Internet-delivered psychological treatments: from innovation to implementation

Patient alliance with the program predicts treatment outcomes whereas alliance with the therapist predicts adherence in internet-based therapy for panic disorder

This study examines relationships among different aspects of therapeutic alliance with treatment outcome, adherence and attrition in internet delivered cognitive behavioral therapy (ICBT) for panic disorder.

We examined alliance-outcome relationships in ICBT (N = 74) using a newly developed self-report alliance measure that disentangles alliance with program content (Internet Patient's Experience of Attunement and Responsiveness with the program; I-PEARp) and with the therapist (I-PEARt). We compared ICBT outcomes of patient rated and therapist-rated alliance with conventional alliance scales (WAI-6 and WAI-T).

Consistent with our hypothesis, I-PEARp and I-PEARt distinguished between different aspects of the alliance and predicted outcomes better than standard alliance scales. Furthermore, higher ratings of I-PEARp were associated with subsequent lower symptoms and lower symptoms were associated with higher subsequent alliance. In contrast, I-PEARt predicted adherence, but not symptoms. Although therapists' ratings of alliance (thI-PEAR) improved significantly during treatment, they did not predict subsequent symptoms, adherence, or dropout.

Results indicate that the patient experience of the alliance in ICBT includes two aspects, each of which uniquely contributes to outcomes; patient connection to the program is related to symptom outcomes whereas the dyadic relationship with the therapist serves as the glue to allow the treatment to hold.

Cognitive Behavior Therapy at the Crossroads

The early development of cognitive behavior therapy (CBT) can be characterized by the coming together of behavioral and cognitive traditions. However, the past decades have arguably seen more divergences than convergences within the field. The 9th World Congress of Behavioural and Cognitive Therapies was held in Berlin in July 2019 with the congress theme "CBT at the Crossroads." This title reflected in part the coming together of people from all over the world, but also the fact that recent developments raise important questions about the future of CBT, including whether we can in fact treat it as a unified field. In this paper, we briefly trace the history of CBT, then introduce a special issue featuring a series of articles exploring different aspects of the past, present, and future of CBT. Finally, we reflect on the possible routes ahead.

Study protocol for a multisite randomized controlled trial of an internet and mobile-based intervention for preventing and reducing perinatal depressive symptoms

Nearly 20% of women in the United States experience clinically significant depressive symptoms during pregnancy or the postpartum period. These women may benefit from easily accessible, nonpharmacologic, and inexpensive self-management approaches, such as via internet and mobile-based interventions, to prevent development of symptoms and/or intervene with current symptoms. This paper summarizes the research protocol of a nationally-funded large-scale randomized controlled study to evaluate "Mamma Mia," a self-guided program with 44 modules that women use throughout pregnancy to 6 months postpartum. The program contains a novel combination of components designed to enable women to enhance self-efficacy, emotional self-regulation, and perceived social support. The overall goal of this three-arm longitudinal randomized controlled trial is to evaluate the effects and mechanisms of this self-management approach in diverse women in the U.S. (n = 1950). Enrolled pregnant women will be randomly assigned to one of three groups: (1) "Mamma Mia" alone, which is self-guided; (2) "Mamma Mia Plus" in which participants engage in the "Mamma Mia" modules plus receive brief guided support from a registered nurse; or (3) usual prenatal/postpartum care. The first specific aim is to evaluate effects by group on the primary outcome of interest, depressive symptoms, over time. The second aim is to evaluate effects by group on subjective well-being, anxiety, and stress. Using a conceptual framework based upon Individual and Family Self-Management Theory, the third aim is to evaluate possible mediators (self-efficacy, emotion self-regulation, perceived support) and possible moderators (e.g., race/ethnicity, type of healthcare clinician) of this self-management approach.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

COVID-19 Pandemic and Eating Disorders: What Can We Learn About Psychopathology and Treatment? A Systematic Review

PURPOSE OF REVIEW

This systematic review aims to collect evidence regarding the impact of the SarsCov-2 pandemic on people affected by eating disorders (EDs) targeting the following variables: psychopathology changes, mechanisms of vulnerability or resilience, and perception of treatment modifications during the pandemic.

RECENT FINDINGS

Since the beginning of the pandemic, a mental health deterioration has been detected in the general population and especially in people affected by pre-existing psychiatric conditions. Furthermore, mental healthcare has moved toward online treatment. ED people showed a trend toward worsening of ED-specific psychopathology and impairment in general psychopathology. The most common vulnerability mechanisms were social isolation and feelings of uncertainty, while heightened self-care and reduced social pressure were resilience factors. The online treatment, although raising many concerns related to its quality, was considered the best alternative to the face-to-face approach. These findings may support the idea that stressful events contribute to the exacerbation of ED psychopathology and highlight the relevance of internalizing symptoms in EDs. The identification of putative risk and resilience variables as well as of subjective factors affecting online treatment perception may inform healthcare professionals and may promote more personalized approaches.

Internet-Based Support and Coaching With Complementary Clinic Visits for Young People With Attention-Deficit/Hyperactivity Disorder and Autism: Controlled Feasibility Study

BACKGROUND

Individuals with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) can experience obstacles in traditional health care situations due to difficulties associated with their impairment.

OBJECTIVE

This controlled study aims to investigate the feasibility of an internet-based support and coaching intervention (IBSC), including 2 weekly chat sessions and 2 complementary clinic visits with coaches over the course of 8 weeks, for adolescents and young adults with ADHD and/or ASD in 2 naturalistic routine care settings.

METHODS

Individuals with ADHD and/or ASD aged 15-32 years were recruited in 2 clinical settings, where they received either IBSC (n=24) or treatment as usual (TAU; n=20). Outcome measures included self-report questionnaires assessing quality of life (Manchester Short Assessment for Quality of Life), sense of coherence (Sense Of Coherence 29), self-esteem (Rosenberg Self-Esteem Scale), and anxiety and depressive symptoms (Hospital Anxiety and Depression Scale [HADS] and Montgomery-Åsberg Depression Rating Scale-Self-reported, respectively).

RESULTS

Significant between-group effects were observed in measures of anxiety (HADS) at postintervention (P=.02) as well as at the 6-month follow-up (P=.004). Significant between-group effects were also noted for depressive symptoms (HADS) postintervention (P=.04). The between-group effects were partially explained by a deterioration in the TAU group. A significant increase in self-esteem (P=.04) as well as a decrease in anxiety (P=.003) at the 6-month follow-up was observed in the intervention group following IBSC. Findings from a qualitative study of the intervention are consistent with the results.

CONCLUSIONS

The findings from this study suggest that IBSC holds promise as a feasible complement or alternative to traditional face-to-face health care meetings.

Efficacy of the web-based PaarBalance program on relationship satisfaction, depression and anxiety - A randomized controlled trial

OBJECTIVE

Although relationship distress is strongly associated with mental health problems, poorer social functioning and lower quality of life, only a minority of distressed couples engage in effective couples therapy. Common barriers are the financial burden, fear of being stigmatized, long waitlists and logistical concerns, such as the difficulty in scheduling appointments. Therefore, more accessible help for relationship distress is needed, such as internet-based interventions.

METHOD

This study evaluates the efficacy of the German web-based PaarBalance program, an 18-sessions online program for couples and individuals in an intimate relationship. Participants with relationship distress recruited via the internet had access to the unguided self-help program for twelve weeks. A total of 117 individuals (N = 60 participated as couples, N = 57 participated without a partner) were randomly assigned to begin the intervention immediately or to a 12-week waitlist control group. The primary outcome was relationship satisfaction. Secondary outcomes included symptoms of depression and anxiety.

RESULTS

The intervention group showed significant improvement in relationship satisfaction (Cohen's d =0.77) compared with the waitlist control group. Small to medium effect sizes in favor of the intervention group, but no statistically significant differences were found regarding depression (d = 0.43) and anxiety (d = 0.45).

CONCLUSION

PaarBalance seems to be an effective self-guided intervention to improve relationship satisfaction in people with relationship problems.

