Navigating Life After the Track: Nicholas Latifi

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In this exclusive episode, we sit down with former F1 driver Nicholas Latifi to discuss life beyond the fast lane. Nicholas candidly shares the mental health challenges drivers face in the high-pressure world of Formula 1, along with his personal strategies for maintaining balance both on and off the track. He talks about the mental strain that comes with being in the public eye and how he navigates those challenges. We dive into the significance of mental resilience and the importance of focusing on what you can control rather than succumbing to the overwhelming nature of the uncontrollable. Whether you're an aspiring young driver or a passionate fan of the sport, Nicholas provides invaluable insights on managing stress, maintaining focus, and preparing for life after racing. Don’t miss this honest conversation with one of F1’s most thoughtful voices.

Para escoger camisetas de fútbol según el tipo de uso, es práctico verificar las medidas indicadas y el tipo de ajuste. Como comprobación final, conviene asegurarse de el precio total, el plazo de entrega y las condiciones de devolución.

Anxiety is a normal human emotion that all of us experience. In small doses, anxiety is useful: it serves as a warning when we’re in danger, and can help to energise us when the stakes are high. But for people, experiences of anxiety are much more intense and debilitating. We might feel anxiety that doesn’t match up to the threat we face in the world, or we might feel its effects so strongly that it interrupts our day-to-day functioning.

If anxiety is causing you a lot of distress and impacting your life, it’s possible that you might be experiencing Generalised Anxiety Disorder (GAD). If you’re not sure what that means, this article outlines everything you need to know about GAD, from its symptoms and diagnosis to treatment.

Remember: you’re not alone. If you’re struggling with anxiety, Cerina is here to support you.

What is Generalised Anxiety Disorder?

Generalised anxiety disorder (GAD) is a long-term mental health condition where people experience a heightened sense of worry that they find difficult to control. People with GAD are constantly anxious and worry about even very small things. They may even worry about being worried. Because the anxiety is not focused, it can occur in response to anything, so the person is constantly on the alert for problems. This ‘hypervigilance’ can result in feeling distracted, tired, irritable or restless, as well as sleep problems, headaches, light-headedness and muscle pain.

GAD can have major impacts on an individual’s ability to function, with negative effects on work, social interactions, studies and many other aspects of life.

Anxiety disorders are among the most common mental health problems in the UK, and it’s thought that 1 in 20 people in the UK are living with GAD. Although anyone can experience an anxiety disorder, research shows that prevalence is slightly higher in women, who are 1.5 times more likely to experience GAD than men throughout their lifetime.

When does Generalised Anxiety Disorder (GAD) occur?

Symptoms of GAD can start at any time, but it's most common in people from the ages of 35 to 55. There are many different possible explanations for why someone might develop GAD. Some  of the risk factors include:

• A family history of mental health conditions or anxiety disorders specifically
• Exposure to difficult life events or stressful environments
• A history of drug or alcohol misuse
• Cognitive factors (i.e. patterns of thinking) can also be a risk factor for GAD. For example, individuals with GAD tend to perceive ambiguous situations as threatening, and to focus excessively on perceived threats.

While these risk factors might increase someone’s likelihood of developing the condition, it’s also possible to develop GAD without experiencing any of these.

What are the symptoms of Generalised Anxiety Disorder (GAD)?

Symptoms of GAD will vary from person to person, and can include both physical and mental effects. Common symptoms include:

• Constant, often disproportionate levels of worry or anxiety
• Not being able to stop worrying about things
• Difficulty concentrating or sleeping
• Feeling dizzy or experiencing heart palpitations
• Preoccupation with future plans, and anticipating negative outcomes

Diagnosing Generalised Anxiety Disorder (GAD)

GAD is diagnosed by a psychiatrist or clinical psychologist, using a clinical screening schedule in combination with screening tools designed to measure anxiety symptoms. The most common of these is called GAD7. When you take the GAD7, you’ll be asked lots of questions about how anxious you’ve been feeling in the last two weeks. Your score on the questionnaire will determine whether or not you meet the criteria for GAD.

GAD can sometimes overlap with other mental health conditions, such as mood disorders and other anxiety disorders. In some cases, a healthcare practitioner may also want to run physical tests to rule out other conditions.

