Our Research Projects

Anxiety disorders are the most common class of psychopathology among youth, with nearly a quarter of adolescents meeting 12-month diagnostic criteria. There is evidence that anxiety prevention programs can be effective for youth. They are not, however, widely available or accessible, particularly among underserved populations where need is greatest. Novel approaches to increase engagement in and access to interventions that prevent the development and impact of anxiety disorders are needed. The goal is to partner with adolescents, providers and community partners to co-design and evaluate a technology-enabled prevention service for anxiety for adolescents. The community-academic partnership fostered for this research is between the Oak Park Public Library and Northwestern University. 

• Project Name: Technology-Enabled Prevention Service for Adolescent Anxiety 
• PI: Ashley A. Knapp, PhD
• Funding: NIMH K01MH121854, Northwestern University’s Alliance for Research in Chicagoland Communities, Community-Engaged Research Partnership Development Seed Grant

Community-Academic Partnership

The teen services program at the Oak Park Public Library is a program specifically designed for teens and by teens that focuses on the social-emotional and academic development of youth in communities in West/Near West Chicago neighborhoods and Western Suburban Cook County. The program is directed by Robert Simmons, director of Social Services and Public Safety, and led by Stephen Jackson, manager of Teen Services, and Darcel Washington, Teen Services coordinator.

Within the last couple years, Simmons has worked with Chicago-area organizations to extend the library’s social services to include mental health services. After learning about this, Ashley Knapp, PhD, reached out to Simmons to discuss the potential of a partnership. At the initial meetings between Simmons, Knapp, Jackson and library executive director David Seleb, it became apparent that the community and research teams shared the common mission of provision of accessible, evidence-based mental health resources to Chicago-area youth and that there was high potential for partnership around designing accessible mental health resources for those youth who most experience health inequities.

To support the design and testing of a technology-enabled prevention service for youth anxiety to be embedded within the teen services program at the library, Knapp applied for and received a Career Development Award through the National Institute of Mental Health with the support of Simmons and the Oak Park Public Library. This grant supports the participant-engaged work and software development of the technology-enabled prevention service.

Most recently, Simmons and Knapp received a seed grant through Northwestern University to form and convene a teen advisory board and an adult community advisory board to oversee project activities, as well as to support the role of a teen investigator to be part of the project’s investigative team.

Our research team worked with the Northwestern Medicine Division of Ambulatory Care Coordination to develop a digital mental health program designed to help care coordinators. These coordinators, who are nurses and social workers by training, provide whole-person care as they manage the physical and mental healthcare for patients who often have multiple chronic conditions and socioeconomic disadvantages.

We conducted a series of interviews, workflow observations and design elicitation workshops and are preparing for a larger clinical trial in which the resulting digital mental health program will be implemented in the Ambulatory Care Coordination service.  

• Project Name: Implementation of Digital Mental Health Tools in Ambulatory Care Coordination
• PI: Andrea Graham, PhD

A significant subset of individuals with obesity have comorbid binge eating. Yet no behavioral treatment produces substantial improvements in both outcomes, and current treatment approaches cannot reach all people in need. We designed FoodSteps, a mobile intervention for obesity and binge eating that has potential for scale and more precisely matches this subgroup's needs. We applied user-centered design methods to design the intervention to address the needs of its users. We are finishing a randomized trial testing the intervention and will soon start another trial to optimize FoodSteps into a highly personalized intervention.

Additionally, we are collaborating with different healthcare clinics to learn how FoodSteps could be implemented in real-world clinical practice. Taken together, this work aims to achieve the ultimate goal of establishing a scalable intervention that improves the precision of care for weight management and binge eating.

• Project Names: 
  • Testing Intervention Strategies for Addressing Obesity & Binge Eating
  • Designing a Mobile Obesity & Binge Eating Intervention for Implementation in Clinical Settings
  • A Micro-Randomized Trial to Optimize Just-in-Time Adaptive Intervention for Binge Eating & Weight-related Behaviors
  • Evaluating a Digital Intervention for Binge Eating and Weight Management among Adults with Food Insecurity  
• PI: Andrea Graham, PhD
• Funding: National Institute of Diabetes and Digestive and Kidney Diseases grants K01-DK116925, R03-DK128531 and R01-DK133300

