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Agency: Cordis | Branch: H2020 | Program: RIA | Phase: SC1-PM-21-2016 | Award Amount: 7.07M | Year: 2017

ImpleMentAll will develop, apply, and evaluate tailored implementation strategies in the context of on-going eHealth implementation initiatives in the EU and beyond. Common mental health disorders account for an alarming proportion of the global burden of disease. Being regarded as an evidence-based psychotherapeutic eHealth intervention, Internet-based Cognitive Behavioural Therapy (iCBT), has the potential to answer to this societal challenge by providing an efficacious and efficient treatment from which more people can benefit. As a result, various iCBT implementation projects are currently conducted across the world. We propose to use this natural laboratory to develop and evaluate a toolkit for tailored implementation strategies that is expected to make implementation trajectories more efficient. The objectives for ImpleMentAll are: 1) To develop a generic Integrated Theory-based Framework for Intervention Tailoring Strategies (the ItFits-toolkit) for data-driven tailored implementation of evidence-based eHealth services. 2) To demonstrate the impact of the ItFits toolkit on the implementation of eHealth for common mental disorders, in 9 European countries, 2 LMIC, and Australia. 3) To disseminate the validated toolkit in various healthcare contexts across Europe. ImpleMentAll is a true multidisciplinary international collaboration that unites key experts in clinical practice, health innovation, clinical research, and implementation science. Combined with its unique setup, ImpleMentAll will be able to test if tailoring implementation strategies lead to more efficient implementation. The resulting ItFits-toolkit will enable data driven evaluation of eHealth implementation projects in terms key performance indicators for process, effectiveness, and efficiency outcomes. Its methods, materials, and strategies will provide concrete guidance on tuning implementation interventions to local determinant of practice across a variety of health care systems.

