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Essential Reads: Medications for Smoking Cessation in Breastfeeding Women

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Post published:August 11, 2021
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Smoking is relatively common during pregnancy, with about 10% of all women smoking at some point during their pregnancy. The rates are even higher among women with psychiatric illnesses. While many women may be able to stop smoking or reduce their intake during pregnancy, most women resume smoking during the postpartum period. And women who suffer from postpartum depression are at even higher risk for smoking relapse.

Nicotine and other chemicals from cigarettes are transferred into breast milk at relatively high levels. The amount of nicotine to which the infant is exposed depends on the number of cigarettes consumed by the mother per day and also on the time interval between the last cigarette and the timing of breastfeeding. Nicotine also accumulates in breast milk (milk/plasma ratio 2.9), and some might be surprised to learn that the amount of nicotine transferred into breast milk is more than double the quantity transferred through the placenta during pregnancy.

Women are strongly encouraged to breastfeed, but women who smoke are more likely to have a lower milk supply, and those who do breastfeed tend to wean their babies earlier than women who don’t smoke. Studies indicate that smoking more than 10 cigarettes per day decreases milk production and alters milk composition. Furthermore, breastfed babies whose mothers smoke more than 5 cigarettes daily exhibit behaviors (e.g. colic and crying) that may promote early weaning.

Most studies have focused only on the effects of nicotine on the nursing infant; thus, we have little information on how the breastfeeding infant may be affected by the other toxic chemicals, including arsenic, cyanide, formaldehyde, and lead, which are found in the breast milk of women who smoke.

In addition to exposure to nicotine and tobacco byproducts in the breast milk, there is well-defined literature regarding the risks children incur as a result of passive, or secondhand, exposure to smoke, including increased susceptibility to Sudden Infant Death Syndrome (SIDS), development and/or exacerbation of allergic diseases, such as asthma, and more recurrent and chronic respiratory illnesses. Less understood are the risks of thirdhand smoke, the residual nicotine, and potentially toxic tobacco-derived chemicals left behind by tobacco smoke on surfaces including hair, skin, clothes, furniture, carpets, and walls.

Are E-Cigarettes a Safer Option?

The data regarding the use of electronic or e-cigarettes in breastfeeding women is limited. The recent reports of EVALI or e-cigarette or vaping-associated lung injury also raise concerns about the safety of using e-cigarettes.

Many people often assume that e-cigarettes are safer than smoking regular cigarettes. While there might be certain health advantages to e-cigarettes, they deliver the same or higher levels of nicotine to the smoker. Thus, we must conclude that e-cigarettes carry many of the same risks associated with nicotine exposure as regular cigarettes and are not a better option for nursing mothers.

What About Nicotine Replacement Products?

According to the data provided by LactMed, a 21 mg transdermal nicotine patch delivers an amount of nicotine to the nursing baby via breast milk which is equivalent to smoking 17 cigarettes per day. Using lower patch strengths (7 or 14 mg) results in proportionately lower amounts of nicotine delivered to the breastfed infant. We have no studies investigating the use of nicotine spray or gum in nursing mothers.

Based on these findings, we would conclude that babies exposed to the nicotine delivered through a transdermal patch may face some of the same risks as babies exposed to nicotine through maternal smoking.

Varenicline or Chantix

Varenicline is a partial nicotine agonist used for smoking cessation. Because there is no information regarding the use of varenicline in breastfeeding women and its impact on the nursing infant, we would typically avoid the use of this medication in this setting, if possible.

Bupropion (Wellbutrin)

There is limited information regarding the use of bupropion in breastfeeding women; however, there are data to indicate that the levels of bupropion in breast milk and in the nursing infant are low. While the risk of adverse events appears to be below, there was one report of a possible seizure in a nursing infant whose mother was taking bupropion. No infant serum levels were obtained. If bupropion is required by a nursing mother for either smoking cessation or the treatment of depression, there is no significant evidence to recommend avoiding or discontinuing breastfeeding.

Some Final Thoughts

Our information on the use of medications for smoking cessation in nursing mothers is limited, and there may be factors at play that may make smoking cessation more difficult, or at least different, in postpartum women (e.g., breastfeeding, sleep deprivation, postpartum depression). Based on the information we do have, it looks as if bupropion (Wellbutrin) is the option that has the most data to support its safety in breastfeeding women and their infants.