Prognosis of Generalised Anxiety Disorder (GAD)

The outlook for GAD varies depending on the person and on the severity of symptoms. Short-term GAD might be easier to treat, while if someone has been experiencing symptoms for many years, they may require a more complex form of treatment (for example, a combination of therapy and medication) over a longer period of time.

For many, GAD is a long-term condition that can be managed throughout one’s life, and may rise up again during difficult life events.

Unfortunately, it’s thought that only half of people affected with GAD seek treatment. This means that GAD often goes untreated and unrecognised.

Treatments for Generalised Anxiety Disorder (GAD)

There are several possible treatments for Generalised Anxiety Disorder (GAD), including talking therapies, medication and digital therapy tools. Here’s a bit more information about the two most common treatments for GAD:

Medication

Medication is often prescribed to people experiencing the symptoms of GAD. The medication prescribed is usually a kind of antidepressant known as selective serotonin reuptake inhibitors (or SSRIs for short). For a more short-term medication plan, medication might be prescribed to simply target the condition’s physical symptoms. These are commonly called anti-anxiety drugs.

The main downside of medication is that it can have side effects, so other treatment methods (like CBT) may be preferable for some.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) has been shown to be effective long-term for treating Generalised Anxiety Disorder (GAD).

CBT helps you recognise and challenge unhelpful thought patterns, beliefs and behaviours that might be contributing to feelings of anxiety. It’s based on the idea that your thoughts impact your feelings and behaviours. So by challenging anxious thoughts, you can also reduce the behaviours that reinforce your anxiety and ultimately feel less anxious. It also equips you with strategies to help you better manage your symptoms.  

CBT can take place face-to-face with a therapist, but it’s also something you can work through yourself if you find the right tool. In fact, there’s evidence to suggest that digital CBT can be effective for managing the symptoms of GAD, allowing you to work through CBT sessions in your own time.

Cerina provides online CBT for anyone in the UK. You can find out more and download the Cerina app here.

How to prevent Generalised Anxiety Disorder (GAD)

Since the cause of GAD isn’t fully understood, it’s not always possible to prevent GAD. However, there are things you can do to help limit the likelihood of the condition developing or getting any worse:

Seek professional help

Diagnosing anxiety disorders early can help to minimise the effects of symptoms, before the condition becomes severe. We recommend seeking professional support from a qualified mental health practitioner to manage your symptoms and also help you rule out the possibility of any other conditions.

Try self-help tools

There are lots of things you can do yourself to help protect yourself against the negative effects of GAD. These include:

• Stopping smoking
• Exercising regularly
• Looking after your physical health
• Limiting your caffeine intake
• Learning relaxation techniques like breathing and grounding exercises
• Trying an online self-help tool
• Finding a support group

Conclusion

Generalised Anxiety Disorder (GAD) is a serious mental health condition that can negatively impact someone’s life. If you think you might be experiencing GAD, it’s important to get support from a qualified professional, who can help you diagnose the condition and help you develop tools to manage your symptoms.

Treatment for GAD is possible, but can take time and often involves a combination of measures. In some cases, lifestyle changes, relaxation techniques and improved coping skills can provide significant support to help people recover.

If you need support, Cerina is here. The Cerina app provides online CBT, designed by psychologists, that you can access in your own time from the comfort of your home.

Download Cerina today on the App Store or Google Play and reduce the impact of anxiety on your life.

We’re so excited to announce that Cerina is now available for anyone in the UK to download on the App Store and Google Play.

We believe that everyone deserves access to effective, affordable mental health support. So we got together an amazing team of passionate psychologists, researchers, and developers to create something that gives you the benefits of face-to-face therapy, from the comfort of your home. We’re very proud of Cerina, and we can’t wait to share it with you.

What is Cerina?

Cerina is a digital mental health app - you can think of it like a therapist in your pocket. It helps you take small, daily steps for lasting change, helping you feel less anxious and learn to manage your worries.

