The impact of guidance on Internet-based mental health interventions — A systematic review

Guided and unguided Acceptance and Commitment Therapy for social anxiety disorder and/or panic disorder provided via the Internet and a smartphone application: A randomized controlled trial

Acceptance and Commitment Therapy (ACT) can be effective in treating anxiety disorders, yet there has been no study on Internet-delivered ACT for social anxiety disorder (SAD) and panic disorder (PD), nor any study investigating whether therapist guidance is superior to unguided self-help when supplemented with a smartphone application. In the current trial, n=152 participants diagnosed with SAD and/or PD were randomized to therapist-guided or unguided treatment, or a waiting-list control group. Both treatment groups used an Internet-delivered ACT-based treatment program and a smartphone application. Outcome measures were self-rated general and social anxiety and panic symptoms. Treatment groups saw reduced general (d=0.39) and social anxiety (d=0.70), but not panic symptoms (d=0.05) compared to the waiting-list group, yet no differences in outcomes were observed between guided and unguided interventions. We conclude that Internet-delivered ACT is appropriate for treating SAD and potentially PD. Smartphone applications may partially compensate for lack of therapist support.

Understanding and Promoting Effective Engagement With Digital Behavior Change Interventions

This paper is one in a series developed through a process of expert consensus to provide an overview of questions of current importance in research into engagement with digital behavior change interventions, identifying guidance based on research to date and priority topics for future research. The first part of this paper critically reflects on current approaches to conceptualizing and measuring engagement. Next, issues relevant to promoting effective engagement are discussed, including how best to tailor to individual needs and combine digital and human support. A key conclusion with regard to conceptualizing engagement is that it is important to understand the relationship between engagement with the digital intervention and the desired behavior change. This paper argues that it may be more valuable to establish and promote "effective engagement," rather than simply more engagement, with "effective engagement" defined empirically as sufficient engagement with the intervention to achieve intended outcomes. Appraisal of the value and limitations of methods of assessing different aspects of engagement highlights the need to identify valid and efficient combinations of measures to develop and test multidimensional models of engagement. The final section of the paper reflects on how interventions can be designed to fit the user and their specific needs and context. Despite many unresolved questions posed by novel and rapidly changing technologies, there is widespread consensus that successful intervention design demands a user-centered and iterative approach to development, using mixed methods and in-depth qualitative research to progressively refine the intervention to meet user requirements.

Internet-delivered transdiagnostic and tailored cognitive behavioral therapy for anxiety and depression: a systematic review and meta-analysis of randomized controlled trials

Anxiety and depressive disorders are often comorbid. Transdiagnostic and tailored treatments seem to be promising approaches in dealing with comorbidity. Although several primary studies have examined the effects of Internet-delivered cognitive behavior therapy (iCBT) for anxiety and depression, no meta-analysis including different types of iCBT that address comorbidity has been conducted so far. We conducted systematic searches in databases up to 1 July 2016. Only randomized trials comparing transdiagnostic/tailored iCBT for adult anxiety and/or depression with control groups were included. Nineteen randomized trials with a total of 2952 participants that met inclusion criteria were analyzed. The quality of the studies was high, however the blinding criteria were not fulfilled. The uncontrolled effect size (Hedges' g) of transdiagnostic/tailored iCBT on anxiety and depression outcomes was large and medium for quality of life. The controlled effect size for iCBT on anxiety and depression outcomes was medium to large (anxiety: g = .82, 95% CI: .58-1.05, depression: g = .79, 95% CI: .59-1.00) and medium on quality of life (g = .56, 95% CI: .37-.73). Heterogeneity was small (quality of life) to moderate (anxiety, depression). There was a large effect on generic outcome measures and a moderate effect on comorbidities. When compared to disorder-specific treatments there were no differences on anxiety and quality of life outcomes, however there were differences in depression outcomes. Transdiagnostic and tailored iCBT are effective interventions for anxiety disorders and depression. Future studies should investigate mechanisms of change and develop outcome measures for these interventions.

Overcoming procrastination: one-year follow-up and predictors of change in a randomized controlled trial of Internet-based cognitive behavior therapy

Procrastination is a common self-regulatory failure that can have a negative impact on well-being and performance. However, few clinical trials have been conducted, and no follow-up has ever been performed. The current study therefore aimed to provide evidence for the long-term benefits and investigate predictors of a positive treatment outcome among patients receiving Internet-based cognitive behavior therapy (ICBT). A total of 150 self-recruited participants were randomized to guided or unguided ICBT. Self-report measures of procrastination, depression, anxiety, and quality of life were distributed at pre-treatment assessment, post-treatment assessment, and one-year follow-up. Mixed effects models were used to investigate the long-term gains, and multiple linear regression for predictors of a positive treatment outcome, using the change score on the Irrational Procrastination Scale as the dependent variable. Intention-to-treat was implemented for all statistical analyses. Large within-group effect sizes for guided and unguided ICBT, Cohen's d = .97-1.64, were found for self-report measures of procrastination, together with d = .56-.66 for depression and anxiety. Gains were maintained, and, in some cases, improved at follow-up. Guided and unguided ICBT did not differ from each other, mean differences -.31-1.17, 95% CIs [-2.59-3.22], and none of the predictors were associated with a better result, bs -1.45-1.61, 95% CIs [-3.14-4.26]. In sum, ICBT could be useful and beneficial in relation to managing procrastination, yielding great benefits up to one year after the treatment period has ended, with comparable results between guided and unguided ICBT.

Internet-delivered acceptance-based behavior therapy for generalized anxiety disorder: A pilot study

OBJECTIVE

Internet-delivered cognitive behavior therapy (ICBT) has been developed and tested for treating persons with generalized anxiety disorder (GAD). A new form of CBT focuses on acceptance (of internal experiences or difficult psychological content), mindfulness and valued actions. To date this form of CBT has not been delivered via the internet for persons with GAD. The aim of this study was to describe the functionality of a new internet-delivered acceptance-based behavior therapy for GAD, and to test the effect of the intervention in an open pilot trial.

METHODS

Following exclusion of two patients we included 14 patients diagnosed with GAD from two primary care clinics. At 2-3 months follow-up after treatment 10 patients completed the outcome measures. The treatment lasted for an average of 15 weeks and consisted of acceptance-based techniques, behavior therapy components and homework assignments.

RESULTS

A majority of participants completed all modules during the treatment. Findings on the Penn State Worry Questionnaire showed a within-group improvement of Cohen's d = 2.14 at posttreatment. At the follow-up results were maintained. Client satisfaction ratings were high.

CONCLUSIONS

We conclude that internet-delivered acceptance-based behavior therapy potentially can be a promising new treatment for GAD. A controlled trial of the program has already been completed.