That said, smoking cessation strategies have limited efficacy, and recent data indicated that multiple medications and interventions may be required for success. If these interventions do not work or are not safe to use in breastfeeding women, one may consider the cessation of breastfeeding instead. While breastfeeding has may benefit, exposure to nicotine and tobacco byproducts in breast milk may pose some degree of risk to the nursing infant.

Ruta Nonacs, MD PhD

References:

Nicotine (LactMed)

New findings on how ketamine prevents depression

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Post published:August 11, 2021
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The discovery that the anesthetic ketamine can help people with severe depression has raised hopes of finding new treatment options for the disease. Researchers at Karolinska Institutet in Sweden have now identified novel mechanistic insights on how the drug exerts its antidepressant effect. The findings have been published in the journal Molecular Psychiatry.

According to the World Health Organization, depression is a leading cause of disability worldwide and the disease affects more than 360 million people every year.

The risk of suffering is affected by both genetics and environmental factors. The most commonly prescribed antidepressants, such as SSRIs, affect nerve signalling via monoamines in the brain. However, it can take a long time for these drugs to help, and over 30 percent of sufferers experience no relief at all.

The need for new types of antidepressants with faster action and wider effect is therefore considerable. An important breakthrough is the anesthetic ketamine, which has been registered for some years in the form of a nasal spray for the treatment of intractable depression.

Unlike classic antidepressants,

However, ketamine can cause unwanted side effects such as hallucinations and delusions and there may be a risk of abuse so alternative medicines are needed. The researchers want to better understand how ketamine works in order to find substances that can have the same rapid effect but without the side effects.

In a new study, researchers at Karolinska Institutet have further investigated the molecular mechanisms underlying ketamine’s antidepressant effects. Using experiments on both cells and mice, the researchers were able to show that ketamine reduced so-called presynaptic activity and the persistent release of the neurotransmitter glutamate.

“Elevated glutamate release has been linked to stress, depression and other mood disorders, so lowered glutamate levels may explain some of the effects of ketamine,” says Per Svenningsson, professor at the Department of Clinical Neuroscience, Karolinska Institutet, and the study’s last author.

When nerve signals are transmitted, the transmission from one neuron to the next occurs via synapses, a small gap where the two neurons meet.

The researchers were able to see that ketamine directly stimulated AMPA receptors, which sit postsynaptically, that is, the part of the nerve cell that receives signals and this leads to the increased release of the neurotransmitter adenosine which inhibits presynaptic glutamate release.

The effects of ketamine could be counteracted by the researchers inhibiting presynaptic adenosine A1 receptors.

“This suggests that the antidepressant action of ketamine can be regulated by a feedback mechanism. It is new knowledge that can explain some of the rapid effects of ketamine,” says Per Svenningsson

In collaboration with Rockefeller University, the same research group has also recently reported on the disease mechanism in depression.

The findings, also published in the journal Molecular Psychiatry, show how the molecule p11 plays an important role in the onset of depression by affecting cells sitting on the surface of the brain cavity, ependymal cells, and the flow of cerebrospinal fluid.

Story Source:

Materials provided by Karolinska Institutet. Note: Content may be edited for style and length.

10 Most Effective Manifestation Techniques For You To Attract Positivity

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Post published:August 11, 2021
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Most of you must have heard of the ‘Law Of Attraction, right? The principle saying that we attract what we think, we believe in. You put positive thoughts out there, you’ll receive positive experiences. Similarly, putting out negative thoughts will attract negative experiences.

Through this Law Of Attraction comes the ‘Law Of Manifestation’ as well. The law of manifestation explains that with the power of our thoughts we are capable of influencing our lives.

In this article, we’ll discover some of the most effective and best manifestation techniques that will help you influence your life, reach your goals and fulfill your dreams. To practice these manifestation techniques you need to keep an open mind and heart. The only way these manifestation methods will work is when you direct yourself to change.

Below are the 10 most effective manifestation techniques for you to attract positivity and bring a positive change in your life!

10 Powerful Manifestation Techniques

manifestation techniques law of attraction

1. Vision Boards

A vision board or a dream board is one of the best manifestation techniques. When you prepare a vision board, it helps you look and subsequently focus on the big picture. Sort of like scrapbooks, vision boards can include images, cut-outs of places you want to visit, positive abbreviations, pictures of what you imagine your future would look like, etc.

Mostly a vision board is artistic and creative. Make sure the print-outs you put on your board are in sync with your values and beliefs.