Cerina is based on cognitive behavioral therapy (CBT), which has been shown to be very effective for treating anxiety. Research also shows that CBT can be effective without the presence of an actual therapist. In fact, digital mental health solutions (like Cerina) can be very impactful, giving you the freedom to work through the exercises in your own time, without worrying about travelling to an appointment, paying high therapy fees or sitting on a long waiting list.

The main component of Cerina is ‘your journey’, where you’ll be guided through short CBT-style sessions, carefully designed by our team of psychologists to help you better understand and manage your anxiety symptoms.

But there’s also so much more to discover in the app: you can track your mood every day, access helpful articles, podcasts and guided breathwork exercises, and when you need to talk, you can chat confidentially to Hedgie: your very own AI pal, available 24/7. You can find out more about the app here.

Who is Cerina for?

Cerina is for anyone who wants to take steps to improve their anxiety symptoms. Although we have plans to expand into new categories very soon (watch this space!), the Cerina app is currently only focused on anxiety, and is designed for people with symptoms of Generalised Anxiety Disorder - although you don’t need a diagnosis to use or benefit from the app.

When you first download Cerina, you’ll be taken through a questionnaire which will measure how anxious you’ve been feeling in the last two weeks. It’s known as the GAD7, and is a globally certified measure of anxiety symptoms. This allows you to see your progress over time, and also helps us provide you with the best possible support.

How can I access the app?

You can find Cerina on the App Store and Google Play Store. Download the app today and start your journey to better mental health - we’ll be with you every step of the way.

The fields of Mental healthcare and AI go parallel to each other. As the 'concept of AI' is inspired by the workings of the human brain, psychologists and computer scientists have been working hand in hand since the days of the Dartmouth workshop to build an AI that propels human growth. The field of psychology has contributed significantly to the advancements in AI, so much so that the first 'artificial neural network (ANN)' was invented by a psychologist named Frank Rosenblatt; this ANN called 'Perceptron', was able to differentiate between objects such as a Circle and a Triangle. However, today, we have come a long way since those days; now, AI can do more than that. Specifically, in 'mental healthcare', it can potentially detect symptoms of mental health issues in an individual and recommend a treatment or even deliver therapy.

Advancements in AI algorithms, fueled by exponential growth in computational power and data due to the tech and internet boom, are creating a new frontier for human development. Digitally delivered Mental Healthcare is one of those frontiers. Digital Mental Healthcare powered by AI can exponentiate access to affordable, culturally relevant, medical-grade care across the globe. Making this our mission, Cerina has embarked on a new journey to create robust AI solutions aiding mental healthcare delivery. It is about time AI contributes back to the field of psychology!

But what about the Trustworthiness of AI in applications such as mental healthcare? Scientists have been grappling with questions on AI Ethics since the 1950s, and we need to answer them now. As a medical-grade device: safety, reliability & clinical efficacy has always been at the forefront of our development ethos. We constantly ask ourselves: Is AI even ready for an application as sensitive as mental health? What about Bias? Will it be reliable? What if AI makes mistakes? Who will be responsible? The lack of regulations, guidelines, laws, and standards surrounding this topic does make it challenging to answer these questions.

Regulations around AI did not match AI's propelled growth in the early days; despite that, recently, a collective effort led by policymakers and industry leaders has expatiated the discussion on this topic and resulted in a robust framework(s) guiding the development of AI.

Some of these frameworks/ initiatives include: -

• Trustworthy Artificial Intelligence by Mozilla Foundation
• Guidelines on AI by National Health Service (UK)
• AI Ethics Framework by the World Economic Forum & NITI Aayog India
• Ethical Guidelines for Application of Artificial Intelligence in Biomedical Research and Healthcare by ICMR (India)
• Ethics and Governance of artificial intelligence for Health by World Health Organisation.

Cerina AI Principals

At Cerina, we understand the importance of having a solid ethical foundation for AI development. Below is the list of our foundational principles for AI ethics; these principles act as our north star when it comes to developing AI responsibly.

• Consent, Control, Privacy & Security for Data

Cerina's robust privacy policy, inspired by the works of Mozilla Foundation's 'privacy not included' project, dictates our privacy approach. We inform our users about all collected data points, their use cases, and how we process and delete them after it has served their purpose. We only collect data after acquiring consent from the user. We respect their Data protection rights and give them complete control of their data. We use robust encryption protocols when data is in transit and at rest. We encourage you to review our industry-leading privacy policy and contact us with any queries.