An Internet-based treatment for flying phobia (NO-FEAR Airlines): study protocol for a randomized controlled trial

BACKGROUND

Flying phobia (FP) is a common and disabling mental disorder. Although in vivo exposure is the treatment of choice, it is linked to a number of limitations in its implementation. Particularly important, is the limited access to the feared stimulus (i.e., plane). Moreover, the economic cost of in vivo exposure should be specially considered as well as the difficulty of applying the exposure technique in an appropriate way; controlling important variables such as the duration of the exposure or the number of sessions. ICTs could help to reduce these limitations. Computer-assisted treatments have remarkable advantages in treating FP. Furthermore, they can be delivered through the Internet, increasing their advantages and reaching more people in need. The Internet has been established as an effective way to treat a wide range of mental disorders. However, as far as we know, no controlled studies exist on FP treatment via the Internet. This study aims to evaluate the efficacy of an Internet-based treatment for FP (NO-FEAR Airlines) versus a waiting list control group. Secondary objectives will be to explore two ways of delivering NO-FEAR Airlines, with or without therapist guidance, and study the patients' acceptance of the program. This paper presents the study protocol.

METHODS/DESIGN

The study is a randomized controlled trial. A minimum of 57 participants will be randomly assigned to three conditions: a) NO-FEAR Airlines totally self-applied, b) NO-FEAR Airlines with therapist guidance, or c) a waiting list control group (6 weeks). Primary outcomes measures will be the Fear of Flying Questionnaire-II and the Fear of Flying Scale. Secondary outcomes will be included to assess other relevant clinical measures, such as the Fear and Avoidance Scales, Clinician Severity Scale, and Patient's Improvement scale. Analyses of post-treatment flights will be conducted. Treatment acceptance and preference measures will also be included. Intention-to-treat and per protocol analyses will be conducted.

DISCUSSION

An Internet-based treatment for FP could have considerable advantages in managing in vivo exposure limitations, specifically in terms of access to treatment, acceptance, adherence, and the cost-effectiveness of the intervention. This is the first randomized controlled trial to study this issue.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02298478 . Trial registration date 3 November 2014.

Effectiveness of Internet-Based Interventions for the Prevention of Mental Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Mental disorders are highly prevalent and associated with considerable disease burden and personal and societal costs. However, they can be effectively reduced through prevention measures. The Internet as a medium appears to be an opportunity for scaling up preventive interventions to a population level.

OBJECTIVE

The aim of this study was to systematically summarize the current state of research on Internet-based interventions for the prevention of mental disorders to give a comprehensive overview of this fast-growing field.

METHODS

A systematic database search was conducted (CENTRAL, Medline, PsycINFO). Studies were selected according to defined eligibility criteria (adult population, Internet-based mental health intervention, including a control group, reporting onset or severity data, randomized controlled trial). Primary outcome was onset of mental disorder. Secondary outcome was symptom severity. Study quality was assessed using the Cochrane Risk of Bias Tool. Meta-analytical pooling of results took place if feasible.

RESULTS

After removing duplicates, 1169 studies were screened of which 17 were eligible for inclusion. Most studies examined prevention of eating disorders or depression or anxiety. Two studies on posttraumatic stress disorder and 1 on panic disorder were also included. Overall study quality was moderate. Only 5 studies reported incidence data assessed by means of standardized clinical interviews (eg, SCID). Three of them found significant differences in onset with a number needed to treat of 9.3-41.3. Eleven studies found significant improvements in symptom severity with small-to-medium effect sizes (d=0.11- d=0.76) in favor of the intervention groups. The meta-analysis conducted for depression severity revealed a posttreatment pooled effect size of standardized mean difference (SMD) =-0.35 (95% CI, -0.57 to -0.12) for short-term follow-up, SMD = -0.22 (95% CI, -0.37 to -0.07) for medium-term follow-up, and SMD = -0.14 (95% CI, -0.36 to 0.07) for long-term follow-up in favor of the Internet-based psychological interventions when compared with waitlist or care as usual.

CONCLUSIONS

Internet-based interventions are a promising approach to prevention of mental disorders, enhancing existing methods. Study results are still limited due to inadequate diagnostic procedures. To be able to appropriately comment on effectiveness, future studies need to report incidence data assessed by means of standardized interviews. Public health policy should promote research to reduce health care costs over the long term, and health care providers should implement existing, demonstrably effective interventions into routine care.

Development and technical functionality of an Internet-based intervention for tinnitus in the UK

PURPOSE

Creative approaches to improve access to evidence-based tinnitus treatments are required. The purpose of this study was to develop an Internet-based cognitive behavioural therapy (iCBT) intervention, for those experiencing tinnitus in the United Kingdom (UK). Furthermore, it aimed, through technical functionality testing, to identify specific aspects of the iCBT that require improving.

METHOD

An innovative iCBT intervention for treating tinnitus in the UK has been developed using a cognitive-behavioural theoretical framework. This iCBT was evaluated by two user groups during this developmental phase. Initially, five expert reviews evaluated the intervention, prior to evaluation by a group of 29 adults experiencing significant levels of tinnitus distress. Both groups evaluated iCBT in an independent measures design, using a specifically designed satisfaction outcome measure.

RESULTS

Overall, similar ratings were given by the expert reviewers and adults with tinnitus, showing a high level of satisfaction regarding the content, suitability, presentation, usability and exercises provided in the intervention. The iCBT intervention has been refined following technical functionality testing.

CONCLUSIONS

Rigorous testing of the developed iCBT intervention has been undertaken. These evaluations provide confidence that further clinical trials can commence in the UK, to assess the feasibility and effectiveness of this iCBT intervention for tinnitus.

Economic evaluation of Internet-based problem-solving guided self-help treatment in comparison with enhanced usual care for depressed outpatients waiting for face-to-face treatment: A randomized controlled trial

BACKGROUND

Previous studies have demonstrated the effectiveness of Internet-based interventions for depression in comparison with usual care. However, evidence on the cost-effectiveness of these interventions when delivered in outpatient clinics is lacking. The aim of this study was to estimate the cost-effectiveness of an Internet-based problem-solving guided self-help intervention in comparison with enhanced usual care for outpatients on a waiting list for face-to-face treatment for major depression. After the waiting list period, participants from both groups received the same treatment at outpatient clinics.

METHODS

An economic evaluation was performed alongside a randomized controlled trial with 12 months follow-up. Outcomes were improvement in depressive symptom severity (measured by CES-D), response to treatment and Quality-Adjusted Life-Years (QALYs). Statistical uncertainty around cost differences and incremental cost-effectiveness ratios were estimated using bootstrapping.

RESULTS

Mean societal costs for the intervention group were €1579 higher than in usual care, but this was not statistically significant (95% CI - 1395 to 4382). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective in comparison with usual care was 0.57 at a ceiling ratio of €15,000/additional point of improvement in CES-D, and 0.25 and 0.30 for an additional response to treatment and an extra QALY respectively, at a ceiling ratio of €30,000. Sensitivity analysis showed that from a mental healthcare provider perspective the probability of the intervention being cost-effective was 0.68 for a ceiling ratio of 0 €/additional unit of effect for the CES-D score, response to treatment and QALYs. As the ceiling ratio increased this probability decreased, because the mean costs in the intervention group were lower than the mean costs in the usual care group.

LIMITATIONS

The patients in the intervention group showed low adherence to the Internet-based treatment. It is possible that greater adherence would have led to larger clinical effects.

CONCLUSIONS

Offering an Internet-based intervention to depressed outpatients on waiting list for face-to-face treatment was not considered cost-effective in comparison with enhanced usual care from a societal perspective. There was a high probability of the intervention being cost-effective in comparison with enhanced usual care from the perspective of the mental healthcare provider.