Once your vision board is set, take a moment to reflect on what you want to experience. Reflect on where you want to go, whom you want to meet, experiences you want to gain, etc.

2. Intent Journaling

Another best manifestation method is intent journaling. Our intentions also play a huge part in how our life is influenced. You can write in this intent journal once a day, a week, or a month. Making it a ritual will help you set your intention and move forward from there.

What you need to do in this intent journal is to make a list of things you intend to do (depending on your day, week, or month). These intentions need to be specific, for example; “I intend to get 2000 steps tomorrow” or “I intend to open my heart and mind to new opportunities this month”.

Again, your intentions should be in sync with your beliefs and values.

3. Gratitude Journaling

Count your blessings whenever you can. Once we are appreciative of the blessings, the things we have, the universe will give us more to appreciate. With the help of a gratitude journal, you can become aware of the blessings you have.

Make writing in your journal a nightly routine. Be grateful for the experiences you had during the day and write them down. Use this journal to express gratitude towards the universe and thank it for the blessings you’ve been given so far.

4. Conscious Belief Assessment

You may not realize it but your mind carries subconscious thoughts and beliefs that may affect our lives whether we like it or not. For example; you might yearn to perform well in competition but somewhere in your subconscious, you might believe that you’re not worthy of winning.

These subconscious beliefs can have an impact on your dreams and aspirations as well. Remember, the law of manifestation states that our thoughts and beliefs transform into real experiences.

For a conscious belief assessment, you can try self-reflection exercises to understand and change your beliefs.

5. Visualization

Apart from the above techniques, you can also try practicing visualization to strengthen your manifestation. Try to introduce different perspectives and visualize your goals. This technique is about imagining your future now!

Visualization techniques for manifestation can help you get a clear vision of what you need or want. To practice visualization you need to have a clear goal in mind, then visualize that you already achieved the goal.

6. Manifestation Affirmations

Positive manifestation affirmations are another best and powerful manifestation technique you can try. Once you’ve done your belief assessment, this technique can come in handy. These manifestation affirmations can help you eliminate negative perceptions and create more positive thoughts and beliefs.

You can try manifestation affirmations such as:

“I’m worthy of getting what I need”

“I believe in the power of the universe”

“I open my mind and my heart to change, trust, and faith”

You can repeat these affirmations during visualization, during meditation, or when you write in your intent journal.

7. Wheel Of Focus

This yet another manifestation technique will help you move your focus from negative thoughts to positive ones. To start with, you can jot down your goal on a piece of paper and write down a positive thought related to that goal next to it.

For example; your goal is to write a novel in one year, then you can write a positive statement next to it such as – I will write 1000 words daily or I will spend one hour of my day on my goal. This manifestation method will help you visualize your thoughts a little better too.

8. 17-Second Manifestation

Taking 17 seconds out of your day doesn’t sound too much right? Manifesting does not need to take more than 17 seconds either. This manifestation technique is not difficult to do. All you need to do is when you wake up, lay still for 17 seconds, and daydream.

How good your life will be if you had the car you wanted, the dream house you dreamt of, the relationship you always yearned for. Once you’ve given 17 seconds to these thoughts, get up and get on with your day.

Nothing will happen in 17 seconds but in these seconds you’ve put your thoughts, your desires out in the universe.

9. The ‘As If’ Practice

Another quick and effective manifestation technique is the ‘As If’ method. Developed by Alfred Adler, this practice aims at acting as if you already have what you desired. Fake it till you make it, ever heard of this? That’s what you need to practice here.

Act as if you’ve reached your goals and fulfilled your dreams. Instead of theorizing what you need, act as if you have everything you’ve been manifesting.

10. Positive Networking

Last but not least, this method of manifesting is as important as the rest of the techniques. Our minds work as a radio, it transmits what it hears, sees, and surrounds itself with. Negative attracts negative, positive attracts positive. Surrounding yourself with positive people can also play a huge role in manifestation.

Hang out with people who give positive vibes, avoid people with negative energies. You can also start this by following positive influencers on social media, read books with positive themes, listen to positivity podcasts, etc.

Thoughts Become Things…

Each of these methods of manifestation has a different role but the result will be the same. No matter which manifestation technique you use, if your intention is not positive and powerful, it won’t work. There is a whole science about the law of manifestation. You can read more about the Law Of Attraction to understand how manifestation works.

Experiment with the above-mentioned manifestation techniques to find the one that works best for you! You can also combine two or more manifestation methods.