The mediating role of insomnia severity in internet-based cognitive behavioral therapy for chronic stress: Secondary analysis of a randomized controlled trial

The aim of this study was to investigate insomnia symptom severity as a putative mediator of treatment response in therapist-guided internet-based cognitive behavioral therapy (ICBT) for chronic stress, using data from a randomized controlled trial. Participants (N = 100) were randomized to 12 weeks of ICBT or to a waitlist control condition (WLC). Insomnia severity was assessed weekly with the Insomnia Severity Index (ISI), as were the stress-related outcomes the Perceived Stress Scale (PSS) and the Shirom-Melamed Burnout Questionnaire (SMBQ). Latent growth models indicated that ICBT (vs. WLC) predicted a decrease in insomnia severity (α-path), and that growth in insomnia severity was predictive of growth in perceived stress and exhaustion (β-paths). Most importantly, there were also significant indirect effects (αβ products) such that the beneficial effects of ICBT on perceived stress and exhaustion were mediated by a reduction in insomnia symptom severity (PSS: αβ = -0.44, 95% CI [-0.92, -0.14]; SMBQ: αβ = -0.08, 95% CI [-0.15, -0.04]). Explorative analysis of moderated mediation showed that more severe insomnia symptoms at baseline were associated with larger mediated effects. We conclude that reducing insomnia severity could be of importance for achieving successful treatment outcomes in ICBT for chronic stress.

Transdiagnostic Internet-delivered cognitive behaviour therapy with therapist support offered once-weekly or once-weekly supplemented with therapist support within one-business-day: Pragmatic randomized controlled trial

In routine care, internet-delivered cognitive behaviour therapy (iCBT) regularly includes therapist support delivered via secure email, but the optimal response time to emails is unknown. In this study, we compared the benefits of therapists providing support once-weekly versus therapists providing support once-weekly supplemented with a one-business-day response to all patient emails. This pragmatic randomized controlled trial included therapists employed by a specialized iCBT clinic or community mental health clinics, where providing iCBT is a secondary service. Patients with depression and/or anxiety who enrolled in transdiagnostic iCBT (5 core lessons over 8 weeks) were randomized to: 1) once-weekly support supplemented with a one-business-day response to patient emails by specialized therapists (n = 233); 2) once-weekly support also offered by specialized therapists (n = 216); or 3) once-weekly support offered by community clinic therapists (n = 226). Outcomes were measured at 8, 12, 24, and 52-weeks post-enrollment. Patient engagement and treatment experiences (e.g., treatment satisfaction, therapist alliance) were also assessed and a focus group was conducted with therapists. Supplementing once-weekly therapist support with a one-business-day response to patient emails resulted in therapists sending more emails to patients (M: 13 versus 9) and required more therapist time over treatment (M: 155 versus 109 min), but was not associated with improved outcomes, patient engagement or treatment experiences. All groups showed large improvements in symptoms of depression and anxiety maintained at 52-week follow-up, strong engagement and positive treatment experiences. Therapists viewed challenges of responding to patient emails within one-business-day to outweigh benefits. Contrary to expectations, supplementing once-weekly therapist support with a one-business-day response to all patient emails did not benefit patients and increased therapist time as well as therapist challenges when delivering iCBT in routine care.

Mediators and mechanisms of change in internet- and mobile-based interventions for depression: A systematic review

The efficacy of Internet- and mobile-based interventions (IMIs) for depression in adults is well established. Yet, comprehensive knowledge on the mediators responsible for therapeutic change in these interventions is pending. Therefore, we conducted the first systematic review on mediators in IMIs for depression, investigating mechanisms of change in interventions with different theoretical backgrounds and delivery modes (PROSPERO CRD42019130301). Two independent reviewers screened references from five databases (i.e., Cochrane Library, Embase, MEDLINE/PubMed, PsycINFO and ICTRP), selected studies for inclusion and extracted data from eligible studies. We included 26 RCTs on mediators in IMIs for depression (6820 participants), rated their risk of bias and adherence to methodological quality criteria for psychotherapy process research. Primary studies examined 64 mediators, with cognitive variables (e.g., perceived control, rumination or interpretation bias) being the largest group of both examined (m = 28) and significant mediators (m = 22); followed by a range of other mediators, including mindfulness, acceptance and behavioral activation. Our findings might contribute to the empirically-informed advancement of interventions and mental health care practices, enabling optimized treatment outcomes for patients with depression. Furthermore, we discuss implications for future research and provide methodological recommendations for forthcoming mediation studies with more pertinent designs, allowing for inferences with higher causal specificity.

Adaptive Elements in Internet-Delivered Psychological Treatment Systems: Systematic Review

BACKGROUND

Internet-delivered psychological treatments (IDPTs) are built on evidence-based psychological treatment models, such as cognitive behavioral therapy, and are adjusted for internet use. The use of internet technologies has the potential to increase access to evidence-based mental health services for a larger proportion of the population with the use of fewer resources. However, despite extensive evidence that internet interventions can be effective in the treatment of mental health disorders, user adherence to such internet intervention is suboptimal.

OBJECTIVE

This review aimed to (1) inspect and identify the adaptive elements of IDPT for mental health disorders, (2) examine how system adaptation influences the efficacy of IDPT on mental health treatments, (3) identify the information architecture, adaptive dimensions, and strategies for implementing these interventions for mental illness, and (4) use the findings to create a conceptual framework that provides better user adherence and adaptiveness in IDPT for mental health issues.

METHODS

The review followed the guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The research databases Medline (PubMed), ACM Digital Library, PsycINFO, CINAHL, and Cochrane were searched for studies dating from January 2000 to January 2020. Based on predetermined selection criteria, data from eligible studies were analyzed.

RESULTS

A total of 3341 studies were initially identified based on the inclusion criteria. Following a review of the title, abstract, and full text, 31 studies that fulfilled the inclusion criteria were selected, most of which described attempts to tailor interventions for mental health disorders. The most common adaptive elements were feedback messages to patients from therapists and intervention content. However, how these elements contribute to the efficacy of IDPT in mental health were not reported. The most common information architecture used by studies was tunnel-based, although a number of studies did not report the choice of information architecture used. Rule-based strategies were the most common adaptive strategies used by these studies. All of the studies were broadly grouped into two adaptive dimensions based on user preferences or using performance measures, such as psychometric tests.

CONCLUSIONS

Several studies suggest that adaptive IDPT has the potential to enhance intervention outcomes and increase user adherence. There is a lack of studies reporting design elements, adaptive elements, and adaptive strategies in IDPT systems. Hence, focused research on adaptive IDPT systems and clinical trials to assess their effectiveness are needed.

A Cost-effectiveness Analysis of an Internet-delivered Pain Management Program Delivered With Different Levels of Clinician Support: Results From a Randomised Controlled Trial

There is growing interest in the potential of internet-delivered pain management programs (PMPs) to increase access to care for people with chronic pain. However, very few economic evaluations of these interventions have been reported. Using existing data, the current study examined the cost-effectiveness of an internet-delivered PMP for a mixed group chronic pain patients (n = 490) provided with different levels of clinician support. The findings indicated that each additional clinical outcome (defined as a ≥ 30% reduction in disability, depression, anxiety, and pain) was associated with cost-savings when the intervention was provided in a self-guided format (ICER range: -$404--$808 AUD) or an optional-guided format (ICER range: -$314--$541 AUD), and a relatively small fixed cost when provided in the clinician-guided format (ICER range: $88-$225 AUD). The results were driven by a reduction in service use costs among the treatment groups, which offset the costs of providing the internet-delivered PMP in the self-guided and optional-guided formats. The same general pattern of results was found when more stringent clinical outcomes (defined as a ≥ 50% reduction) were employed. These findings suggest that carefully developed and administered internet-delivered PMPs, provided with different levels of clinician support, can be highly cost effective for patients with a broad range of pain conditions. PERSPECTIVE: This study examines the cost-effectiveness of an internet-delivered PMP provided to adults with a broad range of chronic pain conditions. Evidence of cost-effectiveness was found across a broad range of clinical outcomes and with different levels of clinician support.