• Non-Discrimination & Fairness

We ensure the accuracy of the dataset being used to train the algorithm and ensure that it is representative of the population in which it is in use. In addition, we proactively give special attention to promoting and protecting the equality of individuals & ensure that our AI does not perpetuate any discrimination or unfair stereotypes. We conduct routine algorithmic audits and monitor continuous end-user feedback analysis to minimise inaccuracies and biases. Our 'AI technologies' are designed for universal usage. We are also working towards making the Cerina app and all its tools available in multiple languages across the globe. Instead of doing the language translation, we will translate the app and AI tools in a culturally contextual manner.

• Accuracy, safety, Risk minimisation & Trust

AI applications in healthcare must be close to if not 100% accurate; we try to make AI models as precise as possible. Audited frequently routine tests and updates, this accuracy is necessary to maintain a medical-grade device's safety and clinical efficacy. We employ different mechanisms to minimise the risk of failure by dividing it among multiple (different) models (e.g., Any prediction, classification or detection is made by various models based on numerous algorithms and results are combined to get the final results). We frequently conduct reviews of our model's accuracy compared with the industry norms and standards. In addition, we take proactive measures to prevent AI from being influenced or misused by bad actors.

• Autonomy, Reversibility, Accountability & Sustainability

Users can use the Cerina app with or without clinical supervision. However, (under supervision) clinical supervisors must have complete control and operational autonomy over the user's treatment pathway. Supervisors can monitor the user's progress in the app and access vital information on the user's treatment (provided with the user's prior consent); they can also monitor predictions/ detections & decisions made by AI models. This way, all our AI's decisions are kept in check. Furthermore, any unsuitable decision is immediately reversible. This human supervision promotes accountability, leading to a sustainable growth of the AI ecosystem in healthcare, inclusive of all stakeholders.

• Compliance

Being a medical-grade device, we not only follow all regulations relating to Privacy and security (HIPAA & GDPR laws) but also go above and beyond to create our own set of industry-leading standards. We follow all regulations/ guidelines/ directives issued by relevant authorities in our respective marketplaces. We frequently engage and communicate with policymakers, industry leaders and other stakeholders to ensure compliance.

• Transparency, Explainability, Intelligibility and Oversight

Under many GDPR-like & Similar laws, users of digital services have the right to know how AI is making decisions for them. Cerina is committed to ensuring that we are transparent about all technologies being used in our AI Stack. In addition, we frequently communicate with our users through social media and with stakeholders at events (e.g., Neuro, Digital & AI Innovation Summit in Lisbon, Oct 2022) & groups such as IT4Anxiety.

We provide all documentation on AI's working to our B2B Partner Companies (upon request) and provide information through policy documents to all individual Customers and users. If any user has any queries or wants to understand how AI makes decisions for them, they can reach us at support@cerina.co.

Cerina closely works with Healthcare, Academia, Research and tech Industries advisors to ensure the latest industry practices are followed during the development cycles.

• Advisors on AI & Data Science

Dr Nicos Savva | Professor at London Business School

Dr Ward van Breda | Director at Sentimentics BV | PhD in Machine Learning (Predictive Modelling in E-Mental Health: Exploring Applicability in Personalised Depression Treatment)

• Psychology and Research Team

Dr Momotaj Islam | Chief Psychologist at Cerina | Chartered Clinical Psychologist

Dr Özlem Eylem-van Bergeijk | Research Lead | Beck Institute for CBT Scholar

The Development and Engineering Teams work Closely with Advisors and Psychology & Research Team to ensure the proper adoption of AI in the field of Mental Healthcare.

We are also actively engaging and collaborating with partner research institutes and projects. For example, Cerina was awarded an "Innovation Support Grant" by Medilink Midlands (supported by the European Union's Regional Development Fund) for AI development in the app. In addition, Cerina recently joined the IT4Anxiety consortium, which is dedicated to helping the implementation of innovative solutions through start-ups to reduce the anxiety of patients suffering from mental disorders.