Remember, manifestation will only work if you keep an open mind and heart. Believe in yourself and the universe.

Did you try these manifestation techniques? Did any of them work? Let me know in the comments below!

Believe in yourself, follow your dreams, and let your thoughts become your reality!

Take Care!

WEBXTRA: Tyler police training to better respond to calls involving mental illness – KLTV

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Post published:August 5, 2021
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TYLER, Texas (KLTV) – The National Alliance on Mental Illness NAMI Tyler and the Tyler Police Department came together this week to further educate law enforcement on mental illness. The training was for patrol officers, detectives and support staff.

The purpose of the training is to provide better outcomes for those with mental illness, their families and law enforcement as the need grows in Tyler and Smith County.

Integrating Digital Therapeutics Into Care of Serious Mental Illness – Psychiatric Times

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Post published:August 5, 2021
Post category:POSTS

Digital health technologies designed for serious mental illness (SMI) have the potential to close mental health treatment gaps.^1-3 Upwards of 85% of individuals with SMI now use mobile phones as part of their daily routines, and over 60% own smartphones.⁴ A significant number of those with SMI have expressed interest in learning to use mobile applications to manage their moods, monitor mental health symptoms, and receive digital treatments.⁵

Academic researchers, startup companies, insurers, and the pharmaceutical industry are investing in the development of digital health interventions for SMI, building on the opportunities afforded by increased technology use.⁶ These interventions may extend therapeutic contact beyond traditional in-person services and can be delivered in a cost-effective manner.⁷ It is prudent for providers to learn about new types of interventions emerging in the marketplace, how the development of these interventions differs from previously available tools, and ultimately how to think about selecting an intervention most appropriate for their patients.

The term digital health has commonly been used as a catch-all to encompass a wide variety of mobile health (mHealth) or telemental health interventions for SMI. Some, such as symptom trackers and those meant to provide patient education, are used to support wellness, but explicitly lack a clinical diagnostic, monitoring, or therapeutic component. Diagnostic and monitoring digital health tools for SMI exist and include tools such as ingestible medication sensors or remote patient monitoring systems that can help providers track patient engagement in clinical interventions.^8,9 A relatively new term that is being used primarily in the industry is “digital therapeutics” (DTx). Software classified as DTx are distinct in that they are specifically designed to deliver clinical interventions in a manner akin to pharmacological intervention. They can be used as independent treatments or in conjunction with other interventions, such as psychotherapy.

The Gap From Science to Service

Health care has long been plagued by a science to service gap, where findings from research take more than 17 years to move into routine care.^10,11 This is a particularly salient issue for the development of DTx, as the pace of technology advancement can result in a new intervention being outdated by the time it is available to the general public, even if delayed by only a few years. Partnerships between private digital health companies and stakeholders from the pharmaceutical and health insurance industries allow intervention developers to take advantage of the marketing and regulatory knowledge that pharmaceutical and health insurance companies have cultivated in order to enhance distribution and reimbursement for their digital tools. However, they also highlight a tension between the desire to rapidly move DTx to market and the importance of carefully researching the effectiveness of an intervention prior to making it available for widespread use.

The vast majority of commercially available digital mental health tools have not completed the rigorous sequence of evaluation that academically-derived interventions go through before they are deemed effective. Although these interventions are readily available to the public, little is known about how well they actually work, or how best to use them in practice. Conversely, a wealth of information is known about digital health interventions developed in academic settings, but these interventions often lack a clear plan to for being disseminated to the public. Neither development pathway is innately the correct one; both have costs and benefits, and integration of lessons from each will help ensure the best products make it to patients in a timely fashion.

Consider FOCUS, a mobile health intervention for individuals with SMI that has been developed and tested extensively in grant-funded academic research since 2013.¹² FOCUS offers both prompted and on-demand training to help individuals improve their management of auditory hallucinations, take their medications effectively, resolve sleep problems, enhance their social functioning, and enhance their mood. A clinician dashboard allows providers to view patient interactions and utilize this information to guide treatment planning. Trials of FOCUS indicate using the intervention leads to clinical improvements similar to in-person care, while also being considerably more engaging and cost-efficient. FOCUS has yet to be released broadly for commercial use, as it continues to undergo research studying how best to implement the tool in community mental health settings. The rigorous development and testing of FOCUS highlights the different pacing of grant-funded academic research and the move fast and break things mindset that is often employed (and required) in industry.

