Harry Minas

This study examines the association between the learning mode and the mental health of Chinese international students (CIS) in Australia and the potential mediating role of acculturative stress. One hundred and twenty-two CIS were recruited through an online survey and assigned to either the in-person or hybrid learning group according to their mode of learning. Depression, anxiety, and acculturative stress were assessed using the Patient Health Questionnaire-9 (PHQ-9), the General Anxiety Disorder-7 (GAD-7), and the Acculturative Stress Scale for Chinese College Students (ASSCS), respectively. The results indicated that compared with participation in in-person learning, participation in hybrid learning was associated with higher levels of self-reported symptoms of depression and anxiety. Acculturative stress was found to play a mediating role in this association.

Depression contributes substantially to the global burden of disease, with large treatment gaps, particularly in low- and middle-income countries (LMICs) like Vietnam. Digital mental health interventions (DMHIs) offer a promising solution, yet evidence for the efficacy and cost-effectiveness of digitally delivered adaptations of evidence-based interventions in LMICs remains limited. This trial evaluated the efficacy and cost-effectiveness of VMood, an app-based DMHI for depression adapted from an evidence-based in-person intervention, in Vietnam. We conducted a stepped-wedge cluster randomized controlled trial across 48 communes in eight Vietnamese provinces. A total of 480 adults screening positive for moderate depression (Patient Health Questionnaire-9 score 10-19), with a retention rate of 97.9%. Communes were randomized to immediate access to VMood or to enhanced usual care, consisting of a limited version of the app during the delay period. The primary outcome was depression caseness (PHQ-9 ≥ 10). Analyses followed an intention-to-treat approach using generalized estimating equations. A cost-effectiveness analysis estimated incremental costs per quality-adjusted life-year (QALY) gained. A total of 477 trial participants were included in the primary analysis. VMood was associated with a 59% reduction in the odds of depression at 6 months (adjusted odds ratio 0.41, 95% CI 0.19–0.89). Mean PHQ-9 scores decreased by 1.9 points (95% CI −3.6 to −0.3) at 6 months. Incremental costs were 1.205 million VND ($47 USD) (95% CI: 1.006 million VND, 1.297 million VND) with 0.008 incremental QALYs (95% CI: 0.006, 0.010), resulting in a 99.7% cost-effectiveness probability at a willingness-to-pay threshold of two times GDP/capita. VMood significantly reduced depressive symptoms and was highly likely to be cost-effective. As a scalable, low-cost intervention, VMood may help reduce the depression treatment gap in settings with limited specialist capacity, supporting investment in evidence-based DMHIs within community-based mental health systems. This trial was registered at ClinicalTrials.gov ( NCT05783531 ) on March 8, 2023. Available from: https://clinicaltrials.gov/study/NCT05783531 . Author Summary: Depression is a leading cause of disability worldwide, yet access to effective treatment remains limited, particularly in low- and middle-income countries (LMICs). Digital mental health interventions (DMHIs), such as mobile apps, can reduce depressive symptoms, especially when adapted from evidence-based treatments and delivered with human support. However, most evidence comes from high-income countries, with limited data on efficacy and cost-effectiveness in LMICs. VMood is a mobile app adapted from supported self-management, a modified approach to psychotherapy that is grounded in principles of Cognitive Behavioural Therapy and delivered in-person with support from non-specialist providers. The in-person intervention was shown to be effective in the Vietnamese context in a clinical trial. Here, we conducted a stepped-wedge cluster randomized controlled trial across eight provinces in Vietnam to evaluate the efficacy and cost-effectiveness of VMood. Participants received either the VMood app with supportive coaching provided by a social worker, or enhanced usual care, with subsequent access to the VMood app. Over six months, VMood significantly reduced depression caseness compared with the control group. Economic analysis showed that VMood represents good value for money and was feasible to deliver through existing community systems. Findings provide novel and policy-relevant evidence demonstrating that DMHIs can reduce depression and provide good value for money in LMICs.