Let's discuss how AI works best for you.

The primary objective of this Article is to inform all our stakeholders about the principles observed during the development of AI. But, along with that, we also intend to initiate a conversation with you. We want to know your thoughts on 'AI in mental healthcare', what concerns you have, your ideas & solutions, and what things you wish to understand more and better; we want to know your feedback and insights on AI features in our app to improve our product. (Basically) We want to talk about 'AI & Mental Health' with you.

As per the regulations (of GDPR), we have appointed a data protection officer (DPO); if you have any questions or queries regarding how AI works in the Cerina app, please get in touch with our DPO.

Name of DPO: Prasannajeet Mane; Email address: prasannajeet.mane@cerina.co ;

Postal address: 71-75 Shelton Street, Covent Garden, London, England, WC2H 9JQ

Alternatively, you can also contact our AI/ML Engineer to discuss more on AI's principles and technical details of the development.

AI/ML Engineer: Omkar Kadam; at omkar@cerina.co

The study was designed as a single-group feasibility open trial where all eligible participants have access to the Cerina application for six weeks (See table 1). The main purposes were to investigate the changes in anxiety, depression, and general functioning scores over time among employees who used Cerina for six weeks. Other purposes of the pilot study were: 1) to explore the usability (i.e. strengths and weaknesses (e.g. user errors, glitches)of the User Interface (UI) of the app, usefulness, and acceptability) of Cerina and 2) to learn about users` views on the clinical content and potential suggestions for improvement. Participants were asked to fill in online self-report measures of anxiety, depression, and general functioning baseline (t0) and at 6 weeks (t1) (see appendix 1 for study materials). Additionally, they filled out the SUS questionnaire and semi-structured interviews were conducted with the participants at 6 weeks (t1) to explore which elements of the intervention facilitated or hindered participants` progress during their participation and how the intervention can be optimised to increase its acceptability, relevance, and user-friendliness in real-life settings (see appendix 2 for the topic guide).

Table 1. Measures collected and the time point of data collection

Outcome measures            Baseline (t0)          6 weeks (t1)

GAD7                                                     X                         X

PHQ-9                                                   X                         X

WSAS                                                    X                         X

SUS                                                                                   X

Semi-structured interviews                                         X

Participants were employees of Tag Worldwide (a big corporate specialised in marketing production) and National Care Group (NCG) (one of the UK`s leading providers of care and support services to vulnerable adults).

Key results

The users have been recruited from the employee networks of Tag Worldwide and National Care Group (NCG). The recruitment started in April 2022 and up until now, 118 employees registered their

interest in using Cerina, 59 (Tag N=24, NCG N=35) filled out their pre-assessment questionnaire, 43 downloaded Cerina, and 20 (Tag N=11, NCG N=9) completed their post-assessment questionnaire. Of all these 20 people, the majority (89%) were female, aged between 30 and 45 (37%) and 18 and 30 (37%), and had an undergraduate degree (42%). The majority of them (67%) were not receiving psychological support at the time of the study and identified friends as their main support network. Additionally, about half of them were on medication for the past 6 months for a physical and/or psychological problem.

Overall, users had mild anxiety (M=10.15, SD=5.75), moderate depression (M=13.52, SD=8.22), and significant functional impairment (M=19.10, SD=11.00) based on their scores on the pre-assessment questionnaire. The initial comparisons of pre and post-assessment questionnaires indicated that there is an overall, but non-significant reduction in anxiety [t(18)=0.76, p=0.46>0.05] and depression [t(16)=0.72, p=0.48>0.05] and significant improvement in general functioning scores [t(180=0.03<0.05] over 6 weeks (see Appendix B). Due to the small sample size, bootstrapping, using 1000 bootstrapped samples, was used for the analyses as implemented in the SPSS version 28.

