Is the Betwixt Application Effective and Acceptable in Improving Emotion Regulation for an Adult Clinical Population?

Study Background Information and Rationale Mental health problems are one of the main causes of overall disease burden globally (7.4%) (more than HIV/AIDs and tuberculosis, diabetes, and transport injuries), and their prevalence continues to rise. Globally, 792 million people (10.7%) experience mental health problems, and anxiety is the most prevalent (284 million/3.8%), followed by depression (264 million/3.4%). One in six adults in England have a common mental disorder (depression or anxiety), which is approximately one woman in five or one man in eight. Hence, mental health problems have a significant public health impact, nationally and globally.

National Context Within the UK, the NHS Long Term Plan (NHSLTP) outlined a new service model to overcome concerns of funding, staffing, increased inequalities, and pressures, by providing more options, better support, and coordinated care at the right time, in the optimal setting. The associated Mental Health Implementation Plan (NHSMHIP) outlined the priorities of the NHSLTP in mental health, including digitally enabled mental health care. This involved NHS England and NHS Improvement supporting the development of applications ("apps"), digitally enabled models of therapy, and online resources to support mental health and recovery. Digital mental health interventions have been found to be effective and acceptable means of delivering mental health support on a large scale.

The NHS previously had a library of approved apps which closed in 2021 and now they only recommend the NHS app and the COVID-19 app. As a result, NHS England created the Digital Technology Assessment Criteria for Health and Social Care, an assessment tool for ensuring digital health technologies meet standards of legislation and good practice. There is currently no database of recommended apps and there is an onus on healthcare organisations to assess each app at the point of procurement. The Mental Health Million project surveyed over 45,000 respondents and found that 50% of individuals with a clinical level of mental health risk did not seek help. The reasons were not knowing what kind of help to seek, thinking it would not make a difference, and a preference for self-help. Hence, individuals may need support with identifying what help is available, including both facilitated and self-help options.

The NHS Five Year Forward View first referenced the importance of 'empowering patients' and 'personalised care' and the NHSLTP then stressed 'personalised care'. A recent study noted significant challenges in digital mental health interventions, particularly regarding a lack of personalisation. In summary, there is a need for digitally enabled mental health care which is personalised, includes self-help, and is supported by good quality, contemporaneous evidence, and although the NHS has criteria for assessing digital technology, they no longer have provision for recommending apps to the public.

Emotion Regulation (ER) Technology ER is defined as: "shaping which emotions one has, when one has them, and how one experiences or expresses these emotions". It entails regulating positive and negative emotions, dependent upon goals. Since the 1990s, there has been vast research into the field of ER, for example, it was proposed that ER is necessary for daily functioning. It has also been found that deficits in ER appear to be relevant to the development, maintenance, and treatment of mental health conditions (such as, depression, borderline personality disorder, substance use, eating disorders, somatoform disorder, and other symptoms), hence, ER is transdiagnostic. It has been outlined the importance of cognitive reappraisal in ER.