Barriers to mental health treatment: results from the WHO World Mental Health surveys

Psychiatric, psychological and addiction management in obesity surgery: Early identification for better support

Although bariatric surgery results in a significant weight reduction and an improvement in the quality of life in most people who undergo surgery, there are inter-individual differences in terms of postoperative results. Psychological, psychiatric and addictive disorders contribute substantially to these difficulties. Between 20% and 50% of bariatric surgery candidates have a current psychiatric/addictive disorder and approximately 30-75% have a history of a psychiatric/addictive disorder within their lifetime. Surgery is accompanied in the short-term by an improvement in depressive symptoms and binge eating, but these symptoms tend to increase again beyond the 3rd postoperative year. Over the long-term, only the improvement in depression remains durable, whilepostoperative anxiety and disordered eating symptoms do not differ significantly from the preoperative levels. There is a two to four fold increased risk of post-surgical suicide and suicide attempts (from the 1st postoperative year onward), as well as an increased risk of alcohol-abuse (beyond two years after surgery). Psychological support must therefore continue long-term. Several psychotherapeutic and pharmacological treatments have demonstrated their effectiveness in improving the postoperative prognosis of patients with psychological/psychiatric disorders. The early integration of psychological/psychiatric/addiction evaluation and support into multidisciplinary management makes it easier to identify these difficulties and to optimize the postoperative prognosis, both in terms of weight and quality of life. Prior to surgery, patients should be systematically evaluated by a psychologist or psychiatrist in order to identify and to manage disorders that could negatively impact the postoperative prognosis. After surgery, this assessment and support can be carried out in a programmed and systematic way for those patients who were identified preoperatively as the most vulnerable, but support can also be offered during follow-up in the event of specific symptoms (i.e., loss of control over food intake, failure in terms of weight or quality of life, suicidal ideation, loss of control over alcohol use, significant depression or anxiety symptoms).

Using the Consolidated Framework for Implementation Research to evaluate a nationwide depression prevention project (ImplementIT) from the perspective of health care workers and implementers: Results on the implementation of digital interventions for farmers

Introduction

Depression has a significant impact on individuals and society, which is why preventive measures are important. Farmers represent an occupational group exposed to many risk factors for depression. The potential of guided, tailored internet-based interventions and a personalized telephone coaching is evaluated in a German project of the Social Insurance for Agriculture, Forestry and Horticulture (SVLFG). While user outcomes are promising, not much is known about actual routine care use and implementation of the two digital health interventions. This study evaluates the implementation from the perspective of social insurance employees to understand determinants influencing the uptake and implementation of digital interventions to prevent depression in farmers.

Methods

The data collection and analysis are based on the Consolidated Framework for Implementation Research (CFIR). Health care workers (n = 86) and implementers (n = 7) completed online surveys and/or participated in focus groups. The surveys consisted of validated questionnaires used in implementation research, adapted items from the CFIR guide or from other CFIR studies. In addition, we used reporting data to map implementation based on selected CFIR constructs.

Results

Within the five CFIR dimensions, many facilitating factors emerged in relation to intervention characteristics (e.g., relative advantage compared to existing services, evidence and quality) and the inner setting of the SVLFG (e.g., tension for change, compatibility with values and existing working processes). In addition, barriers to implementation were identified in relation to the outer setting (patient needs and resources), inner setting (e.g., available resources, access to knowledge and information) and characteristics of individuals (e.g., self-efficacy). With regard to the implementation process, facilitating factors (formal implementation leaders) as well as hindering factors (reflecting and evaluating) were identified.

Discussion

The findings shed light on the implementation of two digital prevention services in an agricultural setting. While both offerings seem to be widely accepted by health care workers, the results also point to revealed barriers and contribute to recommendations for further service implementation. For instance, special attention should be given to "patient needs and resources" by raising awareness of mental health issues among the target population as well as barriers regarding the inner setting.

Clinical Trial Registration

German Clinical Trial Registration: [DRKS00017078]. Registered on 18.04.2019.

The Effectiveness of Mental Health First Aid Training among Undergraduate Students in Switzerland: A Randomized Control Trial

Half to three-fourths of mental disorders appear during adolescence or young adulthood, and the treatment gap is mainly due to lack of knowledge, lack of perceived need, and the stigmatization of mental illness. The aims of this study were to implement and evaluate a Mental Health First Aid (MHFA) training program among undergraduates. Participants were second-year students from two universities in the French-speaking region of Switzerland (N = 107), who were randomly assigned to an intervention group (n = 53) or control group (n = 54). The intervention group received a 12-h MHFA course. Online questionnaires were completed before the intervention (T0), and both 3 months (T1) and 12 months (T2) after the intervention in order to evaluate the participants' mental health knowledge, recognition of schizophrenia, and attitudes and behaviors towards mental illness. We used Generalized Estimating Equations (GEE) to examine the effects of intervention over time. After the MHFA course, the intervention group showed significantly increased basic knowledge and confidence helping others with mental illness and reduced stigmatization at both T1 and T2 compared to their baseline scores and compared to control groups. This suggests that the MHFA training program is effective and has significant short-term and long-term impacts, in terms of enhancing basic knowledge about mental health and improving attitudes towards mental illness among undergraduate students.

A mobile-based aftercare intervention to increase self-esteem in inpatients diagnosed with depression: A randomized controlled trial

OBJECTIVE

In this randomized controlled trial, we investigated the effectiveness, side effects and user satisfaction of the self-help smartphone app "MCT & More" among inpatients with a diagnosis of depression after their discharge from a psychiatric hospital over a period of 4 weeks.

METHODS

A total of 159 inpatients were recruited in four German psychiatric hospitals three days before hospital discharge (intervention group: n = 79; treatment as usual: n = 80). Based on the vulnerability model (low self-esteem contributes to depression), self-esteem represented the primary outcome, quality of life and depressive symptoms the secondary outcomes.

RESULTS

Intention-to-treat analyzes showed no statistical significance for the primary and secondary outcome parameters, except for the subscale self-competence in favor of the intervention group (with a small effect size of d = 0.35), in the context of an exploratory approach (post hoc). The more positive the attitude toward mobile-based interventions and the more positive the treatment expectations, the more frequently the app was used (r = .35, p = .008; r = .34, p = .009).

CONCLUSION

Further symptom reduction could not be obtained. However, the results suggest that an effect on improvement in self-competence could be achieved by low-threshold aftercare programs. Future studies should include long-term assessments to examine the impact of mobile-based aftercare on relapse.Trial registration: DRKS00022559.

The Seeking Mental Health Care model: prediction of help-seeking for depressive symptoms by stigma and mental illness representations

BACKGROUND

Only about half the people with depression seek professional health care services. To constitute the different predictors and associating variables of health care utilisation, we model the process and aim to test our hypothesised Seeking Mental Health Care Model. The model includes empirical influences on the help-seeking process to predict actual behaviour and incorporates superordinate (stigma, treatment experiences) as well as intermediate attitudinal variables (continuum and causal beliefs, depression literacy and self-efficacy).

METHOD

All variables are examined in an online study (baseline, three- and six-month follow-up). The sample consisted of adults with depressive symptoms (PHQ-9 sum score ≥ 8), currently not receiving mental health care treatment. To examine the prediction of variables explaining help-seeking behaviour, a path model analysis was carried out (lavaan package, software R).

RESULTS

Altogether, 1368 participants (Mage = 42.38, SDage = 15.22, 65.6% female) were included, 983 participating in at least one follow-up. Model fit was excellent (i.e., RMSEA = 0.059, CFI = 0.989), and the model confirmed most of the hypothesised predictions. Intermediary variables were significantly associated with stigma and experiences. Depression literacy (ß = .28), continuum beliefs (ß = .11) and openness to a balanced biopsychosocial causal model (ß = .21) significantly influenced self-identification (R2 = .35), which among the causal beliefs and self-efficacy influenced help-seeking intention (R2 = .10). Intention (ß = .40) prospectively predicted help-seeking behaviour (R2 = .16).

CONCLUSION

The Seeking Mental Health Care Model provides an empirically validated conceptualisation of the help-seeking process of people with untreated depressive symptoms as a comprehensive approach considering internal influences. Implications and open questions are discussed, e.g., regarding differentiated assessment of self-efficacy, usefulness of continuum beliefs and causal beliefs in anti-stigma work, and replication of the model for other mental illnesses.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00023557. Registered 11 December 2020. World Health Organization, Universal Trial Number: U1111-1264-9954. Registered 16 February 2021.