News Article | April 6, 2016
Site: www.nature.com

Type 'depression' into the Apple App Store and a list of at least a hundred programs will pop up on the screen. There are apps that diagnose depression (Depression Test), track moods (Optimism) and help people to “think more positive” (Affirmations!). There's Depression Cure Hypnosis (“The #1 Depression Cure Hypnosis App in the App Store”), Gratitude Journal (“the easiest and most effective way to rewire your brain in just five minutes a day”), and dozens more. And that's just for depression. There are apps pitched at people struggling with anxiety, schizophrenia, post-traumatic stress disorder (PTSD), eating disorders and addiction. This burgeoning industry may meet an important need. Estimates suggest that about 29% of people will experience a mental disorder in their lifetime1. Data from the World Health Organization (WHO) show that many of those people — up to 55% in developed countries and 85% in developing ones — are not getting the treatment they need. Mobile health apps could help to fill the gap (see 'Mobilizing mental health'). Given the ubiquity of smartphones, apps might serve as a digital lifeline — particularly in rural and low-income regions — putting a portable therapist in every pocket. “We can now reach people that up until recently were completely unreachable to us,” says Dror Ben-Zeev, who directs the mHealth for Mental Health Program at the Dartmouth Psychiatric Research Center in Lebanon, New Hampshire. Public-health organizations have been buying into the concept. In its Mental Health Action Plan 2013–2020, the WHO recommended “the promotion of self-care, for instance, through the use of electronic and mobile health technologies.” And the UK National Health Service (NHS) website NHS Choices carries a short list of online mental-health resources, including a few apps, that it has formally endorsed. But the technology is moving a lot faster than the science. Although there is some evidence that empirically based, well-designed mental-health apps can improve outcomes for patients, the vast majority remain unstudied. They may or may not be effective, and some may even be harmful. Scientists and health officials are now beginning to investigate their potential benefits and pitfalls more thoroughly, but there is still a lot left to learn and little guidance for consumers. “If you type in 'depression', its hard to know if the apps that you get back are high quality, if they work, if they're even safe to use,” says John Torous, a psychiatrist at Harvard Medical School in Boston, Massachusetts, who chairs the American Psychiatric Association's Smartphone App Evaluation Task Force. “Right now it almost feels like the Wild West of health care.” Electronic interventions are not new to psychology; there is robust literature showing that Internet-based cognitive behavioural therapy (CBT), a therapeutic approach that aims to change problematic thoughts and behaviours, can be effective for treating conditions such as depression, anxiety and eating disorders. But many of these online therapeutic programmes are designed to be completed in lengthy sessions in front of a conventional computer screen. Smartphone apps, on the other hand, can be used on the go. “It's a way of people getting access to treatment that's flexible and fits in with their lifestyle and also deals with the issues around stigma — if people are not quite ready to maybe go and see their doctor, then it might be a first step to seeking help,” says Jen Martin, the programme manager at MindTech, a national centre funded by the United Kingdom's National Institute for Health Research and devoted to developing and testing new mental-health technologies. One of the best-known publicly available apps was devised to meet that desire for flexibility. In 2010, US government psychologists conducting focus groups with military veterans who had PTSD learned that they wanted a tool they could use whenever their symptoms flared up. “They wanted something that they could use in the moment when the distress was rising — so when they were in line at the supermarket,” says Eric Kuhn, a clinical psychologist and the mobile apps lead at the US Department of Veterans Affairs' National Center for PTSD. The department joined up with the US Department of Defense to create PTSD Coach, a free smartphone app released in early 2011. Anyone who has experienced trauma can use the app to learn more about PTSD, track symptoms and set up a support network of friends and family members. The app also provides strategies for coping with overwhelming emotions; it might suggest that users distract themselves by finding a funny video on YouTube or lead users through visualization exercises. In its first three years in app stores, PTSD Coach was downloaded more than 150,000 times in 86 different countries. It has shown promise in several small studies; in a 2014 study of 45 veterans, more than 80% reported that the app helped them to track and manage their symptoms and provided practical solutions to their problems2. More results are expected soon. Kuhn and his colleagues recently completed a 120-person randomized trial of the app, and a Dutch team is currently analysing data from a 1,300-patient trial on a similar app called SUPPORT Coach. Smartphone apps can also interact with users proactively, pinging them to ask about their moods, thoughts and overall well-being. Ben-Zeev created one called FOCUS, which is geared towards patients with schizophrenia. Several times a day, the app prompts users to answer questions such as “How well did you sleep last night?” or “How has your mood been today?” If users report that they slept poorly, or have been feeling anxious, the app will suggest strategies for tackling that problem, such as limiting caffeine intake or doing some deep-breathing exercises. Some apps help people to stay connected to health-care professionals, too. ClinTouch, a psychiatric-symptom-assessment app designed by researchers at the University of Manchester, UK, analyses users' responses for signs that they may be experiencing a relapse; it can even notify a clinical-care team. Small feasibility studies — which are generally designed to determine whether an intervention is practical, but do not necessarily evaluate its efficacy — have shown that patients use and like both apps, and a 2014 study found that those who used FOCUS for a month experienced a reduction in psychotic symptoms and depression3. FOCUS and ClinTouch are both now being evaluated in randomized, controlled trials. Some researchers see opportunities in the data that smartphones collect about their users' movement patterns or communication activity, which could provide a potential window into mental health. “Your smartphone is really this interesting diary of your life,” says Anmol Madan, the co-founder and chief executive of Ginger.io, a digital mental-health company based in San Francisco, California. Studies have now shown that certain patterns of smartphone use can predict changes in mental-health symptoms4; a drop in the frequency of outgoing text messages, for instance, may suggest that a user's depression is worsening. The Ginger.io app, which is still in beta, monitors these sorts of patterns and alerts each user's assigned mental-health coach if it detects a worrying change. The evidence supporting the use of such apps is building5, 6, 7. But this is a science in its infancy. Much of the research has been limited to pilot studies, and randomized trials tend to be small and unreplicated. Many studies have been conducted by the apps' own developers, rather than by independent researchers. Placebo-controlled trials are rare, raising the possibility that a 'digital placebo effect' may explain some of the positive outcomes that researchers have documented, says Torous. “We know that people have very strong relationships with their smartphones,” and receiving messages and advice through a familiar, personal device may be enough to make some people feel better, he explains. But the bare fact is that most apps haven't been tested at all. A 2013 review8 identified more than 1,500 depression-related apps in commercial app stores but just 32 published research papers on the subject. In another study published that year9, Australian researchers applied even more stringent criteria, searching the scientific literature for papers that assessed how commercially available apps affected mental-health symptoms or disorders. They found eight papers on five different apps. The same year, the NHS launched a library of “safe and trusted” health apps that included 14 devoted to treating depression or