Blending online therapy into regular face-to-face therapy for depression: content, ratio and preconditions according to patients and therapists using a Delphi study

Blended transdiagnostic group CBT for emotional disorders: A feasibility trial protocol

INTRODUCTION

Emotional disorders (anxiety and depressive disorders) are a relevant public health concern associated with high prevalence, high costs, and important disability. Therefore, research priorities include designing and testing cost-effective interventions to reach everyone in need. Internet-delivered interventions for emotional disorders are effective and can help to disseminate and implement evidence-based treatments. However, although these treatments are generally effective, not all patients benefit from this treatment format equally. Blended treatments are a new form of intervention that combines the strengths of face-to-face and Internet approaches. Nevertheless, research on blended interventions has focused primarily on individual therapy, and less attention has been paid to the potential of using this format in group psychotherapy. This study aims to analyze the feasibility of blended transdiagnostic group CBT for emotional disorders. The current article describes the study protocol for this trial.

METHOD AND ANALYSIS

A one-armed pilot trial will be conducted. Participants will be 30 adults suffering from DSM-5 anxiety and/or depressive disorders. The treatment consists of a blended transdiagnostic group intervention delivered during a period of 24 weeks. Groups of 6 to 10 patients will attend a total of eight 2-hour, face-to-face sessions, alternated with the use of an online platform where they will find the contents of the treatment protocol. The intervention has four core components: present-focused awareness, cognitive flexibility, identification and modification of behavioral and cognitive patterns of emotional avoidance, and interoceptive and situational exposure. These components are delivered in 16 modules. Assessments will be performed at baseline, during the treatment, at post-treatment, and at 3-month follow-up. Clinical and treatment acceptability outcomes will be included. Quantitative and qualitative data (participants' views about blended group psychotherapy) will be analyzed.

ETHICS AND DISSEMINATION

The trial has received ethical approval from the Ethics Committee of Universitat Jaume I (September 2019) and will be conducted in accordance with the study protocol, the Declaration of Helsinki, and good clinical practice. The results of this study will be disseminated by presentation at conferences and will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04008576. Registered 05 July 2019, https://clinicaltrials.gov/ct2/show/NCT04008576.

Responding to COVID-19: New Trends in Social Workers' Use of Information and Communication Technology

COVID-19 changed the context for Information and Communication Technology (ICT) use globally. With face-to-face practice restricted, almost all communication with clients shifted to ICTs. Starting in April 2019, we conducted semi-structured interviews with social workers from four agencies serving diverse populations in a large urban centre, with the aim of exploring social workers' informal ICT use with clients. Approximately 6 weeks after the cessation of face-to-face practice in March 2020 due to COVID-19 measures, we re-interviewed social workers (n = 11) who had participated in our study. Second interviews were based on a newly developed interview guide that explored social workers' use of ICTs with clients in the context of COVID-19. Analysis of transcribed interviews revealed that the context of COVID-19 had generated two main themes. One, a paradigm shift for social workers was characterized by (a) diverse ICT options, (b) client-driven approach, and (c) necessary creativity. The second theme entails the impact of this transition which involved (a) greater awareness of clients' degree of access, (b) confidentiality and privacy, and (c) professional boundaries. We discuss these themes and sub-themes and present implications for practice and research in a Post-COVID-19 world.

Experiences of Psychotherapists With Remote Psychotherapy During the COVID-19 Pandemic: Cross-sectional Web-Based Survey Study

BACKGROUND

The current situation around the COVID-19 pandemic and the measures necessary to fight it are creating challenges for psychotherapists, who usually treat patients face-to-face with personal contact. The pandemic is accelerating the use of remote psychotherapy (ie, psychotherapy provided via telephone or the internet). However, some psychotherapists have expressed reservations regarding remote psychotherapy. As psychotherapists are the individuals who determine the frequency of use of remote psychotherapy, the potential of enabling mental health care during the COVID-19 pandemic in line with the protective measures to fight COVID-19 can be realized only if psychotherapists are willing to use remote psychotherapy.

OBJECTIVE

This study aimed to investigate the experiences of psychotherapists with remote psychotherapy in the first weeks of the COVID-19 lockdown in Austria (between March 24 and April 1, 2020).

METHODS

Austrian psychotherapists were invited to take part in a web-based survey. The therapeutic orientations of the psychotherapists (behavioral, humanistic, psychodynamic, or systemic), their rating of the comparability of remote psychotherapy (web- or telephone-based) with face-to-face psychotherapy involving personal contact, and potential discrepancies between their actual experiences and previous expectations with remote psychotherapy were assessed. Data from 1162 psychotherapists practicing before and during the COVID-19 lockdown were analyzed.

RESULTS

Psychotherapy conducted via telephone or the internet was reported to not be totally comparable to psychotherapy with personal contact (P<.001). Psychodynamic (P=.001) and humanistic (P=.005) therapists reported a higher comparability of telephone-based psychotherapy to in-person psychotherapy than behavioral therapists. Experiences with remote therapy (both web- and telephone-based) were more positive than previously expected (P<.001). Psychodynamic therapists reported more positive experiences with telephone-based psychotherapy than expected compared to behavioral (P=.03) and systemic (P=.002) therapists. In general, web-based psychotherapy was rated more positively (regarding comparability to psychotherapy with personal contact and experiences vs expectations) than telephone-based psychotherapy (P<.001); however, psychodynamic therapists reported their previous expectations to be equal to their actual experiences for both telephone- and web-based psychotherapy.

CONCLUSIONS

Psychotherapists found their experiences with remote psychotherapy (ie, web- or telephone-based psychotherapy) to be better than expected but found that this mode was not totally comparable to face-to-face psychotherapy with personal contact. Especially, behavioral therapists were found to rate telephone-based psychotherapy less favorably than therapists with other theoretical backgrounds.

A Blended Cognitive-Behavioral Intervention for the Treatment of Postpartum Depression: Study Protocol for a Randomized Controlled Trial

Despite the existence of effective treatment for postpartum depression, few women seek professional help, indicating the need for a new and innovative format of treatment that can overcome help-seeking barriers. This article presents the study protocol for a blended cognitive–behavioral intervention for the treatment of postpartum depression, by integrating face-to-face sessions with a web-based program (Be a Mom) into one treatment protocol. This study will be a two-arm, noninferiority randomized controlled trial comparing blended intervention to usual treatment for postpartum depression provided in healthcare centers. Portuguese postpartum adult women diagnosed with postpartum depression (according to the DSM-5 diagnostic criteria for major depressive disorder) will be recruited during routine care appointments in local healthcare centers and will be eligible to participate. Measures will be completed at baseline, postintervention, and at three- and six-month follow-ups. The primary outcome will be depressive symptoms. Secondary outcomes will include anxiety symptoms, fatigue, quality of life, marital satisfaction, maternal self-efficacy, and mother–child bonding. Cost-effectiveness analysis and mediator and moderator analysis will be conducted. This study will provide insight into the efficacy and cost-effectiveness of a blended psychological intervention in the Portuguese context and increase the empirically validated treatment options for postpartum depression.

The BEACON study: protocol for a cohort study as part of an evaluation of the effectiveness of smartphone-assisted problem-solving therapy in men who present with intentional self-harm to emergency departments in Ontario

BACKGROUND

Patients who present to emergency departments after intentional self-harm are at an increased risk of dying by suicide. This applies particularly to men, who represent nearly two-thirds of those who die by suicide in Ontario. One way of potentially addressing this gap is to offer a course of blended problem-solving therapy, comprised of a brief course of evidence-based psychotherapy for individuals at risk for suicide, facilitated by the use of a patient-facing smartphone application and a clinician-facing "dashboard." This approach has the potential to combine the benefits of face-to-face therapy and technology to create a novel intervention.

METHODS

This is a cohort study nested within a larger pragmatic multicentre pre- and post-design cluster randomised trial. Suicidal ideation assessed by the Beck Scale for Suicide Ideation is the primary outcome variable. Secondary outcome measures include depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder 7-item scale), post-traumatic stress disorder (Primary Care PTSD Screen), health-related quality of life (EuroQol 5-dimension 5-level questionnaire), meaning in life (Experienced Meaning in Life Scale), perceived social supports (Multidimensional Scale of Perceived Social Support), alcohol use (Alcohol Use Disorders Identification Test), drug use (Drug Abuse Screening Test Short Form 10), problem-solving skills (Social Problem-Solving Inventory-Revised Short Form), and self-reported healthcare costs, as well as health service use measured using Ontario administrative health data. A process evaluation will also be conducted following study completion.

DISCUSSION

The cohort study will test whether better adherence to the intervention results in better outcomes. The value of the cohort study design is that we can examine in more detail certain subgroups or other variables that are not available in the larger cluster randomised trial. This trial will aim to improve standards by informing best practice in management of men who self-harm and present to hospitals in Ontario.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03473535 . Registered on March 22, 2018.