Single-case experimental designs: Characteristics, changes, and challenges

Tactics of Scientific Research (Sidman, 1960) provides a visionary treatise on single-case designs, their scientific underpinnings, and their critical role in understanding behavior. Since the foundational base was provided, single-case designs have proliferated especially in areas of application where they have been used to evaluate interventions with an extraordinary range of clients, settings, and target foci. This article highlights core features of single-case experimental designs, how key and ancillary features of the designs have evolved, the special strengths of the designs, and challenges that have impeded their integration in many areas where their contributions are sorely needed. The article ends by placing the methodological approach in the context of other research traditions. In this way, the discussion moves from the specific designs toward foundations and philosophy of science issues in keeping with the strengths of the person and book we are honoring.

A Self-Administered Multicomponent Web-Based Mental Health Intervention for the Mexican Population During the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial

BACKGROUND

The COVID-19 pandemic has become a public health emergency of international concern; it has not only threatened people's physical health but has also affected their mental health and psychological well-being. It is necessary to develop and offer strategies to reduce the psychological impact of the outbreak and promote adaptive coping.

OBJECTIVE

This study protocol aims to describe a self-administered web-based intervention (Mental Health COVID-19) based on the principles of positive psychology supported by elements of cognitive behavioral therapy and behavioral activation therapy to reduce the symptoms of anxiety and depression and increase positive emotions and sleep quality during and after the COVID-19 outbreak through a telepsychology system.

METHODS

A randomized controlled clinical superiority trial with two independent groups will be performed, with intrasubject measures at four evaluation periods: pretest, posttest, 3-month follow-up, and 6-month follow-up. Participants will be randomly assigned to one of two groups: self-administered intervention with assistance via chat or self-administered intervention without assistance via chat. The total required sample size will be 166 participants (83 per group).

RESULTS

The clinical trial is ongoing. This protocol was approved by the Research Ethics Board of the Free School of Psychology-University of Behavioral Sciences (Escuela libre de Psicología-Universidad de Ciencias del Comportamiento). The aim is to publish the preliminary results in December 2020. A conservative approach will be adopted, and the size effect will be estimated using the Cohen d index with a significance level (α) of .05 (95% reliability) and a conventional 80% power statistic.

CONCLUSIONS

The central mechanism of action will be to investigate the effectiveness of an intervention based on positive psychology through a web platform that can be delivered through computers and tablets, with content that has been rigorously contextualized to the Mexican culture to provide functional strategies to help the target users cope with the COVID-19 pandemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04468893; https://clinicaltrials.gov/ct2/show/NCT04468893.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/23117.

Are Internet- and mobile-based interventions effective in adults with diagnosed panic disorder and/or agoraphobia? A systematic review and meta-analysis

BACKGROUND

There is no meta-analysis that specifically evaluates the effectiveness of Internet- and mobile-based interventions (IMIs) in adults with diagnosed panic disorder and/or agoraphobia (PD/A) so far. The current meta-analysis aims to fill this gap (PROSPERO CRD 42016034016).

METHODS

Systematic literature searches in six databases for randomised and controlled clinical trials investigating IMIs in adults, who met diagnostic criteria for PD/A. Study selection and data extraction were conducted independently by two reviewers. Random-effects meta-analyses, pre-planned subgroup and sensitivity analyses were conducted when appropriate. Primary outcomes were PD and A symptom severity. In addition, adherence, response, remission, quality of life, anxiety and depression symptom severity were examined.

RESULTS

A total of 16 trials (1015 patients), with 21 comparisons (9 IMI vs. waitlist; 7 IMI vs. IMI; 5 IMI vs. active treatment condition), were included. IMIs revealed beneficial effects on panic (Hedges' g range -2.61 to -0.25) and agoraphobia symptom severity when compared to waitlist (pooled g = -1.15, [95%-CI = -1.56; -0.74]). Studies comparing IMIs to active controls (i.e., face-to-face CBT and applied relaxation) did not find significant differences for reductions in panic (g = -0.02, [95%-CI = -0.25; 0.21]) and agoraphobia symptom severity (g = -0.10, [95%-CI = -0.39; 0.19]). Furthermore, IMIs were superior to waitlist controls regarding anxiety and depression symptom severity and quality of life.

LIMITATIONS

Tests for publication bias were not feasible due to the limited number of trials per comparison, and the risk of bias assessment indicated some methodological shortcomings.

CONCLUSIONS

Findings from this meta-analytic review provide support for the effectiveness of IMIs in patients with verified PD/A. However, before IMIs can be included in treatment guidelines for PD/A, future high quality research is needed that substantiates and extends the evidence base, especially in regard to intervention safety.

Addressing Healthcare Gaps in Sweden during the COVID-19 Outbreak: On Community Outreach and Empowering Ethnic Minority Groups in a Digitalized Context

Since its early stages, the COVID-19 pandemic has interacted with existing divides by ethnicity and socioeconomic statuses, exacerbating further inequalities in high-income countries. The Swedish public health strategy, built on mutual trust between the government and the society and giving the responsibility to the individual, has been criticized for not applying a dedicated and more diverse strategy for most disadvantaged migrants in dealing with the pandemic. In order to mitigate the unequal burden on the marginalized members of society, increasing efforts have been addressed to digital health technologies. Despite the strong potential of providing collective public health benefits, especially in a highly digitalized context as Sweden, need for a stronger cooperation between the public health authorities and migrant community leaders, representatives of migrant associations, religious leaders and other influencers of disadvantaged groups has emerged. Suggestions are presented on more culturally congruent, patient-centered health care services aimed to empower people to participate in a more effective public health response to the COVID-19 crisis.

Therapist-Supported Online Interventions for Children and Young People With Tic Disorders: Lessons Learned From a Randomized Controlled Trial and Considerations for Future Practice

In recent years, research into internet-based cognitive behavioral therapy (iCBT) has suggested that therapist-guided digital interventions have greater engagement, adherence, and effectiveness than self-directed digital therapies. While research has focused on the effectiveness of, and adherence to, these interventions, less attention has been paid to their implementation in practice and what aspects of the therapist role support success. An understanding of the key factors related to the therapist role and intervention delivery is required if these iCBTs are to be applied in routine clinical care and outcomes optimized. In light of the coronavirus disease 2019 (COVID-19) pandemic, there is greater emphasis on allowing patients access to remote therapies. We report the experiences and reflections of 4 therapists and their 2 supervisors in delivering an online, therapist-supported intervention in a randomized controlled trial for children and young people with tic disorders (the Online Remote Behavioural Intervention for Tics [ORBIT] trial). Themes discussed include the importance of training, supervision, creating support documents/manuals, and record keeping. Alongside this are communication strategies used by therapists to encourage patient adherence and treatment effectiveness. These include rapport building, treatment personalization, and suggestions for overcoming non-engagement. These reflections offer important considerations for the delivery of iCBTs as well as implications associated with the implementation of these interventions in existing services and future research studies. We share thoughts on where iCBTs may sit in a stepped care model, how services may deal with comorbid conditions, and the potential role of iCBTs in collecting clinical data.

Effectiveness of a Guided Web-Based Self-help Intervention to Prevent Depression in Patients With Persistent Back Pain: The PROD-BP Randomized Clinical Trial

IMPORTANCE

Depression is a frequent comorbid condition in patients with persistent back pain and is associated with substantial adverse consequences, including the risk of developing opioid use disorders. Shifting the focus from depression treatment to preventing depression might be a viable way to reduce the disease burden.

OBJECTIVE

To evaluate the effectiveness of a web-based self-help intervention to reduce the incidence of major depressive episode (MDE) in patients with persistent back pain.

DESIGN, SETTING, AND PARTICIPANTS

Prevention of Depression in Back Pain Patients (PROD-BP) was a pragmatic, observer-blinded randomized clinical trial with a parallel design conducted in Germany. Eligible adults with a diagnosis of persistent back pain and subclinical depressive symptoms, but who were depression free, were recruited either on-site or after discharge from 82 orthopedic clinics between October 1, 2015, and July 31, 2017. All analyses were conducted according to the intention-to-treat principle from October 31, 2018, to April 30, 2019.

INTERVENTIONS

The intervention group received an e-coach-guided, web-based self-help intervention that was based on cognitive behavioral therapy and tailored to the needs of patients with persistent back pain. The intervention included 6 obligatory modules and 3 optional modules to be completed by participants as well as feedback from e-coaches. Both the intervention and control groups had unrestricted access to treatment as usual.

