This study has three primary aims: 1) Validate Mirror's Mood Check feature by measuring convergent validity;2) Assess user experience and acceptability metrics (e.g., usability, engagement, satisfaction) of the Mirror app, with a particular focus on the journaling feature; 3) Assess the impact of guided journaling and mood tracking on depressive and anxious symptoms.

BACKGROUND AND SIGNIFICANCE

Depression is a common and serious mental disorder that can negatively affect an individual's thoughts, feelings, and ability to perform daily activities. The onset of depression can occur at any stage of life. The estimated prevalence of depression in childhood is low (1.09%) and the highest in young adulthood (21%) , with a sharp increase seen during adolescence . In 2022, 15.08% of adolescents between the ages of 12 and 17 reported suffering from at least one major depressive episode in the past year. Of those, only 27.2% received consistent treatment. Depression in adolescents, particularly if left untreated, is associated with negative consequences later in life, such as higher levels of substance use disorders, worse health and social functioning, less educational and financial achievement, and increased criminality. Considering these serious and lasting consequences, depression in adolescents is a significant public health issue that deserves proactive approaches to prevent or mitigate its negative impact on individuals and society.

Journaling is recognized as a common, non-pharmacological tool in the management of mental disorders, including depression. Journaling can promote self-reflection and self-awareness, which can help improve mental health (e.g., enhance emotional regulation, reduce stress, facilitate behavioral changes). Although digital journaling can offer equivalent expression and release as traditional journaling with pen and paper, digital journaling has many advantages, such as enhanced accessibility, data organization, data security, analytic potential, and multimedia integration; these features make digital journaling a highly efficient tool for managing mental health. As such, a growing body of research supports the clinical benefits of digital journaling for depression in adults. Yet, the acceptability and efficacy of digital journaling in adolescents are understudied, calling for further investigation.

Mirror is a mobile journaling app developed by the Child Mind Institute (CMI) for youth who want to explore and improve their mental health, particularly addressing symptoms related to depression. Like other mobile journaling apps, the Mirror app enables users to express their thoughts and emotions through multimodal entries (i.e., written, voice, selfie video) and provides prompts to facilitate journal entries. However, the Mirror app offers unique, emotionally supportive features to help users identify and process emotions. First, Mirror users can explore multimodal guided journaling (e.g., video, audio, and written entries with guided prompts); as the app's name suggests, one of the guides encourages users to stand in front of a mirror and start video journaling while making eye contact with themselves. This guided journaling using a mirror can help increase users' self-reflection and self-expression. Second, the Mirror app has a user-centered mood-checking feature ("Mood Check") designed based on the circumplex model of emotions, in which the x- and y-axis represent pleasantness and energy level, respectively. Mirror's Mood Check feature is visually appealing (i.e., two sliders corresponding to the two axes) and allows users to gain more granular insights into their emotional states.

With these unique and user-centered features described above, the Mirror app has great potential for increasing adolescent users' engagement, which could significantly influence the efficacy of digital journaling on mental health. Importantly, the information gained from the proposed study will guide the development of future clinical trials for adolescents suffering from depression.

PROPOSED STUDY

This study has three primary aims: 1) Validate Mirror's Mood Check feature by measuring convergent validity;2) Assess user experience and acceptability metrics (e.g., usability, engagement, satisfaction) of the Mirror app, with a particular focus on the journaling feature; 3) Assess the impact of guided journaling and mood tracking on depressive and anxious symptoms.

This study will enroll 500 young adults ages 18-25 via Prolific Academic (https://www.prolific.com/) an online research participant recruitment tool.

Users on Prolific Academic must be the age of majority in the locality in which they register for an account. Prolific users ages 18-25 that reside in the U.S., have access to a smart device, and are willing to download an external app (screened by Prolific Academic), will be eligible to complete a screening form. Participants with mild to moderate depressive or anxiety symptoms will be eligible to enroll in the study.

Participants on Prolific will complete a baseline assessment and will then be randomized to complete one of four study conditions over the course of 8 weeks:

1. Guided Journaling + Mood Tracking: Structured prompts and regular feedback to facilitate journaling, alongside daily mood tracking.
2. Unguided Journaling + Mood Tracking: Free-form journaling with access to mood tracking tools without additional guidance.
3. Mood Tracking Only: Mood tracking tools without any journaling component.
4. Control Group: Information on mental health resources without journaling or mood tracking.

In addition to their journaling and mood check assignments, all participants will also complete a weekly check in questionnaire, post-study and one month follow up assessment of symptoms and user satisfaction with the app.

Inclusion Criteria:

• Prolific users ages 18-25
• Must reside in the U.S.
• Must have access to a smart device, and are willing to download an external app (screened by Prolific Academic)
• Must complete screening form which consists of the Patient Health Questionnaire (PHQ-2) and the Generalized Anxiety Disorder (GAD-7) Scale.
• Must have mild to moderate depressive or anxiety symptoms, as measured by the screening form

Exclusion Criteria:

- None