Shaping Blended Care: Adapting an Instrument to Support Therapists in Using eMental Health

BACKGROUND

Although eMental health interventions, especially when delivered in a blended way, have great potential to improve the quality and efficiency of mental health care, their use in practice lags behind expectations. The Fit for Blended Care (FfBC) instrument was developed to support therapists and clients in shaping blended care in a way that optimally fits their needs. However, this existing version cannot be directly applied to specific branches of mental health care as it is too broad and generic.

OBJECTIVE

The goal of this study is to adapt the existing FfBC instrument to fit a specific, complex setting-forensic mental health care-by means of participatory development with therapists.

METHODS

The participatory process was divided into 4 phases and was executed by a project team consisting of 1 manager, 3-5 therapists, and 1 researcher. In phase 1, general requirements for the adaptation of the existing instrument were discussed in 2 focus groups with the project team. In phase 2, patient-related factors that influence the use of an existing web-based intervention were elicited through semistructured interviews with all 18 therapists working at an outpatient clinic. In phase 3, multiple focus groups with the project teams were held to create the first version of the adapted FfBC instrument. In phase 4, a digital prototype of the instrument was used with 8 patients, and the experiences of the 4 therapists were discussed in a focus group.

RESULTS

In phase 1, it became clear that the therapists' main requirement was to develop a much shorter instrument with a few items, in which the content was specifically tailored to the characteristics of forensic psychiatric outpatients. The interviews showed a broad range of patient-related factors, of which 5 were used in the instrument: motivation for blended treatment; writing about thoughts, feelings, and behavior; conscientiousness; psychosocial problems; and social support. In addition, a part of the instrument was focused on the practical necessary preconditions that patients should fill by themselves before the treatment was developed. The use of the web-based prototype of the instrument in treatment resulted in overall positive experiences with the content; however, therapists indicated that the items should be formulated in a more patient-centered way to encourage their involvement in discussing the factors.

CONCLUSIONS

The participatory, iterative process of this study resulted in an adapted version of the FfBC instrument that fits the specific forensic context and supports shared decision making. In general, the adaptiveness of the instrument is important: its content and implementation should fit the type of care, the organization, and eHealth intervention. To adapt the instrument to other contexts, the guidelines described in this paper can be followed.

Treatment success of internet-based vestibular rehabilitation in general practice: development and internal validation of a prediction model

OBJECTIVES

To develop and internally validate prediction models to assess treatment success of both stand-alone and blended online vestibular rehabilitation (VR) in patients with chronic vestibular syndrome.

DESIGN

Secondary analysis of a randomised controlled trial.

SETTING

59 general practices in The Netherlands.

PARTICIPANTS

202 adults, aged 50 years and older with a chronic vestibular syndrome who received either stand-alone VR (98) or blended VR (104). Stand-alone VR consisted of a 6-week, internet-based intervention with weekly online sessions and daily exercises. In blended VR, the same intervention was supplemented with physiotherapy support.

MAIN OUTCOME MEASURES

Successful treatment was defined as: clinically relevant improvement of (1) vestibular symptoms (≥3 points improvement Vertigo Symptom Scale-Short Form); (2) vestibular-related disability (>11 points improvement Dizziness Handicap Inventory); and (3) both vestibular symptoms and vestibular-related disability. We assessed performance of the predictive models by applying calibration plots, Hosmer-Lemeshow statistics, area under the receiver operating characteristic curves (AUC) and applied internal validation.

RESULTS

Improvement of vestibular symptoms, vestibular-related disability or both was seen in 121, 81 and 64 participants, respectively. We generated predictive models for each outcome, resulting in different predictors in the final models. Calibration for all models was adequate with non-significant Hosmer-Lemeshow statistics, but the discriminative ability of the final predictive models was poor (AUC 0.54 to 0.61). None of the identified models are therefore suitable for use in daily general practice to predict treatment success of online VR.

CONCLUSION

It is difficult to predict treatment success of internet-based VR and it remains unclear who should be treated with stand-alone VR or blended VR. Because we were unable to develop a useful prediction model, the decision to offer stand-alone or blended VR should for now be based on availability, cost effectiveness and patient preference.

TRIAL REGISTRATION NUMBER

The Netherlands Trial Register NTR5712.

Cost-effectiveness of internet-based vestibular rehabilitation with and without physiotherapy support for adults aged 50 and older with a chronic vestibular syndrome in general practice

OBJECTIVES

To evaluate the cost-effectiveness of stand-alone and blended internet-based vestibular rehabilitation (VR) in comparison with usual care (UC) for chronic vestibular syndromes in general practice.

DESIGN

Economic evaluation alongside a three-armed, individually randomised controlled trial.

SETTING

59 Dutch general practices.

PARTICIPANTS

322 adults, aged 50 years and older with a chronic vestibular syndrome.

INTERVENTIONS

Stand-alone VR consisted of a 6-week, internet-based intervention with weekly online sessions and daily exercises. In blended VR, this intervention was supplemented with face-to-face physiotherapy support. UC group participants received usual general practice care without restrictions.

MAIN OUTCOME MEASURES

Societal costs, quality-adjusted life years (QALYs), Vertigo Symptom Scale-Short Form (VSS-SF), clinically relevant response (≥3 points VSS-SF improvement).

RESULTS

Mean societal costs in both the stand-alone and blended VR groups were statistically non-significantly higher than in the UC group (mean difference (MD) €504, 95% CI -1082 to 2268; and €916, 95% CI -663 to 2596). Both stand-alone and blended VR groups reported non-significantly more QALYs than the UC group (MD 0.02, 95% CI -0.00 to 0.04; and 0.01, 95% CI -0.01 to 0.03), and significantly better VSS-SF Scores (MD 3.8 points, 95% CI 1.7 to 6.0; and 3.3 points, 95% CI 1.3 to 5.2). For stand-alone VR compared with UC, the probability of cost-effectiveness was 0.95 at a willingness-to-pay ratio of €24 161/QALY, €600/point improvement in VSS-SF and €8000/clinically relevant responder in VSS-SF. For blended VR versus UC, the probability of cost-effectiveness was 0.95 at a willingness-to-pay ratio of €123 335/QALY, €900/point improvement in VSS-SF and €24 000/clinically relevant responder in VSS-SF.

CONCLUSION

Stand-alone and blended internet-based VR non-significantly increased QALYs and significantly reduced vestibular symptoms compared with UC, while costs in both groups were non-significantly higher. Stand-alone VR has the highest probability to be cost-effective compared with UC.

TRIAL REGISTRATION NUMBER

The Netherlands Trial Register NTR5712.

Blended Treatment for Depressive Disorders in Youth: a Narrative Review

Depressive disorders are the most prevalent mental health disorder in adolescents with detrimental consequences; effective and available treatment is crucial. Face-to-face and computerized treatments both have advantages but also downsides. Merging these two into one so-called blended treatment seems to be an optimal combination of elements. This current review addresses blended treatment for youth depression and aims to summarize existing knowledge on effectiveness as well as patients’ and therapists’ perspectives. Results showed promising significant decreases in symptoms, but no evidence for differences between blended and face-to-face treatment was found. Patients’ perspectives were mixed; they reported strong preferences for face-to-face treatment, but participants actually receiving blended treatment were mainly positive. Therapists’ attitudes were neutral, but they expressed their worries about the unknown risks on adverse events. Future research is needed and should, beside effectiveness and cost-effectiveness, pay close attention to the risks that are mentioned by therapists.

Design Considerations for the Integrated Delivery of Cognitive Behavioral Therapy for Depression: User-Centered Design Study

BACKGROUND

Adherence to computerized cognitive behavioral therapy (cCBT) programs in real-world settings can be poor, and in the absence of therapist support, effects are modest and short term. Moreover, because cCBT systems tend toward limited support and thus low-intensity treatment, they are typically most appropriate for people experiencing mild to moderate mental health difficulties. Blended therapy, that is, combining direct therapist contact with cCBT or psychoeducational materials, has been identified as one possible approach to address these limitations and widen access to individual CBT for depression. Building on the initial success of blended therapy, we explore an integrated approach that seeks to seamlessly combine face-to-face contact, electronic contact, and between-session activities. Integration also considers how the technology can support therapists' workflow and integrate with broader health care systems. The ultimate aim is to provide a structure within which therapists can deliver high-intensity treatments, while also greatly reducing face-to-face contact.

OBJECTIVE

The research aimed to explore patients' and therapists' views on using a system for the delivery of individual treatment for depression that integrates face-to-face therapist contact with access to online resources and with synchronous online therapy sessions that allow collaborative exercises, and to establish design requirements and thus key design considerations for integrated systems that more seamlessly combine different modes of communication.

METHODS

We conducted a series of four user-centered design studies. This included four design workshops and seven prototype testing sessions with 18 people who had received CBT for depression in the past, and 11 qualitative interviews and three role-play sessions with 12 CBT therapists experienced in the treatment of depression. Studies took place between July and December 2017 in Bristol, United Kingdom.