MAIN OUTCOMES AND MEASURES

Primary outcome was time to onset of an MDE over a 12-month period as assessed by blinded diagnostic raters using the Structured Clinical Interview for DSM-5. Secondary outcomes included depression severity, quality of life, pain intensity, pain-related disability, pain self-efficacy, work capacity, and user satisfaction assessed with a variety of instruments.

RESULTS

A total of 295 participants (mean [SD] age, 52.8 [7.7] years; 184 women [62.4%]) were recruited and randomized to either the intervention group (n = 149) or control group (n = 146). The intervention reduced the risk of MDE onset by 52% (hazard ratio, 0.48; 95% CI, 0.28-0.81; P < .001). Twenty-one participants (14.1%) in the intervention group and 41 participants (28.1%) in the control group experienced an MDE over the 12-month period. The number needed to treat to prevent 1 new case of MDE was 2.84 (95% CI, 1.79-9.44).

CONCLUSIONS AND RELEVANCE

Results of this trial showed that among patients with persistent back pain, depression can be prevented by a guided web-based self-help intervention in addition to treatment as usual. This finding suggests that using a scalable digital approach to integrate psychological treatment into routine pain management is feasible.

TRIAL REGISTRATION

German Clinical Trials Register Identifier: DRKS00007960.

Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic

Suicide is preventable. Nevertheless, each year 800,000 people die of suicide in the world. While there is evidence indicating that suicide rates de-crease during times of crises, they are expected to increase once the immediate crisis has passed. The COVID-19 pandemic affects risk and pro-tective factors for suicide at each level of the socio-ecological model. Economic downturn, augmented barriers to accessing health care, increased access to suicidal means, inappropriate media reporting at the societal level; deprioritization of mental health and preventive activities at the community level; interpersonal conflicts, neglect and violence at the relationship level; unemployment, poverty, loneliness and hopelessness at the individual level: all these variables contribute to an increase of depression, anxiety, post-traumatic stress disorder, harmful use of alcohol, substance abuse, and ultimately suicide risk. Suicide should be prevented by strengthening universal strategies directed to the entire population, including mitigation of unemployment, poverty and inequalities; prioritization of access to mental health care; responsible media reporting, with information about available support; prevention of increased alcohol intake; and restriction of access to lethal means of suicide. Selective interventions should continue to target known vulnerable groups who are socio-economically disadvantaged, but also new ones such as first responders and health care staff, and the bereaved by COVID-19 who have been deprived of the final contact with loved ones and funerals. Indicated preventive strategies targeting individuals who display suicidal behaviour should focus on available pharmacological and psychological treatments of mental disorders, ensuring proper follow-up and chain of care by increased use of telemedicine and other digital means. The scientific community, health care professionals, politicians and decision-makers will find in this paper a systematic description of the effects of the pandemic on suicide risk at the society, community, family and individual levels, and an overview of how evidence-based suicide preventive interventions should be adapted. Research is needed to investigate which adaptations are effective and in which con-texts.

A feasibility trial of an internet-delivered psychological intervention to manage mental health and functional outcomes in neurological disorders

OBJECTIVE

Mental health and cognitive difficulties are highly prevalent across neurological disorders and significantly contribute to poorer patient outcomes. Unfortunately, access to effective psychological services for these comorbidities are limited. To determine whether a novel transdiagnostic internet-delivered psychological intervention, the Wellbeing Neuro Course, was feasible, acceptable and efficacious a single-group feasibility open trial was employed.

METHODS

The Wellbeing Neuro Course, targets mental health and cognitive difficulties, across a variety of neurological disorders. It is comprised of six online lessons, based on Cognitive Behavioural Therapy and Compensatory Cognitive Rehabilitation, delivered over 10 weeks and provided with weekly support from a mental health professional via email and telephone. 105 adults with diagnoses of either epilepsy, multiple sclerosis, Parkinson's disease and/or acquired brain injury, underwent the intervention.

RESULTS

The intervention was found to be highly acceptable with high intervention completion and levels of satisfaction (>95%). There was evidence of clinically significant improvements in primary outcomes (within-group Cohen's d; average reductions) of depression (d = 0.93; avg. reduction ≥36%), anxiety (ds = 0.66, avg. reduction ≥36%), and disability (ds ≥ 0.49; avg. reduction ≥23%) at post-intervention, maintained at 3-month follow-up. For secondary outcomes there were significant improvements in fatigue severity and perceived cognitive difficulties of attention, planning and prospective memory. Findings were achieved with minimal clinician time, highlighting its public health potential.

CONCLUSION

This open trial provides preliminary evidence the Wellbeing Neuro Course is acceptable and reduces symptoms of depression, anxiety and disability in neurological disorders. Future controlled trials of the intervention are now needed.

TRIAL REGISTRATION

ACTRN12617000581369.

Treating perfectionism using internet-based cognitive behavior therapy: A study protocol for a randomized controlled trial comparing two types of treatment

Perfectionism is characterized by setting high standards and striving for achievement, sometimes at the expense of social relationships and wellbeing. Despite sometimes being viewed as a positive feature by others, people with perfectionism tend to be overly concerned about their performance and how they are being perceived by people around them. This tends to create inflexible standards, cognitive biases, and performance-related behaviors that maintain a belief that self-worth is linked to accomplishments. Cognitive behavior therapy has been shown to be a viable treatment for perfectionism, both in terms of reducing levels of perfectionism and improving psychiatric symptoms. Furthermore, a number of recent studies indicate that it can be successfully delivered via the Internet, both with regular support and guidance on demand from a therapist. In the present study protocol, a clinical trial for perfectionism is described and outlined. In total, 128 participants will be recruited and randomized to either a treatment that has already been demonstrated to have many benefits, Internet-based Cognitive Behavior Therapy for perfectionism (iCBT-P), or an active comparison condition, Internet-based Unified Protocol (iUP), targeting the emotions underlying depression and anxiety disorders. The results will be investigated with regard to self-reported outcomes of perfectionism, psychiatric symptoms, self-compassion, and quality of life, at post-treatment and at six- and 12-month follow-up. Both iCBT-P and iUP are expected to have a positive impact, but the difference between the two conditions in terms of their specific effects and adherence are currently unknown and will be explored. The clinical trial is believed to lead to a better understanding of how perfectionism can be treated and the specificity of different treatments.

Mental Health Care Goes Online: Practitioners' Experiences of Providing Mental Health Care During the COVID-19 Pandemic

The outbreak of the COVID-19 pandemic has necessitated sudden and radical changes in mental health care delivery, as strict social distancing and lockdown measures were imposed in the early phases of the pandemic. Almost overnight, practitioners were forced to transfer their face-to-face care practice to online means. To understand the implications of this drastic change for mental health care, and to improve the online care offerings, an online qualitative survey was held among mental health care professionals in Netherlands (n = 51). Our findings indicate that technological and usability problems pose a significant challenge, as do difficulties to establish rapport with clients. Moreover, not all mental health issues and treatment forms are equally amenable to online interaction. In contrast, in many instances, practitioners were positive about the effectiveness of treatment, and reported flexibility, a lower threshold for contact, and lack of travel time as advantages. Their most prominent needs concern better technological, organizational, and logistical support. It is critical that these needs are acted upon by institutions and governments. In addition, current results inform future research on the improvement of e-mental health technologies.

Feasibility of the Internet Attachment-Based Compassion Therapy in the General Population: Protocol for an Open-Label Uncontrolled Pilot Trial

Background

Compassion-based interventions delivered over the internet are showing promising results for the promotion of psychological health and well-being. Several studies have highlighted their feasibility, acceptance, and preliminary efficacy. However, this is an incipient field of research, and to the best of our knowledge, there are no data available from Spanish-speaking countries.

Objective

The aim of this study is to investigate the feasibility, acceptance, and preliminary efficacy of the Internet Attachment–Based Compassion Therapy (iABCT), a web-based version of the Attachment-Based Compassion Therapy, in Spanish speakers from the general population.