anxiety. But when two researchers took a close look at these apps last year, they found that only 4 of the 14 provided any evidence to support their claims10. Simon Leigh, a health economist at Lifecode Solutions in Liverpool, UK, who conducted the analysis, says he wasn't shocked by the finding because efficacy research is costly and may mean that app developers have less to spend on marketing their products. A separate analysis11 found that 35 of the mobile health apps originally listed by the NHS transmitted identifying information — such as e-mail addresses, names and birthdates — about users over the Internet, and two-thirds of these did not encrypt the data. Last year, the NHS took this apps library offline and posted a smaller collection of recommended online mental-health services. The NHS did not respond to e-mailed questions or make an official available for interview, but it did provide this statement: “We are working to upgrade the Health Apps Library, which was launched as a pilot site in 2013 to review and recommend apps against a defined set of criteria which included data protection.” The regulation of mental-health apps is opaque. Some apps designed to be used in a medical context can be considered medical devices and therefore may be regulated by the UK Medicines and Healthcare Products Regulatory Agency, the US Food and Drug Administration (FDA) or equivalent bodies elsewhere. But the lines are fuzzy. In general, an app that claims to prevent, diagnose or treat a specific disease is likely to be considered a medical device and to attract regulatory scrutiny, whereas one that promises to 'boost mood' or provide 'coaching' might not. The FDA has said that it will regulate only those health apps that present the highest risks to patients if they work improperly; even mental-health apps that qualify as medical devices might not be regulated if the agency deems them to be relatively low risk. But the potential risks are not well understood. “At the low end, people might waste their money or waste their time,” says Martin, “and at the higher end, especially with mental health, they might be actively harmful or giving dangerous advice or preventing people from going and getting proper treatment.” When a team of Australian researchers reviewed 82 commercially available smartphone apps for people with bipolar disorder12, they found that some presented information that was “critically wrong”. One, called iBipolar, advised people in the middle of a manic episode to drink hard liquor to help them to sleep, and another, called What is Biopolar Disorder, suggested that bipolar disorder could be contagious. Neither app seems to be available any more. Martin says that in Europe, at least, apps tend to come in two varieties, those that are commercially developed and come with little supporting evidence or plans for evaluation, and those with academic or government backing that take a more rigorous approach. The problem is that the former are generally more engaging for users and the latter take so long to make it to the market — if they even do — that they look out of date. “This is a generalization,” Martin says, “but it's broadly true.” Even well-intentioned apps can produce unpredictable outcomes. Take Promillekoll, a smartphone app created by Sweden's government-owned liquor retailer, designed to help curb risky drinking. While out at a pub or a party, users enter each drink they consume and the app spits out an approximate blood-alcohol concentration. When Swedish researchers tested the app on college students, they found that men who were randomly assigned to use the app ended up drinking more frequently than before, although their total alcohol consumption did not increase. “We can only speculate that app users may have felt more confident that they could rely on the app to reduce negative effects of drinking and therefore felt able to drink more often,” the researchers wrote in their 2014 paper13. It's also possible, the scientists say, that the app spurred male students to turn drinking into a game. “I think that these apps are kind of playthings,” says Anne Berman, a clinical psychologist at the Karolinska Institute in Stockholm and one of the study's authors. There are other risks too. In early trials of ClinTouch, researchers found that the symptom-monitoring app actually exacerbated symptoms for a small number of patients with psychotic disorders, says John Ainsworth at the University of Manchester, who helped to develop the app. “We need to very carefully manage the initial phases of somebody using this kind of technology and make sure they're well monitored,” he says. In a pilot trial published earlier this year, ten US veterans with PTSD were randomly assigned to use PTSD Coach on their own for eight weeks, while another ten used the app with the support and guidance of primary-care providers. At the end of the trial, seven of the ten patients using the app with support showed a reduction in PTSD symptoms, compared with just three of the patients who used the app on their own14. But if apps require medical supervision, that undermines the idea that they will serve as an easy and low-cost way to provide care to the masses. “People think there's an app for everything,” says Helen Christensen, the director of the Black Dog Institute at the University of New South Wales in Sydney, Australia, who has developed and studied mental-health apps. “It's actually about how we build systems around apps, so that people have health care.” Distributing mental-health apps in the developing world presents further challenges. Although mobile technology is spreading rapidly, there are many people who do not have — or cannot afford — smartphones or mobile Internet access. And the content of apps needs to be delivered in local languages and reflect local cultures. “The notion that you can take an intervention and just plop it down in a region where people might not even use the same terms for mental health as you're using is a little unrealistic,” says Ben-Zeev. “What we might call 'hearing voices' in the United States might be something like 'communicating with your elders' in a different region, depending on what label people attach to that experience.” At this point, the notion that apps can deliver quality health care in low-income regions remains largely theoretical. “This is generally where the mHealth field is,” says Natalie Leon, a scientist at the South African Medical Research Council in Cape Town. “It's a promise of potential effectiveness.” To make good on that promise, apps will have to be tested. Between 2013 and 2015, the number of mobile-health trials registered on ClinicalTrials.gov more than doubled, from 135 to 300. And the number of trials specifically focused on mental and behavioural health increased by 32%, according to a report by the IMS Institute for Health Informatics in Parsippany, New Jersey. One digital health company that has earned praise from experts is Big Health, co-founded by Colin Espie, a sleep scientist at the University of Oxford, UK, and entrepreneur Peter Hames. The London-based company's first product is Sleepio, a digital treatment for insomnia that can be accessed online or as a smartphone app. The app teaches users a variety of evidence-based strategies for tackling insomnia, including techniques for managing anxious and intrusive thoughts, boosting relaxation, and establishing a sleep-friendly environment and routine. Before putting Sleepio to the test, Espie insisted on creating a placebo version of the app, which had the same look and feel as the real app, but led users through a set of sham visualization exercises with no known clinical benefits. In a randomized trial, published in 2012, Espie and his colleagues found that insomniacs using Sleepio reported greater gains in sleep efficiency — the percentage of time someone is asleep, out of the total time he or she spends in bed — and slightly larger improvements in daytime functioning than those using the placebo app15. In a follow-up 2014 paper16, they reported that Sleepio also reduced the racing, intrusive thoughts that can often interfere with sleep. The Sleepio team is currently recruiting participants for a large, international trial and has provided vouchers for the app to several groups of independent researchers so that patients who enrol in their studies can access Sleepio for free. “We think this is the way forward for digital health,” says Espie. Mobile-phone-based treatments, he says, “should be tested and judged like any other intervention. We shouldn't treat people's health with any less respect because the treatment is coming through an app.”