Resulting Publications

• Graham AK, Wildes JE, Reddy M, Munson SA, Barr Taylor C, Mohr DC. User-centered design for technology-enabled services for eating disorders. Int J Eat Disord. 2019;52(10):1095-1107. doi: 10.1002/eat.23130. PMCID: PMC7265747.
• Weinheimer EA, Chang A, Neubert SW, Wildes JE, Graham AK. Past, current, and future willingness to engage with treatment targets: Applying user-centered design to inform the design of a mobile behavioral intervention. Int J Eat Disord. 2020;53(4):611-617. doi: 10.1002/eat.23252. PMCID: PMC7271441.
• Graham AK, Munson SA, Reddy M, Neubert SW, Green EA, Chang A, Spring B, Mohr DC, Wildes JE. Integrating user-centered design and behavioral science to design a mobile intervention for obesity and binge eating: Mixed methods analysis. JMIR Form Res. 2021;5(5):e23809. doi: 10.2196/23809. PMCID: PMC8145081.
• Graham AK, Neubert SW, Chang A, Liu J, Fu E, Green EA, Kornfield R, Nicholas J. Applying user-centered design methods to understand users' day-to-day experiences can inform a mobile intervention for binge eating and weight management. Frontiers in Digital Health 2021; 3(42):e651749. doi: 10.3389/fdgth.2021.651749.
• Venkatesh A, Chang A, Green EA, Randall T, Gallagher R, Wildes JE, Graham AK. Perceived facilitators and barriers to engaging with a digital intervention among those with food insecurity, binge eating, and obesity. Nutrients 2021; 13(7): 2458. doi:10.3390/nu13072458.
• Liu J, Munson SA, Chang A, Voss C, Graham AK. Understanding self-monitoring to inform a mobile intervention for binge eating and weight management: A proof-of-concept randomized trial. Int J Eat Disord. 2022; Epub ahead of print. doi: 10.1002/eat.23700. PMID: 35277986.
• Fu E, Neubert SW, Chang A, Smith JD, Graham AK. Characterizing behavior change techniques used in the self-management of binge eating and weight: Applying a user-centered design approach. Eat Behav. 2022; 44. doi: 10.1016/j.eatbeh.2021.101591. PMCID: PMC8885842.

Nonsuicidal self-injury (NSSI) is estimated to affect 13 percent of young adults and is associated with considerable burden, including significant role impairment in daily life, increased risk of developing a mental health disorder, hospitalization or permanent scarring. Repeated NSSI is also associated with high lifetime risk of suicide. Timely interventions aimed at NSSI reduction could have a significant impact on improving mental health and suicide prevention. However, around 50 percent of young adults never disclose their NSSI to anyone, and far fewer ever seek professional help.

Despite these low rates of disclosure and engagement with formal mental healthcare, young people with NSSI report interest in, and receptivity to, digital mental health interventions (DMHIs). Research has shown the effectiveness of DMHIs when applied to treat common mental health conditions, such as depression and anxiety. Given NSSI's prevalence, the potential for the behavior to result in severe and lethal outcomes, and young adults' openness to DMHIs, an effective and usable DMHI for NSSI could provide a unique, accessible and scalable treatment option.

We aim to design, develop and conduct a feasibility trial for a low-intensity DMHI for young adults with repeated NSSI, which can meet the need to provide services to individuals unlikely to engage in formal treatment. Two key challenges for DMHIs are maintaining participant engagement and supporting skill implementation in critical moments of distress. Our DMHI will address challenges with engagement through the use of a highly interactive conversational agent and by evaluating the added benefit of a coach. Our DMHI will also tailor content and interactions to the user's current state, by using ecological momentary assessment to assess NSSI risk and initiate relevant in-the-moment interventions to support users in implementing new coping strategies.

The primary goals of the project are to:

• Design and develop a DMHI for young adults with repeated NSSI, in close collaboration with potential users from this population.
• Examine the feasibility of conducting a 3-arm randomized control trial of the self-guided DMHI treatment and the DMHI treatment with low-intensity coaching, compared to an active control, with frequency of NSSI behaviors and urges as the primary outcomes, and suicidal ideation and depression, anxiety and borderline personality disorder symptom severity as secondary outcomes.
• Explore the mediational effects of psychological targets (emotional, cognitive and behavioral regulation; self-efficacy to resist NSSI) and engagement targets (app use and subjective engagement) on NSSI frequency and urges.

This research program aims to produce a scalable DMHI for NSSI, based on validated psychological strategies.