Transdiagnostic Internet-delivered cognitive behaviour therapy in Canada: An open trial comparing results of a specialized online clinic and nonspecialized community clinics

Effects of Internet-delivered cognitive behaviour therapy (ICBT) for anxiety and depression are not well understood when delivered in non-specialized as compared to specialized clinic settings. This open trial (n=458 patients) examined the benefits of transdiagnostic-ICBT when delivered in Canada by therapists (registered providers or graduate students) working in either a specialized online clinic or one of eight nonspecialized community clinics. Symptoms of depression and anxiety were assessed at pre-treatment, post-treatment and at 3-month follow-up. Completion rates and satisfaction were high. Significant and large reductions (effect sizes 1.17-1.31) were found on symptom measures. Completion rates, satisfaction levels and outcomes did not differ whether ICBT was delivered by therapists working in a specialized online clinic or nonspecialized community clinics. Differences were also not found between registered providers and graduate students, or therapists trained in psychology or another discipline. The findings support the public health potential of ICBT.

Smartphone-Based Psychotherapeutic Micro-Interventions to Improve Mood in a Real-World Setting

BACKGROUND

Using mobile communication technology as new personalized approach to treat mental disorders or to more generally improve quality of life is highly promising. Knowledge about intervention components that target key psychopathological processes in terms of transdiagnostic psychotherapy approaches is urgently needed. We explored the use of smartphone-based micro-interventions based on psychotherapeutic techniques, guided by short video-clips, to elicit mood changes.

METHOD

As part of a larger neurofeedback study, all subjects-after being randomly assigned to an experimental or control neurofeedback condition-underwent daily smartphone-based micro-interventions for 13 consecutive days. They were free to choose out of provided techniques, including viscerosensory attention, emotional imagery, facial expression, and contemplative repetition. Changes in mood were assessed in real world using the Multidimensional Mood State Questionnaire (scales: good-bad, GB; awake-tired, AT; and calm-nervous, CN).

RESULTS

Twenty-seven men participated on at least 11 days and were thus included in the analyses. Altogether, they underwent 335, generally well-tolerated, micro-intervention sessions, with viscerosensory attention (178 sessions, 53.13%) and contemplative repetition (68 sessions, 20.30%) being the most frequently applied techniques. Mixed models indicated that subjects showed better mood [GB: b = 0.464, 95%confidence interval (CI) [0.068, 0.860], t (613.3) = 2.298, p = 0.022] and became more awake [AT: b = 0.514, 95%CI [0.103, 0.925], t (612.4) = 2.456, p = 0.014] and calmer [CN: b = 0.685, 95%CI [0.360, 1.010], t (612.3) = 4.137, p < 0.001] from pre- to post-micro-intervention. These mood improvements from pre- to post-micro-intervention were associated with changes in mood from the 1st day until the last day with regard to GB mood (r = 0.614, 95%CI [0.297, 0.809], p < 0.001), but not AT mood (r = 0.279, 95%CI [-0.122, 0.602], p = 0.167) and CN mood (r = 0.277, 95%CI [0.124, 0.601], p = 0.170).

DISCUSSION

Our findings provide evidence for the applicability of smartphone-based micro-interventions eliciting short-term mood changes, based on techniques used in psychotherapeutic approaches, such as mindfulness-based psychotherapy, transcendental meditation, and other contemplative therapies. The results encourage exploring these techniques' capability to improve mood in randomized controlled studies and patients. Smartphone-based micro-interventions are promising to modify mood in real-world settings, complementing other psychotherapeutic interventions, in line with the precision medicine approach. The here presented data were collected within a randomized trial, registered at ClinicalTrials.gov (Identifier: NCT01921088) https://clinicaltrials.gov/ct2/show/NCT01921088.

Using a transdiagnostic, psychodynamic online self-help intervention to maintain inpatient psychosomatic treatment effects: Study protocol of a feasibility study

BACKGROUND

Online self-help interventions have proven to be effective in treating various specific mental disorders, mainly depression and anxiety. Knowledge regarding their acceptance, efficacy, and usefulness in addition to inpatient or outpatient psychotherapy is limited. Therefore, we plan to evaluate an affect-focused, transdiagnostic, psychodynamic online self-help intervention following inpatient psychotherapy for mixed diagnoses in a feasibility study to determine acceptance, satisfaction, and preliminary estimates of efficacy.

METHODS

The intervention is based on the book "Living Like You Mean It" by Ronald J. Frederick (2009) and the Swedish adaption by Johansson and colleagues (2013). The book was translated into German and thoroughly revised using parts of the Swedish adaption and additional tasks from their intervention. In a pilot phase, corrections concerning comprehensibility of the content and exercises were made based on patient's feedback. In the second step, we developed a website presenting the German adaption in eight units. In the third step, at least N = 66 patients from the Department of Psychosomatic Medicine and Psychotherapy will be recruited for a feasibility study. Patients are randomized into two groups. The intervention group (IG) will receive ten weeks of access to the online self-help intervention together with weekly therapeutic feedback on their progress. The wait-list control group (WLC) will receive access to the intervention for ten weeks as well, but without therapeutic feedback and with a ten-week delay. We will conduct assessments at the beginning of the intervention of the IG (T0), the end of the intervention of the IG (T1), two months later (only IG, T2), and at the end of the intervention of the WLC (T3). The primary outcome is satisfaction with the treatment as measured by the ZUF-8 at T1 and T3 respectively. Secondary outcome measures include emotional competence, depression, anxiety, and quality of life.

CONCLUSION

We expect insight into the usefulness and acceptance of an online self-help intervention used to maintain inpatient treatment effects. Furthermore, we await both groups to benefit from the participation in the intervention. Pre- post and between subject differences will be used as estimate effect sizes to calculate the necessary sample size for a larger efficacy trial.

A sorrow shared is a sorrow halved? A three-arm randomized controlled trial comparing internet-based clinician-guided individual versus group treatment for social anxiety disorder

A growing body of evidence suggests that internet-based cognitive behavioural treatments (ICBT) are effective to treat social anxiety disorder (SAD). Whereas the efficacy of clinician-guided ICBT has been established, ICBT in a group format has not yet been systematically investigated. This three-arm RCT compared the efficacy of clinician-guided group ICBT (GT) with clinician guided individual ICBT (IT) and a wait-list (WL). A total of 149 individuals meeting the diagnostic criteria for SAD were randomly assigned to one of three conditions. Primary endpoints were self-report measures of SAD and diagnostic status taken at baseline, after the twelve-week intervention and at six-month follow-up. Secondary endpoints were symptoms of depression, interpersonal problems and general symptomatology. At post-treatment, both active conditions showed superior outcome regarding SAD symptoms (GT vs. WL: d = 0.84-0.74; IT vs. WL: d = 0.94-1.22). The two active conditions did not differ significantly in symptom reduction (d = 0.12-0.26, all ps > 0.63), diagnostic response rate or attrition. Treatment gains were maintained at follow-up. The group format reduced weekly therapist time per participant by 71% (IT: 17 min, GT: 5 min). Findings indicate that a clinician-guided group format is a promising approach in treating SAD.