Promoting Mental Health Literacy at Schools in South Korea

The onset of many lifelong mental illnesses is during childhood and adolescence. There has been an increase in these conditions among children and adolescents especially, during the COVID-19 pandemic. It is essential to promote mental health literacy (MHL) as a preventive and universal intervention for children and adolescents. Positive mental health status in adolescence is related to an increased level of MHL, and various MHL programs at schools have been reported to be effective for adolescent students worldwide. Recently, MHL programs have been developed in South Korea to be used by schoolteachers. There is a need for active dissemination and development of future programs. For continuous and effective education, it is desirable to include MHL education in regular school curricula.

Effects of psychological treatment for depression among people not actively seeking help: a meta-analysis

Although psychological treatments have been found to be effective for depression in adults, many individuals with depression do not actively seek help. It is currently unclear whether psychological treatments are effective among those not actively seeking help. Besides, little is known about the proportion of patients who completed a screening questionnaire who end up in a clinical trial. Therefore, we conducted a meta-analysis of 52 randomized trials comparing psychotherapies for adults with a diagnosis or elevated symptoms of depression against control conditions (care-as-usual, waiting list, and other inactive treatment). Only studies recruiting participants who do not actively seek help (participants who have been recruited through screening instead of advertisements and clinical referrals) were included. To obtain an overall effect estimate of psychotherapy, we pooled all post-test differences with a random-effects model. We found that psychological treatments had a moderate to high effect on reducing depressive symptoms compared to control groups [g = 0.55; 95% confidence interval (CI) 0.41-0.69]. Heterogeneity was high (I² = 75%; 95% CI 68-80). At 12 months' follow-up, the effects were small but significant (6-8 months: g = 0.33; 95% CI 0.14-0.52; 9-12 months: g = 0.24; 95% CI 0.11-0.37). As a secondary outcome, we found that 13% of patients who completed a screening questionnaire met the inclusion criteria for depression and agreed to be randomized in the trial. Based on the current evidence, psychological treatments for depression might be effective for depressed patients who are not actively seeking help.

[Video-based psychotherapy: current framework conditions, developments, and recommendations for practical implementation]

Video-based psychotherapy is a digital way to deliver psychotherapeutic treatment when traditional on-site psychotherapy cannot be provided due to structural barriers, such as those related to the COVID-19 pandemic. The use of this digital approach has proven to be both effective and accepted among therapists and patients. Legal frameworks for German therapists and recommendations for practical implementation are summarized in this article.

Who seeks sex therapy? Sexual dysfunction prevalence and correlates, and help-seeking among clinical and community samples

Sexual dysfunctions (SD; e.g., female sexual interest/arousal disorder, erectile disorder, female orgasmic disorder, delayed ejaculation, genito-pelvic pain/penetration disorder, etc.) affect up to a third of individuals, impairing sexuality, intimate relationships, and mental health. This study aimed to compare the prevalence of SDs and their sexual, relational, and psychological correlates between a sample of adults consulting in sex therapy (n = 963) and a community-based sample (n = 1,891), as well as examine barriers to sexual health services for SD and the characteristics of individuals seeking such services. Participants completed an online survey. Analyses showed that participants in the clinical sample reported lower levels of sexual functioning and sexual satisfaction and higher levels of psychological distress than participants in the community-based sample. Moreover, higher SD rates were related to lower relational satisfaction and higher psychological distress in the community sample, and to lower sexual satisfaction in both samples. Among participants in the community sample who sought professional services for SD, 39.6% reported that they were unable to access services, and 58.7% reported at least one barrier to receiving help. This study provides important data regarding the prevalence of SD and the link between SD and psychosexual health in clinical and nonclinical samples, as well as barriers to treatment access.

Impact of alternative terminology for depression on help-seeking intention: A randomized online trial

OBJECTIVE

People with depression experience barriers to seeking professional help. Different diagnostic terminology can influence people's treatment/management preferences. The aim of this study was to investigate how alternative depression diagnostic labels and recommendations impact help-seeking intentions and psychosocial outcomes.

METHODS

Participants (18-70 years) were recruited using an online panel (Australia) to complete a randomized controlled trial. They read a hypothetical scenario where they discussed experiencing depressive symptoms with their GP and were randomized to receive one of four diagnoses ("depression," "burnout," "functional impairment syndrome" [fictitious label], no label [control]), and one of two follow-up recommendations ("clinical psychologist," "mind coach").

PRIMARY OUTCOME

help-seeking intention (5-point scale, higher = greater intention); secondary outcomes: intention to speak to boss, self-stigma, worry, perceived severity, illness perceptions, and personal stigma.

RESULTS

A total of 676 participants completed the survey. There was no main effect of diagnostic label on help-seeking intention or stigma outcomes. Intention to speak to a boss was higher with the depression compared to burnout label (MD = 0.40, 95% CI: 0.14-0.66) and perceived severity was higher with the depression label compared to control (MD = 0.48, 95% CI: 0.22-0.74) and all other labels. Those who received the "clinical psychologist" recommendation reported higher help-seeking intention (MD = 0.43, 95% CI: 0.25-0.60) and treatment control (MD = 0.69, 95% CI: 0.29-1.10) compared to the "mind coach" recommendation.

CONCLUSION

Findings highlight the success of efforts to promote help-seeking from clinical psychologists for depression. If burnout is considered a separate diagnostic entity to depression, greater awareness around what such a diagnosis means may be needed. Future research should examine how different terminologies surrounding other mental health conditions impact help-seeking and stigma.

Community-Based Intervention Targeting Depressive Symptomatology in Indian Women: An Exploration of Its Efficacy in a Non-Specialized Healthcare Setting

Depressive symptomatology casts a more adverse impact on the well-being of women in countries with unfavourable societal norms. The prevalence of depressive symptomatology in Indian women and the treatment gap in case of mental health issues are alarming and thus may require interventions at a community level. The present study tested the efficacy of a psychosocial community-based intervention in managing depressive symptomatology and associated factors like rumination, reappraisal, psychological resilience, and self-efficacy using a pre-test post-test control group design. A total of 114 (M_age=23.03, SD = 5.29) and 37 (M_age=24.89, SD = 6.44) adult females were there in the experimental and the control group, respectively. A series of ANOVAs showed that participants' scores on depressive symptomatology and associated vulnerabilities and defences improved as compared to the baseline and the control group. The findings support the use of psychosocial community-based intervention in a non-specialized healthcare setting to manage depressive symptomatology, associated vulnerability and defences.

Home-based and community-based activities that can improve mental wellness: a protocol for an umbrella review

INTRODUCTION

Mental disorders affect about 13% of the world's population. While evidence-based mental health treatments are available, a significant number of persons with mental illnesses are untreated or do not receive adequate mental healthcare due to various reasons, including costs, stigma and the desire to self-manage symptoms. In the past few years, there has been an increase in the body of evidence regarding leisure activities and mental wellness. However, there is currently no published overview of the state of the evidence on these activities and their potential preventive and therapeutic effects on mental health.

METHODS AND ANALYSIS

Using Joanna Briggs Institute (JBI) review guidelines, an umbrella review will be undertaken to synthesise findings from systematic reviews and meta-analyses on the mental health benefits of home-based and community-based activities. MEDLINE, PsycInfo, Embase, CINAHL, Web of Science, Epistemonikos, Cochrane Database of Systematic Reviews, JBI Database of Systematic Reviews and Implementation Reports will be searched for potentially relevant systematic reviews and meta-analyses published from January 1991 to present. Title/abstract screening, full-text review, data extraction and assessment of methodological quality will each be performed independently by two reviewers. A third review author will be available to resolve discrepancies in any of the review tasks. To assess the quality of potentially eligible reviews, the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses will be used. Findings will be presented in table form and will be summarised by study population, type of home-based or community-based activity or intervention, and type of mental health outcomes. Overall assessment of the strength of existing evidence from eligible systematic reviews will be provided following the grading of recommendation, assessment, development and evaluation approach.

ETHICS AND DISSEMINATION

No ethical approval is required. Results of this umbrella review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021266989.