RESULTS

Workshops and prototyping sessions with people who had received CBT identified three important requirements for integrated platforms delivering CBT therapy for depression as follows: (1) features that help to overcome depression-related barriers, (2) features that support engagement, and (3) features that reinforce learning and support the development of new skills. Research with therapists highlighted the importance of the therapist and client working together, the impact of technology on therapists' workflow and workload, challenges and opportunities related to the use of online resources, and the potential of technology to support patient engagement. We use these findings to inform 12 design considerations for developing integrated therapy systems.

CONCLUSIONS

To meet clients' and therapists' needs, integrated systems need to help retain the personal connection, support both therapist- and patient-led activities, and provide access to materials and the ability to monitor progress. However, developers of such systems should be mindful of their capacity to disrupt current work practices and increase therapists' workload. Future research should evaluate the impact of integrated systems on patients and therapists in a real-world context.

Advantages and disadvantages of online and blended therapy: Replication and extension of findings on psychotherapists' appraisals

Therapists hold a key role for the uptake of digital mental health interventions (DMHI) within regular care services but have demonstrated cautious attitudes towards such interventions. It is relevant to explore in detail what factors may positively influence therapists' perception when considering DMHI implementation within routine care. We recently assessed therapist views towards Internet-based and blended treatment in Austria (low implementation level). The present study aims at testing the reliability of previous findings, and moreover, it compares therapists' appraisals to a country with advanced DMHI implementation (Sweden). An online survey was conducted February through June of 2019. Respondents were recruited via email and social media. The survey assessed first-hand experience with Internet-based treatment (IT) and blended treatment (BT). To start, the survey presented a short informational video to half of the respondents, then assessed therapists' views on 17 advantages and 13 disadvantages of IT and BT on 6-point Likert scales. In total N = 300 therapists responded to the invitation, of which N = 165 provided full survey data (Germany 114/220, 52%; Sweden 51/80, 64%). German therapists rated the advantages of IT and BT as neutral (IT, M = 3.6; BT, M = 3.8) and to some extent agreed with disadvantages of IT (IT, M = 4.5; BT, M = 3.5). In comparison, Swedish therapists rated significantly greater advantages (IT, M = 4.6; BT, M = 4.5) and less disadvantages (IT, M = 3.2; BT, M = 2.8). Effect sizes ranged from d = 0.89 to d = 1.83; all P's < .001. Those with first-hand experience with DMHI reported more positive appraisals in both countries. No significant effect was found for exposure to the short informational video. The German sample represented essential characteristics of current German therapists; in comparison Swedish respondents skewed towards younger less experienced therapists (P's < .001). Those confounders accounted for a small non-significant proportion of variance (0.1-4.7%). We found that therapists considered blended treatment to have less disadvantages than Internet treatment, and that first-hand experience with DMHI, but not exposure to an acceptance facilitating video clip, predicted greater acceptability on individual level. The responses among German therapists closely resembled findings from our preceding study in Austria, indicating that reliable results can be achieved in small survey studies if sample and population parameters correspond. Swedish therapists held significantly more favorable attitudes towards both interventions. The comparison between countries, however, is limited by a number of potential confounding variables.

Immediate and long-term effectiveness of adding an Internet intervention for depression to routine outpatient psychotherapy: Subgroup analysis of the EVIDENT trial

OBJECTIVE

To examine immediate and long-term effectiveness of an adjunctive Internet intervention for depression in a large sample of patients undergoing routine psychotherapy.

METHOD

The current study evaluated a subgroup of patients from the Evident trial, a randomized investigation of a 12-week minimally guided Internet intervention (Deprexis) for the treatment of mild to moderate depression. 340 adults (mean age = 43.3 years; 71.7 % female) of the original sample received routine outpatient psychotherapy during the trial period, resulting in a standard psychotherapy group (n = 174) and an augmented therapy group (n = 166). Outcomes were assessed at baseline, post-treatment and 6-month follow-up.

RESULTS

Intention-to-treat analyses indicated that combined treatment led to a greater reduction in symptoms of depression (effect size d = 0.32; p = .002), improved therapeutic progress (d = 0.36; p = .003), and higher mental health-related quality of life (d = 0.34; p = .004). There was no intervention effect on physical health-related quality of life. The same pattern was found at 6-month follow-up, and adjunctive treatment also resulted in increased rates of clinical improvement. Treatment success was independent from therapeutic orientation of combined face-to-face therapy.

CONCLUSION

Results indicate that the adjunctive use of the investigated intervention can produce additional and lasting effects in routine outpatient psychotherapy for mild to moderate levels of depression. The study adds to the ongoing evidence on augmented effects of blended treatment. Future studies should investigate different types of blends in diverse populations by means of change-sensitive assessment strategies.

Design and Evaluation of SONIS, a Wearable Biofeedback System for Gait Retraining

Herein, we introduce SONIS, a wearable system to support gait rehabilitation training after a lower extremity trauma, which combines a sensing sock with a smartphone application. SONIS provides interactive, corrective, real-time feedback combining visual and auditory cues. We report the design of SONIS and its evaluation by patients and therapists, which indicates acceptance by targeted users, credibility as a rehabilitation tool, and a positive user experience. SONIS demonstrates how to successfully combine a number of feedback strategies and modalities: graphical, verbal, and music feedback on gait quality during training (knowledge of performance) and verbal and vibrotactile feedback on gait tracking (knowledge of results).

Implementing Web-Based Therapy in Routine Mental Health Care: Systematic Review of Health Professionals' Perspectives

BACKGROUND

Web-based therapies hold great promise to increase accessibility and reduce costs of delivering mental health care; however, uptake in routine settings has been low.

OBJECTIVE

Our objective in this review was to summarize what is known about health care professionals' perceptions of the barriers to and facilitators of the implementation of web-based psychological treatments in routine care of adults in health care settings.

METHODS

We searched 5 major databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library) for qualitative, quantitative, or mixed-methods studies exploring health professionals' views on computer- or internet-based psychological treatment programs. We coded included articles for risk of bias and extracted data using a prepiloted extraction sheet.

RESULTS

We identified 29 eligible articles: 14 qualitative, 11 quantitative, and 4 mixed methods. We identified the following themes: patient factors, health professional factors, the therapeutic relationship, therapy factors, organizational and system factors, and models of care. Health professionals supported web-based therapies only for patients with relatively straightforward, low-risk diagnoses, strong motivation and engagement, high computer literacy and access, and low need for tailored content. They perceived flexibility with timing and location as advantages of web-based therapy, but preferred blended therapy to facilitate rapport and allow active monitoring and follow-up of patients. They emphasized the need for targeted training and organizational support to manage changed workflows. Health professionals were concerned about the confidentiality and security of client data for web-based programs, suggesting that clear and transparent protocols need to be in place to reassure health professionals before they will be willing to refer.

CONCLUSIONS

Without health professionals' support, many people will not access web-based therapies. To increase uptake, it is important to ensure that health professionals receive education, familiarization, and training to support them in incorporating web-based therapies into their practice, and to design systems that support health professionals in this new way of working with patients and addressing their concerns.

TRIAL REGISTRATION

PROSPERO CRD42018100869; https://tinyurl.com/y5vaoqsk.

Adherence to Blended or Face-to-Face Smoking Cessation Treatment and Predictors of Adherence: Randomized Controlled Trial

BACKGROUND

Blended face-to-face and web-based treatment is a promising way to deliver smoking cessation treatment. Since adherence has been shown to be an indicator of treatment acceptability and a determinant for effectiveness, we explored and compared adherence and predictors of adherence to blended and face-to-face alone smoking cessation treatments with similar content and intensity.

OBJECTIVE

The objectives of this study were (1) to compare adherence to a blended smoking cessation treatment with adherence to a face-to-face treatment; (2) to compare adherence within the blended treatment to its face-to-face mode and web mode; and (3) to determine baseline predictors of adherence to both treatments as well as (4) the predictors to both modes of the blended treatment.

METHODS

We calculated the total duration of treatment exposure for patients (N=292) of a Dutch outpatient smoking cessation clinic who were randomly assigned either to the blended smoking cessation treatment (n=130) or to a face-to-face treatment with identical components (n=162). For both treatments (blended and face-to-face) and for the two modes of delivery within the blended treatment (face-to-face vs web mode), adherence levels (ie, treatment time) were compared and the predictors of adherence were identified within 33 demographic, smoking-related, and health-related patient characteristics.