Adherence to Internet-Based Mobile-Supported Stress Management: A Pooled Analysis of Individual Participant Data From Three Randomized Controlled Trials

Background

Nonadherence to treatment is a prevalent issue in Internet interventions. Guidance from health care professionals has been found to increase treatment adherence rates in Internet interventions for a range of physical and mental disorders. Evaluating different guidance formats of varying intensity is important, particularly with respect to improvement of effectiveness and cost-effectiveness. Identifying predictors of nonadherence allows for the opportunity to better adapt Internet interventions to the needs of participants especially at risk for discontinuing treatment.

Objective

The goal of this study was to investigate the influence of different guidance formats (content-focused guidance, adherence-focused guidance, and administrative guidance) on adherence and to identify predictors of nonadherence in an Internet-based mobile-supported stress management intervention (ie, GET.ON Stress) for employees.

Methods

The data from the groups who received the intervention were pooled from three randomized controlled trials (RCTs) that evaluated the efficacy of the same Internet-based mobile-supported stress management intervention (N=395). The RCTs only differed in terms of the guidance format (content-focused guidance vs waitlist control, adherence-focused guidance vs waitlist control, administrative guidance vs waitlist control). Adherence was defined by the number of completed treatment modules (0-7). An ANOVA was performed to compare the adherence rates from the different guidance formats. Multiple hierarchical linear regression analysis was conducted to evaluate predictors of nonadherence, which included gender, age, education, symptom-related factors, and hope for improvement.

Results

In all, 70.5% (93/132) of the content-focused guidance sample, 68.9% (91/132) of the adherence-focused guidance sample, and 42.0% (55/131) of the participants in the administrative guidance sample completed all treatment modules. Guidance had a significant effect on treatment adherence (F_2,392=11.64, P<.001; ω²=.05). Participants in the content-focused guidance (mean 5.70, SD 2.32) and adherence-focused guidance samples (mean 5.58, SD 2.33) completed significantly more modules than participants in the administrative guidance sample (mean 4.36, SD 2.78; t₂₂₃=4.53, P<.001; r=.29). Content-focused guidance was not significantly associated with higher adherence compared to adherence-focused guidance (t₂₆₂=0.42, P=.67; r=.03). The effect size of r=.03 (95% CI –0.09 to 0.15) did not pass the equivalence margin of r=.20 and the upper bound of the 95% CI lay below the predefined margin, indicating equivalence between adherence-focused guidance and content-focused guidance. Beyond the influence of guidance, none of the predictors significantly predicted nonadherence.

Conclusions

Guidance has been shown to be an influential factor in promoting adherence to an Internet-based mobile-supported stress management intervention. Adherence-focused guidance, which included email reminders and feedback on demand, was equivalent to content-focused guidance with regular feedback while requiring only approximately a quarter of the coaching resources. This could be a promising discovery in terms of cost-effectiveness. However, even after considering guidance, sociodemographic, and symptom-related characteristics, most interindividual differences in nonadherence remain unexplained.

Clinical Trial

DRKS00004749; http://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL _ID=DRKS00004749 (Archived by WebCite at http://www.webcitation.org/6QiDk9Zn8); DRKS00005112; http://drks-neu.uniklinik-freiburg. de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005112 (Archived by WebCite at http://www.webcitation.org/6QiDysvev); DRKS00005384; http://drks-neu.uniklinik-freiburg.de/ drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005384 (Archived by WebCite at http://www.webcitation.org/6QiE0xcpE)

Web-Based Fully Automated Self-Help With Different Levels of Therapist Support for Individuals With Eating Disorder Symptoms: A Randomized Controlled Trial

Background

Despite the disabling nature of eating disorders (EDs), many individuals with ED symptoms do not receive appropriate mental health care. Internet-based interventions have potential to reduce the unmet needs by providing easily accessible health care services.

Objective

This study aimed to investigate the effectiveness of an Internet-based intervention for individuals with ED symptoms, called “Featback.” In addition, the added value of different intensities of therapist support was investigated.

Methods

Participants (N=354) were aged 16 years or older with self-reported ED symptoms, including symptoms of anorexia nervosa, bulimia nervosa, and binge eating disorder. Participants were recruited via the website of Featback and the website of a Dutch pro-recovery–focused e-community for young women with ED problems. Participants were randomized to: (1) Featback, consisting of psychoeducation and a fully automated self-monitoring and feedback system, (2) Featback supplemented with low-intensity (weekly) digital therapist support, (3) Featback supplemented with high-intensity (3 times a week) digital therapist support, and (4) a waiting list control condition. Internet-administered self-report questionnaires were completed at baseline, post-intervention (ie, 8 weeks after baseline), and at 3- and 6-month follow-up. The primary outcome measure was ED psychopathology. Secondary outcome measures were symptoms of depression and anxiety, perseverative thinking, and ED-related quality of life. Statistical analyses were conducted according to an intent-to-treat approach using linear mixed models.

Results

The 3 Featback conditions were superior to a waiting list in reducing bulimic psychopathology (d=−0.16, 95% confidence interval (CI)=−0.31 to −0.01), symptoms of depression and anxiety (d=−0.28, 95% CI=−0.45 to −0.11), and perseverative thinking (d=−0.28, 95% CI=−0.45 to −0.11). No added value of therapist support was found in terms of symptom reduction although participants who received therapist support were significantly more satisfied with the intervention than those who did not receive supplemental therapist support. No significant differences between the Featback conditions supplemented with low- and high-intensity therapist support were found regarding the effectiveness and satisfaction with the intervention.

Conclusions

The fully automated Internet-based self-monitoring and feedback intervention Featback was effective in reducing ED and comorbid psychopathology. Supplemental therapist support enhanced satisfaction with the intervention but did not increase its effectiveness. Automated interventions such as Featback can provide widely disseminable and easily accessible care. Such interventions could be incorporated within a stepped-care approach in the treatment of EDs and help to bridge the gap between mental disorders and mental health care services.

Trial Registration

Netherlands Trial Registry: NTR3646; http://www.trialregister.nl/trialreg/admin/ rctview.asp?TC=3646 (Archived by WebCite at http://www.webcitation.org/6fgHTGKHE)

Uptake and Usage of IntelliCare: A Publicly Available Suite of Mental Health and Well-Being Apps

BACKGROUND

Treatments for depression and anxiety have several behavioral and psychological targets and rely on varied strategies. Digital mental health treatments often employ feature-rich approaches addressing several targets and strategies. These treatments, often optimized for desktop computer use, are at odds with the ways people use smartphone applications. Smartphone use tends to focus on singular functions with easy navigation to desired tools. The IntelliCare suite of apps was developed to address the discrepancy between need for diverse behavioral strategies and constraints imposed by typical app use. Each app focuses on one strategy for a limited subset of clinical aims all pertinent to depression and anxiety. This study presents the uptake and usage of apps from the IntelliCare suite following an open deployment on a large app marketplace.

METHODS

Thirteen lightweight apps, including 12 interactive apps and one Hub app that coordinates use across those interactive apps, were developed and made free to download on the Google Play store. De-identified app usage data from the first year of IntelliCare suite deployment were analyzed for this study.

