JMIR Publications

ABSTRACT

Background:

Traditional in-person psychotherapies are incapable of addressing mental health needs globally. Computer-based interventions are one promising solution to closing the large gap between the amount of global mental health treatment needed and received. Although many meta-analyses have provided evidence to support the efficacy of self-guided, computer-based interventions, most report low rates of treatment engagement (eg, high attrition, low adherence).

Objective:

The present study investigates the efficacy of an adjunctive treatment component that uses task-shifting, wherein mental healthcare is provided by non-specialist peer counselors (eg, nurses, clergy, community members) to enhance engagement in an online, self-directed, evidence-based mindfulness intervention among Chinese undergraduate and graduate students.

Methods:

Fifty-four students from 36 universities across China reporting at least mild stress, anxiety, and/or depression were randomly assigned to a brief, 4-week online mindfulness intervention (MIND) or to the intervention plus peer counselor support (MIND+). The “Be Mindful Online” course delivers all the elements of Mindfulness-Based Cognitive Therapy (MBCT) in an online course that can be completed in 4 weeks. Participants completed daily monitoring of mindfulness practice and mood, as well as baseline and post-treatment self-reported levels of depression, anxiety, stress, and trait mindfulness. Fifty-six volunteer peer counselor candidates without any former training in the delivery of mental health services were screened, 10 were invited to participate in a 1-day training, and 4 were selected. Peer counselors were instructed to provide 6 brief (15-20 minute) “sessions” each week, with the intention of encouraging participants to complete the online intervention. Peer counselors received weekly group supervision online.

Results:

For both conditions, participation in the online intervention was associated with significant improvements in mindfulness and mental health outcomes. Pre-post effect sizes (d) for mindfulness, depression, anxiety, and stress, were 0.55, 0.95, 0.89 and 1.13, respectively. Participants assigned to the MIND+ (vs. MIND) condition demonstrated significantly less attrition and more adherence, as indicated by a greater likelihood of completing post-treatment assessments (16/27, 59% vs. 7/27, 26%; χ21=6.1, P=.013) and a greater percentage of course completion (73% vs 51%; t52=2.10, P=.040), respectively. There were no significant between-group differences in daily self-reports of frequency and duration of mindfulness practice across the trial. Multilevel logistic growth models showed that, compared to participants in the MIND condition, those in the MIND+ condition reported significantly greater pre-post improvements in daily ratings of stress (interaction estimate .39, SE .18; t317=2.29, P=.022) and depression (interaction estimate .38, SE .16; t330=2.37, P=.018).

Conclusions:

This study provides new insights into effective ways of leveraging technology and task-shifting to implement large-scale mental health initiatives that are financially feasible, easily transportable, and quickly scalable in low-resource settings. Findings suggest that volunteer peer counselors receiving low-cost and low-intensity training and supervision may significantly improve participants’ indices of treatment engagement and mental health outcomes in an online mindfulness intervention among college and graduate students in China.