RESULTS

We found no significant difference in adherence between the blended and the face-to-face treatments. Participants in the blended treatment group spent an average of 246 minutes in treatment (median 106.7% of intended treatment time, IQR 150%-355%) and participants in the face-to-face group spent 238 minutes (median 103.3% of intended treatment time, IQR 150%-330%). Within the blended group, adherence to the face-to-face mode was twice as high as that to the web mode. Participants in the blended group spent an average of 198 minutes (SD 120) in face-to-face mode (152% of the intended treatment time) and 75 minutes (SD 53) in web mode (75% of the intended treatment time). Higher age was the only characteristic consistently found to uniquely predict higher adherence in both the blended and face-to-face groups. For the face-to-face group, more social support for smoking cessation was also predictive of higher adherence. The variability in adherence explained by these predictors was rather low (blended R2=0.049; face-to-face R2=0.076). Within the blended group, living without children predicted higher adherence to the face-to-face mode (R2=0.034), independent of age. Higher adherence to the web mode of the blended treatment was predicted by a combination of an extrinsic motivation to quit, a less negative attitude toward quitting, and less health complaints (R2=0.164).

CONCLUSIONS

This study represents one of the first attempts to thoroughly compare adherence and predictors of adherence of a blended smoking cessation treatment to an equivalent face-to-face treatment. Interestingly, although the overall adherence to both treatments appeared to be high, adherence within the blended treatment was much higher for the face-to-face mode than for the web mode. This supports the idea that in blended treatment, one mode of delivery can compensate for the weaknesses of the other. Higher age was found to be a common predictor of adherence to the treatments. The low variance in adherence predicted by the characteristics examined in this study suggests that other variables such as provider-related health system factors and time-varying patient characteristics should be explored in future research.

TRIAL REGISTRATION

Netherlands Trial Register NTR5113; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5113.

Smartphone applications targeting borderline personality disorder symptoms: a systematic review and meta-analysis

BACKGROUND

Smartphone applications could improve symptoms of borderline personality disorder (BPD) in a scalable and resource-efficient manner in the context limited access to specialized care.

OBJECTIVE

This systematic review and meta-analysis aims to evaluate the effectiveness of applications designed as treatment interventions for adults with symptoms such as anger, suicidality, or self-harm that commonly occur in BPD.

DATA SOURCES

Search terms for BPD symptoms, smartphone applications, and treatment interventions were combined on PubMed, MEDLINE, and PsycINFO from database inception to December 2019.

STUDY SELECTION

Controlled and uncontrolled studies of smartphone interventions for adult participants with symptoms such as anger, suicidality, or self-harm that commonly occur in BPD were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Comprehensive Meta-Analysis v3 was used to compute between-groups effect sizes in controlled designs. The primary outcome was BPD-related symptoms such as anger, suicidality, and impulsivity; and the secondary outcome was general psychopathology. An average dropout rate across interventions was computed. Study quality, target audiences, therapeutic approach and targets, effectiveness, intended use, usability metrics, availability on market, and downloads were assessed qualitatively from the papers and through internet search.

RESULTS

Twelve studies of 10 applications were included, reporting data from 408 participants. Between-groups meta-analyses of RCTs revealed no significant effect of smartphone applications above and beyond in-person treatments or a waitlist on BPD symptoms (Hedges' g = - 0.066, 95% CI [-.257, .125]), nor on general psychopathology (Hedges' g = 0.305, 95% CI [- 0.14, 0.75]). Across the 12 trials, dropout rates ranged from 0 to 56.7% (M = 22.5, 95% CI [0.15, 0.46]). A majority of interventions studied targeted emotion dysregulation and behavioral dyscontrol symptoms. Half of the applications are commercially available.

CONCLUSIONS

The effects of smartphone interventions on symptoms of BPD are unclear and there is currently a lack of evidence for their effectiveness. More research is needed to build on these preliminary findings in BPD to investigate both positive and adverse effects of smartphone applications and identify the role these technologies may provide in expanding mental healthcare resources.

Patients' User Experience of a Blended Face-to-Face and Web-Based Smoking Cessation Treatment: Qualitative Study

Background

Blended web-based and face-to-face (F2F) treatment is a promising electronic health service because the strengths of one mode of delivery should compensate for the weaknesses of the other.

Objective

The aim of this study was to explore this compensation by examining patients’ user experience (UX) in a blended smoking cessation treatment (BSCT) in routine care.

Methods

Data on patients’ UX were collected through in-depth interviews (n=10) at an outpatient smoking cessation clinic in the Netherlands. A content analysis of the semantic domains was used to analyze patients’ UX. To describe the UX, the Hassenzahl UX model was applied, examining 4 of the 5 key elements of UX from a user’s perspective: (1) patients’ standards and expectations, (2) apparent character (pragmatic and hedonic attributes), (3) usage situation, and (4) consequences (appeal, emotions, and behavior).

Results

BSCT appeared to be a mostly positively experienced service. Patients had a positive-pragmatic standard and neutral-open expectation toward BSCT at the treatment start. The pragmatic attributes of the F2F sessions were mostly perceived as positive, whereas the pragmatic attributes of the web sessions were perceived as both positive and negative. For the hedonic attributes, there seemed to be a difference between the F2F and web sessions. Specifically, the hedonic attributes of the web sessions were experienced as mostly negative, whereas those of the F2F sessions were experienced as mostly positive. For the usage situation, the physical and social contexts were experienced positively, whereas the task and technical contexts were experienced negatively. Nevertheless, the consequential appeal of BSCT was positive. However, the consequential emotions and behavior varied, ultimately resulting in diverse combinations of consequential appeal, emotions, and behavior (positive, negative, and mixed).

Conclusions

This study provided insights into the UX of a blended treatment, and the results support the expectation that in a blended treatment, the strengths of one mode of delivery may compensate for the weaknesses of the other. However, in this certain setting, this is mainly achieved in only one way: F2F sessions compensated for the weaknesses of the web sessions. As a practical conclusion, this may mean that the web sessions, supported by the strengths of the F2F sessions, offer an interesting approach for further improving the blended treatment. Our theoretical findings reflect the relevance of the aspects of hedonism, such as fun, joy, or happiness in the UX, which were not mentioned in relation to the web sessions and were only scarcely mentioned in relation to the F2F sessions. Future research should further investigate the role of hedonistic aspects in a blended treatment and whether increased enjoyment of a blended treatment could increase treatment adherence and, ultimately, effectiveness.

Integrating People, Context, and Technology in the Implementation of a Web-Based Intervention in Forensic Mental Health Care: Mixed-Methods Study

Background

While eMental health interventions can have many potential benefits for mental health care, implementation outcomes are often disappointing. In order to improve these outcomes, there is a need for a better understanding of complex, dynamic interactions between a broad range of implementation-related factors. These interactions and processes should be studied holistically, paying attention to factors related to context, technology, and people.

Objective

The main objective of this mixed-method study was to holistically evaluate the implementation strategies and outcomes of an eMental health intervention in an organization for forensic mental health care.

Methods

First, desk research was performed on 18 documents on the implementation process. Second, the intervention’s use by 721 patients and 172 therapists was analyzed via log data. Third, semistructured interviews were conducted with all 18 therapists of one outpatient clinic to identify broad factors that influence implementation outcomes. The interviews were analyzed via a combination of deductive analysis using the nonadoption, abandonment, scale-up, spread, and sustainability framework and inductive, open coding.

Results

The timeline generated via desk research showed that implementation strategies focused on technical skills training of therapists. Log data analyses demonstrated that 1019 modules were started, and 18.65% (721/3865) of patients of the forensic hospital started at least one module. Of these patients, 18.0% (130/721) completed at least one module. Of the therapists using the module, 54.1% (93/172 sent at least one feedback message to a patient. The median number of feedback messages sent per therapist was 1, with a minimum of 0 and a maximum of 460. Interviews showed that therapists did not always introduce the intervention to patients and using the intervention was not part of their daily routine. Also, therapists indicated patients often did not have the required conscientiousness and literacy levels. Furthermore, they had mixed opinions about the design of the intervention. Important organization-related factors were the need for more support and better integration in organizational structures. Finally, therapists stated that despite its current low use, the intervention had the potential to improve the quality of treatment.

Conclusions

Synthesis of different types of data showed that implementation outcomes were mostly disappointing. Implementation strategies focused on technical training of therapists, while little attention was paid to changes in the organization, design of the technology, and patient awareness. A more holistic approach toward implementation strategies—with more attention to the organization, patients, technology, and training therapists—might have resulted in better implementation outcomes. Overall, adaptivity appears to be an important concept in eHealth implementation: a technology should be easily adaptable to an individual patient, therapists should be trained to deal flexibly with an eMental health intervention in their treatment, and organizations should adapt their implementation strategies and structures to embed a new eHealth intervention.

Feasibility of a stratified blended physiotherapy intervention for patients with non-specific low back pain: a mixed methods study

INTRODUCTION

Integrating web-based or mobile components and face-to-face components within a treatment process is called blended care. As part of the participatory development of a blended physiotherapeutic intervention for patients with low back pain (e-Exercise LBP), a proof of concept study was carried out and showed promising results.

OBJECTIVE

To investigate the feasibility of the e-Exercise LBP prototype for patients and physiotherapists to improve the intervention.