A meta-analytic review of randomized clinical trials of online treatments for anxiety: Inclusion/exclusion criteria, uptake, adherence, dropout, and clinical outcomes

Over the last decade there has been rapid growth in the number of clinical trials examining internet-delivered interventions for anxiety. While there have been numerous analyses of treatment efficacy, few studies have examined treatment engagement. The current meta-analysis examined participant eligibility, uptake, adherence, and drop-out in clinical trials of internet-delivered treatments for anxiety. This meta-analysis used random effects models to obtain estimates of participant inclusion, uptake, adherence, drop-out, and within-group treatment effect size. Moderator analyses examined the effects of anxiety disorder type, treatment type, and level of clinician guidance. After screening, 140 trials with 199 treatment arms (N = 11,021) were included. An average of 46% (95% CI 42, 50) of interested people were included in the clinical trials. In the active treatment arms, 98% (95% CI 97, 99) of participants began treatment, 81% (95% CI 78, 85) of the assigned treatments were completed, 21% (95% CI 18, 23) of individuals dropped out at post-treatment based on questionnaire non-completion, and an overall within-group effect size of g = 1.03 (95% CI 0.94, 1.13) was obtained. Several moderators of interest were significant (e.g., clinical guidance, anxiety disorder type), and there was substantial heterogeneity in estimates. In conclusion, a large number of inclusion and exclusion criteria have been used in trials of internet-delivered treatments for anxiety. Once recruited into a trial, however, most people appear to begin, adhere, and complete internet-delivered treatment for anxiety. Further research exploring various eligibility criteria and their impact on engagement and efficacy is warranted.

Clinical Need, Perceived Need, and Treatment Use: Estimating Unmet Need for Mental Health Services in the Adult Population

Estimates of unmet need for mental health services in the adult population are too high because many recover without treatment. Untreated recovery suggests that individuals accurately perceive professional help as unnecessary and do not pursue it. If so, perceived need for treatment should predict service use/nonuse more strongly than the presence or seriousness of disorder. With National Comorbidity Survey-Replication data, respondents who recovered from prior disorder by the current year (N = 1,054) were compared to currently unrecovered respondents with less serious (N = 999) and more serious disorders (N = 294). Perceived need covaried positively with the presence and seriousness of disorder and linked to far higher odds of treatment use than disorder seriousness, supporting perceptual accuracy. Two-thirds of respondents who perceived a treatment need obtained care; only one-third had unmet need. Need perceptions may better estimate a treatment gap and prompt research on individuals' self-assessments and treatment decision-making.

Online programs to strengthen the mental health of medical students: A systematic review of the literature

Medical students have been shown to be vulnerable to mental stress. Strengthening individual protective characteristics can be one cornerstone for promoting medical students' mental health and thereby preventing mental disorders. Online programs are an opportunity to provide appropriate options that have the advantage of being accessible from anywhere, at any time, and with a low entry threshold. This review provides a literature overview of current online programs for medical students. The findings can serve as a point of reference for designing effective online programs for mental health-promotion and mental disorder-prevention in medical curricula. We applied a systematic literature search in PubMed, ERIC, Cochrane, and Web of Science. Programs offered had to be web-based, and the addressed group had to be medical students. Protective individual characteristics for mental health and information on the programs' effectiveness were included in the search. As outcomes, we included mental health, burnout, symptoms of depression, anxiety, and well-being. The search yielded 723 articles; of them, 11 met the inclusion criteria. Programs found were grouped according to their focus: mental health literacy, mindfulness, based on Cognitive Behavioral Therapy, or peer support. Two studies showed significant reductions in perceived stress; one study indicated reduced burnout levels. One program had significant immediate effects on mindfulness, empathy, and resilience; two studies indicated strengthening coping strategies. Two programs were qualitatively assessed as helpful; two studies are ongoing. Nine studies lacked control groups; two randomized controlled trials were ongoing. Only a few online programs with limited evidence of effectiveness were found. They addressed protective individual characteristics, highlighting their importance for mental health. Thus, more health-promoting and mental disorder-preventing programs with high-quality effectiveness studies are necessary. An integration of such programs into curricula would allow for greater utilization and could give greater emphasis to and prioritize mental health in medical education.

The complex association of barriers and interest in internet-delivered cognitive behavior therapy for depression and anxiety: informing e-health policies through exploratory path analysis

BACKGROUND

Internet-delivered cognitive behavioral therapy (ICBT) provides critical remote access to mental health care to at-risk populations. However, to our knowledge, no investigation has been conducted to understand complex pathways through which barriers to care (i.e. structural, attitudinal and technological) correlate with patient interest in ICBT.

AIM

The objective of this study is to develop and test a pathway analysis framework using structural equation modeling to understand direct and mediating associations of barriers to care with interest in ICBT.

METHODS

This cross-sectional observational study was conducted among adult (>18 years) urban and rural residents (n = 200) in Saskatchewan, Canada. An online survey assessed interest in ICBT, barriers to ICBT, demographics, and depression and anxiety symptoms. Utilizing structural equation modeling, a path analysis framework was developed.

RESULTS

Path analysis results showed how associations between complex barriers and demographic variables correlate with interest in ICBT. For instance, the negative association of perceived financial concerns and life chaos on interest in ICBT was mediated by perceived access to care.

CONCLUSION

The findings identify specific barriers that could be addressed through targeted population health interventions to improve uptake of ICBT.

Systematic review of economic evaluations for internet- and mobile-based interventions for mental health problems

In view of the staggering disease and economic burden of mental disorders, internet and mobile-based interventions (IMIs) targeting mental disorders have often been touted to be cost-effective; however, available evidence is inconclusive and outdated. This review aimed to provide an overview of the cost-effectiveness of IMIs for mental disorders and symptoms. A systematic search was conducted for trial-based economic evaluations published before 10th May 2021. Electronic databases (including MEDLINE, PsycINFO, CENTRAL, PSYNDEX, and NHS Economic Evaluations Database) were searched for randomized controlled trials examining IMIs targeting mental disorders and symptoms and conducting a full health economic evaluation. Methodological quality and risk of bias were assessed. Cost-effectiveness was assumed at or below £30,000 per quality-adjusted life year gained. Of the 4044 studies, 36 economic evaluations were reviewed. Guided IMIs were likely to be cost-effective in depression and anxiety. The quality of most evaluations was good, albeit with some risks of bias. Heterogeneity across studies was high because of factors such as different costing methods, design, comparison groups, and outcomes used. IMIs for anxiety and depression have potential to be cost-effective. However, more research is needed into unguided (preventive) IMIs with active control conditions (e.g., treatment as usual) and longer time horizon across a wider range of disorders.Trial registration: PROSPERO Registration No. CRD42018093808.

Reducing Smoking Cessation Disparities: Capacity for a Primary Care- and Technology-Based Approach Among Medicaid Recipients

While cigarette use among U.S adults has recently decreased, vulnerable subgroups continue to smoke at high rates, including individuals receiving Medicaid insurance. These individuals have also experienced treatment access disparities, highlighting the need for approaches that leverage their strong desire to quit. We conducted interviews with 100 adult primary care patients receiving Medicaid who were current tobacco users about their use, openness to technology-based interventions, and readiness to change. Most (92%) reported current cigarette use and readiness to change averaged 6.98 out of 10 (SD = 2.82). Nearly all were open to completing an iPad-based tobacco screening (95%) and brief intervention (90%) at their next appointment, while 91% and 88% were willing to talk with their provider or a cessation counselor, respectively, about the subsequent results. Results persisted across age, sex, and race/ethnicity. Openness to technology-based interventions in this population provides support for future work that may ultimately reduce disparities.

Personalised depression forecasting using mobile sensor data and ecological momentary assessment

Introduction

Digital health interventions are an effective way to treat depression, but it is still largely unclear how patients' individual symptoms evolve dynamically during such treatments. Data-driven forecasts of depressive symptoms would allow to greatly improve the personalisation of treatments. In current forecasting approaches, models are often trained on an entire population, resulting in a general model that works overall, but does not translate well to each individual in clinically heterogeneous, real-world populations. Model fairness across patient subgroups is also frequently overlooked. Personalised models tailored to the individual patient may therefore be promising.

Methods

We investigate different personalisation strategies using transfer learning, subgroup models, as well as subject-dependent standardisation on a newly-collected, longitudinal dataset of depression patients undergoing treatment with a digital intervention ( N = 65 patients recruited). Both passive mobile sensor data as well as ecological momentary assessments were available for modelling. We evaluated the models' ability to predict symptoms of depression (Patient Health Questionnaire-2; PHQ-2) at the end of each day, and to forecast symptoms of the next day.

