Demanding and effective: participants' experiences of internet-delivered prolonged exposure provided within two months after exposure to trauma

Background: The use of remotely delivered early intervention after trauma may prevent and/or reduce symptoms of post-traumatic stress. Our research group evaluated a novel three-week therapist-guided internet-delivered intervention based on prolonged exposure (Condensed Internet-Delivered Prolonged Exposure; CIPE) in a pilot trial. The results indicated that the intervention was feasible, acceptable and reduced symptoms of post-traumatic stress at post-intervention compared to a waiting-list condition. Exposure to traumatic memories can be emotionally demanding and there is a need for detailed investigation of participants' experiences in receiving this type of intervention remotely. Objective: Investigate participants' experiences of receiving CIPE early after trauma. Method: In this study, qualitative thematic analysis was used and semi-structured interviews with 11 participants six months after intervention completion were conducted. All interviews were audio-recorded and transcribed verbatim. Results: One overarching theme labelled as 'demanding and effective' was identified. Participants expressed that treatment effects could only be achieved by putting in a lot of effort and by being emotionally close to the trauma memory during exposure exercises. Participants reported CIPE to be a highly credible- and educative intervention that motivated them to fully engage in exposure exercises. The most distressing parts of the intervention was perceived as tolerable and important to do to heal psychologically after trauma. For many participants, the possibility to engage in the intervention whenever and where it suited them was helpful, although some participants described it as challenging to find a balance between their own responsibility and when to expect therapist support. The internet-based format was perceived as a safe forum for self-disclosure that helped some participants overcome avoidance due to shame during imaginal exposure. Conclusion: CIPE was considered demanding, yet effective by the interviewed participants. The most distressing parts of the intervention was perceived to be the most important and were tolerable and feasible to provide online.

Communication Formats and Their Impact on Patient Perception and Working Mechanisms: A Mixed-Methods Study of Chat-Based vs. Face-to-Face Psychotherapy for Insomnia

The application of Internet-based interventions within stepped-care models raises the question of when patients should receive Internet-based treatment and when patients should receive face-to-face (FtF) treatment. To address this question, the patient perception and effects of working mechanisms were evaluated after brief psychotherapy for insomnia applying a mixed-methods approach. Treatment was either delivered through a text-based chat or it was delivered FtF. Almost half of the patients who received the chat-based treatment indicated that chat-based communication was appropriate for them when dealing with sleep difficulties, but that they would prefer FtF communication for more sensitive topics. Results from the therapists' evaluations of working mechanisms yielded that these working mechanisms were more strongly associated with treatment outcome in the FtF condition than they were in the chat-based condition. To understand and to interpret the results, media richness theory may be a useful tool: More severely impaired patients and patients with more complex concerns may need more complex (richer) communication formats for treatment delivery. Such heuristics may help to better justify treatment recommendations and optimize media choice in Internet-based interventions, e.g., by defining moments when human interaction is needed and moments when communication could be conducted by nonhuman chatbots.

Metaphors For Trauma: A Cross-Cultural Qualitative Comparison in Brazil, India, Poland, and Switzerland

The concept of psychological trauma implies that people experiencing traumatic stress are wounded, thus relating to the metaphor of a physical injury. Although this notion is widely accepted by clinicians and researchers in mental health, there is evidence of a broad range of metaphorical idioms for extremely aversive experiences or catastrophic events across different cultures. In this ethnopsychological study, we aimed to investigate and contrast culturally shared metaphors for trauma among four distinct cultural groups: two indigenous communities (Pitaguary from Brazil, Adivasis from India) and two rural communities (mountain villagers of Gondo, Switzerland; the Lemko ethnic minority in Poland). The communities in Brazil and in Poland were marked by historical trauma, and the communities in India and Switzerland each suffered from a natural disaster. Semistructured interviews that focused on metaphors shared within each community were conducted with key informants and laypersons (Brazil: N = 14, India: N = 28, Poland, N = 13, Switzerland: N = 9). We conducted separate metaphor analyses, then cross-culturally contrasted the findings from the four samples. Across the four cultural groups, we found similar metaphorical concepts of trauma related to bodily processes, such as shock, burden, and wound.

Feasibility of a text-based reduction intervention in helping rural and underserved smokeless tobacco users quit

INTRODUCTION

Smokeless tobacco (ST) use significantly affects morbidity and mortality and remains disproportionally prevalent in rural and medically underserved communities. Few programs exist for rural smokeless tobacco users. Text-based interventions may increase the reach of cessation interventions; yet, none has tested them in ST users. We evaluated the feasibility, acceptability, and preliminary efficacy of a text-based Scheduled Gradual Reduction (SGR) intervention in rural and underserved ST users.

METHODS

ST users were randomized in 2:1 fashion to the SGR group (N = 65), a text-based reduction program plus text-based support counseling messages or text-based support messages only group (N = 33). We surveyed participants at 30-days post intervention initiation to assess feasibility and acceptability and examined self-report 7-day point prevalence cessation at 30-days and 6-months post intervention initiation in the two arms.