The usability of Cerina was acceptable (M=70, SD=17.37) based on the users` scores on the System Usability Scale. We conducted interviews to obtain more in-depth information on the specific aspects of usability (see appendix 3 for the main themes). The initial feedback from the interviews with the users pointed out that feeling validated was one of the main potential therapeutic benefits. One user talked about Cerina as if Cerina was a person. She mentioned that she identified herself with a case example about an employee who overprepared him/herself for a presentation. Finding the content relevant helped her to continue the sessions. Another user, who was seeing a therapist for her anxiety problems, said that using Cerina was re-assuring, and Cerina gave her the flexibility to practice anxiety management techniques in her own time and space (see appendix 4 for user testimonials):

“Cerina was very hands-on and it gave me the flexibility to work on my own anxiety, whereas therapy gives me a space to talk about it… It was very convenient that things we were talking about during therapy such as breathing techniques were available on Cerina and I was able to practice them between the sessions” User X, female, Tag

In terms of the usability of Cerina, convenience and flexibility were the main personal facilitators, whereas the simple UI and friendly language were highlighted as the main app-related facilitators whilst using Cerina. There were also barriers restricting the use of Cerina in daily life. The main personal barrier was forgetting to use the app due to workload or not feeling particularly anxious during that week. Also, a few technical problems were named such as not receiving notifications about an action plan for a particular exercise, issues with the navigation (i.e. frozen screen), and the high volume whilst listening to the audio of some of the anxiety management techniques.

There were also some suggestions to improve the usability of Cerina. These were mainly about making Cerina more interactive by incorporating pop-up reminders for using it more frequently and personalising the pop-up notifications. For instance, one user said that she would like it if Cerina realises when she feels bad and sends her a notification directing her to a specific session and/or an exercise momentarily:

When I feel bad, Cerina could advise me to go to a session or practice a specific technique…I would like it if the notifications are personalised depending on how I feel

Other suggestions included adding more sessions and exercises representative of the holistic perspective (e.g. mindfulness exercises) and being able to use Cerina on different platforms (i.e. desktop version, mobile version) in future versions.

Key takeaways

It is important to note that the first employees who completed their assessments had mild clinical symptoms, but their perceived functional impairment in their day-to-day life was more severe. It is known that the impact of having anxiety and depression symptoms (irrespective of the work environment) accounted for almost 18 million lost working days among employees (PHE, 2019). The recent meta-analytic studies also indicated that COVID-19 pandemic and its implications in work life such as decreased employment security, and the imposed demands of working irregular hours resulted in increased perceived impairment and psychological burn-out as well as a higher prevalence of common mental health conditions among employees (Schelhorn et al., 2021; Global Burden of Disease, 2022). Therefore, psychological interventions implemented in the workplace should not only target observable symptoms but also employees` perspectives on the impairment of daily functioning. In this context, if incorporated into an employee well-being programme, Cerina could be beneficial, especially for employees with mild to moderate symptoms of generalised anxiety and other clinical symptoms. Also, it could potentially help improve the manner in which observable symptoms impair the ability to function day to day.

To summarise, these initial results highlight Cerina`s usability and its potential therapeutic benefits. They should be considered in light of the limitations. The small sample size and underrepresentation of males restrict the conclusions drawn from the study. We also did not control for the life events which might have affected the questionnaire scores. Nonetheless, the initial feedback highlighting the usability of Cerina promises its potential to engage with the target users and strengthens its likely clinical effectiveness in future trials.

Key References:

Bangor, A., Kortum, P. T. & Miller, J. T. (2008) An Empirical Evaluation of the System Usability Scale, International Journal of Human–Computer Interaction, 24:6, 574-594, https://doi.org/10.1080/10447310802205776.

Mental, G. B. D., & Collaborators, D. (2022). Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet Psychiatry, 9(2), 137–150. https://doi.org/10.1016/s2215-0366(21)00395-3

Mundt, J., Marks, I., Shear, M., & Greist, J. (2002). The Work and Social Adjustment Scale: A simple measure of impairment in functioning. British Journal of Psychiatry, 180(5), 461-464. doi:10.1192/bjp.180.5.461

PHE document - Commissioning_effective_mental_health_prevention_report.pdf. (n.d.). Work-related stress, anxiety or depression statistics in Great Britain. (2019). March. https://www.hse.gov.uk/statistics/causdis/stress.pdf

Schelhorn, I., Ecker, A., Lüdtke, M. N., Rehm, S., Tran, T., Bereznai, J. L., Meyer, M. L., Sütterlin, S., Kinateder, M., Lugo, R. G., & Shiban, Y. (2021). Psychological Burden During the COVID-19 Pandemic in Germany. In Frontiers in Psychology (Vol. 12). https://doi.org/10.3389/fpsyg.2021.640518

Spitzer RL, Kroenke K, Williams JBW, Löwe B. (2006). A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7. Arch Intern Med.166(10):1092–1097. doi:10.1001/archinte.166.10.1092.