Results

In our experiments, we achieve a best mean-absolute-error (MAE) of 0.801 (25% improvement) for predicting PHQ-2 values at the end of the day with subject-dependent standardisation compared to a non-personalised baseline ( MAE = 1.062 ). For one day ahead-forecasting, we can improve the baseline of 1.539 by 12 % to a MAE of 1.349 using a transfer learning approach with shared common layers. In addition, personalisation leads to fairer models at group-level.

Discussion

Our results suggest that personalisation using subject-dependent standardisation and transfer learning can improve predictions and forecasts, respectively, of depressive symptoms in participants of a digital depression intervention. We discuss technical and clinical limitations of this approach, avenues for future investigations, and how personalised machine learning architectures may be implemented to improve existing digital interventions for depression.

Infraslow closed-loop brain training for anxiety and depression (ISAD): a protocol for a randomized, double-blind, sham-controlled pilot trial in adult females with internalizing disorders

BACKGROUND

The core intrinsic connectivity networks (core-ICNs), encompassing the default-mode network (DMN), salience network (SN) and central executive network (CEN), have been shown to be dysfunctional in individuals with internalizing disorders (IDs, e.g. major depressive disorder, MDD; generalized anxiety disorder, GAD; social anxiety disorder, SOC). As such, source-localized, closed-loop brain training of electrophysiological signals, also known as standardized low-resolution electromagnetic tomography (sLORETA) neurofeedback (NFB), targeting key cortical nodes within these networks has the potential to reduce symptoms associated with IDs and restore normal core ICN function. We intend to conduct a randomized, double-blind (participant and assessor), sham-controlled, parallel-group (3-arm) trial of sLORETA infraslow (<0.1 Hz) fluctuation neurofeedback (sLORETA ISF-NFB) 3 times per week over 4 weeks in participants (n=60) with IDs. Our primary objectives will be to examine patient-reported outcomes (PROs) and neurophysiological measures to (1) compare the potential effects of sham ISF-NFB to either genuine 1-region ISF-NFB or genuine 2-region ISF-NFB, and (2) assess for potential associations between changes in PRO scores and modifications of electroencephalographic (EEG) activity/connectivity within/between the trained regions of interest (ROIs). As part of an exploratory analysis, we will investigate the effects of additional training sessions and the potential for the potentiation of the effects over time.

METHODS

We will randomly assign participants who meet the criteria for MDD, GAD, and/or SOC per the MINI (Mini International Neuropsychiatric Interview for DSM-5) to one of three groups: (1) 12 sessions of posterior cingulate cortex (PCC) ISF-NFB up-training (n=15), (2) 12 sessions of concurrent PCC ISF up-training and dorsal anterior cingulate cortex (dACC) ISF-NFB down-training (n=15), or (3) 6 sessions of yoked-sham training followed by 6 sessions genuine ISF-NFB (n=30). Transdiagnostic PROs (Hospital Anxiety and Depression Scale, HADS; Inventory of Depression and Anxiety Symptoms - Second Version, IDAS-II; Multidimensional Emotional Disorder Inventory, MEDI; Intolerance of Uncertainty Scale - Short Form, IUS-12; Repetitive Thinking Questionnaire, RTQ-10) as well as resting-state neurophysiological measures (full-band EEG and ECG) will be collected from all subjects during two baseline sessions (approximately 1 week apart) then at post 6 sessions, post 12 sessions, and follow-up (1 month later). We will employ Bayesian methods in R and advanced source-localisation software (i.e. exact low-resolution brain electromagnetic tomography; eLORETA) in our analysis.

DISCUSSION

This protocol will outline the rationale and research methodology for a clinical pilot trial of sLORETA ISF-NFB targeting key nodes within the core-ICNs in a female ID population with the primary aims being to assess its potential efficacy via transdiagnostic PROs and relevant neurophysiological measures.

TRIAL REGISTRATION

Our study was prospectively registered with the Australia New Zealand Clinical Trials Registry (ANZCTR; Trial ID: ACTRN12619001428156). Registered on October 15, 2019.

Effects of Cognitive Behavioral Stress Management Delivered by a Virtual Human, Teletherapy, and an E-Manual on Psychological and Physiological Outcomes in Adult Women: An Experimental Test

Technology may expand the reach of stress management to broader populations. However, issues with engagement can reduce intervention effectiveness. Technologies with highly social interfaces, such as virtual humans (VH), may offer advantages in this space. However, it is unclear how VH compare to telehealth and e-manuals at delivering psychological interventions. This experiment compared the effects of single laboratory session of Cognitive Behavioral Stress Management (CBSM) delivered by a VH (VH-CBSM), human telehealth (T-CBSM), and an e-manual (E-CBSM) on psychological and physiological outcomes in a community sample of stressed adult women. A pilot randomized controlled trial (RCT) with a parallel, mixed design was conducted. Adult women (M age =43.21, SD = 10.70) who self-identified as stressed were randomly allocated to VH-CBSM, T-CBSM, or E-CBSM involving one 90 min session and homework. Perceived stress, stress management skills, negative affect, optimism, relaxation, and physiological stress were measured. Mixed factorial ANOVAs and pairwise comparisons with Bonferroni correction investigated main and interaction effects of time and condition. Participants’ data (N = 38) were analysed (12 = VH-CBSM; 12 = T-CBSM; 14 = E-CBSM). Each condition significantly improved stress, negative affect, optimism, relaxation, and physiological stress over time with large effect sizes. No significant differences were found between conditions on outcomes. Overall, all three technologies showed promise for remotely delivering CBSM in a controlled setting. The findings suggest feasibility of the VH-CBSM delivery approach and support conducting a fully powered RCT to examine its effectiveness when delivering a full 10-week CBSM intervention.

Review: School-based mental health literacy interventions to promote help-seeking - a systematic review

BACKGROUND

School-based mental health literacy interventions aim to prevent mental disorders and promote mental wellbeing through improving the knowledge and understanding of mental health, mental disorders, and reducing stigma. Evidence suggests that good mental health literacy helps young people recognise mental health difficulties in themselves and in others, and seek help for mental health problems. Improved help-seeking can allow for early intervention, which prevents the progression of mental disorders and ultimately reduces the burden of mental disorders. The aim of this review is to identify and synthesise evidence on the effectiveness of school-based mental health literacy interventions in improving help-seeking outcomes.

METHODS

We searched MEDLINE, Embase, PsycINFO, ERIC, Child Development and Adolescent Studies, British Education Index and ASSIA (June 2020). Additional searches were conducted a year later to identify any new publications (June 2021). We included randomised controlled trials (RCTs) assessing the effectiveness or cost-effectiveness of school-based interventions to improve help-seeking outcomes for children and young people aged 4-18 years. Included studies were critically appraised.

RESULTS

We identified 11 studies investigating help-seeking outcomes of school-based mental health literacy interventions including a total of 7066 participants from 66 secondary schools. Overall, there is no strong evidence for the effectiveness of school-based mental health literacy interventions in improving help-seeking outcomes, including general attitudes towards help-seeking, personal intentions to seek help, knowledge of when and how to seek help for mental disorders, confidence to seek help, and actual help-seeking behaviours. None of the studies investigated the cost-effectiveness of the interventions.

CONCLUSION

The lack of standardised measures with established reliability and validity for help-seeking outcomes, and the incomprehensive consideration of the multi-faceted concepts of MH literacy and MH stigma have contributed to the scarcity of evidence for the effectiveness. Future research should focus on developing standardised measurement tools and including economic evaluations to understand pragmatic and financial aspects of school-based mental health literacy interventions.

Population mental health improves with increasing access to treatment: evidence from a dynamic modelling analysis

BACKGROUND

Multiple studies indicate that the prevalence of mental disorders in high-income countries has remained stable or increased despite substantial increases in the provision of care, leading some authors to question the effectiveness of increasing access to current treatments as a means of improving population mental health.

METHODS

We developed a system dynamics model of mental disorder incidence and treatment-dependent recovery to assess two potential explanations for the apparent failure of increasing treatment provision to reduce mental disorder prevalence: 1) an increase in the individual-level risk of disorder onset; and 2) declining effectiveness of care resulting from insufficient services capacity growth. Bayesian Markov Chain Monte Carlo (MCMC) methods were used to fit the model to data on the prevalence of high to very high psychological distress in Australia for the period 2008-2019.