RESULTS

We achieved benchmarks for feasibility and acceptability. Among the SGR participants 51% (n = 48) reported that intervention was useful in helping them quit, 83% (n = 48) indicated that they would recommend the intervention to a friend. Over 95% (n = 39) of SGR participants said that they read all alert texts. The SGR participants had a higher quit rate at 30-days compared to support messages alone (SGR = 21.5%, Control = 9.1%, p = 0.1627, Cohen's d equivalent = 0.56, medium effect). However, the quit rate at 6-months was 21% (p = 0.9703) for both groups.

CONCLUSIONS

A text-based intervention was feasible and acceptable among underserved ST users. SGR helped promote short-term cessation. The text-based interventions both had long-term efficacy. Given that text-based interventions have the potential to increase reach in underserved ST users, further testing is warranted.

Traditional Chinese herbal bath therapy for insomnia: A protocol for systematic review

INTRODUCTION

Insomnia is a major public health problem. Due to the side effects of pharmacological therapy, people are seeking to choose complementary and alternative therapies for insomnia disorder. Traditional Chinese herbal bath therapy is an important complementary therapy which combines advantages of Chinese herbs and bathing therapy. This protocol describes the methodology of a systematic review assessing the effectiveness and safety of traditional Chinese herbal bath therapy for insomnia.

METHODS AND ANALYSIS

Reporting of this review will be adherent to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We will electronically search the following seven databases from inception to January 23, 2020: PubMed, Cochrane database (CENTRAL), EMBASE, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), VIP Database, and Wanfang Database. Parallel randomized controlled trials evaluating the effectiveness and safety of traditional Chinese herbal bath therapy for insomnia will be included. Study selection, data extraction and assessment of risk of bias will be performed independently by two researchers. The sleep quality will be assessed as the primary outcome. Global symptom improvement, anxiety and depression, and adverse events will be evaluated as secondary outcomes. The Cochrane's risk of bias tool will be utilized for assessing the methodological quality of included studies. Revman software (v.5.3) will be used for data synthesis and statistical analysis. Data will be synthesized by either fixed-effects or random-effects model according to a heterogeneity test. If it is not appropriate for a meta-analysis, a descriptive analysis will be conducted. GRADE system will be used to assess the quality of evidence.

PROSPERO REGISTRATION NUMBER

CRD42020168507.

Co-Creation with Older Adults to Improve User-Experience of a Smartphone Self-Test Application to Assess Balance Function

This co-creation study aimed to develop a smartphone self-test application for balance and leg strength in collaboration between older adults and the research team. The paper describes older participants’ preferences for, and their contribution to, the application design. Technology to assess movements is available in smartphones with built-in sensors, and one of the challenges is to develop a valuable self-test for older adults. The participants contributed to the design of the application’s instructions and user interface. Multiple data collection methods were used: user-test with Think aloud method, mock-ups, homework assignment as co-researcher, audio and video recordings. Qualitative content analysis with a deductive-inductive approach was used, guided by the Optimized Honeycomb model for user experience (UX) as a categorization matrix. The analysis resulted in 17 subcategories within the seven facets of the UX Honeycomb model (findable, accessible, usable, desirable, credible, useful, and valuable), and describes the older participants’ preferences and experiences. The main results were participants’ desire to know why, to get clear and appropriate information, and expectations of the self-test to be useful. It was feasible and valuable to develop the self-test application in co-creation with the intended user-group, in order to get direct feedback and suggestions for the development.

Reconsidering perfect: a qualitative study of the experiences of internet-based cognitive behaviour therapy for perfectionism

Background:

Internet-based cognitive behaviour therapy (ICBT) is a promising format for treating different psychiatric disorders. In addition, several clinical trials have found positive results when using it to target transdiagnostic processes, such as perfectionism. However, few qualitative investigations have been conducted on the experiences of clients undergoing such treatments.

Method:

In the current study, clients completing 12-week guided ICBT for perfectionism responded to open-ended questions at post-treatment. In total, 30 out of 62 (48.4%) described their impressions of its content and the support provided by their guide.

Results:

The results were analysed qualitatively using thematic analysis. Five themes were found in the responses: Learning how to do things differently, Noticing the positives, Feeling safe to be honest, A comfortable treatment format and Barriers to treatment.

Conclusions:

The results suggest that many clients were able to achieve a change in perspective in relation to their perfectionism and started facing their fears. They were also able to report the benefits of doing things differently as part of treatment, such as an improvement in their interpersonal relationships. Most clients were also positive about the treatment format, enjoying its flexibility and the encouragement offered by their therapist. However, obstacles such as conflicting commitments, personal difficulties, time-consuming and comprehensive treatment modules, and a desire for more support were brought up by some, suggesting that there are aspects that could be considered in the future.

E-Learning to Improve Suicide Prevention Practice Skills Among Undergraduate Psychology Students: Randomized Controlled Trial

BACKGROUND

Despite increasing evidence of the effectiveness of digital learning solutions in higher vocational education, including the training of allied health professionals, the impact of Web-based training on the development of practical skills in psychiatry and psychology, in general, and in suicide prevention, specifically, remains largely understudied.

OBJECTIVE

This study aimed to determine the effectiveness of an electronic learning (e-learning) module on the adherence to suicide prevention guidelines, knowledge of practical skills, and provider's confidence to have a conversation about suicidal behavior with undergraduate psychology students.

METHODS

The e-learning module, comprising video recordings of therapist-patient interactions, was designed with the aim of transferring knowledge about suicide prevention guideline recommendations. The program's effects on guideline adherence, self-evaluated knowledge, and provider's confidence were assessed using online questionnaires before the program (baseline and at 1 month [T1] and 3 months after baseline). The eligible third- and fourth-year undergraduate psychology students were randomly allocated to the e-learning (n=211) or to a waitlist control condition (n=187), with access to the intervention after T1.

RESULTS

Overall, the students evaluated e-learning in a fairly positive manner. The intention-to-treat analysis showed that the students in the intervention condition (n=211) reported higher levels of self-evaluated knowledge, provider's confidence, and guideline adherence than those in the waitlist control condition (n=187) after receiving the e-learning module (all P values<.001). When comparing the scores at the 1- and 3-month follow-up, after both groups had received access to the e-learning module, the completers-only analysis showed that the levels of knowledge, guideline adherence, and confidence remained constant (all P values>.05) within the intervention group, whereas a significant improvement was observed in the waitlist control group (all P values<.05).

CONCLUSIONS

An e-learning intervention on suicide prevention could be an effective first step toward improved knowledge of clinical skills. The learning outcomes of a stand-alone module were found to be similar to those of a training that combined e-learning with a face-to-face training, with the advantages of flexibility and low costs.

A Scoping Review of Self-Management Interventions Following Spinal Cord Injury

Objective: To conduct a scoping review to identify what components of self-management are embedded in self-management interventions for spinal cord injury (SCI). Methods: In accordance with the approach and stages outlined by Arksey and O'Malley (2005), a comprehensive literature search was conducted using five databases. Study characteristics were extracted from included articles, and intervention descriptions were coded using Practical Reviews in Self-Management Support (PRISMS) (Pearce et al, 2016), Barlow et al (2002), and Lorig and Holman's (2003) taxonomy. Results: A total of 112 studies were included representing 102 unique self-management programs. The majority of the programs took an individual approach (52.0%) as opposed to a group (27.4%) or mixed approach (17.6%). While most of the programs covered general information, some provided specific symptom management. Peers were the most common tutor delivering the program material. The most common Barlow components included symptom management (n = 44; 43.1%), information about condition/treatment (n = 34; 33.3%), and coping (n = 33; 32.4%). The most common PRISMS components were information about condition and management (n = 85; 83.3%), training/rehearsal for psychological strategies (n = 52; 51.0%), and lifestyle advice and support (n = 52; 51.0%). The most common Lorig components were taking action (n = 62; 60.8%), resource utilization (n = 57; 55.9%), and self-tailoring (n = 55; 53.9%). Conclusion: Applying self-management concepts to complex conditions such as SCI is only in the earliest stages of development. Despite having studied the topic from a broad perspective, this review reflects an ongoing program of research that links to an initiative to continue refining and testing self-management interventions in SCI.

Experiences of internet-delivered and work-focused cognitive behavioral therapy for stress: A qualitative study

INTRODUCTION

Stress is one of the major challenges of modern society, causing significant costs and personal problems. In the recent decade a growing body of research has provided support for the efficacy of internet interventions for stress. However, few studies have focused on how participants experience internet interventions for stress.

METHOD

The current study was a qualitative follow-up study of an internet-delivered and work-focused cognitive behavioral treatment for stress. The aim was to capture participants' experiences of the treatment and their views on effects on health and well-being. Participants were selected from a controlled study (n = 27), using a criterion-based sampling approach selecting those participants who had completed all treatment modules. Nine semi-structured interviews were held, and the material was analyzed using Thematic Analysis.

RESULTS

The results indicated that most of the participants experienced positive effects on their mental health and well-being in both life and at work. All participants emphasized the importance of having access to therapist support. In line with previous research, participants found the intervention to be extensive and demanding and expressed the need for extended treatment time and therapist support.

CONCLUSIONS

Considering the limitations of the present study, future research could examine the feasibility of reducing the length of each session, extending deadlines and increasing therapist support. This could improve treatment efficacy and further enhance utilization in the target population.

A design and evaluation framework for digital health interventions

Digital health interventions (DHIs) have the potential to help the growing number of chronic disease patients better manage their everyday lives. However, guidelines for the systematic development of DHIs are still scarce. The current work has, therefore, the objective to propose a framework for the design and evaluation of DHIs (DEDHI). The DEDHI framework is meant to support both researchers and practitioners alike from early conceptual DHI models to large-scale implementations of DHIs in the healthcare market.

Academic procrastination and academic performance: An initial basis for intervention

Academic procrastination is a prevalent phenomenon with a range of negative outcomes. Many studies focused on causes and correlates of academic procrastination; however, the study of interventions for academic procrastination is scarce. The present study is an initial effort to study the relationship between academic procrastination, online course participation, and achievement, as a basis for developing an intervention for academic procrastination. Findings indicated that studying procrastination was negatively associated with final exam grade as well as with the three online course participation measures. Final exam grade was positively associated with two of the online course participation measures, and they positively correlated with each other. In addition, results indicated that studying procrastination, in combination with online course participation measures, explained about 50% of variance in final exam's grade. Frequency of activities in course Web site had the strongest positive effect on final exam's grade. These findings strengthen the notion that studying procrastination is an impediment to students' academic performance and outcomes and clarifies the need to develop and study academic interventions for academic procrastination as a means to decrease its prevalence in academic settings.

Outcomes and Device Usage for Fully Automated Internet Interventions Designed for a Smartphone or Personal Computer: The MobileQuit Smoking Cessation Randomized Controlled Trial

BACKGROUND

Many best practice smoking cessation programs use fully automated internet interventions designed for nonmobile personal computers (desktop computers, laptops, and tablets). A relatively small number of smoking cessation interventions have been designed specifically for mobile devices such as smartphones.

OBJECTIVE

This study examined the efficacy and usage patterns of two internet-based best practices smoking cessation interventions.

METHODS

Overall, 1271 smokers who wanted to quit were randomly assigned to (1) MobileQuit (designed for-and constrained its use to-mobile devices, included text messaging, and embodied tunnel information architecture) or (2) QuitOnline (designed for nonmobile desktop or tablet computers, did not include text messages, and used a flexible hybrid matrix-hierarchical information architecture). Primary outcomes included self-reported 7-day point-prevalence smoking abstinence at 3- and 6-month follow-up assessments. Program visits were unobtrusively assessed (frequency, duration, and device used for access).

RESULTS

Significantly more MobileQuit participants than QuitOnline participants reported quitting smoking. Abstinence rates using intention-to-treat analysis were 20.7% (131/633) vs 11.4% (73/638) at 3 months, 24.6% (156/633) vs 19.3% (123/638) at 6 months, and 15.8% (100/633) vs 8.8% (56/638) for both 3 and 6 months. Using Complete Cases, MobileQuit's advantage was significant at 3 months (45.6% [131/287] vs 28.4% [73/257]) and the combined 3 and 6 months (40.5% [100/247] vs 25.9% [56/216]) but not at 6 months (43.5% [156/359] vs 34.4% [123/329]). Participants in both conditions reported their program was usable and helpful. MobileQuit participants visited their program 5 times more frequently than did QuitOnline participants. Consistent with the MobileQuit's built-in constraint, 89.46% (8820/9859) of its visits were made on an intended mobile device, whereas 47.72% (691/1448) of visits to QuitOnline used an intended nonmobile device. Among MobileQuit participants, 76.0% (459/604) used only an intended mobile device, 23.0% (139/604) used both mobile and nonmobile devices, and 0.1% (6/604) used only a nonmobile device. Among QuitOnline participants, 31.3% (137/438) used only the intended nonmobile devices, 16.7% (73/438) used both mobile and nonmobile devices, and 52.1% (228/438) used only mobile devices (primarily smartphones).

CONCLUSIONS

This study provides evidence for optimizing intervention design for smartphones over a usual care internet approach in which interventions are designed primarily for use on nonmobile devices such as desktop computers, laptops. or tablets. We propose that future internet interventions should be designed for use on all of the devices (multiple screens) that users prefer. We forecast that the approach of designing internet interventions for mobile vs nonmobile devices will be replaced by internet interventions that use a single Web app designed to be responsive (adapt to different screen sizes and operating systems), share user data across devices, embody a pervasive information architecture, and complemented by text message notifications.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01952236; https://clinicaltrials.gov/ct2/show/NCT01952236 (Archived by WebCite at http://www.webcitation.org/6zdSxqbf8).

Targeting Procrastination Using Psychological Treatments: A Systematic Review and Meta-Analysis

Background: Procrastination can be stressful and frustrating, but it seldom causes any major distress. However, for some people, it can become problematic, resulting in anxiety, lowered mood, physical complaints, and decreased well-being. Still, few studies have investigated the benefits of targeting procrastination. In addition, no attempt has previously been made to determine the overall efficacy of providing psychological treatments.

Methods: A systematic review and meta-analysis was conducted by searching for eligible records in Scopus, Proquest, and Google Scholar. Only randomized controlled trials comparing psychological treatments for procrastination to an inactive comparator and assessing the outcomes by a self-report measure were included. A random effects model was used to determine the standardized mean difference Hedge's g at post-treatment. Furthermore, test for heterogeneity was performed, fail-safe N was calculated, and the risk of bias was explored. The study was pre-registered at Prospero: CRD42017069981.

Results: A total of 1,639 records were identified, with 12 studies (21 comparisons, N = 718) being included in the quantitative synthesis. Overall effect size g when comparing treatment to control was 0.34, 95% Confidence Interval [0.11, 0.56], but revealing significant heterogeneity, Q(20) = 46.99, p < 0.00, and I² = 61.14%, 95% CI [32.83, 84.24]. Conducting a subgroup analysis of three out of four studies using cognitive behavior therapy (CBT) found an effect size g of 0.55, 95% CI [0.32, 0.77], and no longer showing any heterogeneity, Q(4) = 3.92, p = 0.42, I² = 0.00%, 95% CI [0.00, 91.02] (N = 236). Risk of publication bias, as assessed by the Egger's test was not significant, z = −1.05, p = 0.30, fail-safe N was 370 studies, and there was some risk of bias as rated by two independent researchers. In terms of secondary outcomes, the self-report measures were too varied to present an aggregated estimate.

Conclusions: Psychological treatments seem to have small benefits on procrastination, but the studies displayed significant between-study variation. Meanwhile, CBT was associated with a moderate benefit, but consisted of only three studies. Recommendations for future research are provided, including the use of more valid and reliable outcomes and a screening interview at intake.

The Family Check-Up Online Program for Parents of Middle School Students: Protocol for a Randomized Controlled Trial

Background

Research has established that skillful family management during adolescence protects youth from a variety of mental health and behavioral problems. Interventions associated with this research have focused on parenting skills as the mediator that links early risk factors with a profile of later behavioral risk, including problem behavior, substance use, and school failure. Fortunately, positive changes in family management skills have been linked to meaningful improvements in adolescent behavior, and these improvements have been significant across a variety of cultural groups.

Objective

We describe the background, research design, and intervention components of an electronic health version of the Family Check-Up program that is targeting middle school children and is being evaluated in a randomized controlled trial for its usability, feasibility, and efficacy.

Methods

We used an iterative formative research process to develop an electronic health version of the Family Check-Up program. In our ongoing randomized controlled trial, eligible families are randomly assigned to 1 of 3 conditions: Family Check-Up Online-only (n≈100), Family Check-Up Online + Coach (n≈100), and a waitlist control condition (middle school as usual; n≈100). We are conducting assessments at baseline, 3 months following randomization (posttest), and at follow-ups scheduled for 6 months and 12 months.

Results

This randomized controlled trial project was funded in 2015. Participant recruitment was completed in spring 2018 and enrollment is ongoing. Follow-up assessments will be completed in 2019.

Conclusions

The innovative Family Check-Up Online program has the potential to help address many of the barriers that more traditional school-based behavioral mental health implementation strategies have yet to solve, including staffing and resources to implement family-centered support within schools.

Trial Registration

ClinicalTrials.gov NCT03060291; https://clinicaltrials.gov/ct2/show/NCT03060291 (Archived by WebCite at http://www.webcitation.org/70f8keeN4)

Trial Registration

RR1-10.2196/11106

Patients' experiences in a guided Internet- and App-based stress intervention for college students: A qualitative study

INTRODUCTION

Academic education is often associated with increased stress and adverse effects on mental health. Internet-based interventions have shown to be effective in reducing stress-related symptoms. However, college students as target group so far have not been reached appropriately with psychological interventions and little is known about college students' perception of Internet-based stress management interventions. The objective of this study was to explore the experiences of students participating in an Internet- and App-based stress management intervention originally developed for stressed employees and subsequently adapted and tailored to college students.

METHOD

Semi-structured interviews were conducted with ten participants selected from a randomized controlled trial that evaluated the effectiveness of an Internet- and App-based stress training. The selection of participants aimed to include students with different levels of treatment success. In order to enable an in-depth examination of intervention elements causing dissatisfaction, the interviews were systematically adapted regarding participants' statements in a precedent questionnaire. The interview material was analyzed based on the grounded theory method and thematic analysis.

RESULTS

Results suggest students perceive a necessity to adapt Internet-based interventions to their particular needs. Students' statements indicate that a scientific perspective on the intervention and instable life circumstances could be student-specific factors affecting treatment experience. General themes emerging from the data were attitudes towards individualization and authenticity as well as demands towards different functions of feedback.

DISCUSSION

Participants' experiences hint at certain intellectual and lifestyle-related characteristics of this population. Future studies should explore whether adaptions to these characteristics lead to a higher acceptance, adherence and effectiveness in the target population.

Gamified Cognitive Control Training for Remitted Depressed Individuals: User Requirements Analysis

BACKGROUND

The high incidence and relapse rates of major depressive disorder demand novel treatment options. Standard treatments (psychotherapy, medication) usually do not target cognitive control impairments, although these seem to play a crucial role in achieving stable remission. The urgent need for treatment combined with poor availability of adequate psychological interventions has instigated a shift toward internet interventions. Numerous computerized programs have been developed that can be presented online and offline. However, their uptake and adherence are oftentimes low.

OBJECTIVE

The aim of this study was to perform a user requirements analysis for an internet-based training targeting cognitive control. This training focuses on ameliorating cognitive control impairments, as these are still present during remission and can be a risk factor for relapse. To facilitate uptake of and adherence to this intervention, a qualitative user requirements analysis was conducted to map mandatory and desirable requirements.

METHODS

We conducted a user requirements analysis through a focus group with 5 remitted depressed individuals and individual interviews with 6 mental health care professionals. All qualitative data were transcribed and examined using a thematic analytic approach.

RESULTS

Results showed mandatory requirements for the remitted sample in terms of training configuration, technological and personal factors, and desirable requirements regarding knowledge and enjoyment. Furthermore, knowledge and therapeutic benefits were key requirements for therapists.

CONCLUSIONS

The identified requirements provide useful information to be integrated in interventions targeting cognitive control in depression.

Treating Procrastination Using Cognitive Behavior Therapy: A Pragmatic Randomized Controlled Trial Comparing Treatment Delivered via the Internet or in Groups

Procrastination is a common problem among university students, with at least half of the population reporting great difficulties initiating or completing tasks and assignments. Procrastination can have a negative impact on course grades and the ability to achieve a university degree, but can also lead to psychological distress. Cognitive behavior therapy (CBT) is believed to reduce procrastination, but few studies have investigated its effectiveness in a regular clinical setting. The current study explored its effects using a pragmatic randomized controlled trial comparing treatment delivered during 8 weeks as self-guided CBT via the Internet (ICBT) or as group CBT. In total, 92 university students with severe procrastination were included in the study (registered as a clinical trial on Clinicaltrials.gov: NCT02112383). Outcome measures on procrastination, depression, anxiety, and well-being were distributed at pre- and posttreatment as well as 6-month follow-up. An outcome measure of procrastination was administered weekly. Linear mixed and fixed effects models were calculated, along with improvement and deterioration rates. The results showed large within-group effect sizes on procrastination, Cohen's d of 1.29 for ICBT, 95% Confidence Interval (CI) [0.81, 1.74], and d of 1.24 for group CBT, 95% CI [0.76, 1.70], and small to moderate benefits for depression, anxiety, and well-being. In total, 33.7% were regarded as improved at posttreatment and 46.7% at follow-up. No differences between conditions were observed after the treatment period, however, participants in group CBT continued or maintained their improvement at follow-up, while participants in self-guided ICBT showed some signs of deterioration. The findings from the current study suggest that CBT might be an effective treatment for those struggling with severe procrastination, but that a group format may be better for some to sustain their benefits over time and that the clinical significance of the results need to be investigated further.

eHealth in Treatment of Offenders in Forensic Mental Health: A Review of the Current State

BACKGROUND

Treatment of offenders in forensic mental health is complex. Often, these in- or outpatients have low treatment motivation, suffer from multiple disorders, and have poor literacy skills. eHealth may be able to improve treatment outcomes because of its potential to increase motivation and engagement, and it can overcome the predominant one-size-fits-all approach by being tailored to individual patients.

OBJECTIVE

To examine its potential, this systematic review studies the way that eHealth has been used and studied in forensic mental health and identifies accompanying advantages and disadvantages for both patients and treatment, including effectiveness.

METHODS

A systematic search in Scopus, PsycINFO, and Web of Science was performed up until December 2017. Studies were included if they focused on technological interventions to improve the treatment of forensic psychiatric patients.

RESULTS

The search resulted in 50 studies in which eHealth was used for treatment purposes. Multiple types of studies and technologies were identified, such as virtual reality, web-based interventions, and videoconferencing. The results confirmed the benefits of technology, for example, the acquisition of unique information about offenders, effectiveness, and tailoring to specific characteristics, but indicated that these are not fully taken advantage of.

DISCUSSION

To overcome the barriers and obtain the benefits, eHealth has to have a good fit with patients and the forensic psychiatric context. It has to be seamlessly integrated in existing care and should not be added as an isolated element. To bridge the gap between the current situation and eHealth's potential, further research on development, implementation, and evaluation should be conducted.

Commencing and Persisting With a Web-Based Cognitive Behavioral Intervention for Insomnia: A Qualitative Study of Treatment Completers

Background

Computerized cognitive behavioral therapy for insomnia (CCBT-I) has a growing evidence base as a stand-alone intervention, but it is less clear what factors may limit its acceptability and feasibility when combined with clinical care.

Objective

The purpose of this study was to explore barriers and facilitators to use of an adjunctive CCBT-I program among depressed patients in a psychiatric clinic by using both quantitative and qualitative approaches.

Methods

We conducted the qualitative component of the study using face-to-face or telephone interviews with participants who had enrolled in a clinical trial of a CCBT-I program as an adjunctive treatment in a psychiatric clinical setting. In line with the grounded theory approach, we used a semistructured interview guide with new thematic questions being formulated during the transcription and data analysis, as well as being added to the interview schedule. A range of open and closed questions addressing user experience were asked of all study participants who completed the 12-week trial in an online survey.

Results

Three themes emerged from the interviews and open questions, consistent with nonadjunctive CCBT-I implementation. Identification with the adjunctive intervention’s target symptom of insomnia and the clinical setting were seen as key reasons to engage initially. Persistence was related to factors to do with the program, its structure, and its content, rather than any nonclinical factors. The survey results showed that only the key active behavioral intervention, sleep restriction, was rated as a major problem by more than 15% of the sample. In this clinical setting, the support of the clinician in completing the unsupported program was highlighted, as was the need for the program and clinical treatment to be coordinated.

Conclusions

The use of a normally unsupported CCBT-I program as an adjunctive treatment can be aided by the clinician’s approach. A key behavioral component of the intervention, specific to insomnia treatment, was identified as a major problem for persistence. As such, clinicians need to be aware of when such components are delivered in the program and coordinate their care accordingly, if the use of the program is to be optimized.

ClinicalTrial

Australian and New Zealand Clinical Trials Registry ACTRN12612000985886; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=362875&isReview=true (Archived by WebCite at http://www.webcitation.org/6njjhl42X)

Academic Procrastination and Goal Accomplishment: A Combined Experimental and Individual Differences Investigation

This study examined the relationship between academic procrastination and goal accomplishment in two novel ways. First, we experimentally tested whether undergraduate students (N = 177) could reduce their academic procrastination over a course of three weeks after performing goal-related exercises to set so-called SMART goals and/or to prepare those students with specific strategies to resist their temptations (forming implementation intentions). Second, we conducted systematic regression analyses to examine whether academic procrastination at baseline uniquely predicts later goal-related outcomes, controlling for various correlated variables, including personality traits (e.g., impulsivity), motivational factors (e.g., motivation for the generated goals), and situational factors (e.g., memory for the goals). Results indicated that neither the SMART-goal nor implementation-intention intervention significantly reduced academic procrastination in the three-week interval, even when relevant moderating variables were examined. Initial levels of academic procrastination, however, were predictive of the success of accomplishing the goals generated during the initial exercises, above and beyond a wide range of other candidate correlates. These results provided new correlational evidence for the association between academic procrastination and goal accomplishment, but suggest a need for further research to understand what interventions are effective at reducing academic procrastination.

Active Involvement of End Users When Developing Web-Based Mental Health Interventions

BACKGROUND

Although many web-based mental health interventions are being released, the actual uptake by end users is limited. The marginal level of engagement of end users when developing these interventions is recognized as an important cause for uptake problems. In this paper, we offer our perceptive on how to improve user engagement. By doing so, we aim to stimulate a discourse on user involvement within the field of online mental health interventions.

METHODS

We shortly describe three different methods (the expert-driven method, intervention mapping, and scrum) that were currently used to develop web-based health interventions. We will focus to what extent the end user was involved in the developmental phase, and what the additional challenges were. In the final paragraph, lessons learned are summarized, and recommendations provided.

RESULTS

Every method seems to have its trade-off: if end users are highly involved, availability of end users and means become problematic. If end users are less actively involved, the product may be less appropriate for the end user. Other challenges to consider are the funding of the more active role of technological companies, and the time it takes to process the results of shorter development cycles.

CONCLUSION

Thinking about user-centered design and carefully planning, the involvement of end users should become standard in the field of web-based (mental) health. When deciding on the level of user involvement, one should balance the need for input from users with the availability of resources such as time and funding.

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

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

Training mental health professionals in suicide practice guideline adherence: Cost-effectiveness analysis alongside a randomized controlled trial

BACKGROUND

There is a lack of information on the cost-effectiveness of suicide prevention interventions. The current study examines the cost-effectiveness of a multifaceted structured intervention aiming to improve adherence to the national suicide practice guideline in comparison with usual implementation.

METHODS

In the intervention condition, professionals of psychiatric departments were trained using an e-learning supported Train-the-Trainer program. Newly admitted suicidal patients were assessed as soon as their department was trained and at 3 months follow-up. The primary outcome was improvement in suicide ideation. Missing cost and effect data were imputed using multiple imputation. Cost-effectiveness planes were plotted, and cost-effectiveness acceptability curves were estimated.

RESULTS

For the total group of suicidal patients (n=566), no effect of the intervention on suicide ideation or costs was found. For a subgroup of depressed suicidal patients (n=154, intervention=75, control=79), mean level of suicide ideation decreased with 2.7 extra points in the intervention condition, but this was not statistically significant. For this subgroup, the intervention may be considered cost-effective in comparison with usual implementation if society is willing to pay≥€ 6100 per unit of effect on the suicide ideation scale extra.

LIMITATIONS

Considering the cost outcomes, we had almost no cases that were complete, and heavily relied on statistical techniques to impute the missing data. Also, diagnoses were not derived from structured clinical interviews.

CONCLUSIONS

We presented the first randomized trial (trial registration: The Netherlands Trial Register (NTR3092 www.trialregister.nl)) on cost-effectiveness of a suicide practice guideline implementation in mental health care. The intervention might be considered cost-effective for depressed suicidal patients if society is willing to make substantial investments.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to tobacco dependence and long-term use can lead to health problems including periodontal disease, cancer, and cerebrovascular and cardiovascular disease.

OBJECTIVES

To assess the effects of behavioural and pharmacologic interventions for the treatment of ST use.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group specialised register in June 2015.

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by the Cochrane Collaboration. We summarised outcomes as risk ratios (RRs). For subgroups of trials with similar types of intervention and without substantial statistical heterogeneity, we estimated pooled effects using a Mantel-Haenszel fixed-effect method.

MAIN RESULTS

We identified 34 trials that met the inclusion criteria, of which nine were new for this update, representing over 16,000 participants. There was moderate quality evidence from two studies suggesting that varenicline increases ST abstinence rates (risk ratio [RR] 1.34, 95% confidence interval (CI) 1.08 to 1.68, 507 participants). Pooled results from two trials of bupropion did not detect a benefit of treatment at six months or longer (RR 0.89, 95% CI 0.54 to 1.44, 293 participants) but the confidence interval was wide. Neither nicotine patch (five trials, RR 1.13, 95% CI 0.93 to 1.37, 1083 participants) nor nicotine gum (two trials, RR 0.99, 95% CI 0.68 to 1.43, 310 participants) increased abstinence. Pooling five studies of nicotine lozenges did increase tobacco abstinence (RR 1.36, 95% CI 1.17 to 1.59, 1529 participants) but confidence in this estimate is low as the result is sensitive to the exclusion of three trials which did not use a placebo control.Statistical heterogeneity was evident among the 17 trials of behavioural interventions: eight of them reported statistically and clinically significant benefits; six suggested benefit but with wide CIs and no statistical significance; and three had similar intervention and control quit rates and relatively narrow CIs. Heterogeneity was not explained by study design (individual or cluster randomization), whether participants were selected for interest in quitting, or specific intervention components. In a post hoc subgroup analysis, trials of behavioural interventions incorporating telephone support, with or without oral examination and feedback, were associated with larger effect sizes, but oral examination and feedback alone were not associated with benefit.In one trial an interactive website increased abstinence more than a static website. One trial comparing immediate cessation using nicotine patch versus a reduction approach using either nicotine lozenge or brand switching showed greater success for the abrupt cessation group.

AUTHORS' CONCLUSIONS

Varenicline, nicotine lozenges and behavioural interventions may help ST users to quit. Confidence in results for nicotine lozenges is limited. Confidence in the size of effect from behavioural interventions is limited because the components of behavioural interventions that contribute to their impact are not clear.

Randomized Controlled Trial of the Combined Effects of Web and Quitline Interventions for Smokeless Tobacco Cessation

BACKGROUND

Use of smokeless tobacco (moist snuff and chewing tobacco) is a significant public health problem but smokeless tobacco users have few resources to help them quit. Web programs and telephone-based programs (Quitlines) have been shown to be effective for smoking cessation. We evaluate the effectiveness of a Web program, a Quitline, and the combination of the two for smokeless users recruited via the Web.

OBJECTIVES

To test whether offering both a Web and Quitline intervention for smokeless tobacco users results in significantly better long-term tobacco abstinence outcomes than offering either intervention alone; to test whether the offer of Web or Quitline results in better outcome than a self-help manual only Control condition; and to report the usage and satisfaction of the interventions when offered alone or combined.

METHODS

Smokeless tobacco users (N= 1,683) wanting to quit were recruited online and randomly offered one of four treatment conditions in a 2×2 design: Web Only, Quitline Only, Web + Quitline, and Control (printed self-help guide). Point-prevalence all tobacco abstinence was assessed at 3- and 6-months post enrollment.

RESULTS

69% of participants completed both the 3- and 6-month assessments. There was no significant additive or synergistic effect of combining the two interventions for Complete Case or the more rigorous Intent To Treat (ITT) analyses. Significant simple effects were detected, individually the interventions were more efficacious than the control in achieving repeated 7-day point prevalence all tobacco abstinence: Web (ITT, OR = 1.41, 95% CI = 1.03, 1.94, p = .033) and Quitline (ITT: OR = 1.54, 95% CI = 1.13, 2.11, p = .007). Participants were more likely to complete a Quitline call when offered only the Quitline intervention (OR = 0.71, 95% CI = .054, .093, p = .013), the number of website visits and duration did not differ when offered alone or in combination with Quitline. Rates of program helpfulness (p <.05) and satisfaction (p <.05) were higher for those offered both interventions versus offered only quitline.

CONCLUSION

Combining Web and Quitline interventions did not result in additive or synergistic effects, as have been found for smoking. Both interventions were more effective than a self-help control condition in helping motivated smokeless tobacco users quit tobacco. Intervention usage and satisfaction were related to the amount intervention content offered. Usage of the Quitline intervention decreased when offered in combination, though rates of helpfulness and recommendations were higher when offered in combination.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00820495; http://clinicaltrials.gov/ct2/show/NCT00820495.

Positive Imagery-Based Cognitive Bias Modification as a Web-Based Treatment Tool for Depressed Adults: A Randomized Controlled Trial

Depression is a global health problem requiring treatment innovation. Targeting neglected cognitive aspects may provide a useful route. We tested a cognitive-training paradigm using positive mental imagery (imagery cognitive bias modification, imagery CBM), developed via experimental psychopathology studies, in a randomized controlled trial. Training was delivered via the Internet to 150 individuals with current major depression. Unexpectedly, there was no significant advantage for imagery CBM compared with a closely matched control for depression symptoms as a whole in the full sample. In exploratory analyses, compared with the control, imagery CBM significantly improved anhedonia over the intervention and improved depression symptoms as a whole for those participants with fewer than five episodes of depression and those who engaged to a threshold level of imagery. Results suggest avenues for improving imagery CBM to inform low-intensity treatment tools for depression. Anhedonia may be a useful treatment target for future work.