Methods

This feasibility study features a single-arm, uncontrolled, within-group design with an embedded qualitative and quantitative process evaluation at baseline, immediately after the intervention and at the 3-month follow-up. A minimum of 35 participants from the general population will be allocated to iABCT. Feasibility measures will include attrition rate, patterns of use of the web-based system, and participants’ acceptability, usability, and opinion. The primary outcome was measured using the Pemberton Happiness Index. Secondary outcomes were measured using the Compassion Scale, Self-Compassion Scale, Forms of Self-Criticizing/Attacking and Self-Reassuring Scale-Short form, Five Facets of Mindfulness Questionnaire, Relationships Questionnaire, General Health Questionnaire, Non-Attachment Scale, International Positive and Negative Affect Schedule Short Form, Purpose-In-Life Test, and difficulties regarding the practice of compassion (Compassion Practice Quality Questionnaire). Mixed models will be used to evaluate primary and secondary outcome measures. A qualitative content analysis of the participants’ qualitative responses will also be performed.

Results

Enrollment started in February 2020 and will be finished in April 2020. Data analysis will start in October 2020.

Conclusions

To our knowledge, this study will, for the first time, show data on the feasibility, acceptability, and preliminary efficacy of web-based compassion (and self-compassion) training—that is, the adapted iABCT—in Spanish speakers from the general population. Further aspects of their implementation (ie, facilitators, barriers, and unwanted effects) and mechanisms of change will be investigated. This study will allow the revision and fine-tuning of the developed intervention, study design, and planning procedures, as well as the initiation of a future randomized controlled trial.

Trial Registration

Clinicaltrials.gov: NCT03918746. Registered on April 17, 2019. Protocol version 1, 6 March 2019.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16717

Web-based MINDfulness and Skills-based distress reduction in cancer (MINDS): study protocol for a multicentre observational healthcare study

INTRODUCTION

Although a high percentage of patients with cancer experience severe psychological distress, few of them receive psycho-oncological care, largely due to barriers on the side of patients and healthcare providers that pose great challenges to delivering such care. In response, low-threshold, self-guided eHealth interventions can enable patients with cancer to deal independently and effectively with disease-related challenges and distress. Mindfulness and Skills-Based Distress Reduction in Oncology Training, nicknamed Make It Training, is one such innovative, self-guided eHealth intervention. In our study, we propose to assess different characteristics of such patients in order to define target populations for Make It Training, evaluate the intervention in terms of its usability, feasibility and sustainability and gather longitudinal data concerning the intervention's efficacy.

METHODS AND ANALYSIS

Self-guided and web-based Make It Training consists of eight 30 min modules involving the use of techniques of mindfulness therapy, cognitive-behavioural therapy and acceptance and commitment therapy to be completed in a 4-month period. In our observational study, adult patients with cancer who possess adequate German language skills and provide their informed consent will be recruited at Essen, Erlangen and Tübingen University Hospitals at outpatient oncological institutions and via online channels. Patients will undergo a baseline online assessment (T0), an assessment directly after completing the intervention (T1) and assessments 3 and 6 months later (T2 and T3, respectively). With the results of those assessments, we will perform descriptive analyses of their sociodemographic and medical data, compare means and conduct regression analyses.

ETHICS AND DISSEMINATION

The Ethics Committees of the University Hospitals Essen, Erlangen and Tübingen have approved the study (19-8643-BO, 27_19 B, 293/2018BO1). Results will be published in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

DRKS00017119.

A Randomised Controlled Trial Study of the Effects of a Digital Divorce Platform on Mental and Physical Health

BACKGROUND

Two decades of divorce research has consistently documented adverse mental and physical health effects of divorce. Responding to calls for evidence-based online divorce interventions, this study tests effects of the "Cooperation after Divorce" (CAD) digital intervention platform on divorcees' mental and physical health.

METHODS

Randomised control trial 12-month longitudinal study using a sample of 1,856 newly divorced Danes. Mental and physical health were measured using the SF-36 at baseline and 3, 6, and 12 months from baseline. Intervention effects were investigated using linear mixed effect models and Cohen's (d) for effect sizes.

RESULTS

The study found significant treatment effects of the CAD intervention on mental and physical health. These effects were evident across all eight health domains constituting the mental and physical health components. The study also found that the intervention group had significantly better mental health than the control group at subsequent 6- and 12-month assessments from baseline while for physical health, the intervention group had significantly better physical health at the 6-month assessment from baseline only.

CONCLUSION

The results indicate that digital solutions allowing for individually tailored user experiences may hold great potential in reducing well-known adverse health effects of divorce.

PRACTITIONER'S POINTS

The study finds highly significant treatment effects of the "CAD" digital divorce intervention on mental and physical health indicating that online interventions may be successfully integrated into help offered to divorcees post-divorce.

Internet-Delivered Cognitive Behavioral Therapy for Problematic Alcohol Use in a Workplace Setting: Protocol for Quantitative and Qualitative Evaluation of Feasibility and Outcomes

BACKGROUND

Internet-based cognitive behavioral therapy (ICBT) for mental health issues has been successfully implemented in routine health care settings, and research indicates that ICBT can also be applied to decrease problematic alcohol use in workplace settings. However, studies investigating the feasibility of implementing ICBT in a workplace setting have been lacking.

OBJECTIVE

The current study aims to investigate the feasibility of delivering ICBT for problematic alcohol use within an employee assistance program (EAP).

METHODS

The study has a quantitative naturalistic design, quantitively comparing ICBT and face-to-face treatment, and allowing for qualitative interviews with employees and employers. Recruitment of participants follows a five-session in-person psychological assessment at an EAP regarding an employee's presumed problematic alcohol consumption. All assessed employees referred to ICBT or face-to-face treatment will be offered participation in the study. Interviews will be held with employees and their employer representatives following ICBT to elucidate both stakeholders' experience and perception of ICBT and its context. Outcome comparisons between ICBT and face-to-face treatment will be assessed quantitatively using a Reliable Change Index and analysis of variance. Thematic analysis and Grounded Theory will be used to analyze the interview material.

RESULTS

The study is set to begin in April 2020 and to end in September 2021. The aim is to recruit up to 150 participants to the quantitative part of the study and 45 participants (15 employees and 30 employer representatives) to the qualitative part of the study.

CONCLUSIONS

The current study will provide knowledge that is lacking and urgently needed on how to implement ICBT for problematic alcohol use in a workplace setting.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/18693.

Behavioral couples therapy versus cognitive behavioral therapy for problem gambling: a randomized controlled trial

Background and aims

There is evidence that cognitive behavioral therapy (CBT) is effective for treating problem gambling (PG). Some research points to the possible benefits of involving concerned significant others (CSOs) in treatment. This study compared the efficacy of behavioral couples therapy (BCT) and CBT for both the gambler and the CSO.

Design

Two parallel‐group randomized controlled study comparing two different internet‐based treatments for PG. Follow‐up measures were conducted at treatment finish, and at 3‐, 6‐ and 12‐month post‐treatment.

Setting

Stockholm, Sweden.

Participants

A total of 136 problem gamblers and 136 CSOs were included in the study: 68 gamblers and 68 CSOs for each treatment condition. The gamblers were on average 35.6 years old and 18.4% were female. CSOs were on average 45.3 years old and 75.7% were women.

Interventions

A treatment based on BCT was compared with a CBT intervention. Both treatments were internet‐based, with 10 therapist‐guided self‐help modules accompanied by weekly telephone and e‐mail support from a therapist. CSOs were given treatment in the BCT condition, but not in the CBT condition.

Measurements

The primary outcome measures were time‐line follow‐back for gambling (TLFB‐G) and the NORC Diagnostic Screen for Gambling Problems (NODS) for problem gamblers, corresponding to DSM‐IV criteria for pathological gambling. Secondary outcomes measures were the Patient Health Questionnaire‐9 (PHQ‐9), the Generalized Anxiety Disorder seven‐item scale (GAD‐7), the Relation Assessment Scale Generic (RAS‐G), the Alcohol Use Disorders Identification Test (AUDIT), the Inventory of Consequences of Gambling for the Gambler and CSO (ICS) and adherence to treatment for both the problem gambler and the CSO.