Boonstra T.W.,University of New South Wales | Boonstra T.W.,Black Dog Institute | Boonstra T.W.,VU University Amsterdam | Breakspear M.,University of New South Wales | And 3 more authors.
Journal of Neurophysiology | Year: 2012

Oscillatory activity plays a crucial role in corticospinal control of muscle synergies and is widely investigated using corticospinal and intermuscular synchronization. However, the neurophysiological mechanisms that translate these rhythmic patterns into surface electromyography (EMG) are not well understood. This is underscored by the ongoing debate on the rectification of surface EMG before spectral analysis. Whereas empirical studies commonly rectify surface EMG, computational approaches have argued against it. In the present study, we employ a computational model to investigate the role of the motor unit action potential (MAUP) on the translation of oscillatory activity. That is, diverse MUAP shapes may distort the transfer of common input into surface EMG. We test this in a computational model consisting of two motor unit pools receiving common input and compare it to empirical results of intermuscular coherence between bilateral leg muscles. The shape of the MUAP was parametrically varied, and power and coherence spectra were investigated with and without rectification. The model shows that the effect of EMG rectification depends on the uniformity of MUAP shapes. When output spikes of different motor units are convolved with identical MUAPs, oscillatory input is evident in both rectified and nonrectified EMG. In contrast, a heterogeneous MAUP distribution distorts common input and oscillatory components are only manifest as periodic amplitude modulations, i.e., in rectified EMG. The experimental data showed that intermuscular coherence was mainly discernable in rectified EMG, hence providing empirical support for a heterogeneous distribution of MUAPs. These findings implicate that the shape of MUAPs is an essential parameter to reconcile experimental and computational approaches. © 2012 the American Physiological Society.

Rozbroj T.,Australian Research Center in Sex | Lyons A.,Australian Research Center in Sex | Pitts M.,Australian Research Center in Sex | Mitchell A.,Australian Research Center in Sex | Christensen H.,Black Dog Institute
Journal of Medical Internet Research | Year: 2014

Lesbians and gay men have disproportionately high rates of depression and anxiety, and report lower satisfaction with treatments. In part, this may be because many health care options marginalize them by assuming heterosexuality, or misunderstand and fail to respond to the challenges specifically faced by these groups. E-therapies have particular potential to respond to the mental health needs of lesbians and gay men, but there is little research to determine whether they do so, or how they might be improved. Objective: We sought to examine the applicability of existing mental health e-therapies for lesbians and gay men. Methods: We reviewed 24 Web- and mobile phone-based e-therapies and assessed their performance in eight key areas, including the use of inclusive language and content and whether they addressed mental health stressors for lesbians and gay men, such as experiences of stigma related to their sexual orientation, coming out, and relationship issues that are specific to lesbians and gay men. Results: We found that e-therapies seldom addressed these stressors. Furthermore, 58% (14/24) of therapies contained instances that assumed or suggested the user was heterosexual, with instances especially prevalent among better-evidenced programs. Conclusions: Our findings, and a detailed review protocol presented in this article, may be used as guides for the future development of mental health e-therapies to better accommodate the needs of lesbians and gay men.