METHODS

A mixed methods study was executed, embedded in the development phase of e-Exercise LBP. 21 physiotherapists treated 41 patients with e-Exercise LBP. Quantitative data consisted of: patients' satisfaction on a five-point Likert Scale; patients' and physiotherapists' experienced usability of the web-based application (System Usability Scale) and; patients' experiences with e-Exercise LBP (closed-ended questions and statements related to the elements and goals of e-Exercise LBP). Semi-structured interviews about experiences with e-Exercise LBP were conducted with seven patients and seven physiotherapists. Qualitative data were analyzed by a phenomenological approach. Quantitative data were analyzed with descriptive statistics.

RESULTS

Patients were satisfied with e-Exercise LBP (mean: 4.0; SD:0.8; range: extreme dissatisfaction (1)-extreme satisfaction (5)). Usability of the web-based application was acceptable (patients: mean: 73.2 (SD:16.3); physiotherapists: mean: 63.3 (SD:12.0); range: 0-100). Interviews revealed that physiotherapists' training is essential to successfully integrate the web-based application and face-to-face sessions within physiotherapy treatment. Also, patients addressed the need of reminder messages to support long-term (exercise) adherence.

CONCLUSION

e-Exercise LBP appeared to be feasible. However, various prerequisites and points of improvement were mentioned to improve physiotherapists' training and the prototype.

Mental Health Therapy Protocols and eHealth Design: Focus Group Study

Background

Electronic health (eHealth) programs are often based on protocols developed for the original face-to-face therapies. However, in practice, therapists and patients may not always follow the original therapy protocols. This form of personalization may also interfere with the intended implementation and effects of eHealth interventions if designers do not take these practices into account.

Objective

The aim of this explorative study was to gain insights into the personalization practices of therapists and patients using cognitive behavioral therapy, one of the most commonly applied types of psychotherapy, in a youth addiction care center as a case context.

Methods

Focus group discussions were conducted asking therapists and patients to estimate the extent to which a therapy protocol was followed and about the type and reasons for personalization of a given therapy protocol. A total of 7 focus group sessions were organized involving therapists and patients. We used a commonly applied protocol for cognitive behavioral therapy as a therapy protocol example in youth mental health care. The first focus group discussions aimed at assessing the extent to which patients (N=5) or therapists (N=6) adapted the protocol. The second focus group discussions aimed at estimating the extent to which the therapy protocol is applied and personalized based on findings from the first focus groups to gain further qualitative insight into the reasons for personalization with groups of therapists and patients together (N=7). Qualitative data were analyzed using thematic analysis.

Results

Therapists used the protocol as a “toolbox” comprising different therapy tools, and personalized the protocol to enhance the therapeutic alliance and based on their therapy-provision experiences. Therapists estimated that they strictly follow 48% of the protocol, adapt 30%, and replace 22% by other nonprotocol therapeutic components. Patients personalized their own therapy to conform the assignments to their daily lives and routines, and to reduce their levels of stress and worry. Patients estimated that 29% of the provided therapy had been strictly followed by the therapist, 48% had been adjusted, and 23% had been replaced by other nonprotocol therapeutic components.

Conclusions

A standard cognitive behavioral therapy protocol is not strictly and fully applied but is mainly personalized. Based on these results, the following recommendations for eHealth designers are proposed to enhance alignment of eHealth to therapeutic practice and implementation: (1) study and copy at least the applied parts of a protocol, (2) co-design eHealth with therapists and patients so they can allocate the components that should be open for user customization, and (3) investigate if components of the therapy protocol that are not applied should remain part of the eHealth applied. To best generate this information, we suggest that eHealth designers should collaborate with therapists, patients, protocol developers, and mental health care managers during the development process.

Exploring User-Related Drivers of the Early Acceptance of Certified Digital Stress Prevention Programs in Germany

Electronic mental health services represent innovative instruments to increase the dissemination of stress programs in primary prevention. However, little is known about facilitators of their uptake. This study aimed to explore determinants of the acceptance of centrally certified digital stress coping programs and preferences for service delivery modes among adult members of German statutory health insurances. Participants completed a multi-construct 45-item questionnaire covering acceptance of digital stress prevention (behavioral use intention) and potential predictors we assessed using hierarchical regression analysis-(1) socio-demographic variables and time spent online, (2) openness to experience, (3) perceived stress, and (4) attitudes toward e-mental health. Preferences in terms of the willingness to use online, face-to-face and blended programs were analyzed using paired t-tests. Participants (N = 171, 66% female, 18-69 years) reported a moderate acceptance of digital stress management (M = 2.76, SD = 1.16, range: 1-5). We identified younger age (ß = -0.16, P = .009), openness to experience (ß = 0.17, P = .003), and positive attitudes (ß = 0.61, P < .001) as predictors of acceptance (R ² = .50, P < .001). Face-to-face was preferred over online (d = 0.40) and blended (d = 0.33), and blended over stand-alone online delivery mode (d = 0.19; all P < .001). Our findings indicate that promoting favorable attitudes toward digital stress prevention through tailored information may be a starting point to facilitate their adoption.

Using the Personalized Advantage Index for Individual Treatment Allocation to Blended Treatment or Treatment as Usual for Depression in Secondary Care

A variety of effective psychotherapies for depression are available, but patients who suffer from depression vary in their treatment response. Combining face-to-face therapies with internet-based elements in the sense of blended treatment is a new approach to treatment for depression. The goal of this study was to answer the following research questions: (1) What are the most important predictors determining optimal treatment allocation to treatment as usual or blended treatment? and (2) Would model-determined treatment allocation using this predictive information and the personalized advantage index (PAI)-approach result in better treatment outcomes? Bayesian model averaging (BMA) was applied to the data of a randomized controlled trial (RCT) comparing the efficacy of treatment as usual and blended treatment in depressive outpatients. Pre-treatment symptomatology and treatment expectancy predicted outcomes irrespective of treatment condition, whereas different prescriptive predictors were found. A PAI of 2.33 PHQ-9 points was found, meaning that patients who would have received the treatment that is optimal for them would have had a post-treatment PHQ-9 score that is two points lower than if they had received the treatment that is suboptimal for them. For 29% of the sample, the PAI was five or greater, which means that a substantial difference between the two treatments was predicted. The use of the PAI approach for clinical practice must be further confirmed in prospective research; the current study supports the identification of specific interventions favorable for specific patients.

Working Alliance in Blended Versus Face-to-Face Cognitive Behavioral Treatment for Patients with Depression in Specialized Mental Health Care

This study investigates working alliance in blended cognitive behavioral therapy (bCBT) for depressed adults in specialized mental health care. Patients were randomly allocated to bCBT (n = 47) or face-to-face CBT (n = 45). After 10 weeks of treatment, both patients and therapists in the two groups rated the therapeutic alliance on the Working Alliance Inventory Short-Form Revised (WAI-SR; Task, Bond, Goal, and composite scores). No between-group differences were found in relation to either patient or therapist alliance ratings, which were high in both groups. In the full sample, a moderate positive association was found between patient and therapist ratings on Task (ρ = 0.41, 95% CI 0.20; 0.59), but no significant associations emerged on other components or composite scores. At 30 weeks, within-and between-group associations between alliance and changes in depression severity (QIDS, Quick Inventory of Depressive Symptomatology) were analyzed with linear mixed models. The analyses revealed an association between depression over time, patient-rated alliance, and group (p < 0.001). In face-to-face CBT, but not in bCBT, lower depression scores were associated with higher alliance ratings. The online component in bCBT may have led patients to evaluate the working alliance differently from patients receiving face-to-face CBT only.

Implementing complaint-directed mini-interventions for depressive complaints in primary care to increase participation among patients with a lower socioeconomic status: design of a cluster randomised controlled trial

BACKGROUND

Depression is a major public health concern. E-health interventions for preventing and reducing depressive complaints have proven to be effective, and have the potential to make (mental) health care more accessible and efficient. However, the reach of these interventions needs to be improved, especially among people with a lower socioeconomic status (SES). Stimulating and supporting implementation of e-health in primary care, and offering guidance from general practice nurses (GP nurses) may be important strategies to achieve this.

METHODS/DESIGN

The online 'Complaint Directed Mini-Interventions' (CDMIs) for stress, sleep and worry complaints, which were found to be (cost-)effective in a self-guided format, will be implemented in the primary care setting using a blended care format (i.e. combining e-health with face-to-face sessions) with minimal guidance provided by the GP nurse. The main aim is to evaluate whether a SES-sensitive implementation strategy improves the participation rate (i.e. reach) of lower-SES patients in the blended online CDMIs as compared to a regular implementation strategy in a cluster randomised controlled trial. Randomisation will occur at the level of the GP nurse, and 228 patients will be included in the study. The primary outcome is the participation rate (completing at least one face-to-face session and two online exercises) of the lower-SES target group. It is hypothesised that this percentage will be higher in the SES-sensitive group as compared to the regular group. Secondary objectives are to evaluate the implementation process, to monitor and evaluate psychological complaints (depression, sleep, stress, worry and anxiety) and well-being over time. Patient assessments will take place at baseline, 3 and 12 months post baseline.