RESULTS

In the first year of public availability, 5,210 individuals downloaded one or more of the IntelliCare apps, for a total of 10,131 downloads. Nearly a third of these individuals (31.8%) downloaded more than one of these apps. The modal number of launches for each of the apps was 1, however the mean number of app launches per app ranged from 3.10 to 16.98, reflecting considerable variability in the use of each app.

CONCLUSIONS

The use rate of the IntelliCare suite of apps is higher than public deployments of other comparable digital resources. Our findings suggest that people will use multiple apps and provides support for the concept of app suites as a useful strategy for providing diverse behavioral strategies.

Internet-delivered Cognitive Behaviour Therapy for Depressive Symptoms: An Exploratory Examination of Therapist Behaviours and their Relationship to Outcome and Therapeutic Alliance

Background: A previous study of therapist-assisted Internet-delivered cognitive behaviour therapy (ICBT) for generalized anxiety (Paxling et al., 2013) identified eight distinct therapist behaviours in ICBT (task reinforcement, self-efficacy shaping, task prompting, alliance bolstering, psychoeducation, empathetic utterances, deadline flexibility, and self-disclosure). It is unknown how generalizable these behaviours are across ICBT programs. Aims: We systematically examined the frequency of these eight therapist behaviours and additional newly identified behaviours in e-mails sent to patients during the course of ICBT for depressive symptoms. We also conducted exploratory analyses to examine relationships between therapist behaviours, symptom improvement, and therapeutic alliance. Method: Data was obtained from a previously published open trial (Hadjistavropoulos et al., 2014). A total of 1013 e-mails sent from therapists (n = 24) to patients (n = 41) during ICBT for depressive symptoms were analyzed. Therapist behaviours were correlated with symptom change scores and ratings of therapeutic alliance at mid- and post-treatment. Results: Therapist behaviours described by Paxling et al. were reliably identified in the e-mails using qualitative content analysis; the frequencies of these behaviours differed, however, from the Paxling et al. study and three additional therapist behaviours were identified (administrative statements, questionnaire feedback, asking clarifying questions). Several therapist behaviours (e.g. administrative statements, task prompting) were associated with lower symptom improvement at post-treatment. Questionnaire feedback and task reinforcement were associated with higher patient ratings of therapeutic alliance. Conclusions: The study provides partial support for the generalizability of therapist-assistance across ICBT programs. Experimental research is needed to examine the impact of varying therapist-assistance on patient outcomes.

Prevention and early intervention of anxiety problems in young children: A pilot evaluation of Cool Little Kids Online

Anxiety disorders are common, debilitating, and begin early in life. Early intervention to prevent anxiety disorders in children who are at risk could have long-term impact. The 'Cool Little Kids' parenting group program has previously been shown to be efficacious in preventing anxiety disorders in temperamentally inhibited young children. Wider dissemination of the program could be achieved with an internet-based delivery platform, affording greater accessibility and convenience for parents. The aim of this study was to evaluate 'Cool Little Kids Online', a newly developed online version of the existing parenting group program. Fifty-one parents of children aged 3-6 years were recruited to evaluate the online program's acceptability and preliminary efficacy in reducing inhibited young children's anxiety problems. Parents were randomized to receive either a clinician-supported version or an unsupported version of the program. Parents had 10 weeks to access the program and completed questionnaires at baseline and post-intervention. Both groups showed medium-to-large reductions in children's anxiety symptoms, emotional symptoms, number of child anxiety diagnoses, and improvements in life interference from anxiety. The effect of clinician support was inconsistent and difficult to interpret. Parents reported high levels of satisfaction with the program. These encouraging results indicate that the online version is acceptable and useful for parents with temperamentally inhibited young children. Cool Little Kids Online may be a promising direction for improving access to an evidence-based prevention and early intervention program for child anxiety problems. A large randomized trial is warranted to further evaluate efficacy.

Cluster randomised controlled trial of the e-couch Anxiety and Worry program in schools

BACKGROUND

Anxiety is a common mental health problem in youth. The current study aimed to test the effectiveness of an online self-directed anxiety prevention program in a school-based sample and to compare two methods of implementing an anxiety program in schools.

METHODS

A three-arm cluster stratified randomised controlled trial was conducted with 30 Australian schools. Each school was randomly assigned to receive: (1) externally-supported intervention, (2) teacher-supported intervention, or (3) wait-list control. All consenting students (N=1767) were invited to complete pre-intervention, post-intervention, 6- and 12-month follow-up questionnaires measuring generalised anxiety, social anxiety, anxiety sensitivity, depressive symptoms and mental wellbeing. Intervention participants completed the e-couch Anxiety and Worry program over 6 weeks.

RESULTS

At post-intervention, 6- and 12-month follow-up no significant differences were observed between the intervention and control conditions for generalised anxiety (Cohen's d=-0.14 to 0.15), social anxiety (d=0.04-0.23), anxiety sensitivity (d=-0.07 to 0.07), depressive symptoms (d=-0.05 to 0.04) or mental wellbeing (d=-0.06 to -0.30).

LIMITATIONS

The current study only included self-report measures that may have been influenced by situational factors or biases.

CONCLUSIONS

The e-couch Anxiety and Worry program did not have a significant positive effect on participant mental health or wellbeing. The addition of a mental health education officer to support classroom teachers in the delivery of the program also had no effect on intervention outcomes. Future prevention research should look to develop briefer and more interactive interventions that are more engaging for youth.

Therapeutic Alliance in Internet-Delivered Cognitive Behaviour Therapy for Depression or Generalized Anxiety

There has been limited research on therapeutic alliance in the context of therapist-assisted Internet-delivered cognitive behaviour therapy (ICBT) when delivered in clinical practice. The present study investigated therapeutic alliance in ICBT delivered to patients seeking treatment for symptoms of depression (n = 83) or generalized anxiety (n = 112) as part of an open dissemination trial. ICBT was provided by 27 registered therapists or 28 graduate students working in six geographically dispersed clinics; therapist-assistance was delivered primarily through secure messages and occasionally telephone calls. The Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 were collected pre-, mid- and post-treatment, and the Therapeutic Alliance Questionnaire was assessed mid- and post-treatment. Therapeutic alliance ratings were high both at mid-treatment and post-treatment (above 80%). There was no relationship between therapeutic alliance ratings and improvement on primary outcomes. Among patients treated for depression, lower ratings of mid-treatment alliance were associated with concurrent treatment by a psychiatrist and fewer phone calls and emails from their therapist. Among patients treated for generalized anxiety, ratings of mid-treatment alliance were higher among registered providers as compared to graduate students. Multiple directions for future research on therapeutic alliance in ICBT are offered, including suggestions for developing a new measure of therapeutic alliance specific to ICBT and measuring therapeutic alliance throughout the treatment process. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

This research demonstrated that therapeutic alliance ratings were very strong at both mid- and post-treatment among patients who received Internet-delivered cognitive behaviour therapy (ICBT) for depression or anxiety in clinical practice. Among patients receiving ICBT for depression, lower ratings of therapeutic alliance were associated with patients reporting concurrent treatment by a psychiatrist and with the receipt of fewer phone calls and emails from the therapist. Among patients receiving ICBT for generalized anxiety, ratings of alliance were higher when patients were treated by registered providers as compared to graduate students. Therapeutic alliance ratings did not predict outcome in ICBT for depression or anxiety. Practitioners have reason to be confident that a therapeutic relationship can be formed in ICBT when delivered in clinical practice.