Loo C.K.,University of New South Wales | Loo C.K.,St George Hospital | Alonzo A.,University of New South Wales | Martin D.,University of New South Wales | And 5 more authors.
British Journal of Psychiatry | Year: 2012

Background: Preliminary evidence suggests transcranial direct current stimulation (tDCS) has antidepressant efficacy. Aims: To further investigate the efficacy of tDCS in a double-blind, sham-controlled trial (registered at www.clinicaltrials.gov: NCT00763230). Method: Sixty-four participants with current depression received active or sham anodal tDCS to the left prefrontal cortex (2 mA, 15 sessions over 3 weeks), followed by a 3-week open-label active treatment phase. Mood and neuropsychological effects were assessed. Results: There was significantly greater improvement in mood after active than after sham treatment (P50.05), although no difference in responder rates (13% in both groups). Attention and working memory improved after a single session of active but not sham tDCS (P<0.05). There was no decline in neuropsychological functioning after 3-6 weeks of active stimulation. One participant with bipolar disorder became hypomanic after active tDCS. Conclusions: Findings confirm earlier reports of the antidepressant efficacy and safety of tDCS. Vigilance for mood switching is advised when administering tDCS to individuals with bipolar disorder. Declaration of interest: None.

Bird K.D.,University of New South Wales | Hadzi-Pavlovic D.,Black Dog Institute | Hadzi-Pavlovic D.,University of New South Wales
Psychological Methods | Year: 2014

Multivariate experiments are often analyzed by multistage multiple-comparison procedures (MCPs) that prohibit univariate testing on individual dependent variables if an overall multivariate analysis of variance (MANOVA) test fails to reject the relevant overall null hypothesis. Although the sole function of the MANOVA test in such analyses is to control the overall Type I error rate, it is known that the most popular MANOVA-protected MCPs do not control the maximum familywise error rate (MFWER). In this article, we show that the MFWER associated with standard MANOVA-protected MCPs can be so large that the protection provided by the initial MANOVA test is illusory. We show that the MFWER can be controlled nonconservatively with modified protected MCPs and with single-stage MCPs that allow for the construction of simultaneous confidence intervals on effect sizes. We argue that, given the ease with which these MCPs can be implemented, there is no justification for continued use of the standard procedures. © 2013 American Psychological Association.

Bai S.,University of New South Wales | Loo C.,University of New South Wales | Loo C.,St George Hospital | Loo C.,Black Dog Institute | And 2 more authors.
Brain Stimulation | Year: 2012

Background: Electroconvulsive therapy (ECT) is a highly effective treatment for severe depressive disorder. Efficacy and cognitive outcomes have been shown to depend on variations in electrode placement and other stimulus parameters, presumably because of differences in the pattern of neuronal activation. This latter effect, however, is poorly understood. Objective: In this study, we present an anatomically accurate human head computational model to stimulate neuronal excitation during ECT, to better understand the effects of varying electrode placement and stimulus parameters. Methods: Electric field and current density throughout the head, as well as direct neural activation within the brain, were computed using the finite element method. Regions representing passive volume conductors (skin, skull, cerebrospinal fluid) were extracellularly coupled to an excitable neural continuum region representing the brain. The skull was modeled with anistropic electrical conductivity. Results: Simulation results indicated that direct activation of the brain occurred immediately beneath the electrodes on the scalp, consistent with existing imaging studies. In addition, we found that the brainstem was also activated using a right unilateral electrode configuration. Simulation also demonstrated that a reduction in stimulus amplitude or pulse width led to a reduction in the spatial extent of brain activation. Conclusions: The novel model described in this study was able to simulate direct excitation of the brain during ECT, was useful in characterizing differences in neuronal activation as electrode placement, pulse width, and amplitude were altered, and is proposed as a tool for further exploring the effects of variations in ECT stimulation approaches. Results from the simulations assist in understanding recently described clinical phenomena, in particular, the reduction in cognitive side effects with ultrabrief pulse width stimulation, and greater effects of the ECT stimulus on cardiovascular function with unilateral electrode placement. © 2012 Elsevier Inc. All rights reserved.