• Project Name: Digital Mental Health Intervention for Nonsuicidal Self-Injury in Young Adults
• PIs: David Mohr, PhD and Kaylee Kruzan, PhD
• Funding: R34MH128410-01

Resulting Publications

• Kruzan, K. P., Mohr, D. & Reddy, M. (2022). How Technologies Can Support Self-injury Self-management: Perspectives of Young Adults with Lived Experience of Nonsuicidal Self-injury. Frontiers in Digital Health. https://doi.org/10.3389/fdgth.2022.913599

Among older adults with multiple chronic conditions (MMCs), anxiety and depression can exacerbate patient perceptions of symptoms, which lead to further declines in functioning. Symptoms of anxiety and depression (e.g., amotivation, difficulty concentrating) can hinder effective communication and reduce patient's ability to engage in a collaborative relationship with their healthcare team. The long-term goal of this research is to improve quality of life, reduce functional impairments and increase independence among older adults with MCCs, including depression and anxiety. This developmental project aims to identify patient barriers to effective communication with internal medicine providers among older adults with symptoms of anxiety and depression and their caregivers and to develop a low-fidelity prototype of a patient organizational system to enhance communication with providers that will be detailed in a design document.

• Project Name: Assessing needs and designing solutions to help older adults communicate with healthcare teams
• PI: Andrew B L Berry, PhD
• Funding: P30-AG059988

Technology-enabled services (TESs), which include mobile applications (apps) supported by low-intensity coaching or care-management, have shown great potential, with a large number of randomized controlled trials consistently demonstrating efficacy. However, the many attempts to implement these validated interventions into large value-based care systems have failed.

There are two broad reasons for these failures. First, patients in real world settings simply do not use the tools that were developed in research settings. Related to this issue, recruitment efforts in research trials have often focused on easily engaged populations. As such, it is unclear how inclusively designed and generalizable findings on TESs have been for traditionally underserved populations. Second, TESs have not been designed to fit into the workflows in clinical practice settings.

To address these issues, this research project will use a comprehensive user-centered design approach to engage patients, Family Medicine staff and physicians from Rush University Medical Center (RUMC) in the design of a TES — comprised of technologies, a service protocol and implementation plan — that can be successfully deployed in Family Medicine clinics. The design innovation focus of this research project will be to design a patient app that is simple, usable, useful and fits into the fabric of people’s lives.

To achieve this goal, we will first engage young people (13 years of age and older) from the west side communities of Chicago in user-centered design practices. Member checking of resulting designs will occur with adults from the west side communities to evaluate likely generalizability of the TES to broader age ranges. Concurrently, RUMC Family Medicine staff and physicians will be interviewed to inform an implementation plan of the TES into their care system. Following this, the effectiveness and implementation of the TES will be evaluated in a roll out cluster randomized trial in Family Medicine clinics at RUMC. This project will be the first to integrate the emerging capabilities of personal sensing into intervention apps informed by young people from communities most impacted by behavioral health disparities. The resulting TES has the potential to be the first that is usable by real-world patients, fits into clinic workflows and can be successfully implemented in Family Medicine clinics. 

• Project Name: Technology Enabled Services for Depression in Family Medicine
• Research Team: David C. Mohr, PhD (PI), Colleen Stiles-Shields, PhD (PI), Steve Rothschild, MD (Co-PI), Karen Reyes (Site Research Manager)
• Funding: NIMH P50-MH119029

Perinatal depression (PD) affects one in seven women. Untreated PD can have devastating consequences, including pregnancy-associated suicide, which has remained among the leading contributors to maternal mortality in the U.S. Collaborative care (CC) has been shown in randomized trials to improve PD outcomes. But a major challenge in the implementation of postpartum collaborative care is the overburdened role of the care manager (CM), the lynchpin of the collaborative care model. CMs are managing many more patients than recommended targets.

Additionally, the unique context of the postpartum period, including newly competing priorities when managing demands of newborn care, often requires multiple outreach attempts by the CM to promote engagement. Due to these challenges, CMs are only able to complete the core CC tasks for women with critical mental health needs, leaving most women without the active management of care or brief behavioral interventions needed to achieve remission of depression.

Technology-enabled services (TES), which use web-based and mobile applications supported by low-intensity coaching or care management, represent a novel solution that would enable the CMs to more efficiently and effectively adhere to the core tenets of CC that have been demonstrated to improve depression outcomes. This research project will use a comprehensive user-centered design approach to engage patients, care managers and physicians in the design of a TES — comprised of technologies, CM service protocol and implementation plan — that can be successfully deployed in a perinatal collaborative care program.

The overall TES will be designed to support the existing collaborative care model, facilitating the acquisition of ongoing depression symptom tracking from patients and improving communication with patients, both critical to informing the stepped care processes. The design innovation focus of this research project will be to design a CM dashboard that will help organize the CM workflow, promote patient engagement, facilitate communication and automate tasks.

We will leverage ongoing research efforts in our center developing CM dashboards that help CMs better organize their work. Patient-facing tools will focus on completing psychological assessments and receiving feedback. The effectiveness and implementation of the developed TES will be evaluated in a randomized trial across five obstetric clinics. This project has the potential to create and assess implementation of the first fully functional TES for perinatal collaborative care.  