E-Health Interventions for Eating Disorders: Emerging Findings, Issues, and Opportunities

This study aimed to review the emerging findings regarding E-health interventions for eating disorders and to critically discuss emerging issues as well as challenges for future research. Internet-based cognitive behavioral therapy and guided self-help have demonstrated promising results in terms of reducing eating disorder psychopathology. Emerging findings also suggest that E-health interventions reach an underserved population and improve access to care. The use of smartphone applications is becoming increasingly popular and has much potential although their clinical utility and effectiveness is presently unknown and requires investigation. Important challenges include the diagnostic process in E-health interventions, the optimization of E-health within existing health care models, and the investigation and implementation of blended care. More high-quality research is needed to bring the field forward and to determine the place for E-health in our health care service delivery systems.

A Randomised Controlled Trial of Therapist-Assisted, Internet-Delivered Cognitive Behavior Therapy for Women with Maternal Depression

Postpartum depression impacts up to 15% of Canadian women following childbirth. Remarkably, many women suffering from this disorder do not receive appropriate treatment. The aim of this study was to conduct a parallel-group randomized controlled trial to determine the efficacy of Therapist-Assisted Internet-delivered Cognitive Behavior Therapy (TA-ICBT) for the treatment of postpartum depression. This study was registered with the International Standard Randomized Controlled Trials (ISRCTN: 85456371) and received funding from Canadian Institutes of Health Research (#101526) and the Saskatchewan Health Research Foundation. Fifty women who gave birth to an infant in the past year, who scored above 10 on the Edinburgh Postnatal Depression Scale (EPDS), and who resided in Saskatchewan, Canada were eligible to participate. Participants were randomly assigned to receive either TA-ICBT (n = 25) or waitlist control (n = 25). The efficacy of the treatment was investigated at baseline and at seven- to 10-week follow-up. TA-ICBT participants were also contacted four-weeks following treatment completion. Symptoms of postpartum depression decreased more for participants in the TA-ICBT group (average reduction of 6.24 points on the EPDS; n = 21 included in analyses) compared to those participants in the waitlist control group (average reduction of 2.42 points on the EPDS; n = 20 included in analyses), and these results were clinically significant and maintained at four-week follow-up. TA-ICBT participants demonstrated a reduction in postnatal anxiety, general stress, and parental distress, and an increase in psychological and environmental quality of life when compared to the waitlist control participants. Study implications, limitations, and future research directions are discussed.

An online guided ACT intervention for enhancing the psychological wellbeing of university students: A randomized controlled clinical trial

Stress, anxiety and depression are relatively common problems among university students. This study examined whether an online psychological intervention aiming at enhancing the wellbeing of university students could be an effective and practical alternative for meeting the needs of a university population. University students (N = 68; 85% female; 19-32 years old) were randomly assigned to either a guided seven-week online Acceptance and Commitment Therapy (iACT) intervention or a waiting list control condition (WLC). A between-groups pre-post (iACT vs WLC) design with 12-month follow-up for the iACT participants was conducted. The intervention participants were offered two face-to-face meetings, completed online exercises during a five-week period, and received personal weekly written feedback via the website from their randomly assigned, trained student coaches. Waitlist participants were offered the intervention program soon after the post measurements. Results in this small efficacy trial showed that the iACT participants had significantly higher gains in wellbeing (between group, d = 0.46), life satisfaction (d = 0.65), and mindfulness skills (d = 0.49). In addition, iACT participants' self-reported stress (d = 0.54) and symptoms of depression (d = 0.69) were significantly reduced compared to the participants in the control group. These benefits were maintained over a 12-month follow-up period (within iACT group, d = 0.65-0.69, for primary measures). The results suggest that an online-based, coach-guided ACT program with blended face-to-face and online sessions could be an effective and well-accepted alternative for enhancing the wellbeing of university students.

Internet-based treatment for Romanian adults with panic disorder: protocol of a randomized controlled trial comparing a Skype-guided with an unguided self-help intervention (the PAXPD study)

BACKGROUND

Efficacy of self-help internet-based cognitive behavior therapy (ICBT) for anxiety disorders has been confirmed in several randomized controlled trials. However, the amount and type of therapist guidance needed in ICBT are still under debate. Previous studies have shown divergent results regarding the role of therapist guidance and its impact on treatment outcome. This issue is central to the development of ICBT programs and needs to be addressed directly. The present study aims to compare the benefits of regular therapist guidance via online real-time audio-video communication (i.e. Skype) to no therapist guidance during a 12-week Romanian self-help ICBT program for Panic Disorder. Both treatments are compared to a waiting-list control group.

METHODS/DESIGN

A parallel group randomized controlled trial is proposed. The participants, 192 Romanian adults fulfilling diagnostic criteria for panic disorder according to a diagnostic interview, conducted via secured Skype or telephone, are randomly assigned to one of the three conditions: independent use of the internet-based self-help program PAXonline, the same self-help treatment with regular therapist support via secured Skype, and waiting-list control group. The primary outcomes are severity of self-report panic symptoms (PDSS-SR) and diagnostic status (assessors are blind to group assignment), at the end of the intervention (12 weeks) and at follow-up (months 3 and 6). The secondary measures address symptoms of comorbid anxiety disorders, depression, quality of life, adherence and satisfaction with ICBT. Additional measures of socio-demographic characteristics, personality traits, treatment expectancies, catastrophic cognitions, body vigilance and working alliance are considered as potential moderators and/ or mediators of treatment outcome.

DISCUSSION

To the best of our knowledge, the present study is the first effort to investigate the efficacy of a self-help internet-based intervention with therapist guidance via real-time video communication. A direct comparison between therapist guided versus unguided self-directed intervention for panic disorder will also be addressed for the first time. Findings from this study will inform researchers and practitioners about the added value of online video-therapy guidance sessions and the type of patients who may benefit the most from guided and unguided ICBT for Panic disorder.

TRIAL REGISTRATION

ACTRN12614000547640 (Australian New Zealand Clinical Trials Registry). Registered 22/05/2014.

Internet interventions for chronic pain including headache: A systematic review

Chronic pain is a major health problem and behavioral based treatments have been shown to be effective. However, the availability of these kinds of treatments is scarce and internet-based treatments have been shown to be promising in this area. The objective of the present systematic review is to evaluate internet-based interventions for persons with chronic pain. The specific aims are to do an updated review with a broad inclusion of different chronic pain diagnoses and to assess disability and pain and also measures of catastrophizing, depression and anxiety. A systematic search identified 891 studies and 22 trials were selected as eligible for review. Two of the selected trials included children/youth and five included individuals with chronic headache and/or migraine. The most frequently measured domain reflected in the primary outcomes was interference/disability, followed by catastrophizing. Result across the studies showed a number of beneficial effects. Twelve trials reported significant effects on disability/interference outcomes and pain intensity. Positive effects were also found on psychological variable such as catastrophizing, depression and anxiety. Several studies (n = 12) were assessed to have an unclear level of risk bias. The attrition levels ranged from 4% to 54% where the headache trials had the highest drop-out levels. However, findings suggest that internet-based treatments based on cognitive behavioural therapy (CBT) are efficacious measured with different outcome variables. Results are in line with trials in clinical settings. Meta-analytic statistics were calculated for interference/disability, pain intensity, catastrophizing and mood ratings. Results showed that the effect size for interference/disability was Hedge's g = - 0.39, for pain intensity Hedge's g = - 0.33, for catastrophizing Hedge's g = - 0.49 and for mood variables (depression) Hedge's g = - 0.26.

Acceptability of internet interventions for youth mental health in Vietnam

BACKGROUND

Despite high levels of mental illness, Vietnamese youth have limited access to mental health care. Internet interventions, evidence-based psychotherapy treatments delivered through the internet, have the potential to increase access to mental health for youth in Vietnam. This study explored the perceptions of youths and parents toward internet interventions for youth mental health.

METHODS

Four focus groups were conducted with youths (n = 20) and parents (n = 20) in Danang, Vietnam. The Technology Acceptance Model was used a framework for focus group questions. The data were analyzed using direct content analysis.

RESULTS

Most youths and parents agreed that the internet serves well as a care delivery model. Participants expressed that the web would be useful for psychoeducation and sharing and receiving information with others. Both groups reported lack of awareness of web-based interventions and logistical concerns regarding access as main barriers. In addition, many parents were concerned about internet addiction. Specific adaptations in Vietnam such as standalone internet service centers and partnering with local organizations may benefit uptake of internet interventions.

CONCLUSION

This study suggests that internet-based programs for youth mental health, particularly interventions incorporating psychoeducation and social networking components, will be well received in Vietnam. Barriers need to be addressed to successfully implement internet-based treatment. Future initiatives should incorporate acceptance models to improve development of internet interventions for youth.

Promoting Personal Recovery in People with Persisting Psychotic Disorders: Development and Pilot Study of a Novel Digital Intervention

BACKGROUND

For people with persisting psychotic disorders, personal recovery has become an important target of mental health services worldwide. Strongly influenced by mental health service consumer perspectives, personal recovery refers to being able to live a satisfying and contributing life irrespective of ongoing symptoms and disability. Contact with peers with shared lived experience is often cited as facilitative of recovery. We aimed to develop and pilot a novel recovery-based digitally supported intervention for people with a psychotic illness.

METHODS

We developed a website to be used on a tablet computer by mental health workers to structure therapeutic discussions about personal recovery. Central to the site was a series of video interviews of people with lived experience of psychosis discussing how they had navigated issues within their own recovery based on the Connectedness-Hope-Identity-Meaning-Empowerment model of recovery. We examined the feasibility and acceptability of an 8-session low intensity intervention using this site in 10 participants with persisting psychotic disorders and conducted a proof-of-concept analysis of outcomes.

RESULTS

All 10 participants completed the full course of sessions, and it was possible to integrate use of the website into nearly all sessions. Participant feedback confirmed that use of the website was a feasible and acceptable way of working. All participants stated that they would recommend the intervention to others. Post-intervention, personal recovery measured by the Questionnaire for the Process of Recovery had improved by an average standardized effect of d = 0.46, 95% CI [0.07, 0.84], and 8 of the 10 participants reported that their mental health had improved since taking part in the intervention.

CONCLUSION

In-session use of digital resources featuring peer accounts of recovery is feasible and acceptable and shows promising outcomes. A randomized controlled trial is the next step in evaluating the efficacy of this low intensity intervention when delivered in conjunction with routine mental health care.

Internet-Delivered Psychological Treatments

During the past 15 years, much progress has been made in developing and testing Internet-delivered psychological treatments. In particular, therapist-guided Internet treatments have been found to be effective for a wide range of psychiatric and somatic conditions in well over 100 controlled trials. These treatments require (a) a secure web platform, (b) robust assessment procedures, (c) treatment contents that can be text based or offered in other formats, and (d) a therapist role that differs from that in face-to-face therapy. Studies suggest that guided Internet treatments can be as effective as face-to-face treatments, lead to sustained improvements, work in clinically representative conditions, and probably are cost-effective. Despite these research findings, Internet treatment is not yet disseminated in most places, and clinical psychologists should consider using modern information technology and evidence-based treatment programs as a complement to their other services, even though there will always be clients for whom face-to-face treatment is the best option.

Therapist behaviours in internet-based cognitive behaviour therapy (ICBT) for depressive symptoms

Internet-based cognitive behaviour therapy (ICBT) is efficacious for treating depression, with therapist guidance identified as important for favourable outcomes. We have limited knowledge, however, about the fundamental components of therapist guidance in ICBT. The purpose of this study was to systematically examine therapist messages sent to patients during the course of ICBT for depressive symptoms in order to identify common "therapist behaviours" and the extent to which these behaviours correlate with completion of modules and improvements in symptoms at post-treatment, one- and two-year follow-up. A total of 664 e-mails from 5 therapists to 42 patients were analysed using qualitative content analysis. The most frequent behaviour was encouraging that accounted for 31.5% of the total number of coded behaviours. This was followed by affirming (25.1%), guiding (22.2%) and urging (9.8%). Less frequently the therapists clarified the internet treatment framework, informed about module content, emphasised the importance of patient responsibility, confronted the patient and made self-disclosures. Six of the nine identified therapist behaviours correlated with module completion. Three behaviours correlated with symptom improvement. Affirming correlated significantly (r = .42, p = .005) with improvement in depressive symptoms at post-treatment and after two years (r = .39, p = .014). Encouraging was associated with outcome directly after treatment (r = .52, p = .001). Self-disclosure was correlated with improvement in depressive symptoms at post-treatment (r = .44, p = .003). The study contributes to a better understanding of therapist behaviours in ICBT for depressive symptoms. Future directions for research are discussed.

Preventing anxiety problems in children with Cool Little Kids Online: study protocol for a randomised controlled trial

Background

Anxiety disorders are the most common type of mental health problem and begin early in life. Early intervention to prevent anxiety problems in young children who are at risk has the potential for long-term impact. The ‘Cool Little Kids’ parenting group program was previously established to prevent anxiety disorders in young children at risk because of inhibited temperament. This group program was efficacious in two randomised controlled trials and has recently been adapted into an online format. ‘Cool Little Kids Online’ was developed to widen and facilitate access to the group program’s preventive content. A pilot evaluation of the online program demonstrated its perceived utility and acceptability among parents. This study aims to evaluate the efficacy of Cool Little Kids Online in a large randomised controlled trial.

Methods/Design

Parents of young children who are 3–6 years old and who have an inhibited temperament will be recruited (n = 385) and randomly assigned to either immediate access to Cool Little Kids Online or delayed access after a waiting period of 24 weeks. The online program contains eight modules that help parents address key issues in the development of anxiety problems in inhibited children, including children’s avoidant coping styles, overprotective parenting behaviours, and parents’ own fears and worries. Intervention participants will be offered clinician support when requested. The primary outcome will be change in parent-reported child anxiety symptoms. Secondary outcomes will be child internalising symptoms, child and family life interference due to anxiety, over-involved/protective parenting, plus child anxiety diagnoses assessed by using a new online diagnostic tool. Assessments will take place at baseline and 12 and 24 weeks after baseline.

Discussion

This trial expands upon previous research on the Cool Little Kids parenting group program and will evaluate the efficacy of online delivery. Online delivery of the program could result in an easily accessible evidence-based resource to help families with young children at temperamental risk for anxiety disorders.

Trial registration

Australian New Zealand Clinical Trials Registry 12615000217505 (registered 5 March 2015)

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-1022-5) contains supplementary material, which is available to authorized users.

Treating eating disorders using the internet

PURPOSE OF REVIEW

This article evaluates the empirical standing of online treatment (eTherapy) for people with an established eating disorder.

RECENT FINDINGS

There have been four randomized controlled trials of eTherapy for people with an eating disorder. All four focused on eating disorders characterized by binge eating and recruited adult participants direct from the community. The interventions were cognitive behavioural in nature, lasted between 3 and 7 months, and were accompanied by external support. In common with eTherapy for other mental health problems, there were problems engaging and retaining the users, and maximizing their implementation of the intervention. A minority (10-37%, intent-to-treat figures) improved substantially.

SUMMARY

This is a new field. The findings of the four randomized controlled trials are consistent with the earlier reports indicating that guided eTherapy interventions of a cognitive behavioural nature are acceptable to (female) adults with a binge eating problem and that a subgroup improves substantially. More effective interventions are required and their use in different healthcare settings needs to be investigated. Direct-to-sufferer eTherapy interventions have the potential to increase access to effective forms of treatment and, in younger cases, they might serve as a form of secondary prevention.

Evaluating the (cost-)effectiveness of guided and unguided Internet-based self-help for problematic alcohol use in employees--a three arm randomized controlled trial

Background

Problematic alcohol consumption is associated with a high disease burden for affected individuals and has a detrimental impact on companies and society due to direct and indirect health costs. This protocol describes a study design to evaluate the (cost)-effectiveness of a guided and unguided Internet-based self-help intervention for employees called “GET.ON Clever weniger trinken” (be smart – drink less) compared to a waiting list control group.

Methods

In a three-arm randomized controlled trial, 528 German adults who are currently members of the workforce will be recruited by occupational health departments of major health insurance companies. Employees aged 18 and older displaying problematic drinking patterns (>21/14 drinks per week and an AUDIT score > 8/6 for men/women) will be randomly assigned to one of three following study conditions: 1. unguided web-based self-help for problematic drinking, 2. adherence-focused guided self-help, and 3. waiting list control. Self-report data will be collected at baseline (T1), 6 weeks (T2), and 6 months (T3) after randomization. The primary outcome will be the reduction of alcohol standard units during the 7 days prior to T2, using the Timeline Followback method. Cost-effectiveness analyses to determine direct and indirect costs will be conducted from the perspectives of employers and the society. Data will be analyzed on an intention-to-treat basis and per protocol.

Discussion

There is a need to identify effective low-threshold solutions to improve ill-health and reduce the negative economic consequences due to problematic alcohol drinking in workforces. If the proposed web-based intervention proves both to be efficacious and cost-effective, it may be a useful tool to increase utilization rates of interventions for problematic drinking in occupational settings.

Trial Registration

German Register of Clinical Studies (DRKS): DRKS00006105, date of registration: 2014-07-07.

Internet- und Mobilebasierte Interventionen in der Psychotherapie

Strukturelle Versorgungslücken und niedrige Inanspruchnahmeraten therapiebedürftiger Menschen beschränken eine bedarfsgerechte psychotherapeutische Versorgung. Internet- und Mobilebasierte Interventionen (IMIs) können als ort- und zeitunabhängige Angebote dazu beitragen, die psychotherapeutische Versorgung zu verbessern. Der vorliegende Beitrag gibt einen Überblick zum Gegenstandsbereich, der Evidenzbasierung sowie den Implementierungsmöglichkeiten von IMIs.

Developing a roadmap for the translation of e-mental health services for depression

OBJECTIVE

e-Mental health services have been shown to be effective and cost-effective for the treatment of depression. However, to have optimal impact in reducing the burden of depression, strategies for wider reach and uptake are needed.

METHOD

A review was conducted to assess the evidence supporting use of e-mental health programmes for treating depression. From the review, models of dissemination and gaps in translation were identified, with a specific focus on characterising barriers and facilitators to uptake within the Australian healthcare context. Finally, recommendations for promoting the translation of e-mental health services in Australia were developed.

RESULTS

There are a number of effective and cost-effective e-health applications available for treating depression in community and clinical settings. Four primary models of dissemination were identified: unguided, health service-supported, private ownership and clinically guided. Barriers to translation include clinician reluctance, consumer awareness, structural barriers such as funding and gaps in the translational evidence base.

CONCLUSION

Key strategies for increasing use of e-mental health programmes include endorsement of e-mental health services by government entities, education for clinicians and consumers, adequate funding of e-mental health services, development of an accreditation system, development of translation-focused activities and support for further translational research. The impact of these implementation strategies is likely to include economic gains, reductions in disease burden and greater availability of more interventions for prevention and treatment of mental ill-health complementary to existing health and efficient evidence-based mental health services.

The Application of Intervention Coding Methodology to Describe the Tinnitus E-Programme, an Internet-Delivered Self-Help Intervention for Tinnitus

PURPOSE

This article describes the Tinnitus E-Programme, a previously untested Internet-delivered self-help intervention for tinnitus.

METHOD

Intervention coding methodology was applied to describe the intervention components, techniques, and mode of delivery.

RESULTS

The intervention consists of 5 self-management intervention components, 5 behavior change techniques, and 3 modes of Internet delivery, which aim to promote relaxation behavior and reduce tinnitus distress.

CONCLUSIONS

The intervention coding provided a reliable method for reporting Internet-delivered self-help interventions. It will be used to facilitate our understanding of the intervention's potential mechanisms of change and will guide future evaluation work.

A meta-review of Internet computer-based psychological treatments for anxiety disorders

Introduction

Internet computer-based psychological treatments have enjoyed rapid growth. Today, there are a number of them available for many mental disorders and psychological problems. Internet-based psychological treatments for anxiety disorders and phobias are amongst the most frequently observed. Treatment results with these resources are promising, but inconclusive.

Methods

This paper reviews 11 systematic reviews and meta-analyses about the efficacy of Internet-based psychological treatments for anxiety disorders, including studies and clinical trials covering the majority of anxiety disorders and phobias, usually with adult patient samples.

Results

In general, these reviews agree on the efficacy of Internet-based psychological treatment as compared with non-treatment groups (with large effect sizes), finding similar efficacy compared with face-to-face therapies. Internet-based psychological treatments are further improved when combined with some type of therapist contact. On the negative side, some systematic reviews highlight high attrition rates of Internet-based psychological treatments.

Discussion

These findings remain inconclusive and more refined reviews (involving patient samples, therapy comparisons, type of therapist contact, etc.) are needed, in order to establish the scope and limits of Internet-based psychological treatments for anxiety disorders.