RESULTS

Estimates of yearly rates of increase in the per capita incidence of high to very high psychological distress and the proportion of patients recovering when treated indicate that the individual-level risk of developing high to very high levels of distress increased between 2008 and 2019 (posterior probability > 0.999) but provide no evidence for declining treatment effectiveness. Simulation analyses suggest that the prevalence of high to very high psychological distress would have decreased from 14.4% in 2008 to 13.6% in 2019 if per capita incidence had not increased over this period (prevalence difference 0.0079, 95% credible interval 0.0015-0.0176).

CONCLUSIONS

Our analyses indicate that a modest but significant effect of increasing access to mental health care in Australia between 2008 and 2019 was obscured by a concurrent increase in the incidence of high to very high psychological distress.

Predicting non-initiation of care and dropout in a blended care CBT intervention: Impact of early digital engagement, sociodemographic, and clinical factors

Objective

This study examines predictors of non-initiation of care and dropout in a blended care CBT intervention, with a focus on early digital engagement and sociodemographic and clinical factors.

Methods

This retrospective cohort analysis included 3566 US-based individuals who presented with clinical levels of anxiety and depression and enrolled in a blended-care CBT (BC-CBT) program. The treatment program consisted of face-to-face therapy sessions via videoconference and provider-assigned digital activities that were personalized to the client's presentation. Multinomial logistic regression and Cox proportional hazard survival analysis were used to identify predictors of an increased likelihood of non-initiation of therapy and dropout.

Results

Individuals were more likely to cancel and/or no-show to their first therapy session if they were female, did not disclose their ethnicity, reported poor financial status, did not have a college degree, endorsed more presenting issues during the onboarding triage assessment, reported taking antidepressants, and had a longer wait time to their first appointment. Of those who started care, clients were significantly more likely to drop out if they did not complete the digital activities assigned by their provider early in treatment, were female, reported more severe depressive symptoms at baseline, reported taking antidepressants, and did not disclose their ethnicity.

Conclusions

Various sociodemographic and clinical predictors emerged for both non-initiation of care and for dropout, suggesting that clients with these characteristics may benefit from additional attention and support (especially those with poor early digital engagement). Future research areas include targeted mitigation efforts to improve initiation rates and curb dropout.

A randomized controlled trial to pilot the efficacy of a computer-based intervention with elements of virtual reality and limited therapist assistance for the treatment of post-traumatic stress disorder

Although well-established therapies exist for post-traumatic stress disorder (PTSD), barriers to seek mental health care are high. Technology-based interventions may play a role in improving the reach of efforts to treat, especially when therapist availability is low. The goal of the current randomized controlled trial was to pilot the efficacy of a computer-based trauma intervention with elements of virtual reality (VR; 3MR system) and limited therapist involvement for the treatment of PTSD in a childhood sexual abuse (CSA) and war veteran sample and to compare this to "treatment as usual" (TAU). TAU consisted of evidence-based approaches such as imaginal exposure, EMDR, or narrative exposure therapy. A total of 44 patients with PTSD were included and randomly assigned to 12 sessions of 3MR intervention or TAU (completer n 3MR = 12, TAU = 18). Several measures (PCL-5, BDI-II, OQ-45-2, and the M.I.N.I. 5.0.0.) were administered to measure symptoms of PTSD and depression and scores of overall well-being at pre, post, and a three-month follow-up measurement. Analyses suggest that symptoms of PTSD and depression in the 3MR condition decreased, and overall well-being increased between pre and post measurements. Results did not indicate any clear differences between the treatment conditions over time which suggests that treatment gains of the 3MR intervention seem no less than those of TAU. Finally, both treatment conditions produced similar remission rates of PTSD and depression. Therefore, the 3MR intervention could possibly constitute an appropriate treatment alternative. The small sample size as well as evident drop-out rates in the 3MR condition (45%) do warrant further research. The procedures of this study were approved by the Medical Ethical Research Committee (MERC) of the Erasmus Medical Center in Rotterdam (MEC-NL46279.078.13) and pre-registered via ClinicalTrials.gov (Protocol Record CI1-12-S028-1).

Mindfulness to Manage Moral Injury: Rationale and development of a live online 7-week group intervention for veterans with moral injury

Background

Military service puts service members at risk for moral injury. Moral injury is an array of symptoms (e.g., guilt, shame, anger) that develop from events that violate or transgress one's moral code.

Objective

We describe adaption of in-person mindfulness training program, Mindfulness to Manage Chronic Pain (MMCP), to address symptoms of moral injury to be delivered live via the web. We discuss how we will assess benchmarks (i.e., recruitment, credibility and acceptability, completion rates, and adherence) of the Mindfulness to Manage Moral Injury (MMMI) program.

Methods

Aim 1: To develop and then adapt the MMCP program based on feedback from experts and veterans who took part in Study 1. Aim 2: To develop an equally intensive facilitator-led online Educational Support (ES) program to serve as a comparison intervention and conduct a run-through of each program with 20 veterans (10 MMMI; 10 ES). Aim 3: To conduct a small-scale randomized controlled trial (N = 42 veterans; 21 MMMI; 21 ES) in which we will collect pre-post-test and weekly benchmark data for both refined intervention arms.

Results

Study 1 and 2 are completed. Data collection for Study 3 will be completed in 2022.

Conclusion

MMMI is designed to provide a live facilitated mindfulness program to address symptoms of moral injury. If Study 3 demonstrates good benchmarks, with additional large-scale testing, MMMI may be a promising treatment that can reach veterans who may not seek traditional VAMC care and/or who prefer a web-based program.

Metaverse as a possible tool for reshaping schema modes in treating personality disorders

Personality disorders (PD) are usually treated with face-to-face sessions and/or digital mental health services. Among many schools of therapies, schema therapy stands out because rather than simply targeting the symptoms of PD, it cordially targets the cause of PD and heals the early maladaptive schema, thus is exceptionally good at soothing emotional disturbances before enacting cognitive restructuring, resulting in long-term efficacy. However, according to Piaget's genetic epistemology, the unmet needs lie in the fact that the schemata that determine the adaptive behavior can only be formed in the interaction with the real world that the patient is living in and reconsolidated by the feedback from the object world upon the patient's newly-formed behavior. Therefore, in order to reshape the patient's schema modes to support adaptive behavior and regain emotional regulation capabilities of the healthy adult, one may have to reconstruct the object world surrounding the patient. Metaverse, the bestowed successor to the Internet with the cardinal feature of "the sense of full presence," can become a powerful tool to reconstruct a new object world for the patient with the prescription of a psychotherapist, so as to transform the treatment techniques in schema therapy into the natural autobiographical experiences of patients in the new object world, thus gradually reshape the patient's schema modes that can ultimately result in an adaptive, and more inclusive, interaction with the real world. This work describes the underlying theory, the mechanism, the process, and ethical considerations of such promising technology for the not-too-far future.

Patients' and relatives' views on unmet mental health care needs through a qualitative study: Symptoms are a major barrier

Unmet needs in mental health care are a prominent issue and concern almost half of people with such disorders. Psymobile is a mobile outreach psychiatric team whose objective is to facilitate access to psychiatric services. Its intervention is at the request of relatives or social workers, making it possible to encounter situations of long-standing unmet needs. Our objective was to understand the barriers to accessing mental health care as perceived by patients and their relatives. We conducted a qualitative study with patients and their relatives using face-to-face semi-structured interviews and a hierarchical thematic analysis. Four major themes were identified: psychological and behavioural barriers, socio-economic barriers, structural barriers and physical barriers. Anosognosia or lack of insight is cited as a primary barrier, as are fear of stigma, and former negative experiences. The complexity of the French care system and the lack of literacy about mental illnesses were also emphasized by the participants. Physical determinants, such as the distance to healthcare facilities, were rarely mentioned. As a conclusion, outreach teams appear to be an appropriate way to address the issue of unmet mental health care needs when they provide psychiatric care.

Let's teach peer support skills to all college students: Here's how and why

The mental health of students at U.S. colleges and universities is rapidly deteriorating, and our counseling infrastructure struggles to meet rising demand. Given this reality, colleges must supplement reactive counseling services with preventive, campus-wide initiatives targeting root causes of distress, including loneliness and lack of social support. One promising innovation would be to provide basic training on listening and helping skills to all students so they can take turns reciprocally supporting each other. Self-disclosure and providing support both have strong mental health benefits. This would also increase social connection, which is likely to improve academics and retention. This paper reviews the benefits and limitations of teaching peer support skills to a large volume of students, which may enable colleges to deliver the social and emotional aspects of education that are critical to health and academics, yet often sorely missing.