• Project Name: Technology-Enabled Services for Postpartum Depression
• PI: Emily S. Miller, MD, MPH 
• Co-I: Madhu Reddy, PhD, FACMI
• Funding: NIMH P50-MH119029

Open-Access IRB Materials

To promote research on digital mental health and technology-enabled services, we have made IRB materials related to this project freely accessible on our IRB Document Repository. Investigators may adapt or reference these materials when forming their own IRB submissions for projects related to digital mental health. 

For many older adults, home is an extension of the health system. Homebound older adults are more likely than their ambulatory peers to suffer from depression. While over 70 percent receive pharmacotherapy, most homebound older adults with depression cannot access needed psychological services since they are unable to leave the home for ongoing care. For homebound older adults, family caregivers commonly play the role of care coordinator, implementing provider recommendations and encouraging the loved one with depression, usually without adequate support. Family caregivers often experience high levels of stress, burden and anxiety coping with and in some instances attempting to alleviate depressive symptoms.

Older adults have often been on the fringe of benefitting from technology. However, voice-controlled intelligent personal assistants, VIPAs (e.g., Google Home, Amazon Echo), with their natural interaction style and ease of use, are technologies with simple interfaces that may be useful to older adults with depression in the home setting. Family caregivers would be able to schedule and follow the older adults and their VIPAs. The VIPAs could provide functional, cognitive and social stimulation as well as improve anti-depressant medication adherence through reminders to homebound older adults. The aim of this study is to create a technology-enabled service connected with VIPA (TES-VIPA) to provide family caregivers with the skills and tools to act as a care manager of homebound older adults with depression.

Through user-centered design (UCD) we will adapt the VIPA technologies to assist the older adult with psychoeducation, goal setting, monitoring, feedback and reminders, as well as dashboard tools to enable the caregiver to manage the tool and support the older adult. The resulting low-cost, commonly used technology has the potential to deliver effective care to millions of homebound older adults, who currently are unable to access effective treatment.

To achieve these goals, we have the following three aims, which will develop the TES and pilot the procedures for a larger randomized controlled trial:

• Design and tailor a Technology-Enabled Service via a Voice-Controlled Intelligent Personal Assistant (TES-VIPA) to support family caregivers of homebound older adults with depression.
• Conduct an Optimization, Effectiveness, Implementation (OEI) Hybrid trial of the TES-VIPA: We will pilot the procedures of an OEI Hybrid trial that extends the hybrid (type 1) effectiveness-implementation trial design, including recruitment, assessment, and statistical analyses to evaluate the delivery of the TES-VIPA treatment in the context of a geriatric service, resulting from user-centered design (UCD) and optimization, compared to a control arm. 
• Experimental Therapeutics Aims: We will explore the impact of core UCD targets, including usability, usefulness and satisfaction on technology and their downstream effects on depression severity as well as explore other moderating effects of older adult characteristics on engagement and treatment response.

• Project Name: Technology-Enabled Services to Support Family Caregivers of Older Adults with Depression
• PIs: David C. Mohr, PhD and Allison Carroll, PhD
• Funding: NIMH P50-MH119029

Young adults in the U.S. have the highest and fastest-growing rates of suicidal thoughts and behaviors, but the lowest rates of mental health care. Attitudinal barriers, such as a low perceived need for treatment, time constraints, and preferences for self-management, are some of the primary reasons for low rates of mental health treatment among this age group. But despite low utilization of traditional mental health care, young adults are interested in using self-directed digital technologies to help manage their mental health symptoms.

Safety planning is a preventive mental health intervention that is a clinical best practice for individuals experiencing thoughts of suicide and has been shown to be effective for reducing the likelihood of suicidal behaviors, however, it is often only delivered once an individual has made contact with a mental health professional and disclosed suicidal thoughts and behaviors. This gate-kept model of intervention means that most young adults who experience suicidal thoughts and behaviors will never recieve the safety planning intervention. 

To increase access to this suicide prevention intervention, the Center for Behavioral Intervention Technologies — in partnership with Mental Health America and individuals with lived experience of suicidal thoughts and behaviors — will develop an automated and self-directed safety planning intervention that is integrated into a digital space where young adults already spend a significant amount of time: text messages. 

This project aims to design and pilot an automated interactive safety planning service delivered via SMS that yields highly personalized safety plans and supports use over time. By accomplishing the proposed training goals and research project, this project will generate data to support an efficacy trial.

• Project Name: mHealth for suicide prevention: Design, development, and feasibility of a scalable SMS-based safety planning intervention
• PI: Jonah Meyerhoff, PhD
• Funding: K08-MH128640