Spitzer, R. L., Kroenke, K., & Williams, J. B. (1999). Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA, 282(18), 1737–1744.

Appendix 1. Study Materials

Materials

Primary outcome measure

1. The Generalised Anxiety Disorder Scale-7 (GAD-7) (Spitzer et al., 2006) is a 7-item self-report scale that identifies and measures the severity of GAD. Scores range from 0 to 21, with a cut-off score of 5 distinguishing between clinical and non-clinical populations. The scale has good psychometric properties (Spitzer et al., 2006; Lovell et al., 2017).

Secondary outcome measures

2. The Patient Health Questionnaire (PHQ-9) (Spitzer, Kroenke & Williams, 1999) is a 9-item self-report scale that measures depression symptoms. Scores range from 0 to 27, with a score of 10 and above considered to be a clinically significant level of depression. The PHQ-9 has good reliability and validity Spitzer, Kroenke & Williams, 1999).

3. The Work and Social Adjustment Scale (WSAS) (Mundt et al., 2002) is a 5 item self-report measure that assesses functional impairment. Scores range from 0 to 40. The scale assesses the impact on work, home, social and private activities, and personal and family relationships. A score 20 and above is considered to indicate severe functional impairment, scores between 10 and 20 suggest severe but functional impairment, and scores of 10 and less are considered subclinical. The scale has good reliability and validity (Mundt et al., 2002).

4. The usability of Cerina will be measured with the System Usability Scale (SUS) and with semi-structured interviews. The SUS is composed of 10 statements that are scored on a 5-point scale of the extent of agreement (score 0 to 100). The reliability is good (Cronbach's alpha 0.91) (Bangor, Kortum & Miller, 2008). Interventions with scores of 70 and above are accepted as highly usable (Bangor et al., 2008) and scores between 50 and 70 indicate acceptable usability of an intervention. Interventions with scores of 50 and below are subject to concerns about their usability by the target population and should be investigated further (Bangor et al., 2008).

Appendix 2. Topic Guide for the Semi-Structured Interviews

1. What did you think of the device overall? Usability

a. Did you find any parts complex?

b. On a scale of 1-10 how easy did you find the app to navigate?

c. How often did you encounter bugs and glitches whilst navigating through the app?

d. On a scale of 1-10 how would you rate the look and feel of the app?

e. Do you have any suggestions for what could we do differently to make it easier to use?

f. Do you have any suggestions for what could we do to make it look better?

g. Since your first time using the app, did you notice any changes, can you give any examples?

2. What words or feelings come to mind when you think about Cerina?  Branding/ customer experience

a. In terms of information provided by the app did you feel confident in using the app effectively?

b. Do you have any suggestions when it comes to content for the app?

c. Would you recommend this app to a friend who suffers with anxiety problems?

2. Clinical Questions

1. How much time did you spend on the app per day or week? Did you complete all the sessions and how long did each session take you? If not, how far did you get? Why did you not complete?

2. Does the app help you in a way that you had expected? If not, what was missing or what exceeded your expectations?

3. Do you feel Cerina understands individuals with anxiety problems?

4. Is there anything that Cerina got wrong, did you feel misunderstood or any parts of the app felt irrelevant for your anxiety problems? (Please describe)

5. Do you think Cerina helped you in managing your anxiety problems?

If ‘yes’, please describe which aspects you found helpful

If ‘no’, please describe why you think Cerina was not helpful and share your ideas about what might have been more helpful

6. How did you find the anxiety management techniques?

7. Were you able to easily perform the tasks, if not what further information do you need, what would have helped you, do you have any suggestions?

8. Was there anything in the app that triggered you to feel upset or more anxious?

9. Closing General Question: Do you have any other feedback for us regarding the development of this app, or in general about the use of mental health apps?