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

Implicit attitudes toward psychotherapy and explicit barriers to accessing psychotherapy in youths and parent–youth dyads

Background

Few studies have investigated implicit and explicit attitudes toward psychotherapy in youths (Study 1), although information about attitudes would improve interventions that aim to decrease barriers to accessing psychotherapy including parents (Study 2), who facilitate the help-seeking process of youths.

Method

The Study 1 sample comprised 96 youths (14–21 years) and the Study 2 sample 38 parent–youth dyads. Differences in implicit attitudes regarding psychotherapy and a medical treatment were measured with the Implicit Association Test, and psychotherapy knowledge and self-reported barriers to psychotherapy were assessed with questionnaires. The actor-partner interdependence model was used to test the dyadic effects of implicit attitudes on explicit attitudes in parents and youths.

Results

We did not find evidence for an implicit bias toward psychotherapy compared to a medical treatment, neither in youths, nor in parents. Self-reported barriers were a predictor for lower help-seeking intentions. Deficits in psychotherapy knowledge were more relevant in younger participants. Having a prior or current experience with psychotherapy and having a friend or family member with a prior or current experience with psychotherapy were predictors for better psychotherapy knowledge, but was not for lower barriers to accessing psychotherapy. Partner effects (degree to which the individual’s implicit attitudes are associated with explicit attitudes of the other dyad’s member) were not found.

Conclusion

Specific deficits in psychotherapy knowledge should be addressed in interventions to lower barriers accessing psychotherapy. Parents should be included in interventions as a valuable resource to support youths in seeking psychotherapy for mental disorders.

Professional Values and Educational Needs among Mental Health Specialists in Russia: Survey Results

BACKGROUND

Exploring the professional values and educational needs of future and practicing mental health specialists is required to develop effective measures aiming at improving their skills and interest in their work.

AIM

Our aim was to explore professional values and educational needs of mental health specialists in Russia.

METHODS

We conducted a survey that captured socio-demographic data, professional characteristics, professional values, and educational needs. Fisher's exact test, logistic regression, and the k-means cluster analysis were used in our statistical analysis.

RESULTS

The survey included 133 participants, 71% of whom had completed their postgraduate education. The following items were mentioned as important professional values by the respondents: "Job opportunities", "Stimulation of intellectual activity", and "Work-life balance". The most popular options for educational activities were English language (63.4%), the principles of evidence-based medicine (63.4%), and developing skills for conducting scientific research (59.4%).In comparison with practicing specialists, respondents who had not yet completed their postgraduate education were more interested in developing their curriculum vitae (39% vs. 60%, p=0.044) and communication skills (49% vs. 77%, p=0.0048). Compared to male respondents, female respondents were more interested in developing skills in conducting scientific research (47 vs. 70%, p=0.0165).A cluster analysis showed that specialists who attached more importance to almost all professional values, in comparison to those who did not, were more interested in activities aimed at developing their research skills (64% vs. 41%, p=0.0287), learning about the principles of evidence-based medicine (70% vs. 41%, p=0.0063), and participating in journal clubs (39% vs. 11%, p=0.0193).

CONCLUSION

The present study suggests that job opportunities, intellectual stimulation, and work-life balance are the most important professional values for future and practicing mental health specialists. These findings might be used as a basis for developing educational activities for mental health specialists.

Efficacy and Conflicts of Interest in Randomized Controlled Trials Evaluating Headspace and Calm Apps: Systematic Review

BACKGROUND

Although there are thousands of mental health apps, 2 apps, Headspace and Calm, claim a large percentage of the marketplace. These two mindfulness and meditation apps have reached tens of millions of active users. To guide consumers, clinicians, and researchers, we performed a systematic review of randomized controlled trials (RCTs) of Headspace and Calm.

OBJECTIVE

Our study aimed to evaluate intervention efficacy, risk of bias, and conflicts of interest (COIs) in the evidence base for Headspace and Calm, the two most popular mental health apps at the time of our search.

METHODS

To identify studies, we searched academic databases (Google Scholar, MEDLINE, and PsycINFO) and the websites of Headspace and Calm in May 2021 for RCTs of Headspace and Calm testing efficacy via original data collection, published in English in peer-reviewed journals. For each study, we coded (1) study characteristics (eg, participants, sample size, and outcome measures), (2) intervention characteristics (eg, free vs paid version of the app and intended frequency of app usage), (3) all study outcomes, (4) Cochrane risk of bias variables, and (5) COI variables (eg, presence or absence of a preregistration and the presence or absence of a COI statement involving the company).

RESULTS

We identified 14 RCTs of Headspace and 1 RCT of Calm. Overall, 93% (13/14) of RCTs of Headspace and 100% (1/1) of RCTs of Calm recruited participants from a nonclinical population. Studies commonly measured mindfulness, well-being, stress, depressive symptoms, and anxiety symptoms. Headspace use improved depression in 75% of studies that evaluated it as an outcome. Findings were mixed for mindfulness, well-being, stress, and anxiety, but at least 40% of studies showed improvement for each of these outcomes. Studies were generally underpowered to detect "small" or "medium" effect sizes. Furthermore, 50% (7/14) of RCTs of Headspace and 0% (0/1) of RCTs of Calm reported a COI that involved Headspace or Calm (the companies). The most common COI was the app company providing premium app access for free for participants, and notably, 14% (2/14) of RCTs of Headspace reported Headspace employee involvement in study design, execution, and data analysis. Only 36% (5/14) of RCTs of Headspace were preregistered, and the 1 RCT of Calm was not preregistered.

CONCLUSIONS

The empirical research on Headspace appears promising, whereas there is an absence of randomized trials on Calm. Limitations of this study include an inability to compare Headspace and Calm owing to the dearth of RCTs studying Calm and the reliance on author reports to evaluate COIs. When determining whether or not mental health apps are of high quality, identification of high-quality apps and evaluation of their effectiveness and investigators' COIs should be ensured.

Waiting Lists for Psychotherapy and Provider Attitudes Toward Low-Intensity Treatments as Potential Interventions: Survey Study

BACKGROUND

Common mental disorders, including depression and anxiety, are leading causes of disability worldwide. Digital mental health interventions, such as web-based self-help and other low-intensity treatments (LITs) that are not digital (eg, bibliotherapy), have the potential to reach many individuals by circumventing common barriers present in traditional mental health care. It is unclear how often LITs are used in clinical practice, or whether providers would be interested in their use for treatment waiting lists.

OBJECTIVE

The aims of this study were to (1) describe current practices for treatment waiting lists, (2) describe providers' attitudes toward digital and nondigital LITs for patients on a waiting list, and (3) explore providers' willingness to use digital and nondigital LITs and their decisions to learn about them.

METHODS

We surveyed 141 practicing mental health care providers (eg, therapists and psychologists) and provided an opportunity for them to learn about LITs.

RESULTS

Most participants reported keeping a waiting list. Few participants reported currently recommending digital or nondigital LITs, though most were willing to use at least one for patients on their waiting list. Attitudes toward digital and nondigital LITs were neutral to positive. Guided digital and nondigital LITs were generally perceived to be more effective but less accessible, and unguided interventions were perceived to be less effective but more accessible. Most participants selected to access additional information on LITs, with the most popular being web-based self-help.

CONCLUSIONS

Results suggest providers are currently not recommending LITs for patients on treatment waiting lists but would be willing to recommend them. Future work should explore barriers and facilitators to implementing digital and nondigital LITs for patients on treatment waiting lists.

ACTonDiabetes: study protocol of a pragmatic randomised controlled trial for the evaluation of an acceptance and commitment-based internet-based and mobile-based intervention for adults living with type 1 or type 2 diabetes

INTRODUCTION

Living with diabetes can be burdensome and lead to serious emotional distress and impaired mental health. Acceptance and commitment therapy (ACT) can support people facing the challenges of living with diabetes. This trial aims to evaluate the effectiveness and cost-effectiveness of the internet-based and mobile-based intervention (IMI) 'ACTonDiabetes' in reducing diabetes distress against enhanced treatment as usual (TAU+) following specialised diabetes care.