Regulation Pathways

The US Food and Drug Administration (FDA) is exploring models of regulation for DTx as a means to provide oversight, potentially opening up new pathways for these interventions to translate into routine care more quickly. Recognizing that software-based interventions require updates in a fashion different than traditional medications, the FDA has been developing a precertification program in which individual companies, rather than individual interventions, can achieve approval based on the quality of their development process.¹³ The program takes into account that software products benefit from insight gained after release for broad use and aims to recognize developers who are able to monitor real-world efficacy. To date, 9 companies are participating in the precertification program, and indications are positive that the program results in a streamlined development pathway for DTx. If successful, regulatory frameworks similar to the FDA’s precertification program may help bring together development pathways that include both rapid pace and rigorous research.

Debate exists, however, about the extent to which regulation of DTx is necessary, and whether or not it will actually help patients access these tools. On one hand, regulation offers the opportunity to verify therapeutic benefits, assess risks, and may help these interventions to obtain inclusion on insurance formularies allowing for reimbursement.⁶ On the other, increased regulation is accompanied by high costs, delays in development, and may serve as an additional barrier to the use of digital tools among patients.

As a part of this debate, it is worth noting that the risk of adverse side-effects (which federal regulation is meant to help mitigate in new pharmacological interventions) is likely not the same for DTx. Whereas a new, unregulated medication may carry significant health consequences as a result of its biological effects, the risk of a misused DTx is considerably lower and is perhaps more closely related to other psychosocial approaches. Unless a clinician is engaging in unprofessional or unethical behavior, patients disengage rather than experience life-threatening physical side effects. Perhaps recognizing this distinction, the FDA temporarily relaxed its regulatory stance toward computerized behavioral therapies for psychiatric disorders during the COVID-19 pandemic—a move that may signal a wider recognition of the need for a differing regulatory approach when considering digital health versus pharmacological interventions.¹⁴

Selecting the Best DTx

While the future of digital therapeutic regulation remains in flux, clinicians should be aware of steps they can currently take to select the best digital interventions to use with their patients. One place for clinicians to start is by accessing online clearinghouses that include intervention reviews from a variety of perspectives (eg, clinicians, app developers, people with lived experience) and offer easy to understand breakdowns of interventions across a number of key features (eg, content quality, usability, security).^15-19 These clearinghouses include digital health interventions beyond DTx, so clinicians should think carefully about the intention of each listed intervention and understand that some listed tools will not be providing any therapeutic interventions (eg, mood trackers) despite still being useful for care delivery. Developing and maintaining these online clearinghouses is also highly resource-intensive, making it difficult for them to stay up to date.²⁰ Clinicians should be aware that these resources may not include newly released tools and may have outdated information based on previous versions of interventions that have since been updated.

To help clinicians critically think about digital health interventions on their own, a workgroup of the American Psychiatric Association developed an easy-to-follow framework that guides clinicians through evaluating an intervention across 5 domains.²¹ The framework includes opinions from peers, clinicians, and informatics. When using the framework, clinicians are provided questions to help evaluate an intervention’s development background, privacy and safety standards, clinical foundation, usability, and therapeutic application. While not every question will be immediately easy for a clinician to answer, the framework helps shape one’s thinking about whether a particular intervention will be a good fit for practice, especially when limited research or information is available.

After identifying an intervention, clinicians should consider how they will present it to their patients. Following a shared decision-making model, the clinician and patient should take a balanced view of what to expect from DTx and how it may aid their recovery.²² Clinicians would benefit from having personal experience with an intervention to aid in this discussion and provide a detailed explanation of an intervention’s content, interface design, any potential concerns, and alternative options that may be worth considering.

If a patient chooses to use DTx, clinicians should take time to help them learn how to use the intervention, set goals about use, and discuss how the intervention’s content will integrate with the patient’s larger treatment plan.²³ For example, if part of the patient’s treatment plan involves managing auditory hallucinations, then the patient should be introduced to how the content of a selected intervention is intended to help with this goal.

Concluding Thoughts

In the end, the degree to which a clinician recommends, demonstrates effectiveness, and incorporates the content into ongoing care will go far in helping patients make the most out of using digital therapeutic in their care process.

Dr Tauscher works at the Behavioral Research in Technology and Engineering (BRiTE) Center, and in the Department of Psychiatry and Behavioral Sciences at the University of Washington, Seattle. Dr Ben-Zeev is a professor of psychiatry and behavioral sciences at the University of Washington, Director of the BRiTE Center, and Director of the mHealth for Mental Health Program.