Findings

The outcomes of both gambler groups improved, and differences between the groups were not statistically significant: TLFB‐G: multiplicative effect = 1.13, 95% confidence interval (CI) = 0.30;4.31); NODS: multiplicative effect = 0.80, 95%, 95% CI = 0.24;2.36. BCT gamblers began treatment to a higher proportion than CBT gamblers: P = 0.002.

Conclusions

Differences in the efficacy of internet‐based behavioral couples therapy and cognitive behavioral therapy for treatment of problem gambling were not significant, but more gamblers commenced treatment in the behavioral couples therapy group.

A Machine Learning Approach to Understanding Patterns of Engagement With Internet-Delivered Mental Health Interventions

IMPORTANCE

The mechanisms by which engagement with internet-delivered psychological interventions are associated with depression and anxiety symptoms are unclear.

OBJECTIVE

To identify behavior types based on how people engage with an internet-based cognitive behavioral therapy (iCBT) intervention for symptoms of depression and anxiety.

DESIGN, SETTING, AND PARTICIPANTS

Deidentified data on 54 604 adult patients assigned to the Space From Depression and Anxiety treatment program from January 31, 2015, to March 31, 2019, were obtained for probabilistic latent variable modeling using machine learning techniques to infer distinct patient subtypes, based on longitudinal heterogeneity of engagement patterns with iCBT.

INTERVENTIONS

A clinician-supported iCBT-based program that follows clinical guidelines for treating depression and anxiety, delivered on a web 2.0 platform.

MAIN OUTCOMES AND MEASURES

Log data from user interactions with the iCBT program to inform engagement patterns over time. Clinical outcomes included symptoms of depression (Patient Health Questionnaire-9 [PHQ-9]) and anxiety (Generalized Anxiety Disorder-7 [GAD-7]); PHQ-9 cut point greater than or equal to 10 and GAD-7 scores greater than or equal to 8 were used to define depression and anxiety.

RESULTS

Patients spent a mean (SD) of 111.33 (118.92) minutes on the platform and completed 230.60 (241.21) tools. At baseline, mean PHQ-9 score was 12.96 (5.81) and GAD-7 score was 11.85 (5.14). Five subtypes of engagement were identified based on patient interaction with different program sections over 14 weeks: class 1 (low engagers, 19 930 [36.5%]), class 2 (late engagers, 11 674 [21.4%]), class 3 (high engagers with rapid disengagement, 13 936 [25.5%]), class 4 (high engagers with moderate decrease, 3258 [6.0%]), and class 5 (highest engagers, 5799 [10.6%]). Estimated mean decrease (SE) in PHQ-9 score was 6.65 (0.14) for class 3, 5.88 (0.14) for class 5, and 5.39 (0.14) for class 4; class 2 had the lowest rate of decrease at -4.41 (0.13). Compared with PHQ-9 score decrease in class 1, the Cohen d effect size (SE) was -0.46 (0.014) for class 2, -0.46 (0.014) for class 3, -0.61 (0.021) for class 4, and -0.73 (0.018) for class 5. Similar patterns were found across groups for GAD-7.

CONCLUSIONS AND RELEVANCE

The findings of this study may facilitate tailoring interventions according to specific subtypes of engagement for individuals with depression and anxiety. Informing clinical decision needs of supporters may be a route to successful adoption of machine learning insights, thus improving clinical outcomes overall.

Digital interventions in adult mental healthcare settings: recent evidence and future directions

PURPOSE OF REVIEW

Internet and mobile-based interventions (IMI) can be used as online delivered forms of psychotherapeutic mental health treatments. These interventions can be an effective as well as time and cost-efficient treatment with the potential to scale up mental healthcare. In this review, we map implementation possibilities into routine mental healthcare settings and provide the most recent evidence.

RECENT FINDINGS

Fourteen articles on digital mental healthcare approaches published in the last 18 months were included. Despite the limited number, the studies provide evidence for the effectiveness of IMI in treating inpatients and outpatients with various disorders in different mental healthcare settings. IMI were investigated as stand-alone interventions, in combination with other treatment forms (blended-care), or as aftercare.

SUMMARY

Although there is encouraging evidence for the effectiveness of IMI in mental healthcare settings, several limitations have to be considered. The small number of studies conducted within the healthcare system, especially with inpatient samples, calls for more collaboration between researchers and clinical practitioners to unravel barriers and develop efficient protocols for the integration into routine care. Nonetheless, IMI are a promising tool for the endeavour of closing the treatment gap and should, therefore, be further explored in varying settings.

Internet-based psychodynamic versus cognitive behaviour therapy for adolescents with depression: study protocol for a non-inferiority randomized controlled trial (the ERiCA study)

Background

Adolescent depression is a common mental health problem and there is an urgent need for effective and accessible treatments. Internet-based interventions solve many obstacles for seeking and receiving treatment, thus increasing access to effective treatments. Internet-based cognitive behavioural therapy (ICBT) for adolescent depression has demonstrated efficacy in previous trials. In order to broaden the range of evidence-based treatments for young people, we evaluated a newly developed affect-focused Internet-based psychodynamic treatment (IPDT) in a previous study with promising results. The purpose of the planned study is to evaluate the efficacy of IPDT for adolescent depression in a non-inferiority trial, comparing it to ICBT.

Methods

The study will employ a parallel randomized non-inferiority design (ratio 1:1; n = 270). Eligible participants are adolescents 15–19 years suffering from depression. The primary hypothesis is that IPDT will be non-inferior to ICBT in reducing depressive symptoms from pre-treatment to end of treatment. Secondary research questions include comparing outcomes of IPDT and ICBT regarding anxiety symptoms, emotion regulation and self-compassion. Additional data will be collected to evaluate cost-effectiveness as well as investigating predictors, moderators and mediators of outcome. In addition, we will examine long-term outcome up to 1 year after end of treatment. Diagnostic interviews with MINI 7.0 will be used to establish primary diagnosis of depression as well as ruling out any exclusion criteria. Both treatments consist of eight modules over 10 weeks, complemented with therapist support through text messages and weekly chat sessions. Primary outcome measure is the Quick Inventory of Depressive Symptomatology in Adolescents Self-Rated (QIDS-A17-SR). Primary outcome will be analysed using data from all participants entering the study using a multilevel growth curve strategy based on the weekly measurements of QIDS-A17-SR. The non-inferiority margin is defined as d = 0.30.

Discussion

This trial will demonstrate whether IPDT is non-inferior to ICBT in the treatment of adolescent depression. The study might therefore broaden the range of evidence-based treatment alternatives for young people struggling with depression. Further analyses of data from this trial may increase our knowledge about “what works for whom” and the pathways of change for two distinct types of interventions.

Trial registration

ISRCTN12552584, Registered on 13 August 2019.

The Impact of Quarantine and Physical Distancing Following COVID-19 on Mental Health: Study Protocol of a Multicentric Italian Population Trial

The COVID-19 pandemic and its related containment measures-mainly physical distancing and isolation-are having detrimental consequences on the mental health of the general population worldwide. In particular, frustration, loneliness, and worries about the future are common reactions and represent well-known risk factors for several mental disorders, including anxiety, affective, and post-traumatic stress disorders. The vast majority of available studies have been conducted in China, where the pandemic started. Italy has been severely hit by the pandemic, and the socio-cultural context is completely different from Eastern countries. Therefore, there is the need for methodologically rigorous studies aiming to evaluate the impact of COVID-19 and quarantine measures on the mental health of the Italian population. In fact, our results will help us to develop appropriate interventions for managing the psychosocial consequences of pandemic. The "COVID-IT-mental health trial" is a no-profit, not-funded, national, multicentric, cross-sectional population-based trial which has the following aims: a) to evaluate the impact of COVID-19 pandemic and its containment measures on mental health of the Italian population; b) to identify the main areas to be targeted by supportive long-term interventions for the different categories of people exposed to the pandemic. Data will be collected through a web-platform using validated assessment tools. Participants will be subdivided into four groups: a) Group 1-COVID-19 quarantine group. This group includes the general population which are quarantined but not isolated, i.e., those not directly exposed to contagion nor in contact with COVID-19+ individuals; b) Group 2-COVID-19+ group, which includes isolated people directly/indirectly exposed to the virus; c) Group 3-COVID-19 healthcare staff group, which includes first- and second-line healthcare professionals; d) Group 4-COVID-19 mental health, which includes users of mental health services and all those who had already been diagnosed with a mental disorder. Mental health services worldwide are not prepared yet to manage the short- and long-term consequences of the pandemic. It is necessary to have a clear picture of the impact that this new stressor will have on mental health and well-being in order to develop and disseminate appropriate interventions for the general population and for the other at-risk groups.