METHODS AND ANALYSIS

A two-armed pragmatic randomised controlled trial will be conducted to evaluate the guided IMI ACTonDiabetes against TAU+. A total of 210 adults with type 1 or type 2 diabetes and elevated diabetes distress (Problem Areas in Diabetes ≥40) will be recruited at a specialised diabetes centre. The intervention begins 2-4 weeks after hospital discharge and takes about 7-10 weeks to complete. Assessments are performed at baseline and 5 and 10 weeks as well as 6 and 12 months after randomisation. The primary outcome is diabetes distress at a 10-week follow-up (T2). Secondary outcomes are depression (Patient Health Questionnaire-8), psychological well-being (WHO-5), quality of life (Assessment of Quality of Life-8 Dimension), Diabetes-related Self-Management Questionnaire, diabetes acceptance (Acceptance and Action Diabetes Questionnaire) and negative treatment effects (Inventory for the Assessment of Negative Effects of Psychotherapy). All statistical analyses will be performed based on the intention-to-treat principle with additional per-protocol analyses. Changes in outcomes will be evaluated using the general linear model. A health-economic evaluation will be conducted from a societal perspective. Reasons for drop-out will be systematically investigated.

ETHICS AND DISSEMINATION

This clinical trial has been approved by the State Medical Chamber of Baden-Württemberg (file no. B-F-2019-010). Trial results will be submitted for publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00016738.

Comparative effectiveness and acceptability of different ACT delivery formats to treat depression: A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Acceptance and Commitment Therapy (ACT) has been shown to be effective in the treatment of acute depression. However, whether ACT can be effectively delivered in individual, group, internet, and combined delivery format remain unclear. We aimed to examine the most effective delivery format for ACT via a network meta-analysis (NMA).

METHODS

An electronic literature search was conducted by two reviewers in the Pubmed, Cochrane library, Embase, PsycINFO, CINAHL, CNKI, Wangfang databases to identify relevant studies that were published up to March 21th, 2021. We conducted pairwise and NMA to evaluate the relative effectiveness and rank the probability of different ACT delivery formats. A series of analyses and assessments, such as the risk of bias, and GRADE were performed concurrently.

RESULTS

A total of 23 studies were included in our analysis based on a series of rigorous screenings, which comprised 690 depressed patients. The effectiveness of individual, group, internet, and combine ACT did not differ statistically significantly from each other. Compared with control group, individual delivery format (standardized mean difference [SMD] = -1.44, confidence interval (CI) = -2.11 to -0.76 GRADE low), group delivery format (SMD = -1.34, 95 % CI = -1.91 to -0.78 GRADE moderate), and internet delivery format (SMD = -0.66, 95 % CI = -1.25 to -0.06 GRADE low) showed the largest improvement on depressive symptoms, whereas the combined group and individual ACT was less effective. In terms of acceptability (dropout for any reason), all delivery formats did not differ statistically significantly from each other.

CONCLUSIONS

For depression symptoms, individual, group, and internet treatment formats appeared to be effective interventions. Applying effective and acceptable ACT in a range of different formats will make ACT easier to implement, disseminate, and deliver across different settings and diverse patient populations. More research is needed to verify the ACT in telephone and combined formats for the management of depression.

Machine learning models to detect anxiety and depression through social media: A scoping review

Despite improvement in detection rates, the prevalence of mental health disorders such as anxiety and depression are on the rise especially since the outbreak of the COVID-19 pandemic. Symptoms of mental health disorders have been noted and observed on social media forums such Facebook. We explored machine learning models used to detect anxiety and depression through social media. Six bibliographic databases were searched for conducting the review following PRISMA-ScR protocol. We included 54 of 2219 retrieved studies. Users suffering from anxiety or depression were identified in the reviewed studies by screening their online presence and their sharing of diagnosis by patterns in their language and online activity. Majority of the studies (70%, 38/54) were conducted at the peak of the COVID-19 pandemic (2019-2020). The studies made use of social media data from a variety of different platforms to develop predictive models for the detection of depression or anxiety. These included Twitter, Facebook, Instagram, Reddit, Sina Weibo, and a combination of different social sites posts. We report the most common Machine Learning models identified. Identification of those suffering from anxiety and depression disorders may be achieved using prediction models to detect user's language on social media and has the potential to complimenting traditional screening. Such analysis could also provide insights into the mental health of the public especially so when access to health professionals can be restricted due to lockdowns and temporary closure of services such as we saw during the peak of the COVID-19 pandemic.

The Impact of Payment Scheme Changes on Medication Adherence and Persistence of Patients Diagnosed with Depression in Korea

As of 1 July 2018, the Korean National Health Insurance Service (NHIS) changed the fee schedule for individual psychotherapy (IP). We sought to analyze the impact of the IP payment scheme changes on the medication adherence and persistence of patients diagnosed with depression in Korea. We utilized the NHIS claims database from 2017 to 2019. Patients who were newly diagnosed with depression and utilized IP and were prescribed antidepressants during the study period were included. Adherence was measured using the medication possession ratio (MPR), and persistence was measured using the length of therapy (LOT) during the follow-up period. Adherence and persistence during the pre-policy period (before the change of the payment scheme, from January 2018 until June 2018) and the post-policy period (after the change, from July 2018 until December 2019) were compared. During the study period, a total of 176,740 patients with depression were identified. The average MPR significantly increased from 0.20 to 0.33 in the pre- and post-policy periods, respectively (p < 0.001). The average LOT of the patients improved considerably from 36 to 56 days in the pre- and post-policy periods, respectively (p < 0.001). Poisson regression analysis showed that patients with depression who were female, 19-34 years of age (vs. 50-64 years or over 64 years), and in the post-policy period were significantly associated with greater adherence and persistence rates. Payment scheme changes were associated with an increased adherence and persistence of medication use among patients diagnosed with depression.

Review: Unaccompanied refugee minors' perception of mental health services and professionals: a systematic review of qualitative studies

BACKGROUND

Unaccompanied refugee minors (URMs) are a population at risk of mental health problems and a population with whom the therapeutic alliance can be difficult to set up. The therapeutic alliance's quality can impact the result and effectiveness of psychotherapeutic interventions. The aim of the present study was to gather URMs' points of view about mental health services and mental health professionals (MHP) in the host country. A summary of interviews conducted with URMs will allow a better understanding of their perception and expectations.

METHODS

Seven databases were searched with English and French keywords. In the end, nine studies were selected.

RESULTS

The review of the interviews shows that URMs do not have a clear perception of MHP - it seems difficult for them to trust MHP, but also to understand the value of sharing past painful experiences to reduce current symptoms. They can have a negative perception of mental health and consider that this is not a priority. URMs prefer to focus on day-to-day problems, do activity-based interventions and do group sessions to value social interactions.

CONCLUSIONS

Clinical and methodological implications are discussed. The development of an instrument to evaluate therapeutic care for URMs could be interesting for future research and for clinicians.

Falling behind: The role of student loans on forgoing healthcare

An area for concern in public health research is the extent to which USA student loans are associated with poor health. This study's objective examines whether falling behind on student loans may compound ill-health by deterring people from seeking healthcare. The results of this study confirm that borrowers behind or in collections on student loans are forgoing healthcare after self-reporting general physical ill-health. This study used the 2019 Survey of Household Economics and Decision-making (SHED) questionnaire that measures the economic well-being of USA households. There were 337 participants behind or in collections on student loans. The size effects for forgoing mental healthcare and seeing a specialist were observed. Respondents behind on student loans were more likely to forgo mental healthcare (adjusted odds ratio (AOR) = 1.66, 95% confidence interval [CI] = 1.18, 2.33) and seeing a doctor/specialist (AOR = 1.53, 95% CI = 1.13, 2.07) even when controlling for sociodemographic variables, health insurance, childcare and eldercare payments, and medical debt. The implications for enlarging access to healthcare among people behind on student loans are discussed.

Reconceptualising the treatment gap for common mental disorders: a fork in the road for global mental health?

SUMMARY

In this analysis, we argue that the 'treatment gap' for common mental disorders often reflects lack of demand, arising because services fail to address the needs of disadvantaged communities. We propose a route forward for global mental health, with explicit focus on action on the socioeconomic determinants of psychological suffering.

Mental Health Beliefs, Access, and Engagement with Military Sexual Trauma-Related Mental Health Care

BACKGROUND

Military sexual trauma (MST) is associated with negative mental health outcomes. Mental health beliefs, such as stigma or secondary victimization, have been identified as possible barriers to care; however, it is unclear whether such beliefs impact receiving care.

OBJECTIVE

To assess if mental health beliefs impact MST-related mental health care access and engagement.

DESIGN

Veterans completed a survey following detection of MST. Survey data were linked to Veteran's Health Administration administrative data in order to examine associations with outpatient MST-related care in the year following MST detection.