Al revisar camiseta visitante de fútbol, conviene empezar por los colores y elementos propios de cada versión. Las fotografías y la ficha del producto deberían confirmar que las fotografías correspondan al mismo modelo descrito.

Cerina is an app founded on the principles of empathy and efficiency, two words that you rarely see go hand in hand. A medical-grade evidence-based digital therapist application providing disorder-specific psychological support through an interactive interface, Cerina works to provide mental health support where conventional routes fail to deliver. It distinguishes itself from the oversaturated market of technological wellbeing services through its personalised treatment programme.

Anyone familiar with the mental health services will know how frustrating it is being sent in circles trying to access the substantial and effective support we all deserve. Cerina wants to provide a solution to this inaccessibility, providing users with a compassionate and evidence-based support programme accessible 24/7 that adheres to The National Institute for Health and Care Excellence (NICE) ethical practice guidelines. A therapist in your pocket, whenever you need it, tailored to your personal needs. No more waiting lists, no more compromising your finances to jump to the front of the queue. The team behind Cerina know first-hand that your mental wellbeing is something that should be prioritised and protected whenever necessary, not just when you can be fit in.

The brainchild of Prasannajeet Mane, Cerina emerged from the CEO’s personal struggles with Obsessive Compulsive Disorder (OCD). Mane comes from a small village in Western India, and describes his upbringing as challenging, losing his father at just 14 years old. He started to develop severe symptoms of OCD during his undergraduate studies, leading to multiple suicide attempts. He was eventually diagnosed with OCD in early 2013 and describes his diagnosis and treatment as life-changing, altering the way he thought, behaved and learned for the better.

Mane’s own positive experience with treatment provoked a budding interest in mental health and psychology, which led him to take mental health elective courses and study brain and behavioural patterns. As his awareness of psychology behind mental health deepened, he expanded his interest into the commercial mental health space, identifying what was on offer and what gaps existed in the market. Whilst there are a lot of digital support systems out there, most tend to be focused on general wellness and lack in depth and clinically vigorous elements.

With the UK’s supply and demand ratio in regards to mental health support being devastatingly disproportionate, accessibility to engaging, interactive and humanised therapy is something that Cerina want to affordably provide. Cerina differentiates itself from other products within its market by not sacrificing one feature to amplify another. It aims to provide a personalised treatment programme offering the regulatory breathing exercises of its competitors in the same breath that it integrates Cognitive Behavioural Therapy (CBT) frameworks used in traditional therapy. The product is in the process of obtaining a medical-grade status to distinguish it as serving a medical purpose rather than simply being an app playing into the current trend of ‘self-care’, because Cerina believe in long-term and fundamental change. We also understand that mental health support is not one-size-fits-all, which is why we provide disorder-specific support for those seeking help with OCD, depression and anxiety, as opposed to general wellbeing and coaching with no particular focus. OCD is just one of many mental health conditions that Cerina focuses on, but in light of COVID-19 it is particularly interesting to reflect upon.

The pandemic has no doubt had an impact on the mental health of society at large, with restrictions behind placed on our social interactions, and general habits and conventions we had accepted as the norm being taken away to protect the health of the global population. Consequences such as these seem to naturally link to disorders like anxiety and depression, but perhaps most specific to COVID-19, and yet least publicly discussed, is how the hyper-focus on health, hygiene and sanitation has the potential to influence a spike in OCD tendencies. Mental health digital support in the mainstream tends to focus on low or anxious mood, so against the landscape of Coronavirus, Cerina stands out in its ability to provide support programs for those who may have an increased sensitivity to contamination. With social distancing guidelines meaning that even in-person therapy is currently taking place remotely, the multidimensionality of Cerina and the merits it can offer where conventional routes fail no longer seem substandard given how much we have had to rely on technology to function, and how successful we have all been in doing so.As we gradually ease COVID restrictions and return to some form of normality, it is so vital that we focus on our mental wellbeing and pay attention to the long-term mental impacts and collective traumas that the pandemic has brought upon us. Cerina want to use digital integration to support this process, and will soon be fully equipped to provide the wide variety of support different individuals may need.