DISCUSSION

This study should contribute to our knowledge of reaching the lower-SES groups with a brief and complaint-specific blended approach for depressive complaints in primary care. It should also further our knowledge on successful strategies to implement depression prevention in primary care.

TRIAL REGISTRATION

Netherlands Trial Register, ID: NL6595. Registered on 12 November 2017.

Blended cognitive behavioural therapy for adolescents with panic disorder co-morbid with autism spectrum disorder: a case study

Cognitive behavioural therapy (CBT) is an effective treatment for improving anxiety symptoms in patients with autism spectrum disorder (ASD). However, some patients with ASD take extra time for learning, and they can find it hard to change their thinking styles and behaviour due to cognitive deficits. The therapist must be creative when implementing CBT in this context. Here, it may be helpful for the patient with ASD to understand CBT’s concepts by using visual aid material. Blended CBT during which the patient is shown visual aid material with his or her therapist has been suggested as effective for adults without ASD to reduce anxiety. Blended CBT combines face-to-face treatment with internet guided support and resource. Blended CBT may facilitate an understanding of essential knowledge and help people with ASD and anxiety acquire skills based on cognitive behavioural science. However, as far as we know, no previous studies have reported on the use of blended CBT for patients with panic disorder co-morbid with ASD. This study, therefore, consecutively performed 16 blended CBT sessions on a biweekly basis to treat panic disorder (PD) in an adolescent Japanese female co-morbid with ASD. The patient exhibited improvements in PD symptoms and agoraphobia after treatment: the Panic Disorder Severity Scale score decreased from 18 to 2. These results indicate that visual aid-assisted treatment may help patients with impaired imagination and social cognition related to ASD. Furthermore, this study’s therapist notes the need for paced treatments and repeated psychoeducation for patients with impairments in central coherence and cognitive flexibility.

Key learning aims

(1)

Internet Interventions for Mental Health: Current State of Research, Lessons Learned and Future Directions

This article gives an overview of current research on internet interventions in the field of mental health. As a result of COVID-19, the implementation of internet interventions has been given a boost in the mental health sectors of several countries all over the world. With regard to these developments, a definition of internet interventions is provided and the current state of research on different formats, treatment contents, and settings of internet interventions is discussed. Current research on the therapeutic alliance in internet interventions and possible negative effects is also described. The review closes with lessons learned from the past decades of research on internet interventions along with possible implications and future directions.

Internet based vestibular rehabilitation with and without physiotherapy support for adults aged 50 and older with a chronic vestibular syndrome in general practice: three armed randomised controlled trial

OBJECTIVE

To investigate the clinical effectiveness and safety of stand alone and blended internet based vestibular rehabilitation (VR) in the management of chronic vestibular syndromes in general practice.

DESIGN

Pragmatic, three armed, parallel group, individually randomised controlled trial.

SETTING

59 general practices in the Netherlands.

PARTICIPANTS

322 adults aged 50 and older with a chronic vestibular syndrome.

INTERVENTIONS

Stand alone VR comprising a six week, internet based intervention with weekly online sessions and daily exercises (10-20 minutes a day). In the blended VR group, the same internet based intervention was supplemented by face-to-face physiotherapy support (home visits in weeks 1 and 3). Participants in the usual care group received standard care from a general practitioner, without any restrictions.

MAIN OUTCOME MEASURES

The primary outcome was vestibular symptoms after six months as measured by the vertigo symptom scale-short form (VSS-SF range 0-60, clinically relevant difference ≥3 points). Secondary outcomes were dizziness related impairment, anxiety, depressive symptoms, subjective improvement of vestibular symptoms after three and six months, and adverse events.

RESULTS

In the intention-to-treat analysis, participants in the stand alone and blended VR groups had lower VSS-SF scores at six months than participants in the usual care group (adjusted mean difference -4.1 points, 95% confidence interval -5.8 to -2.5; and -3.5 points, -5.1 to -1.9, respectively). Similar differences in VSS-SF scores were seen at three months follow-up. Participants in the stand alone and blended VR groups also experienced less dizziness related impairment, less anxiety, and more subjective improvement of vestibular symptoms at three and six months. No serious adverse events related to online VR occurred during the trial.

CONCLUSION

Stand alone and blended internet based VR are clinically effective and safe interventions to treat adults aged 50 and older with a chronic vestibular syndrome. Online VR is an easily accessible form of treatment, with the potential to improve care for an undertreated group of patients in general practice.

TRIAL REGISTRATION

Netherlands Trial Register NTR5712.

Women's expectations and experiences regarding e-health treatment: A systematic review

There is a gap in knowledge of women's perceptions of e-health treatment. This review aims to investigate women's expectations and experiences regarding e-health. A search was conducted in MEDLINE, EMBASE, CINAHL and PsycInfo in March 2016. We included articles published between 2000 and March 2016, reporting on e-health interventions. The initial search yielded 2987 articles. Eventually, 16 articles reporting on 16 studies were included. Barriers to e-health treatment were lower for women than barriers to face-to-face treatment, such as feelings of shame and time constraints. Women were able to develop an online therapeutic relationship. As reduced feelings of obligation and lack of motivation were women's greatest challenges in completing e-health treatment, they expressed a wish for more support during e-health treatment, preferably blended care. e-Health lowers the threshold for women to seek healthcare. Combining e-health interventions with face-to-face sessions may enhance women's motivation to complete treatment.

The therapist experience of internet delivered CBT for problem gambling: Service integration considerations

INTRODUCTION

Countries with legalized gambling offer a network of government funded face-to-face therapy, but usage of this expertise is on the decline. One way to address this issue is to recruit therapists from existing services whereby they provide guidance for the delivery of internet delivered CBT.

OBJECTIVE

To explore the experiences and perceptions of therapists supporting guided online cognitive-behavioural therapy.

METHODS

Interviewees were a sub-sample of therapists from a randomised trial that investigated the relative efficacy of online guided self-directed versus pure self-directed interventions in Australia.

RESULTS

In-person, semi-structured interviews with seven service providers were completed, and thematic content analysis identified five themes which related to: participant suitability and screening (e.g., motivation, computer literacy and access); program content and modality acceptability (e.g., amount of content, look and feel); participant information and management (e.g., program engagement and progression); email communication (e.g., use of templates, appointments, rapport building), and; ongoing service integration (e.g., infrastructure, confidence in product). Overall experiences and perceptions of therapists were positive, notwithstanding barriers concerning assessment of participant suitability, participant management systems and low participant engagement.

CONCLUSIONS

Key themes emphasized the benefits of Internet-based interventions for problem gambling, and suggested several areas for improvement. Results should inform the development of future treatments to enable flexible tailoring of interventions to individuals.

An expert consensus on the most effective components of cognitive behavioural therapy for adults with depression: a modified Delphi study

Designing new approaches to delivering cognitive behavioural therapy (CBT) requires an understanding of the key components. This study aimed to establish an expert consensus on the effective components of CBT for depressed adults. An international panel of 120 CBT experts was invited to participate in a modified Delphi study. Thirty-two experts participated in round 1; 21 also provided data in round 2. In round 1, experts rated the effectiveness of 35 content and process components. A priori rules identified components carried forward to round 2, in which experts re-rated items and final consensus items were identified. Consensus was achieved for nine content components (ensuring understanding; developing and maintaining a good therapeutic alliance; explaining the rationale for CBT; eliciting feedback; identifying and challenging avoidant behaviour; activity monitoring; undertaking an initial assessment; relapse prevention methods; homework assignments); and three process components (ensuring therapist competence; scheduling sessions flexibly; scheduling sessions for 45-60 mins). Five of the twelve components identified were generic therapeutic competences rather than specific CBT items. There was less agreement about the effectiveness of cognitive components of CBT. This is an important first step in the development of novel approaches to delivering CBT that may increase access to treatment for patients.

The Importance of Systematically Reporting and Reflecting on eHealth Development: Participatory Development Process of a Virtual Reality Application for Forensic Mental Health Care

Background

The use of electronic health (eHealth) technologies in practice often is lower than expected, mostly because there is no optimal fit among a technology, the characteristics of prospective users, and their context. To improve this fit, a thorough systematic development process is recommended. However, more knowledge about suitable development methods is necessary to create a tool kit that guides researchers in choosing development methods that are appropriate for their context and users. In addition, there is a need for reflection on the existing frameworks for eHealth development to be able to constantly improve them.

Objective

The two main objectives of this case study were to present and reflect on the (1) methods used in the development process of a virtual reality application for forensic mental health care and (2) development model that was used: the CeHRes Roadmap (the Centre for eHealth Research Roadmap).

Methods

In the development process, multiple methods were used to operationalize the first 2 phases of the CeHRes Roadmap: the contextual inquiry and value specification. To summarize the most relevant information for the goals of this study, the following information was extracted per method: (1) research goal, (2) explanation of the method used, (3) main results, (4) main conclusions, and (5) lessons learned about the method.