PARTICIPANTS

A national sample of women and men Veterans (N = 1,185) with newly detected MST who reported a perceived need for MST-related mental health treatment.

MAIN MEASURES

Building on prior work that identified four latent classes of mental health beliefs (Hahn et al., J Trauma Stress 34:394-404, 2020; low barrier, stigma-related beliefs, negative perceptions of care, high barrier), we examined associations with outpatient mental health care indicated by a provider as related to MST. Care was examined in total, as well as the specific categories of medication management, individual psychotherapy, and group psychotherapy.

KEY RESULTS

Access to care following MST detection was high: most (71.6%) Veterans had an MST-related mental health visit within 30 days, and nearly all (83.6%) within 180 days, with the median number of days to receiving care being 2. Negative perceptions of care predicted a lower likelihood of treatment engagement (3+ encounters) with MST-related individual psychotherapy (OR = 0.65, 95% CI (0.43-0.96)), whereas the stigma-related beliefs and high barrier classes did not.

CONCLUSIONS

There appears to be excellent access to mental health care among Veterans with a perceived need for MST-related mental health treatment. However, treatment beliefs that represented negative perceptions of care may serve as barriers to engagement. Interventions targeting negative perceptions of care during early encounters could help promote subsequent engagement.

Digital Interventions to Enhance Readiness for Psychological Therapy: Scoping Review

BACKGROUND

Psychological therapy is an effective treatment method for mental illness; however, many people with mental illness do not seek treatment or drop out of treatment early. Increasing client uptake and engagement in therapy is key to addressing the escalating global problem of mental illness. Attitudinal barriers, such as a lack of motivation, are a leading cause of low engagement in therapy. Digital interventions to increase motivation and readiness for change hold promise as accessible and scalable solutions; however, little is known about the range of interventions being used and their feasibility as a means to increase engagement with therapy.

OBJECTIVE

This review aimed to define the emerging field of digital interventions to enhance readiness for psychological therapy and detect gaps in the literature.

METHODS

A literature search was conducted in PubMed, PsycINFO, PsycARTICLES, Scopus, Embase, ACM Guide to Computing Literature, and IEEE Xplore Digital Library from January 1, 2006, to November 30, 2021. The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology was applied. Publications were included when they concerned a digitally delivered intervention, a specific target of which was enhancing engagement with further psychological treatment, and when this intervention occurred before the target psychological treatment.

RESULTS

A total of 45 publications met the inclusion criteria. The conditions included depression, unspecified general mental health, comorbid anxiety and depression, smoking, eating disorders, suicide, social anxiety, substance use, gambling, and psychosis. Almost half of the interventions (22/48, 46%) were web-based programs; the other formats included screening tools, videos, apps, and websites. The components of the interventions included psychoeducation, symptom assessment and feedback, information on treatment options and referrals, client testimonials, expectation management, and pro-con lists. Regarding feasibility, of the 16 controlled studies, 7 (44%) measuring actual behavior or action showed evidence of intervention effectiveness compared with controls, 7 (44%) found no differences, and 2 (12%) indicated worse behavioral outcomes. In general, the outcomes were mixed and inconclusive owing to variations in trial designs, control types, and outcome measures.

CONCLUSIONS

Digital interventions to enhance readiness for psychological therapy are broad and varied. Although these easily accessible digital approaches show potential as a means of preparing people for therapy, they are not without risks. The complex nature of stigma, motivation, and individual emotional responses toward engaging in treatment for mental health difficulties suggests that a careful approach is needed when developing and evaluating digital readiness interventions. Further qualitative, naturalistic, and longitudinal research is needed to deepen our knowledge in this area.

Real-world behavioral dataset from two fully remote smartphone-based randomized clinical trials for depression

Most people with mental health disorders cannot receive timely and evidence-based care despite billions of dollars spent by healthcare systems. Researchers have been exploring using digital health technologies to measure behavior in real-world settings with mixed results. There is a need to create accessible and computable digital mental health datasets to advance inclusive and transparently validated research for creating robust real-world digital biomarkers of mental health. Here we share and describe one of the largest and most diverse real-world behavior datasets from over two thousand individuals across the US. The data were generated as part of the two NIMH-funded randomized clinical trials conducted to assess the effectiveness of delivering mental health care continuously remotely. The longitudinal dataset consists of self-assessment of mood, depression, anxiety, and passively gathered phone-based behavioral data streams in real-world settings. This dataset will provide a timely and long-term data resource to evaluate analytical approaches for developing digital behavioral markers and understand the effectiveness of mental health care delivered continuously and remotely.

Psychological Factors That Suppress Help-Seeking among Middle-Aged and Older Adults Living Alone

Help-seeking among destitute adults has not been adequately investigated. Therefore, this study clarifies the mechanisms that suppress help-seeking in middle-aged and older adults living alone. Data were collected from 1274 individuals (aged 50-79 years) who were living alone, using a survey that measured future time perspective, barriers to help-seeking, help-seeking intentions, and current and childhood economic statuses. Men living alone experienced lower help-seeking intention than women, were more likely to try to solve problems by themselves, and experienced greater distrust in others. No sex differences were observed in "future anxiety" and "resignation to the future." Poor economic status was associated with high "resignation to the future," "future anxiety," and "distrust of others" for both sexes. "Resignation to the future" was particularly higher among men with a poorer current economic status, which suppressed help-seeking. Abandoning hope for the future, which is characteristic of middle-aged and older men living alone, may inhibit help-seeking behavior.

A longitudinal study of headspace youth oriented mental health service satisfaction, service utilization and clinical characteristics

AIM

This study examined satisfaction with accessibility, staff attitudes, personal outcomes service components of youth-oriented mental health service, Headspace, and those components' associations with psychological distress and functional status at intake, service utilization patterns and demographic characteristics at middle and end of treatment.

METHODS

Data were collected between March 2016 and June 2018 from 112 participants (12-25 years) who consented and completed at least seven sessions at the Headspace youth integrated-care centre in Israel using the centre's registries and the Youth Service Satisfaction Scale.

RESULTS

Headspace participants attended an average of 12 sessions (SD = 3.12), they waited up to 2 weeks for their first intake (n = 57; 73%), after which most were offered a psychotherapy session (n = 80, 71%) within 2 months. Participants' satisfaction with Headspace was above the mid-point for all service aspects. The overall effect for time was not significant, F(1) = 1.14, p > .05. However, a significant increase in satisfaction with personal outcomes was found between the middle and the end of treatment, F(2,4) = 3.11, p < .05 compared to all other aspects. The length of waiting time, level of distress, number of sessions attended by parents and age were correlated with satisfaction. Correlations were found with waiting time, distress level, number of sessions attended by parents and age.

CONCLUSIONS

High levels of satisfaction with Headspace service aspects strengthens the evidence for areas of importance in designing youth mental health services: youth-friendly staff, general environment, accessibility and outcomes achievement.

Real world effectiveness of digital mental health services during the COVID-19 pandemic

Background

The COVID-19 pandemic created an unprecedented need for mental health services that can be remotely delivered. Digital mental health services that offer personalized care recommendations hold promise to efficiently expand service, but evidence of the effectiveness of digitally delivered mental health care in real-world settings remains limited.

Methods

A retrospective cohort of adults (N = 1,852) receiving care through a digital mental health platform with elevated depressive symptoms during the COVID-19 pandemic was analyzed to estimate changes in subjective well-being and clinical improvement in depressive symptoms (using the World Health Organization-Five [WHO-5] Well-Being Index), as well as compare the relative effectiveness and cost of different care utilization patterns.

Results

The average improvement in WHO-5 score was 10.1 points (CI: 9.3–10.9, p<0.001) at follow-up, which constituted a medium effect size (d = 0.73). The odds of clinical improvement in depressive symptoms were significantly greater among those who utilized telecoaching (aOR = 2.45, 95%CI: 1.91–3.15, p < .001), teletherapy (aOR = 2.01, 95%CI: 1.57–2.57, p < .001), and both services (aOR = 2.28, 95%CI: 1.67–3.11, p < .001) compared to those who only utilized assessments, adjusting for baseline WHO-5 score, age, sex, and number of days between baseline and follow-up assessments. The average estimated cost of care for telecoaching was $124 per individual, which was significantly less than teletherapy ($413) or both services ($559).

Conclusion

Digitally delivered care with a therapist and/or coach was effective in improving subjective well-being and clinical improvement in depressive symptoms. Although clinical outcomes were similar across utilization patterns, the cost of care was lowest among those utilizing telecoaching.