Background Digital health interventions (DHIs) are efficacious for several mental disorders in youth; however, integrated, evidence-based knowledge about the mechanisms of change in these interventions is lacking. Objective This systematic review aims to comprehensively evaluate studies on mediators and mechanisms of change in different DHIs for common mental disorders in children and adolescents. Methods A systematic literature search of the electronic databases Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PsycINFO was conducted, complemented by backward and forward searches. Two independent reviewers selected studies for inclusion, extracted the data, and rated the methodological quality of eligible studies (ie, risk of bias and 8 quality criteria for process research). Results A total of 25 studies that have evaluated 39 potential mediators were included in this review. Cognitive mediators were the largest group of examined intervening variables, followed by a broad range of emotional and affective, interpersonal, parenting behavior, and other mediators. The mediator categories with the highest percentages of significant intervening variables were the groups of affective mediators (4/4, 100%) and combined cognitive mediators (13/19, 68%). Although more than three-quarters of the eligible studies met 5 or more quality criteria, causal conclusions have been widely precluded. Conclusions The findings of this review might guide the empirically informed advancement of DHIs, contributing to improved intervention outcomes, and the discussion of methodological recommendations for process research might facilitate mediation studies with more pertinent designs, allowing for conclusions with higher causal certainty in the future.

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BACKGROUND Digital health interventions (DHIs) are efficacious for several mental disorders in youth; however, integrated, evidence-based knowledge about the mechanisms of change in these interventions is lacking. OBJECTIVE This systematic review aims to comprehensively evaluate studies on mediators and mechanisms of change in different DHIs for common mental disorders in children and adolescents. METHODS A systematic literature search of the electronic databases Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PsycINFO was conducted, complemented by backward and forward searches. Two independent reviewers selected studies for inclusion, extracted the data, and rated the methodological quality of eligible studies (ie, risk of bias and 8 quality criteria for process research). RESULTS A total of 25 studies that have evaluated 39 potential mediators were included in this review. Cognitive mediators were the largest group of examined intervening variables, followed by a broad range of emotional and affective, interpersonal, parenting behavior, and other mediators. The mediator categories with the highest percentages of significant intervening variables were the groups of affective mediators (4/4, 100%) and combined cognitive mediators (13/19, 68%). Although more than three-quarters of the eligible studies met 5 or more quality criteria, causal conclusions have been widely precluded. CONCLUSIONS The findings of this review might guide the empirically informed advancement of DHIs, contributing to improved intervention outcomes, and the discussion of methodological recommendations for process research might facilitate mediation studies with more pertinent designs, allowing for conclusions with higher causal certainty in the future.

This paper attempts to bring to light a little-known genre of ukiyo-e (Japanese woodblock prints), the awate-e (hysteria pictures). This genre of polychrome ukiyo-e (nishiki-e) belongs among caricatures because it treats current events in a satirical way. The Namamugi incident (September 14, 1862), when samurai of the Satsuma domain killed one British merchant and injured two, led to the emergence of the awate-e. The British Crown demanded reparations for those killed. While the shogunate postponed payment, British warships gathered in the Bay of Edo to exert pressure. The danger of war was real and the cities of Yokohama and Edo were considered the main targets of a British attack. Many people moved to rural areas or at least sent their families and belongings away. This led to an increased demand for transport, houses, and land in the countryside. Hardly anybody remaining in the cities spent time in the pleasure quarters or bought luxury goods. The results were dramatic for people in those trades. This situation is satirised in the awate-e. Starting with the question ‘Why is the Geisha hitting the Westerner?’, this paper explores the genre of awate-e and its relevance for historical and ukiyo-e research by studying 21 awate-e as primary sources. It reveals a negative appraisal of Westerners, of people leaving the danger zone, and of professions in high demand. The producers of awate-e are biased towards people staying in areas become dangerous, professions suddenly grown poor, and the foreigners-out policy of the Emperor.