Results

Information on 10 methods used is presented in a structured manner. These 10 methods were stakeholder identification, project team composition, focus groups, literature study, semistructured interviews, idea generation with scenarios, Web-based questionnaire, value specification, idea generation with prototyping, and a second round of interviews. The lessons learned showed that although each method added new insights to the development process, not every method appeared to be the most appropriate for each research goal.

Conclusions

Reflection on the methods used pointed out that brief methods with concrete examples or scenarios fit the forensic psychiatric patients the best, among other things, because of difficulties with abstract reasoning and low motivation to invest much time in participating in research. Formulating clear research questions based on a model’s underlying principles and composing a multidisciplinary project team with prospective end users appeared to be important in this study. The research questions supported the project team in keeping the complex development processes structured and prevented tunnel vision. With regard to the CeHRes Roadmap, continuous stakeholder involvement and formative evaluations were evaluated as strong points. A suggestion to further improve the Roadmap is to explicitly integrate the use of domain-specific theories and models. To create a tool kit with a broad range of methods for eHealth development and further improve development models, studies that report and reflect on development processes in a consistent and structured manner are needed.

Unraveling the Black Box: Exploring Usage Patterns of a Blended Treatment for Depression in a Multicenter Study

BACKGROUND

Blended treatments, combining digital components with face-to-face (FTF) therapy, are starting to find their way into mental health care. Knowledge on how blended treatments should be set up is, however, still limited. To further explore and optimize blended treatment protocols, it is important to obtain a full picture of what actually happens during treatments when applied in routine mental health care.

OBJECTIVE

The aims of this study were to gain insight into the usage of the different components of a blended cognitive behavioral therapy (bCBT) for depression and reflect on actual engagement as compared with intended application, compare bCBT usage between primary and specialized care, and explore different usage patterns.

METHODS

Data used were collected from participants of the European Comparative Effectiveness Research on Internet-Based Depression Treatment project, a European multisite randomized controlled trial comparing bCBT with regular care for depression. Patients were recruited in primary and specialized routine mental health care settings between February 2015 and December 2017. Analyses were performed on the group of participants allocated to the bCBT condition who made use of the Moodbuster platform and for whom data from all blended components were available (n=200). Included patients were from Germany, Poland, the Netherlands, and France; 64.5% (129/200) were female and the average age was 42 years (range 18-74 years).

RESULTS

Overall, there was a large variability in the usage of the blended treatment. A clear distinction between care settings was observed, with longer treatment duration and more FTF sessions in specialized care and a more active and intensive usage of the Web-based component by the patients in primary care. Of the patients who started the bCBT, 89.5% (179/200) also continued with this treatment format. Treatment preference, educational level, and the number of comorbid disorders were associated with bCBT engagement.

CONCLUSIONS

Blended treatments can be applied to a group of patients being treated for depression in routine mental health care. Rather than striving for an optimal blend, a more personalized blended care approach seems to be the most suitable. The next step is to gain more insight into the clinical and cost-effectiveness of blended treatments and to further facilitate uptake in routine mental health care.

Internet Interventions for Adults with Anxiety and Mood Disorders: A Narrative Umbrella Review of Recent Meta-Analyses

Internet-delivered cognitive behaviour therapy (ICBT) has existed for 20 years and there are now several controlled trials for a range of problems. In this paper, we focused on recent meta-analytic reviews of the literature and found moderate to large effects reported for panic disorder, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder, and major depression. In total, we reviewed 9 recent meta-analytic reviews out of a total of 618 meta-analytic reviews identified using our search terms. In these selected reviews, 166 studies were included, including overlap in reviews on similar conditions. We also covered a recent review on transdiagnostic treatments and 2 reviews on face-to-face v. internet treatment. The growing number of meta-analytic reviews of studies now suggests that ICBT works and can be as effective as face-to-face therapy.

Mobile Health Adoption in Mental Health: User Experience of a Mobile Health App for Patients With an Eating Disorder

Background

Despite the worldwide growth in mobile health (mHealth) tools and the possible benefits for both patients and health care providers, the overall adoption levels of mHealth tools by health professionals remain relatively low.

Objective

This study aimed (1) to investigate attitudes of health care providers and mHealth experts toward mHealth tools in the health context in general, and this study aimed (2) to test the acceptability and feasibility of a specific mHealth tool for patients with an eating disorder (ED), called TCApp, among patients and ED specialists.

Methods

To this purpose, we conducted an explorative qualitative study with 4 in-depth group discussions with several groups of stakeholders: our first focus group was conducted with 11 experts on mHealth from the Catalan Association of Health Entities; the second focus group included 10 health care professionals from the Spanish College of Doctors of Barcelona; the third focus group involved 9 patients with an ED who had used the TCApp over a 12-week period, and the fourth and last focus group involved 8 ED specialists who had monitored such ED patients on the Web.

Results

The focus groups showed that health care providers and mHealth experts reported barriers for mHealth adoption more often than facilitators, indicating that mHealth techniques are difficult to obtain and use. Most barriers were attributed to external factors relating to the human or organizational environment (ie, lack of time because of workload, lack of direct interest on a legislative or political level) rather than being attributed to internal factors relating to individual obstacles. The results of the mHealth intervention study indicate that the TCApp was considered as easy to use and useful, although patients and the ED specialists monitoring them on the Web reported different adoption problems, such as the inability to personalize the app, a lack of motivational and interactive components, or difficulties in adhering to the study protocol.

Conclusions

In general, this paper indicates that both health professionals and patients foresee difficulties that need to be addressed before comprehensive adoption and usage of mHealth techniques can be effectively implemented. Such findings are in line with previous studies, suggesting that although they acknowledge their possible benefits and cost-effectiveness, health care providers are quite resistant and conservative about integrating mHealth technologies in their daily practice.

Feasibility of a traditional and teletreatment approach to mirror therapy in patients with phantom limb pain: a process evaluation performed alongside a randomized controlled trial

OBJECTIVE

To evaluate the delivery, acceptance and experiences regarding a traditional and teletreatment approach to mirror therapy as delivered in a randomized controlled trial.

DESIGN

Mixed methods, prospective study.

SETTING

Rehabilitation centres, hospital and private practices.

SUBJECTS

Adult patients with phantom pain following lower limb amputation and their treating physical and occupational therapists.

INTERVENTIONS

All patients received 4 weeks of traditional mirror therapy (n = 51), followed by 6 weeks of teletreatment (n = 26) or 6 weeks of self-delivered mirror therapy (n = 25).

MAIN MEASURES

Patient files, therapist logs, log files teletreatment, acceptance questionnaire and interviews with patients and their therapists.

RESULTS

In all, 51 patients and 10 therapists participated in the process evaluation. Only 16 patients (31%) received traditional mirror therapy according to the clinical framework during the first 4 weeks. Between weeks 5 and 10, the teletreatment was used by 14 patients (56%) with sufficient dose. Teletreatment usage decreased from a median number of 31 (weeks 5-10) to 19 sessions (weeks 11-24). Satisfactory teletreatment user acceptance rates were found with patients demonstrating higher scores (e.g. regarding the usefulness to control pain) than therapists. Potential barriers for implementation of the teletreatment perceived by patients and therapists were related to insufficient training and support as well as the frequency of technical problems.

CONCLUSION

Traditional mirror therapy and the teletreatment were not delivered as intended in the majority of patients. Implementation of the teletreatment in daily routines was challenging, and more research is needed to evaluate user characteristics that influence adherence and how technology features can be optimized to develop tailored implementation strategies.

Online Therapy for Depressive Symptoms: An Evaluation of Counselor-Led and Peer-Supported Life Review Therapy

Objectives

Life review therapy is recognized as an evidence-based treatment for depression in later life. The current article evaluates an online life review therapy in middle-aged and older persons, comparing a counselor-led to a peer-supported mode of delivery.

Methods

A pilot randomized controlled trial (RCT) was carried out with 3 conditions and 4 measurement points: (a) online life review therapy with online counseling, (b) online life review therapy with online peer support, and (c) a waitlist control condition. A mixed methods study provided insight in the reach, adherence, effectiveness, user experiences, and acceptability.

Results

Fifty-eight people were included in the study. The intervention reached a vulnerable group of mainly middle-aged, college-educated women. The pilot RCT on effectiveness showed that participants in all conditions improved significantly in depressive symptoms, engaged living, mastery, and vitality, but not in ego integrity and despair, social support, loneliness, and well-being. The adherence, user experience, and acceptability were better in the counselor condition than in the peer condition. No differences were found between middle-aged and older adults.

Conclusion

Despite the nonsignificant effects, possibly due to the small sample size, online life review therapy might be a good method for alleviating depressive symptoms in people in their second half of life. Further research is needed, addressing how online life review is best offered.

