Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Depressive symptoms are common in people with type 2 diabetes and exacerbate disease burden through increased social and occupational impairment and greater morbidity and mortality. Effective depression treatments exist, however rates of depression screening in type 2 diabetes are variable, access to psychological support is characteristically low, and impact of treatment on daily functioning remains unclear. Web-based cognitive behaviour therapy (CBT) is easily accessible, private, non-stigmatising and a potential solution to reducing the substantial personal and public health impact of comorbid type 2 diabetes and depression. Objective: To evaluate the efficacy of the web-based CBT program, myCompass, for improving social and occupational functioning in a large community sample of people with type 2 diabetes and self-reported mild-to-moderate depressive symptoms. myCompass is an unguided, public health treatment program for common mental health problems. Impact of treatment on depressive symptoms, diabetes-related distress, anxiety symptoms and self-care behaviour was also examined. Methods: Participants with type 2 diabetes and mild-to-moderate depressive symptoms (N = 780) were recruited online and via community and general practice settings. Screening, consent and data collection were conducted online, and randomisation was to either myCompass (n = 391) for 8 weeks plus a 4-week tailing off period, or an active placebo intervention (n = 379). At baseline and post-intervention (3-months), participants completed the Work and Social Adjustment Scale (WSAS), the primary outcome measure. Secondary outcome measures included the Patient Health Questionnaire-9 item (PHQ-9), Diabetes Distress Scale (DDS), Generalised Anxiety Disorder Questionnaire-7 item (GAD-7) and items from the Self-Management Profile for Type 2 Diabetes (SMP-T2D). Results: At baseline, mean scores on several outcome measures, including the primary outcome of work and social functioning, were near to the normal range, despite a varied and extensive recruitment process. Of the 780 trial participants, 473 (61%) completed the post-intervention assessment. Intention-to-treat analyses revealed improvement in functioning, depression, anxiety, diabetes distress and healthy eating over time in both groups. Except for blood glucose monitoring and medication adherence, there were no specific between-group effects. Follow-up analyses suggested the outcomes did not depend on age, morbidity or treatment engagement. Conclusions: Improvement in social and occupational functioning and the secondary outcomes was generally no greater for myCompass users than users of the control program at 3 months post-intervention. These findings should be interpreted in light of near-normal mean baseline scores on several variables, the self-selected study sample and sample attrition. Further attention to factors influencing uptake and engagement with mental health treatments by people with type 2 diabetes, and the impact of illness comorbidity on patient conceptualisation and experience of mental health symptoms, is essential to reduce the burden of type 2 diabetes. Clinical Trial: ACTRN12615000931572

Background: In most e-mental health (eMH) research to date, adherence is defined according to a trial protocol. However, adherence to a study protocol may not completely capture a key aspect of why participants engage with eMH tools, namely, to achieve personal mental health goals. As a consequence, trial attrition reported as non-adherence or dropout may reflect e-attainment, the discontinuation of eMH engagement after personal goals have been met. Clarifying engagement patterns, such as e-attainment, and how these align with mental health trajectories, may help optimize eMH design and implementation science. Objective: This study aimed to use clustering techniques to identify real-world engagement profiles in a community of eMH users and examine if such engagement profiles are associated with different mental health outcomes. The novelty of this approach was our attempt to identify actual user engagement behaviors, as opposed to employing engagement benchmarks derived from a trial protocol. The potential of this approach is to link naturalistic behaviors to beneficial mental health outcomes, which would be especially informative when designing eMH programs for the general public. Methods: Between May 2013 and June 2018, Australian adults (N=43,631) signed up to myCompass, a self-guided eMH program designed to help alleviate mild to moderate symptoms of depression, anxiety, and stress. Recorded usage data included number of logins, frequency of mood tracking, number of started and completed learning activities, and number of tracking reminders set. A subset of users (n=168) completed optional self-assessment mental health questionnaires (Patient Health Questionnaire-9 item, PHQ-9; Generalized Anxiety Disorder Questionnaire-7 item, GAD-7) at registration and at 28 and 56 days after sign-up. Another subset of users (n=861) completed the PHQ-9 and GAD-7 at registration and at 28 days. Results: Two-step cluster analyses revealed 3 distinct usage patterns across both subsamples: moderates, trackers, and super users, signifying differences both in the frequency of use as well as differences in preferences for program functionalities. For both subsamples, repeated measures analysis of variances showed significant decreases over time in PHQ-9 and GAD-7 scores. Time-by-cluster interactions, however, did not yield statistical significance in both subsamples, indicating that clusters did not predict symptom reduction over time. Interestingly, users who completed the self-assessment questionnaires twice had slightly but significantly lower depression and anxiety levels at sign-up compared with users who completed the questionnaires a third time at 56 days. Conclusions: Findings suggested that although users engaged with myCompass in different but measurable ways, those different usage patterns evoked equivalent mental health benefits. Furthermore, the randomized controlled trial paradigm may unintentionally limit the scope of eMH engagement research by mislabeling early mental health goal achievers as dropouts. More detailed and naturalistic approaches to study engagement with eMH technologies may improve program design and, ultimately, program effectiveness.

Social psychology highlights ingroup identity as an important determinant of intergroup attitudes and relations; however, research has demonstrated that its effects can be positive, negative, or nonexistent depending on how such identity is conceptualized. This research explores how national identity inclusiveness (Study 1) and centrality (Study 2) are associated with immigration related attitudes in school and countrywide settings, respectively. Study 1 showed that teachers’ inclusive (i.e., overlapping) identities regarding their immigrant students related to positive attitudes toward these students, but not to attitudes about immigrants in general or immigration policy preferences. Study 2 found that national identity centrality was related to negative attitudes toward the social impact of immigrants, and to higher support for policies inhibiting the social inclusion of immigrants in the receiving community. Combined, these studies highlight the importance of considering different conceptualizations of ingroup identity in identifying relations to immigration‐based attitudes. Moreover, the studies highlight the value of promoting inclusive identities when aiming to improve attitudes toward immigrants. We conclude by discussing a new approach for promoting inclusive identities by framing immigrants as indispensable to the receiving community.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: People with type 2 diabetes often experience mental health symptoms that impair functioning, exacerbate illness and increase mortality risk. Access to psychological support is typically low in people with type 2 diabetes. Detection of depression is variable in the primary care setting and can be further impacted by the stigma attached to mental health conditions. Electronic mental health (eMH) programs may provide an accessible, private, non-stigmatising mental health solution for this group. Objective: To evaluate the efficacy of an eMH program (myCompass) for improving social and occupational functioning in a community sample of people with type 2 diabetes and self-reported mild-to-moderate depressive symptoms. myCompass is a fully-automated and self-guided online public health program for people with depression and/or anxiety. The effects of myCompass on depressive symptoms, diabetes-related distress, anxiety symptoms and self-care behaviour were also examined. Methods: Adults with type 2 diabetes and mild-to-moderate depressive symptoms (n = 780) were recruited via online advertisements, community organisations and general practices. Screening, consent and self-report questionnaires were administered online. Eligible participants were randomised to receive either myCompass (n = 391) for 8 weeks plus a 4-week tailing off period, or an active attention control (n = 379). At baseline and at 3-, 6-, and 12-months post-intervention, participants completed the Work and Social Adjustment Scale (WSAS), the Patient Health Questionnaire-9 item (PHQ-9), Diabetes Distress Scale (DDS), Generalised Anxiety Disorder Questionnaire-7 item (GAD-7) and items from the Self-Management Profile for Type 2 Diabetes (SMP-T2D). Glycosylated haemoglobin (HbA1c) measures were obtained at baseline, 6- and 12-months post-intervention. Results: myCompass users logged-in an average of six times and completed an average of .29 modules. Healthy Lifestyles users logged-in an average of four times and completed an average of 1.37 modules. At baseline, mean scores on several outcome measures, including the primary outcome of work and social functioning, were near to the normal range, despite a varied and extensive recruitment process. Of the 780 trial participants, 304 (39%) completed all post-intervention assessments. Intention-to-treat analyses revealed slightly greater improvement in work and social functioning for the Healthy Lifestyles group relative to the myCompass group. All participants reported equivalent improvements in depression anxiety, diabetes distress, diabetes self-management and glycaemic control across the trial. Conclusions: The Healthy Lifestyles group reported higher ratings of social and occupational functioning than the myCompass group, but no differences were observed for any secondary outcome. Although these findings should be interpreted in light of the near-floor symptom scores at baseline, the trial yields insights into mental health research in the context of T2DM, particularly the issues of engagement with programs which focus specifically on mental health. Several avenues emerge for continued investigation into how best to deal with the growing mental health burden in adults with T2DM. Clinical Trial: ACTRN12615000931572

Identification of mental health risk is important for optimising diabetes care in type 2 diabetes mellitus (T2DM). Personality is linked to diabetes health and may assist detection of individuals with T2DM most at risk of chronic mental health difficulties. This study examined the moderator effect of personality factors on changes in psychological distress and functioning in adults with T2DM and mild-to-moderate depressive symptoms across a 12-month period. Data were obtained from participants in a randomised controlled trial of adults with T2DM. Participants completed measures of depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder-7), general functioning (Work and Social Adjustment Scale), diabetes distress (Diabetes Distress Scale), and diabetes self-management (Self-Management Profile for Type 2 Diabetes) at baseline, 3-, 6- and 12-months. Glycaemic control (HbA1c) was measured at baseline, 6- and 12-months. Two hundred trial completers agreed to complete a personality inventory (Big Five Inventory). Low neuroticism was linked with reduced depression, anxiety, functional impairment and diabetes distress over the year. High extraversion was associated with decreased anxiety and functional impairment. High conscientiousness was linked to increased healthy eating. No personality trait moderated HbA1c levels. Personality screening may help identify mental health risk and guide medical carer approach in T2DM patients.

Background: Shift is a novel smartphone app for providing a digital-first mental health resource to junior doctors. It contains psychoeducational material, cognitive behavioral modules, guided mediations, information on common work stressors, and a section on help-seeking options for psychological problems through workplace and private avenues. Objective: This study aimed to conduct a preliminary investigation of the use and potential effectiveness of Shift on depressive and anxiety symptoms (primary outcomes) and work and social functioning, COVID-19 safety concerns, and help seeking (secondary outcomes). This study also sought feedback on whether Shift was seen as an acceptable tool. Methods: Junior doctors in New South Wales, Australia, were approached through promotional activities from the Ministry of Health, specialist medical colleges, and social media advertisements between June and August 2020. Consenting participants provided web-based baseline data, used the Shift app for 30 days, and were asked to complete a poststudy web-based questionnaire. Outcomes were analyzed under the intention-to-treat principle. Results: A total of 222 (n=156 female, 70.3%; mean age 29.2, SD 4.61 years) junior doctors provided full baseline data. Of these, 89.2% (198/222) downloaded the app, logged into the app approximately 6 times (mean 5.68, SD 7.51), completed 4 in-app activities (mean 3.77, SD 4.36), and spent a total of 1 hour on in-app activities (mean 52:23, SD 6:00:18) over 30 days. Postintervention and app use data were provided by 24.3% (54/222) of participants. Depressive and anxiety symptoms significantly decreased between the pre- and postassessment points as expected; however, physicians’ COVID-19 safety concerns significantly increased. Work and social functioning, COVID-19 concerns for family and friends, and help seeking did not change significantly. There was no significant relationship between symptom changes and app use (number of log-ins, days between first and last log-in, and total activity time). Most poststudy completers (31/54, 57%) rated Shift highly or very highly. Conclusions: Despite high levels of nonresponse to the poststudy assessment and increases in COVID-19 safety concerns, junior doctors who used the app reported some improvements in depression and anxiety, which warrant further exploration in a robust manner.