Consensus statement on the problem of terminology in psychological interventions using the internet or digital components

Since the emergence of psychological interventions delivered via the Internet they have differed in numerous ways. The wealth of formats, methods, and technological solutions has led to increased availability and cost-effectiveness of clinical care, however, it has simultaneously generated a multitude of terms. With this paper, we first aim to establish whether a terminology issue exists in the field of Internet-delivered psychological interventions. If so, we aim to determine its implications for research, education, and practice. Furthermore, we intend to discuss solutions to mitigate the problem; in particular, we propose the concept of a common glossary. We invited 23 experts in the field of Internet-delivered interventions to respond to four questions, and employed the Delphi method to facilitate a discussion. We found that experts overwhelmingly agreed that there were terminological challenges, and that it had significant consequences for conducting research, treating patients, educating students, and informing the general public about Internet-delivered interventions. A cautious agreement has been reached that formulating a common glossary would be beneficial for the field to address the terminology issue. We end with recommendations for the possible formats of the glossary and means to disseminate it in a way that maximizes the probability of broad acceptance for a variety of stakeholders.

A survey study of attitudes toward, and preferences for, e-therapy interventions for eating disorder psychopathology

OBJECTIVE

E-therapy shows promise as a solution to the barriers that stand in the way of people receiving eating disorder (ED) treatment. Despite the potential for e-therapy to reduce the well-known treatment gap, little is known about public views and perspectives on this mode of intervention delivery. This study explored attitudes toward, and preferences for, e-therapy among individuals spanning the spectrum of eating pathology.

METHOD

Survey data assessing e-therapy attitudes and preferences were analyzed from 713 participants recruited from the public. Participants were categorized into one of five subgroups based on the type of self-reported ED symptoms and severity/risk level, ranging from high risk to a probable threshold or subthreshold ED.

RESULTS

Attitudes toward e-therapies appeared to be relatively positive; participants largely supported health care insurance coverage of costs for e-therapies, and were optimistic about the wide-ranging benefits of e-therapy. Although three-quarters of participants expressed a preference for face-to-face therapy, a significant percentage of participants (∼50%) reported an intention to use an e-therapy program for current or future eating problems, with intention ratings highest (70%) among those with probable bulimia nervosa (BN). Variables associated with an e-therapy preference were not currently receiving psychotherapy, more positive e-therapy attitudes, and greater stigma associated with professional help-seeking. Variables associated with e-therapy intentions were more positive e-therapy attitudes and a probable BN classification.

CONCLUSIONS

Present findings have important implications for increasing online intervention acceptance, engagement, and help-seeking among those at different stages of illness.

Dimensionality of the system usability scale among professionals using internet-based interventions for depression: a confirmatory factor analysis

BACKGROUND

The System Usability Scale (SUS) is used to measure usability of internet-based Cognitive Behavioural Therapy (iCBT). However, whether the SUS is a valid instrument to measure usability in this context is unclear. The aim of this study is to assess the factor structure of the SUS, measuring usability of iCBT for depression in a sample of professionals. In addition, the psychometric properties (reliability, convergent validity) of the SUS were tested.

METHODS

A sample of 242 professionals using iCBT for depression from 6 European countries completed the SUS. Confirmatory Factor Analysis (CFA) was conducted to test whether a one-factor, two-factor, tone-model or bi-direct model would fit the data best. Reliability was assessed using complementary statistical indices (e.g. omega). To assess convergent validity, the SUS total score was correlated with an adapted Client Satisfaction Questionnaire (CSQ-3).

RESULTS

CFA supported the one-factor, two-factor and tone-model, but the bi-factor model fitted the data best (Comparative Fit Index = 0.992, Tucker Lewis Index = 0.985, Root Mean Square Error of Approximation = 0.055, Standardized Root Mean Square Residual = 0.042 (respectively χ²_diff (9) = 69.82, p < 0.001; χ²_diff (8) ₌ 33.04, p < 0.001). Reliability of the SUS was good (ω = 0.91). The total SUS score correlated moderately with the CSQ-3 (CSQ1 r_s = .49, p < 0.001; CSQ2 r_s = .46, p < 0.001; CSQ3 r_s = .38, p < 0.001), indicating convergent validity.

CONCLUSIONS

Although the SUS seems to have a multidimensional structure, the best model showed that the total sumscore of the SUS appears to be a valid and interpretable measure to assess the usability of internet-based interventions when used by professionals in mental healthcare.

IAPT and the internet: the current and future role of therapist-guided internet interventions within routine care settings

Compared with the traditional face-to-face format, therapist-guided internet interventions offer a different approach to supporting clients in learning skills to manage and overcome mental health difficulties. Such interventions are already in use within IAPT (Improving Access to Psychological Therapies) and other routine care settings, but given their potential to deliver treatment more efficiently and therefore increase availability and access to evidence-based interventions, their use is likely to increase significantly over the coming years. This article outlines what is meant by therapist-guided internet interventions and why an online format is thought to be advantageous for clients, therapists, services, and communities more broadly. It reviews the current evidence in the context of common therapist beliefs about internet-based treatment. It aims to identify gaps where further research is required, particularly in relation to the broader implementation of these treatments in IAPT and other routine clinical services. Specifically, it emphasises the importance of choosing the right programmes, providing adequate therapist training in their use, and considering practical and organisational issues, all of which are likely to determine the success of implementation efforts.

KEY LEARNING AIMS

To understand what therapist-guided internet interventions are and their potential advantages.To understand the current evidence base for these interventions.To learn where further research is needed with regard to both the interventions themselves, and to their broader implementation in IAPT.

A Mixed-Method Modified Delphi Study toward Identifying Key Elements of Psychotherapy in Iran

PURPOSE

In Iran, psychotherapy is regarded as an effective treatment for psychiatric disorders. However, no previous research has identified the key elements of psychotherapy that may be specific to Iranian society. The current study was conducted in an attempt to identify these elements.

METHODS

A mixed-method modified Delphi approach was used, taking place over several stages during 2017-2018. The first stage involved interviewing 12 experts in psychotherapy to identify key elements of psychotherapy in Iran by thematic analysis. Then, successive Delphi rounds were conducted to obtain consensus (75% agreement) from 70 psychotherapy experts on these key elements.

RESULTS

Key elements of psychotherapy were grouped into the following themes: (1) systematic education/training; (2) psychotherapist competency; (3) psychotherapy reflective of Iranian societal needs; and (4) the substrate (scientific/ethical principles) of psychotherapy. Consensus was reached during two Delphi rounds. In Delphi round 1, 52.8% of the statements reached consensus, and all remaining statements reached consensus in round 2.

CONCLUSIONS

The key elements of psychotherapy in Iran are a set of conditions for the education and training of competent psychotherapists who can perform psychiatric interventions appropriate to Iranian society under supervised rules. These should serve as a framework for improving the current delivery of psychotherapy in Iran.

Patients' experiences of internet-based Acceptance and commitment therapy for chronic pain: a qualitative study

Background

Chronic pain is a globally widespread condition with complex clusters of symptoms within a heterogeneous patient group. Internet-delivered Acceptance and Commitment Therapy (IACT) has shown promising results in the treatment of chronic pain. How IACT is experienced by patients is less well known. Qualitative studies of patients’ experiences are needed to further understand factors behind both engagement and negative effects. The aim of this study was to explore how IACT was experienced by chronic pain patients who had participated in a controlled trial.

Methods

Through an open and exploratory approach this study aimed to investigate how IACT was experienced when delivered as a guided self-help program to persons with chronic pain. Eleven participants were interviewed over telephone after completing IACT.

Results

Qualitative analysis based on grounded theory resulted in 2 core categories and 8 subcategories. In treatment: Physical and cognitive restraints, Time and deadline, Therapist contact, and Self-confrontation. After treatment: Attitude to pain, Image of pain, Control or Command, and Acting with pain. Individual differences as well as specific conditions of the treatment may explain variations in how the treatment was approached, experienced and what consequences it led to. Therapist guidance and deadlines for homework play complex roles in relation to autonomy and change.

Conclusions

Adjusting treatment content and format based on participants’ characteristics, such as expectations, motivation and restraints, might positively affect engagement, autonomy and change. Further research on attrition and negative effects of treatment might clarify what enables chronic pain patients to benefit from IACT.

Trial registration

clinicaltrials.gov (NCT01603797). Registered 22 May 2012. Retrospectively registered.

Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression: Randomized Controlled Trial

BACKGROUND

Adolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments.

OBJECTIVE

This trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents.

METHODS

The trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment.

RESULTS

IPDT was significantly more effective than the control condition in reducing depression (d=0.82, P=.01), the result of which was corroborated by the second depression measure (d=0.80, P<.001). IPDT was also significantly more effective in reducing anxiety (d=0.78, P<.001) and increasing emotion regulation (d=0.97, P<.001) and self-compassion (d=0.65, P=.003). Significantly more patients in the IPDT group compared to the control group met criteria for response (56% vs 21%, respectively) and remission (35% vs 8%, respectively). Results on depression and anxiety symptoms were stable at 6 months follow-up. On average, participants completed 5.8 (SD 2.4) of the 8 modules.

CONCLUSIONS

IPDT may be an effective intervention to reduce adolescent depression. Further research is needed, including comparisons with other treatments.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number (ISRCTN) 16206254; http://www.isrctn.com/ISRCTN16206254.

Measuring Alliance Toward Embodied Virtual Therapists in the Era of Automated Treatments With the Virtual Therapist Alliance Scale (VTAS): Development and Psychometric Evaluation

BACKGROUND

Automated virtual reality exposure therapies (VRETs) are self-help treatments conducted by oneself and supported by a virtual therapist embodied visually and/or with audio feedback. This simulates many of the nonspecific relational elements and common factors present in face-to-face therapy and may be a means of improving adherence to and efficacy of self-guided treatments. However, little is known about alliance toward the virtual therapist, despite alliance being an important predictor of treatment outcome.

OBJECTIVE

In this study, we aimed to evaluate the first alliance instrument developed for use with embodied virtual therapists in an automated treatment format-the Virtual Therapist Alliance Scale (VTAS)-by (1) assessing its psychometric properties, (2) verifying the dimensionality of the scale, and (3) determining the predictive ability of the scale with treatment outcome.

METHODS

A psychometric evaluation and exploratory factor analysis of the VTAS was conducted using data from two samples of spider-fearful patients treated with VRET and the help of an embodied, voice-based virtual therapist (n=70). Multiple regression models and bivariate correlations were used to assess the VTAS relationship with treatment outcome, according to self-reported fear and convergence with presence and user-friendliness process measures.

RESULTS

The VTAS showed a sound two-factor solution composed of a primary factor covering task, goal, and copresence; adequate internal consistency; and good convergent validity, including moderate correlation (r=.310, P=.01) with outcomes over follow-up.

CONCLUSIONS

These preliminary results suggest that alliance toward a virtual therapist is a significant predictor of treatment outcome, favors the importance of a task-goal over bond-factor, and should be explored in studies with larger sample sizes and in additional forms of embodiment.

Internet-based psychodynamic therapy vs cognitive behavioural therapy for social anxiety disorder: A preference study

OBJECTIVE

Both Internet-delivered cognitive behavioural therapy (ICBT) and Internet-delivered psychodynamic psychotherapy (IPDT) have shown promise in the treatment of social anxiety disorder (SAD). However, little is known about client preferences and what predicts treatment outcome. The objective of the present pilot study was to examine preference for ICBT versus IPDT in the treatment of SAD and whether participants' preference strength and therapeutic alliance predicted treatment response. Further, we also investigated the effect of the two treatments, including 6-months follow-up.

METHOD

Thirty-six participants were instructed to choose between either IPDT or ICBT based on a brief description. Both treatments were 10 weeks long. Liebowitz Social Anxiety Scale - Self Report was used as the primary outcome measure.

RESULTS

IPDT (N = 23; 63.9%) was preferred more often than ICBT (N = 13; 36.1%), but the difference did not reach statistical significance (p = .10). Preference strength did not predict the treatment effect but therapeutic alliance did. The observed within-group effects for the treatment period were d = 0.40 [-0.21, 0.99] for the IPDT group and d = 0.53 [-0.29, 1.31] for the ICBT group. An intention-to-treat (ITT) analysis revealed no significant difference between the two treatments on any outcome measure at either post-treatment or at six months follow-up.

CONCLUSION

The present pilot study did not find a difference in preference for IPDT or ICBT in the treatment of SAD and both treatments resulted in small to moderate improvements in symptoms of SAD. Preference strength might not predict treatment effect, but this needs to be tested in larger studies.

Adherence Predictors in Internet-Delivered Self-Help Intervention for Life Stressors-Related Adjustment Disorder

Background: There is a growing body of evidence to show that low-intensity self-help internet-delivered interventions are effective in the treatment of mental disorders. Despite the promising effectiveness of internet-delivered interventions, there is still a challenge for mental health services to implement internet-delivered interventions in routine health care. The aim of this study was to analyze the predictors of adherence to a self-help internet-delivered intervention for adjustment disorder. Methods: This was a secondary report of data, including unpublished data, from a randomized controlled trial of an internet-delivered self-help intervention for adjustment disorder. The study included 1,077 participants who had completed online baseline assessments. All participants had experienced significant life stressors over the last 2 years and had high levels of adjustment disorder symptoms. We analyzed the role of sociodemographic variables, pre-treatment adjustment disorder symptoms, outcome expectations, and perceived barriers to mental health services on the use of the intervention. Results: We found that usage of internet-delivered self-help intervention and higher adherence was associated with female gender, greater age, higher pre-intervention outcome expectations, exposure to other forms of psychological therapy in addition to the internet-intervention at the time of the study, and reported perceived barriers to mental health services by the study participants. Conclusions: The findings of the study indicated the importance of non-specific therapeutic factors on adherence during internet-delivered intervention. Perceived barriers to mental health services were associated with higher adherence to self-help intervention, which indicated that communities with restricted access to mental health services could benefit from low-intensity internet-delivered interventions.

A comparison of the characteristics and treatment outcomes of migrant and Australian-born users of a national digital mental health service

BACKGROUND

To explore the characteristics and compare clinical outcomes of non-Australian born (migrant) and Australian-born users of an Australian national digital mental health service.

METHODS

The characteristics and treatment outcomes of patients who completed online treatment at the MindSpot Clinic between January 2014 and December 2016 and reported a country of birth other than Australia were compared to Australian-born users. Data about the main language spoken at home were used to create distinct groups. Changes in symptoms of depression and anxiety were measured using the Patient Health Questionnaire-9 Item (PHQ-9), and Generalized Anxiety Disorder Scale - 7 Item (GAD-7), respectively.

RESULTS

Of 52,020 people who started assessment at MindSpot between 1st January 2014 and 22nd December 2016, 45,082 reported a country of birth, of whom 78.6% (n = 35,240) were Australian-born, and 21.4% (n = 9842) were born overseas. Of 6782 people who completed the online treatment and reported country of birth and main language spoken at home, 1631 (24%) were migrants, 960 (59%) were from English-speaking countries, and 671 (41%) were from non-English speaking countries. Treatment-seeking migrant users reported higher rates of tertiary education than Australian-born users. The baseline symptom severity, and rates of symptom reduction and remission following online treatment were similar across groups.

CONCLUSIONS

Online treatment was associated with significant reductions in anxiety and depression in migrants of both English speaking and non-English speaking backgrounds, with outcomes similar to those obtained by Australian-born patients. DMHS have considerable potential to help reduce barriers to mental health care for migrants.

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.