Canadian Centre for Mental Health and Sport (CCMHS) Position Statement: Principles of Mental Health in Competitive and High-Performance Sport

The brave decision made by many Canadian athletes to share their experience with mental illness has fed a growing dialogue surrounding mental health in competitive and high-performance sport. To affect real change for individuals, sport culture must change to meet demands for psychologically safe, supportive, and accepting sport environments. This position statement addresses mental health in competitive and high-performance sport in Canada, presenting solutions to current challenges and laying a foundation for a unified address of mental health by the Canadian sport community. The paper emerged from the first phase of a multidisciplinary Participatory Action Research (PAR) project, in which a sport-focused mental health care model housed within the Canadian Centre for Mental Health and Sport (CCMHS) is currently being designed, implemented, and evaluated by a team of 20 stakeholders, in collaboration with several community partners and advisors.

Effects, Adherence, and Therapists' Perceptions of Web- and Mobile-Supported Group Therapy for Depression: Mixed-Methods Study

Background

Blended group therapy (bGT) has been investigated a several times for anxiety and depression, but information on patients’ adherence to and therapists’ perception of the novel format is nonexistent. Furthermore, many studies investigated mainly female and highly educated populations, limiting the validity of previous findings.

Objective

This study aimed to reduce the gaps and limitations of the previous findings by evaluating an integrated internet- and mobile-supported bGT format.

Methods

A total of 27 patients diagnosed with major depression (14/27, 52% female and 7/27, 25.9% compulsory education) participated in a 7-week treatment at a university outpatient clinic. Furthermore, 8 novice therapists participated in semistructured interviews and a subsequent cross-validation survey.

Results

Primary symptom reduction was high (d=1.31 to 1.51) and remained stable for the follow-up period. Therapists identified advantages (eg, patient engagement, treatment intensification, and improved therapeutic relation) and disadvantages (eg, increased workload, data issues, and undesired effects) of bGT. The required online guidance time was 10.3 min per patient and week, including guidance on exercises (67% or 6.9 min) and intimate communication (33% or 3.4 min). Concerning patients’ adherence to bGT, tracked completion of all Web-based and mobile tasks was high and comparable with group attendance.

Conclusions

Results suggest high feasibility of bGT in a gender-balanced, moderately educated sample. bGT provides group therapists with tools for individual care, resulting in an optimization of the therapy process, and high completion rates of the implemented bGT elements. The limited work experience of the involved therapists restricts the study findings, and potential drawbacks need to be regarded in the development of future bGT interventions.

eHealth Apps Replacing or Complementing Health Care Contacts: Scoping Review on Adverse Effects

Background

The use of eHealth has increased tremendously in recent years. eHealth is generally considered to have a positive effect on health care quality and to be a promising alternative to face-to-face health care contacts. Surprisingly little is known about possible adverse effects of eHealth apps.

Objective

We conducted a scoping review on empirical research into adverse effects of eHealth apps that aim to deliver health care at a distance. We investigated whether adverse effects were reported and the nature and quality of research into these possible adverse effects.

Methods

For this scoping review, we followed the five steps of Arksey and O’Malley’s scoping review methodology. We searched specifically for studies into eHealth apps that replaced or complemented the face-to-face contact between a health professional and a patient in the context of treatment, health monitoring, or supporting self-management. Studies were included when eHealth and adverse effects were mentioned in the title or abstract and when empirical data on adverse effects were provided. All health conditions, with the exception of mental health conditions, all ages, and all sample sizes were included. We examined the literature published between December 2012 and August 2017 in the following databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and the Cochrane Library. The methodological quality of the studies was assessed using the Critical Appraisal Skills Programme (CASP) checklists.

Results

Our search identified 79 papers that were potentially relevant; 11 studies met our inclusion criteria after screening. These studies differed in many ways and the majority were characterized by small research populations and low study quality. Adverse effects are rarely subject to systematic scientific research. So far, information on real adverse effects is mainly limited to incidental reporting or as a bycatch from qualitative pilot studies. Despite the shortage of solid research, we found some indications of possible negative impact on patient-centeredness and efficiency, such as less transparency in the relationship between health professionals and patients and time-consuming work routines.

Conclusions

There is a lack of high-quality empirical research on adverse effects of eHealth apps that replace or complement face-to-face care. While the development of eHealth apps is ongoing, the knowledge with regard to possible adverse effects is limited. The available research often focuses on efficacy, added value, implementation issues, use, and satisfaction, whereas adverse effects are underexplored. A better understanding of possible adverse effects could be a starting point in improving the positive impact of eHealth-based health care delivery.

Prospective acceptance of distinct mobile mental health features in psychiatric patients and mental health professionals

BACKGROUND

Despite numerous mobile health (mHealth) applications available, current impact on mental healthcare is low. Users face overwhelming variety of applications and sensors. Evidence for distinct features' effectiveness is largely lacking. Along with technical feasibility and data security issues, readiness and preferences of patients predetermine engagement and impact of mHealth in psychiatry.

OBJECTIVE

We aimed to assess the prospective attitudes of psychiatric patients and mental health professionals (MHP) towards mHealth applications in general and with regard to distinct features.

METHODS

We conducted a survey entailing 486 subjects (297 MHP and 189 patients).

RESULTS

Professionals and patients indicate both, considerable acceptance and rejection for most features. Marked concerns across groups relate to data security in general. Actimetry and geotracking were considered particularly skeptical. Importantly, most patients prefer to be prompted timely about health status changes.

CONCLUSION

Altogether, evidence indicates substantial support for mHealth features in mental healthcare despite considerable rejection of distinct features. We conclude that tighter collaboration between researchers, developers and clinicians must address matching mHealth-apps to patients' needs. Improved information on potential risks and possibilities associated with mHealth features is strongly indicated in MHP and psychiatric patients in order to reach an appropriately informed decision on individual involvement.

The Advantages and Disadvantages of Online and Blended Therapy: Survey Study Amongst Licensed Psychotherapists in Austria

Background

Web-based and blended (face-to-face plus Web-based) interventions for mental health disorders are gaining significance. However, many licensed psychotherapists still have guarded attitudes toward computer-assisted therapy, hindering dissemination efforts.

Objective

The objective of this study was to provide a therapist-oriented evaluation of Web-based and blended therapies and identify commonalities and differences in attitudes toward both formats. Furthermore, it aimed to test the impact of an information clip on expressed attitudes.

Methods

In total, 95 Austrian psychotherapists were contacted and surveyed via their listed occupational email address. An 8-minute information video was shown to half of the therapists before 19 advantages and 13 disadvantages had to be rated on a 6-point Likert scale.

Results

The sample resembled all assessed properties of Austrian psychotherapists (age, theoretical orientation, and region). Therapists did not hold a uniform overall preference. Instead, perceived advantages of both interventions were rated as neutral (t₉₄=1.89, P=.06; d=0.11), whereas Web-based interventions were associated with more disadvantages and risks (t₉₄=9.86, P<.001; d=0.81). The information clip did not excerpt any detectable effect on therapists’ attitudes (r₉₅=−.109, P=.30). The application of modern technologies in the own therapeutic practice and cognitive behavioral orientation were positively related to the given ratings.

Conclusions

This study is the first to directly compare therapists’ attitudes toward Web-based and blended therapies. Positive attitudes play a pivotal role in the dissemination of new technologies, but unexperienced therapists seem to lack knowledge on how to benefit from technology-aided treatments. To speed up implementation, these aspects need to be addressed in the development of new interventions. Furthermore, the preference of blended treatments over Web-based interventions seems to relate to avoidance of risks. Although this study is likely to represent therapists’ attitudes in countries with less advanced electronic health services, therapists’ attitudes in more advanced countries might present differently.

A randomized controlled trial on a smartphone self-help application (Be Good to Yourself) to reduce depressive symptoms

Depressive symptoms are common, yet only a subgroup of individuals receive adequate treatment. To reduce the treatment gap, several online self-help programs have been developed, yielding small to moderate effects. We developed a smartphone self-help application addressing depressive symptoms. We sought to evaluate its feasibility and efficacy in participants reporting a subjective need for help (a diagnosis of depression was not mandatory). We conducted a randomized controlled trial (N = 90). The primary outcome was a reduction of depressive symptoms measured with the Patient Health Questionnaire-9 (PHQ-9). Secondary outcomes included improved self-esteem (Rosenberg Self-Esteem Scale) and quality of life (WHOQOL-BREF). The intervention group obtained access to the application for four weeks, the wait-list group received access after the post assessment. No group differences emerged in either outcome in intention-to-treat analyses. Per protocol analyses with frequent users (i.e., several times a week or more) yielded a small effect size (η²_p = 0.049) at trend level on the reduction of depressive symptoms in favor of the treatment group. However, 39% of the participants did not use the application frequently. Mobile self-help applications represent a promising addition to existing treatments, but it is important to increase patients' motivation to use them.

Working alliance as a predictor of change in depression during blended cognitive behaviour therapy

Blended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT.