Equity in Digital Mental Health Interventions in the United States: Where to Next?

Health care technologies have the ability to bridge or hinder equitable care. Advocates of digital mental health interventions (DMHIs) report that such technologies are poised to reduce the documented gross health care inequities that have plagued generations of people seeking care in the United States. This is due to a multitude of factors such as their potential to revolutionize access; mitigate logistical barriers to in-person mental health care; and leverage patient inputs to formulate tailored, responsive, and personalized experiences.

Improvements in Work Productivity and Activity Impairment Among Adults With Anxiety or Depressive Symptoms Participating in a Relational Agent-Delivered Digital Mental Health Intervention.

Objectives: The study aimed to assess changes between baseline and end of treatment in work-related absenteeism, presenteeism, productivity, and nonwork-related activity impairment and estimate cost savings associated with observed improvements.

Methods: Data from 91 employed adult participants who enrolled in a single-arm, exploratory study of a relational agent-delivered digital mental health intervention and completed Work Productivity and Activity Impairment assessments were analyzed; overall work productivity improvement was multiplied by the overall and education-adjusted US median annual salary to arrive at potential cost savings estimates.

Results: Adjusted models indicated more than 20% improvements in presenteeism, work productivity impairment, and activity impairment, yielding cost-savings estimates between $14,000 and more than $18,000 annually.

Cost, Utilization, and Patient and Family Experience With ACO-Based Pediatric Care Management.

Background And Objectives: Children and Youth with Special Health Care Needs have high healthcare utilization, fragmented care, and unmet health needs. Accountable Care Organizations (ACOs) increasingly use pediatric care management to improve quality and reduce unnecessary utilization. We evaluated effects of pediatric care management on total medical expense (TME) and utilization; perceived quality of care coordination, unmet needs, and patient and family experience; and differential impact by payor, risk score, care manager discipline, and behavioral health diagnosis.

User Engagement Clusters of an 8-Week Digital Mental Health Intervention Guided by a Relational Agent (Woebot): Exploratory Study.

Background: With the proliferation of digital mental health interventions (DMHIs) guided by relational agents, little is known about the behavioral, cognitive, and affective engagement components associated with symptom improvement over time. Obtaining a better understanding could lend clues about recommended use for particular subgroups of the population, the potency of different intervention components, and the mechanisms underlying the intervention's success.

Objective: This exploratory study applied clustering techniques to a range of engagement indicators, which were mapped to the intervention's active components and the connect, attend, participate, and enact (CAPE) model, to examine the prevalence and characterization of each identified cluster among users of a relational agent-guided DMHI.

Engagement, Satisfaction, and Mental Health Outcomes Across Different Residential Subgroup Users of a Digital Mental Health Relational Agent: Exploratory Single-Arm Study.

Background: Mental illness is a pervasive worldwide public health issue. Residentially vulnerable populations, such as those living in rural medically underserved areas (MUAs) or mental health provider shortage areas (MHPSAs), face unique access barriers to mental health care. Despite the growth of digital mental health interventions using relational agent technology, little is known about their use patterns, efficacy, and favorability among residentially vulnerable populations.

Using a Claims-Based Frailty Index to Investigate Frailty, Survival, and Healthcare Expenditures among Older Adults Hospitalized for COVID-19 at an Academic Medical Center.

Background: Frailty is associated with mortality in older adults hospitalized with COVID-19, yet few studies have quantified healthcare utilization and spending following COVID-19 hospitalization.

Objective: To evaluate whether survival and follow-up healthcare utilization and expenditures varied as a function of claims-based frailty status for older adults hospitalized with COVID-19.

Design: Retrospective cohort study.

When the Process Is the Problem: Racial/Ethnic and Language Disparities in Care Management.

Objectives: Achieving health equity requires addressing disparities at every level of care delivery. Yet, little literature exists examining racial/ethnic disparities in processes of high-risk care management, a foundational tool for population health. This study sought to determine whether race, ethnicity, and language are associated with patient entry into and service intensity within a large care management program.

Less imitation of arbitrary actions is a specific developmental precursor to callous-unemotional traits in early childhood.

Objective: Callous-unemotional (CU) traits in early childhood explain heterogeneity within conduct problems and are associated with higher risk for later diagnoses of childhood disruptive behavior disorders and antisocial behavior in adulthood. Emerging research implicates impairments in affiliative processes in the etiology of CU traits. The current study tests whether the imitation of intentional actions with no functional significance -a behavior that supports the acquisition of social conventions and affiliative bonds, is a specific developmental precursor to CU traits in early childhood.

Fearlessness and low social affiliation as unique developmental precursors of callous-unemotional behaviors in preschoolers.

Background: Early callous-unemotional (CU) behaviors identify children at risk for severe and persistent aggression and antisocial behavior. Recent work suggests that fearlessness and low social affiliation are implicated in the etiology of CU behaviors, although more research is needed to clarify these etiological pathways, as well as the role of parenting.

Method: Using a sample of preschoolers (N = 620), we examined pathways between observed fear in response to social and non-social stimuli and observed social affiliation during social interactions at age 3 and increases child CU behaviors and oppositional-defiant behaviors from ages 3 to 5.

Effects of socioeconomic status and executive function on school readiness across levels of household chaos.

Isolating child attributes and familial characteristics that support school readiness in children on the upper half of the socioeconomic spectrum can complement existing research on lower-socioeconomic status (SES) children and facilitate a more complete understanding of how children's performance varies across the full SES spectrum. This study examined if relations between SES, two components of executive function (EF; set-shifting and inhibitory control), and school readiness vary as a function of household chaos in 564 four-year-old children, primarily from middle-to upper-middle class families in the Northeast Region of the United States. Structural equation modeling of direct and indirect effects revealed three major findings: 1) higher levels of EF were related to better school readiness regardless of level of household chaos; 2) SES had an indirect effect on school readiness through set-shifting; and 3) household chaos was negatively associated with school readiness.

Longitudinal Links Between Callous-Unemotional Behaviors and Parenting in Early Childhood: A Genetically Informed Design.

Objective: Most research on callous-unemotional behaviors (CU) and parenting does not focus on directions of effect, and work that does so has not been genetically informed. The present study is the first to examine potential reciprocal effects between parenting and CU in a community sample of early childhood. Use of a twin sample also allows us to distinguish child-based genetic effects from environmentally driven effects, which is necessary before translating this research to interventions.

Parent- and Observer-Rated Positive Affect in Early Childhood: Genetic Overlap and Environmental Specificity.

The sources of individual differences in both observed and parent-rated positive affect (PA) were examined in a sample of 304 3-year-old twin pairs (140 MZ, 164 DZ). Based on model-fitting analyses, individual differences in observed PA were attributed to moderate genetic and high nonshared environmental factors, but not shared environmental factors. In contrast, shared environmental effects accounted for over half of the variance in parent-rated PA and genetic and nonshared environmental effects were more modest.

Genetic and environmental links between motor activity level and attention problems in early childhood.

Cross-lagged biometric models were used to examine genetic and environmental links between actigraph-assessed motor activity level (AL) and parent-rated attention problems (AP) in 314 same-sex twin pairs (MZ = 145, DZ = 169) at ages 2 and 3 years. At both ages, genetic correlations between AL and AP were moderate (r = .35; r = .

Do Genetic Factors Explain the Links Between Callous-Unemotional, Attention Hyperactivity and Oppositional Defiant Problems in Toddlers?

Research demonstrates that callous-unemotional (CU) behaviors, Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Problems (ODD) are related, but little is known about the sources of covariation among the three externalizing behaviors. The present study looked at genetic and environmental links between all three behavioral domains in twins at ages 2 and 3 years (MZ = 145, DZ = 169), a time when CU behaviors are beginning to emerge. CU, ADHD, and ODD behaviors as assessed using the Child Behavior Checklist 1.

In vivo neuroimaging and behavioral correlates in a rat model of chemotherapy-induced cognitive dysfunction.

Adjuvant chemotherapy has been used for decades to treat cancer, and it is well known that disruptions in cognitive function and memory are common chemotherapeutic adverse effects. However, studies using neuropsychological metrics have also reported group differences in cognitive function and memory before or without chemotherapy, suggesting that complex factors obscure the true etiology of chemotherapy-induced cognitive dysfunction (CICD) in humans. Therefore, to better understand possible mechanisms of CICD, we explored the effects of CICD in rats through cognition testing using novel object recognition (NOR) and contextual fear conditioning (CFC), and through metabolic neuroimaging via [F]fluorodeoxyglucose (FDG) positron emission tomography (PET).

Callous-unemotional behaviors in early childhood: Genetic and environmental contributions to stability and change.

Callous-unemotional (CU) behaviors demonstrate meaningful individual differences in early childhood, even in nonclinical samples with low mean levels of CU, but the factors underlying this variation have not been examined. This study investigated genetic and environmental contributions to individual differences and to sources of continuity and change in CU in toddler twins (145 monozygotic, 169 dizygotic) assessed at ages 2 and 3 years. CU, as assessed by the Child Behavior Checklist 1.

Tipping points? Curvilinear associations between activity level and mental development in toddlers.

Background: The Theory of Optimal Stimulation (Zentall & Zentall, Psychological Bulletin, 94, 1983, 446) posits that the relation between activity level (AL) and cognitive performance follows an inverted U shape where midrange AL predicts better cognitive performance than AL at the extremes.

Methods: We explored this by fitting linear and quadratic models predicting mental development from AL assessed via multiple methods (parent ratings, observations, and actigraphs) and across multiple situations (laboratory play, laboratory test, home) in over 600 twins (2- and 3-year olds).

Results: Only observed AL in the laboratory was curvilinearly related to mental development scores.

Infant hair cortisol: associations with salivary cortisol and environmental context.

Early chronic stress has enduring implications for physical and mental health outcomes. Hair cortisol concentration (HCC) has emerged as a marker of cumulative cortisol exposure, yet HCC in infants is not well understood. We examined how infant HCC relates to widely used basal salivary cortisol measures, maternal HCC, and environmental context in 111 infants assessed at 6 and 12 months of age.