University students are an at-risk population for developing mental health problems which can negatively impact their academic performance, social relationships, physical health, and future life. Among this population, the cohort of international students is more vulnerable. Chinese international students (CIS) form the largest international student group in the world, but research on their mental health is limited. Although researchers have become increasingly interested in their mental health in recent years, a comprehensive review of existing evidence is not yet available. The proposed review aims to integrate quantitative and qualitative findings concerning factors associated with CIS mental health. The systematic review will follow the PRISMA guidelines. Nine online databases-six English language and three Chinese language-will be searched. Peer-reviewed journal articles will be examined and screened according to the inclusion and exclusion criteria. Both quantitative and qualitative data will be extracted and narratively synthesised to generate an improved understanding of factors associated with the mental health of CIS. Findings from this systematic review will provide researchers, education professionals, mental health workers, and universities with knowledge concerning the factors associated with CIS mental health that is necessary for practical actions and will inform further research. PROSPERO CRD42023402503.

Online learning was widely implemented in university teaching activities during the pandemic and remains an important component of education following cessation of pandemic-related restrictions. Although university students reported worsening mental health during the pandemic little is known about how current learning modes (in-person, hybrid and online) are associated with mental health of international students, particularly among Chinese international students (CIS). We conducted a cross-sectional online survey of 122 CIS enrolled at an Australian university between April and May 2024. Depression and anxiety symptoms were measured using the Patient Health Questionnaire (PHQ-9) scale and Generalised Anxiety Disorder Questionnaire (GAD-7) scale. Acculturative stress was assessed using the Acculturative Stress Scale for Chinese Students (ASSCS). Associations between learning mode (in-person vs. hybrid) and mental health outcomes were examined, and the potential mediating role of acculturative stress was explored. Results indicated that compared with students in the in-person learning group, those in the hybrid learning group reported higher scores for depression (geometric mean ratio (GMR) = 1.32, 95% CI: [1.05, 1.65]) and anxiety (GMR = 1.31, 95% CI: [1.03, 1.67]). Only minimal change was observed after adjusting for age, gender, financial difficulties, online learning self-efficacy, and acculturative stress. Mediation analysis showed that acculturative stress may partially account for these differences. While acculturative stress may play a role in this association, longitudinal research is required to clarify directionality and causal pathways. These findings suggest that assistance with effective acculturation could be a potentially important component of university-based mental health programs.

Chinese international students (CIS) form the biggest cohort in popular host countries such as the United States, Australia, and the United Kingdom, but research shows that their mental health is challenged by multifaceted stressors. Despite this, we are unaware of any previous systematic review that has synthesised both quantitative and qualitative findings on factors associated with their mental health across different countries, and no existing review has included studies done during or after the COVID-19 pandemic. This systematic review aims to answer the following questions: What are the factors associated with the mental health of CIS across different countries? Among identified factors which factors emerged during the COVID-19 pandemic, and which were exacerbated during the pandemic? This review follows PRISMA guidelines. Six English and three Chinese databases were searched in November 2023: PsycINFO, MEDLINE, Embase, ERIC, Scopus, Web of Science, CNKI, Wanfang, and VIP. All types of empirical studies were eligible. Quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Data were extracted and findings were narratively synthesised using a convergent approach. Thirty-nine English language papers and one Chinese language paper were included. The mental health of CIS is associated with various factors, including academic issues, parents and family, language proficiency, social support, discrimination, acculturative stress, the COVID-19 pandemic, and other factors. Among these, academic-related issues are their main concern, intertwined with family expectation and Confucian cultural values. Language plays a fundamental role in their daily life. During COVID-19, other than pandemic-related fear, there was an increase in experiences of discrimination and social isolation, associated with poorer mental health. Satisfaction with online learning is related to better mental health. Concerns about face, self-esteem, perfectionism, physical health, green space usage, and other factors were also reported. The mental health of CIS is associated with various factors, and it worsened during the pandemic. Universities, and professionals in education and mental health could provide resources for students to enhance language abilities, academic skills, and social networks. CIS could be more prepared academically and mentally. Suggestions on future research directions were also provided.

Youth mental health is recognized as an urgent priority worldwide. Life skills education and self-management skills delivered at the population level are evidence-based approaches to promote mental well-being and resilience among youth and digital technologies are identified as promising approaches for delivering these interventions. The study objective is to assess implementation and clinical outcomes of the delivery of a life skills and self-management intervention delivered at the population level via an app (Y-MIND) in Vietnamese secondary schools. Y-MIND was co-designed with Vietnamese youth to promote appropriateness, acceptability and uptake. We will conduct a hybrid type 2, sequence pre-post, quasi-experimental study in twelve schools across three Vietnamese provinces. Participants will be students aged fifteen years who provide assent to participate and receive parental consent. Control and intervention cohorts from participating schools will be enrolled in subsequent years. The primary clinical outcome measure is well-being measured using the Warwick Edinburgh Well-Being Scale. Secondary outcomes will explore factors including resilience, common mental health conditions, positive childhood experiences, academic stress, internet addiction, substance use and experiences of bullying and punishment. Implementation outcomes include app engagement, uptake, retention and qualitative interviews to understand acceptability and appropriateness of the intervention. Assessments will be administered via an online survey using Qualtrics at baseline, six and twelve months. The intervention cohort will receive access to the app, while the control cohort will receive usual care. The control cohort will have access to the app following the study period, but no app-use data will be collected. Generalized Linear Mixed-Effect Models, with the school specified as the clustering variable, will be used for all outcomes data. Understanding the potential for clinical effectiveness and successful implementation of the Y-MIND app will contribute important evidence to the fields of global youth mental health, digital health and implementation science. Trial registration: This study is registered at ClinicalTrials.gov (NCT06753344).

Background: Low- and middle-income countries (LMICs), which bear a larger proportion of the global mental illness burden, have been disproportionately impacted by the COVID-19 pandemic due to preexisting mental health care system deficiencies. The pandemic has also led to a considerable increase in care delivered through digital mental health interventions (DMHIs), many of which have been adapted from in-person formats. Thus, there is a need to examine their fidelity to the original format along with issues regarding usability and other challenges to and facilitators of their uptake in LMICs. As most DMHIs have been developed in high-income countries, examining their cultural adaptation to LMIC settings is also critical. Objective: The purpose of this research was to conduct a rapid scoping review of the available evidence on DMHIs for depression and anxiety, two of the most common mental disorders, in LMICs. Methods: A rapid scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) and processes for rapid reviews by Tricco et al. The PubMed and PsycINFO databases were searched for records published between January 2020 (when COVID-19 was declared a public health emergency) and January 2025 using a search strategy developed in consultation with a liaison librarian. The pandemic accelerated the development and application of DMHIs, and this time frame was used to capture the recent literature that may have incorporated new methods of application. The search strategy was developed across three domains: (1) digital health interventions, (2) depression or anxiety, and (3) LMICs. Data were charted from the final records according to (1) intervention type; (2) discussions on fidelity, usability, and cultural adaptation; and (3) challenges to and facilitators of their uptake in LMICs. Results: A total of 80 records were included in the final analysis, with reasons for exclusion (eg, focused on mental health in general, not being a DMHI, or not focused on LMICs) reported. Six DMHI platforms were identified: (1) mobile app, (2) the web, (3) virtual reality, (4) videoconferencing, (5) telemedicine, and (6) social media. Less than half of the records referenced fidelity (16/80, 20%), usability (29/80, 36%), and cultural adaptation (31/80, 39%). Challenges pertained to the technological system, engagement issues, structural barriers, and concerns regarding privacy and confidentiality. Facilitators included widespread mobile phone use, built-in supervision and training features, and convenience. Conclusions: Despite the opportunities that DMHIs offer for reducing the mental health treatment gap, further work examining and improving their fidelity, usability, and cultural adaptation is required. In addition, various challenges to the uptake of DMHIs in LMICs, including contextual issues, structural barriers, and privacy concerns, must be mitigated to avoid contributing further to the digital divide.

Background: Worldwide, the COVID-19 pandemic contributed to further gaps in mental health care, particularly in low- and middle-income countries such as Vietnam, where care is inaccessible for 90% of those who need it. There has subsequently been a considerable increase in the use of digital mental health interventions such as smartphone apps. Presently, the evidence for such interventions is limited, especially in cases in which the interventions have been adapted from evidence-based in-person formats. Implementation science aims to promote the incorporation of scientific findings into practice. A key determinant of implementation success is an intervention’s usability. Hurdles to usability include an intervention being too confusing or time-intensive to use. Facilitators include incorporating a greater number of engagement features and integrating human support. Objective: The aim of this implementation science feasibility study was to describe the challenges and mitigation strategies used in the development, usability testing, and implementation of a digital depression intervention (VMood smartphone app) developed in Vietnam. VMood was adapted from an evidence-based in-person intervention originally developed in Canada that is grounded in principles of cognitive behavioral therapy with supportive coaching by a lay health or social services worker. The research team is currently testing the effectiveness and cost-effectiveness of VMood in a randomized controlled trial across 8 provinces in Vietnam informed by the results of this feasibility assessment. Methods: This mixed methods feasibility study was organized using an implementation outcome framework focused on acceptability, adoption, appropriateness, and feasibility. This study involved three data collection components: (1) usability testing (interviews and focus groups with app user and provider participants who tested VMood in 1 Vietnamese province), (2) app metrics (from the early phase of the randomized controlled trial in the same province but from different municipalities), and (3) discourse data (notes from various team meetings, communications, and reports on VMood’s development and implementation). Qualitative data were analyzed using thematic content analysis. App use data were analyzed using basic descriptive statistics. Results: The findings of the 3 data components showed that there were seven main challenges: (1) challenges with recruitment and uptake of the app, (2) challenges with use and engagement, (3) screening challenges, (4) digital divide, (5) limitations to digital applications for mental health, (6) technological challenges, and (7) funding and policy constraints. Various solutions to help mitigate the challenges were used by the team. Conclusions: The findings contribute important evidence on the challenges to the development and feasibility assessment of a digital depression app adapted from an in-person intervention in Vietnam. The findings have applicability for others looking to develop and implement digital interventions in similar contexts, serving as a unique opportunity to share the lessons learned regarding the development and testing process.

(1) Research is fundamentally important in developing evidence-informed and effective policies and appropriate programs and services to reduce the burden of mental health problems, and prevent suicide, among migrants. However, this population continues to be underrepresented in mental health and suicide research, resulting in large evidence gaps that limit policy making, service design and delivery, as well as evaluation of outcomes. (2) Experts in mental health and suicide prevention research with migrants provided free-text responses to a survey that asked about the knowledge and skills required to effectively conduct mental health and suicide prevention research with migrants, and effective strategies for engaging migrant and refugee communities in such research. An adapted thematic analysis method was used to analyze the free-text responses to the six questions. (3) The study identified specific areas of knowledge and skills required for effective mental health and suicide research with migrants; the methodological and ethical challenges that may arise in such research; and strategies that are likely to be effective in engaging people with lived experience and migrant and refugee communities in such research. (4) The findings from this project can be used to inform researchers on how to ethically and effectively undertake mental health and suicide research with migrant and refugee populations.

BACKGROUND Low- and middle-income countries (LMICs), which bear a larger proportion of the global mental illness burden, have been disproportionately impacted by the COVID-19 pandemic due to preexisting mental health care system deficiencies. The pandemic has also led to a considerable increase in care delivered through digital mental health interventions (DMHIs), many of which have been adapted from in-person formats. Thus, there is a need to examine their fidelity to the original format along with issues regarding usability and other challenges to and facilitators of their uptake in LMICs. As most DMHIs have been developed in high-income countries, examining their cultural adaptation to LMIC settings is also critical. OBJECTIVE The purpose of this research was to conduct a rapid scoping review of the available evidence on DMHIs for depression and anxiety, two of the most common mental disorders, in LMICs. METHODS A rapid scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) and processes for rapid reviews by Tricco et al. The PubMed and PsycINFO databases were searched for records published between January 2020 (when COVID-19 was declared a public health emergency) and January 2025 using a search strategy developed in consultation with a liaison librarian. The pandemic accelerated the development and application of DMHIs, and this time frame was used to capture the recent literature that may have incorporated new methods of application. The search strategy was developed across three domains: (1) digital health interventions, (2) depression or anxiety, and (3) LMICs. Data were charted from the final records according to (1) intervention type; (2) discussions on fidelity, usability, and cultural adaptation; and (3) challenges to and facilitators of their uptake in LMICs. RESULTS A total of 80 records were included in the final analysis, with reasons for exclusion (eg, focused on mental health in general, not being a DMHI, or not focused on LMICs) reported. Six DMHI platforms were identified: (1) mobile app, (2) the web, (3) virtual reality, (4) videoconferencing, (5) telemedicine, and (6) social media. Less than half of the records referenced fidelity (16/80, 20%), usability (29/80, 36%), and cultural adaptation (31/80, 39%). Challenges pertained to the technological system, engagement issues, structural barriers, and concerns regarding privacy and confidentiality. Facilitators included widespread mobile phone use, built-in supervision and training features, and convenience. CONCLUSIONS Despite the opportunities that DMHIs offer for reducing the mental health treatment gap, further work examining and improving their fidelity, usability, and cultural adaptation is required. In addition, various challenges to the uptake of DMHIs in LMICs, including contextual issues, structural barriers, and privacy concerns, must be mitigated to avoid contributing further to the digital divide.