Bunce D.,University of Leeds | Batterham P.J.,Australian National University | Christensen H.,Black Dog Institute | MacKinnon A.J.,University of Melbourne
American Journal of Geriatric Psychiatry | Year: 2014

Objective To evaluate the temporal association between depression symptoms and cognitive function in older adults over a 4-year period. Methods Using a longitudinal, cross-lagged, population-based design, we studied depression symptoms and cognitive domains (including processing speed, verbal fluency, face and word recognition, episodic memory, and simple and choice reaction time) in 896 community-dwelling adults aged 70-97 years. Results Cross-lagged structural equation models suggested that initial depression symptoms affected subsequent processing speed and simple and choice reaction time but that cognition did not predict depression symptoms over time. The associations between depression and cognitive variables were attenuated when the models were adjusted for sensory impairment, physical health, and locus of control. Conclusion The findings suggest that, causally, depression precedes cognitive impairment in this age group and that the association is related to physical health and perceptions of a lack of control. © 2014 American Association for Geriatric Psychiatry.

Hegarty B.D.,Black Dog Institute | Hegarty B.D.,University of Sydney | Parker G.B.,Black Dog Institute | Parker G.B.,University of Sydney
Acta Psychiatrica Scandinavica | Year: 2011

Objective: While there has long been interest in any nutritional contribution to the onset and treatment of mood disorders, there has been increasing scientific evaluation of several candidate nutritional and dietary factors in recent years. In this inaugural study of our 'Food for Thought' series, we will overview the evidence for any role of omega-3 fatty acids (FA) in regulating mood. Method: Relevant literature was identified through online database searches and cross-referencing. Results: Plausible mechanisms exist by which omega-3 FA may influence neuronal function and mood. Cross-sectional studies demonstrate an association between omega-3 fatty acid deficiency and both depressive and bipolar disorders. Studies investigating the efficacy of omega-3 fatty acid supplementation for mood disorders have however provided inconsistent results. The proportion of treatment studies showing a significant advantage of omega-3 supplementation has dropped over the last 5years. However, the vast heterogeneity of the trials in terms of constituent omega-3 FAs, dose and length of treatment makes comparisons of these studies difficult. Conclusion: More research is required before omega-3 supplementation can be firmly recommended as an effective treatment for mood disorders. Whereas increased omega-3 FA intake may alleviate depressive symptoms, there is little evidence of any benefit for mania. © 2011 John Wiley & Sons A/S.

Rozbroj T.,La Trobe University | Lyons A.,La Trobe University | Pitts M.,La Trobe University | Mitchell A.,La Trobe University | Christensen H.,Black Dog Institute
Journal of Medical Internet Research | Year: 2015

Background: E-therapies for depression and anxiety rarely account for lesbian and gay users. This is despite lesbians and gay men being at heightened risk of mood disorders and likely to benefit from having access to tailored self-help resources. Objective: We sought to determine how e-therapies for depression and anxiety could be improved to address the therapeutic needs of lesbians and gay men. Methods: We conducted eight focus groups with lesbians and gay men aged 18 years and older. Focus groups were presented with key modules from the popular e-therapy "MoodGYM". They were asked to evaluate the inclusiveness and relevance of these modules for lesbians and gay men and to think about ways that e-therapies in general could be modified. The focus groups were analyzed qualitatively using a thematic analysis approach to identify major themes. Results: The focus groups indicated that some but not all aspects of MoodGYM were suitable, and suggested ways of improving e-therapies for lesbian and gay users. Suggestions included avoiding language or examples that assumed or implied users were heterosexual, improving inclusiveness by representing non-heterosexual relationships, providing referrals to specialized support services and addressing stigma-related stress, such as "coming out" and experiences of discrimination and harassment. Focus group participants suggested that dedicated e-therapies for lesbians and gay men should be developed or general e-therapies be made more inclusive by using adaptive logic to deliver content appropriate for a user's sexual identity. Conclusions: Findings from this study offer in-depth guidance for developing e-therapies that more effectively address mental health problems among lesbians and gay men. © Tomas Rozbroj, Anthony Lyons, Marian Pitts, Anne Mitchell, Helen Christensen.

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