my gosh, that one's not so exciting. I wouldn't want kind of students to be not, you wouldn't want to, but is there kind of any broad decision points you have where you kind of keep looking, or you say, pass on? I think this question is getting at like, there's so many out there. How do you? Yes. Overwhelmed. Yeah, no, it can be overwhelming. And one of the key things that I've been keeping in mind as I've been working more through questions around digital mental health implementation over recent years is a program can't be effective for an individual if the individual isn't accepting of using that program. And so there can be programs that have a really big evidence base. And if we could get a person to use it, we would be somewhat confident that they would get a clinical benefit from it. But if we are aware, either through preferences that are explicitly stated by an individual or by some trial and error of them trying out other things that a person's, say, not really interested and willing to sit down for 30 to 45 minute sessions on their computer to work through a specific tool, then they're not going to get benefit from it. And it might be, you know, more beneficial to look at, like brief mobile app based programs that are sending people notifications a few times a day to engage them in that type of thing. And so, yeah, I think part of it is what figuring out the individuals like motivation and tolerance for engaging in some of these programs is going to be key to figuring out what can help them. That makes sense. And one thing someone said, you mentioned earlier in the talk, co-design and making sure these products dealt with people have lived experience of mental illnesses. How? Is there any easy way to tell if something is co-designed this question says? Not necessarily. Some products or programs will, you know, really advertise the type of methods that went into building it. But not necessarily. And so I think using co-design kind of methods using having deep input from people with lived experience from the get go and doing an iterative pattern can likely lead to better, more relevant products and programs. But part of the way I think to, you know, see, not necessarily prove that something was co-designed. But to see how users are talking about a program, how they're feeling about it, and if it is meeting a lot of their needs, and is in line with the ways that the, you know, that subpopulation is thinking about stuff, there's a decent chance it was developed more responsibly than just trying to take a therapy workbook and translate it into a website without anyone else looking at it. That makes sense. And I agree, it can just be hard to know, know which ones were built really well and not. In terms of you, you focus on how to support and kind of make sure any things are engaging. And you talked about the role of, of peers in this, how if programs want to start kind of using or incorporating peers to kind of support digital mental health for students or have fellow students supporting them? What are kind of the first stages to even kind of building successful peer networks to kind of help run digital mental health for SMI for students? Yeah, so I haven't seen a lot of this being done yet. But I think we're right on like the precipice of it, because there are more and more colleges and universities across the country are developing peer counseling programs where peers are getting trained in supportive listening and like, are getting trained in what their role is as like a face to face peer supporter. And a lot of the digital mental health programs that have been tested in both research and larger clinical settings will have somebody who's serving in the role of a coach who provides some level of supportive accountability to the person who's using the program. And oftentimes coaching is done by fairly brief phone calls and text messaging to check in on if somebody is using something if they have any questions. And so I think that we're likely to see in upcoming years, peer counseling types of models encompassing some peer coaching for digital mental health services. Because a lot of the framework is the same and requires a, you know, just a similar level of a similar level of skill of engaging, supporting being, you know, helpful and enthusiastic. That makes sense. And probably a new workforce in some ways coming. We're running, we'll do a couple more questions. I realized we're beginning to run low on time. You mentioned, I said that a lot of the research has been done not on as diverse and minority populations as possible. Is there anything specific you've seen that the evidence has kind of pointed that that's coming out on minority population? Are we still waiting to learn more about what works and doesn't work well there? So I have seen that, you know, in terms of early digital mental health programs that are being tested, programs that are designed specifically for minoritized populations and might incorporate some lessons around things like minority stress theory, along with evidence based practices are likely to be more engaging and acceptable to members of the specific groups that it was being developed for. I think part of it to part of the problems that we've had is, you know, there's a lot of very understandable mistrust around healthcare systems and around big tech companies. And so I think, as we are, as a, you know, a field of digital mental health, learning to be more transparent, learning to be more clear about what we're looking for, and recognizing that the, you know, the lived experience of people from different groups is going to be really valuable for developing the kinds of tools that those groups can use, then we're likely to start doing better. That makes sense. So there's certainly a lot more to come in this work. So we asked, I want to wrap up and make sure everyone gets their CME credit. So we're going to pause questions now, I'm going to switch to the next slide, which, if anyone has follow up questions, I said, I know, we didn't get to a couple of them. I said, you can basically talk to SMI, you can basically query our clinical experts who are available for online consultation. Any mental health clinician can submit a question and receive a response from one of our experts. The consultations are free and completely confidential. So SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center for Excellence in Eating Disorders and Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opiate epidemic. Thank you for joining us. Until next time, take care. Thank you for participating in today's free course from SMI Advisor. We know that you may have additional questions on this topic, and SMI Advisor is here to help. Education is only one of the free resources that SMI Advisor offers. Let's briefly review all SMI Advisor has to offer on this topic and many others. We'll start at the SMI Advisor website and show you how you can use our free and evidence-based resources. SMI Advisor's mission is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. We offer several services specifically for clinicians. This includes access to education, consultations, and more. These services help you make evidence-based treatment decisions. Click on consult request and submit questions to our national experts on bipolar disorder, major depression, and schizophrenia. Receive guidance within one business day. It only takes two minutes to submit a question, and it is completely confidential and free to use. This service is available to all mental health clinicians, peer specialists, and mental health administrators. Ask us about psychopharmacology, recovery supports, patient and family engagement, comorbidities, and more. You can visit our online knowledge base to find hundreds of evidence-based answers and resources on serious mental illness. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Harvard, Emory, NAMI, University of Texas at Austin, and more. Browse by key topics or search for a specific keyword in the search bar. Access our free education catalog to find more than 100 free courses on topics related to serious mental illness. You can search the education catalog by topic, format, or credit type to find courses that fit your needs. SMI Advisor also offers live webinars each month that let you learn about evidence-based practices and participate in live Q&A with faculty. Check out our education catalog often to find new courses and earn continuing education credits. For individuals, families, friends, people who have questions, or people who care for someone with serious mental illness, SMI Advisor offers access to resources and answers from our national network of experts. The individuals and families section of our website contains an array of evidence-based resources on a variety of topics. This is a great place to refer individuals in your care for information about their conditions. They can choose from a list of important questions that individuals who have SMI typically ask. SMI Advisor worked with experts from the National Alliance on Mental Illness to develop these important questions and many of the resources in this section. Watch videos on important topics around SMI, such as what to know about a new diagnosis. They can also find dozens of fact sheets, infographics, and links to other important resources. To access even more evidence-based resources for individuals and families, visit our online knowledge base. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and more. Browse by key topics and select View All to uncover a list of resources on each topic. SMI Advisor offers a smartphone app that lets you access all of the same features on our website in an easy-to-use, mobile-friendly format. You can download the app for both Apple and Android devices. Submit questions, browse courses, and access clinical rating scales that you can use in your practice with individuals who have SMI. SMI Advisor also created My Mental Health Crisis Plan, a smartphone app that helps individuals in your care to create a crisis plan. The app is available on both Apple and Android devices. It helps people prepare in case of a mental health crisis. They can make their treatment preferences known and specify who should be contacted and who should make decisions on their behalf. The app even guides individuals through the process to turn their crisis plan into a psychiatric advance directive. Thank you for your interest in SMI Advisor. Access our free education, consultations, and more on smiadvisor.org at any time.

Digital mental health interventions

Serious mental illness in students

Higher education mental health

Technology-enabled mental health services

Web-based programs

Mobile apps for mental health

Peer support in mental health interventions

College student mental health

Evidence-based interventions

Culturally grounded mental health programs