References

1. Camacho E, Levin L, Torous J. Smartphone apps to support coordinated specialty care for prodromal and early course schizophrenia disorders: systematic review. J Med Internet Res. 2019;21(11):e16393.

2. Firth J, Torous J. Smartphone apps for schizophrenia: a systematic review. JMIR mHealth uHealth. 2015;3(4):e4930.

3. Wu A, Scult MA, Barnes ED, et al. Smartphone apps for depression and anxiety: a systematic review and meta-analysis of techniques to increase engagement. NPJ Digit Med. 2021;4(1):20.

4. Young AS, Cohen AN, Niv N, et al. Mobile phone and smartphone use by people with serious mental illness. Psychiatr Serv. 2020;71(3):280-283.

5. Noel VA, Acquilano SC, Carpenter-Song E, Drake RE. Use of mobile and computer devices to support recovery in people with serious mental illness: survey study. JMIR Mental Health. 2019;6(2):e12255.

6. Burrone V, Graham L, Bevan A. Digital therapeutics: past trends and future prospects. Evidera. 2020. Accessed August 2, 2021. https://www.evidera.com/digital-therapeutics-past-trends-and-future-prospects/

7. Ben-Zeev D, Razzano LA, Pashka NJ, Levin CE. Cost of mHealth versus clinic-based care for serious mental illness: same effects, half the price tag. Psychiatr Serv. 2021;72(4):448-451.

8. Papola D, Gastaldon C, Ostuzzi G. Can a digital medicine system improve adherence to antipsychotic treatment? Epidemiol Psychiatr Sci. 2018;27(3):227-229.

9. Velligan D, Mintz J, Maples N, et al. A randomized trial comparing in person and electronic interventions for improving adherence to oral medications in schizophrenia. Schizophr Bull. 2013;39(5):999-1007.

10. Patel NA, Butte AJ. Characteristics and challenges of the clinical pipeline of digital therapeutics. NPJ Digit Med. 2020;3(1):1-5.

11. Munro CL, Savel RH. Narrowing the 17-year research to practice gap. Am J Crit Care. 2016;25(3):194-196.

12. Ben-Zeev D, Kaiser SM, Brenner CJet al. Development and usability testing of FOCUS: a smartphone system for self-management of schizophrenia. Psychiatr Rehabil J. 2013;36(4):289-296.

13. US Food and Drug Administration. Digital health software precertification (pre-cert) program. Updated May 6, 2021. Accessed August 2, 2021. https://www.fda.gov/medical-devices/digital-health-center-excellence/digital-health-software-precertification-pre-cert-program

14. US Food and Drug Administration. Enforcement policy for digital health devices for treating psychiatric disorders during the coronavirus disease 2019 (COVID-19) public health emergency. April 2020. Accessed August 2, 2021. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-digital-health-devices-treating-psychiatric-disorders-during-coronavirus-disease

15. American Psychiatric Association. Sample app evaluations. Accessed August 2, 2021. https://www.psychiatry.org/psychiatrists/practice/mental-health-apps/evaluations

16. Behavioral Health & Recovery Services. The Peers’ Guide to Behavioral Health Apps [Internet]. Kern Behavioral Health and Recovery Services. Updated March 2021. Accessed August 2, 2021. https://www.kernbhrs.org/appguide

17. Department of Veterans Affairs. VA App Store. 2021. Accessed August 2, 2021. https://mobile.va.gov/appstore/

18. Garland AF, Jenveja AK, Patterson JE. Psyberguide: a useful resource for mental health apps in primary care and beyond. Fam Syst Health. 2021;39(1):155-157.

19. NYCWell. NYCWell App Library. 2021. Accessed August 2, 2021. https://nycwell.cityofnewyork.us/en/app-library/

20. Montgomery RM, Brandysky L, Neary M, et al. Curating the digital mental health landscape with a guide to behavioral health apps: a county-driven resource. Psychiatr Serv. 2021 May 25;appips202000803.

21. Torous JB, Chan SR, Gipson SY-MT, et al. A hierarchical framework for evaluation and informed decision making regarding smartphone apps for clinical care. Psychiatr Serv. 2018;69(5):498-500.

22. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367.

23. Borghouts J, Eikey E, Mark G, et al. Barriers to and facilitators of user engagement with digital mental health interventions: systematic review. J Med Internet Res. 2021;23(3):e24387.